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Issues & Evidence: Summary Mother, Father & Infant
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For each of the issues addressed during this presentation, a summary of the available evidence is given below. Following that summary, the limitations of the existing evidence are described, and references cited in the presentation, along with other references relevant to that issue, are listed. Copies of the slides can be downloaded or information from this presentation can be used in making presentations or informing people about issues related to the implementation of early hearing detection and intervention programs. Information included here, which has not previously been published, should not be cited or used in other publications without written permission from the authors of that information.

Prevalence of Congential Hearing Loss

A key issue in deciding whether universal newborn hearing screening programs should be recommended is how many children have permanent congenital hearing loss (PCHL). Existing data related to this issue must be interpreted with respect to how PCHL was defined (the severity of the loss [ranging from 20 dBHL to 50 dBHL; single frequency loss vs. an average across several frequencies], whether unilateral or only bilateral losses were included, the technique used to make a determination of PCHL [diagnostic ABR vs. behaviorally-confirmed losses], and what efforts were made to account for PCHL acquired after infancy). Obviously, how individual studies address each of these issues will have a dramatic effect on the reported prevalence rate. Retrospective population-based studies with large samples from around the world consistently show bilateral PCHL from about one per thousand (for PTA losses > 50 dBHL) to three per thousand (for PTA bilateral losses > 20 dBHL). Because none of these studies differentiated between acquired losses and congenital losses, they over-estimate congenital PCHL to some unknown degree (as noted below however, this over-estimate is probably very small). There is also substantial evidence that including unilateral PCHL would increase these estimates by about 40%.

Data from universal newborn hearing screening programs which have operated since the early 1990's provides similar information about the prevalence of congenital hearing loss. Data from these programs must be interpreted in conjunction with issues such as how a determination was made that a child had a congenital hearing loss (behavioral diagnosis or diagnostic ABR), whether screening was designed to find unilateral or bilateral losses, and the number of infants lost to follow up during the screening and diagnosis process (some programs have not been able to follow as many as 60% of the children initially referred from the screening program). Those programs with large numbers of children who have been successful in following most of the refers, and who have screened for unilateral and mild or worse PCHL, report prevalence rates of three to four per thousand. Programs that have been operational for 5+ years and who have monitored the identification of children with PCHL at older ages report finding very few, if any, acquired hearing losses. The absence of children with acquired losses in those places where universal screening programs have been operational for 5+ years suggests that much of what was previously believed to be acquired hearing loss was probably congenital mild or moderate loss that was progressive.

Taken together, the evidence is quite convincing that congenital PCHL > 25 dBHL in the worst ear is present for at least three infants per thousand.

Limitations of Existing Evidence

Evidence concerning prevalence comes from studies around the world and is based on large cohorts of children. It is reasonably consistent after accounting for issues related to definition, diagnostic procedures, and completeness of follow up. Weaknesses with these data include: a) the methods for diagnosing PCHL are often not adequately described; and b) no definitive methods of accounting for how many children in these data sets have acquired hearing loss. Anecdotal evidence suggests that the percentage of PCHL children with acquired loss is much lower than has historically been assumed.

References About "Prevalence Estimates"

Barsky-Firkser, L., & Sun, S. (1997). Universal newborn hearing screenings: A three year experience. Pediatrics, 99(6), 1-5.

Barr, B. (1980). Early detection of hearing impairment. In I. G. Taylor & A. Markides (Eds.), Disorders of auditory function (Vol. III, pp. 33-42). New York: Academic Press.

Brookhouser, P. E., Worthington, D. W., & Kelly, W. J. (1991). Unilateral hearing loss in children. Laryngoscope, 101, 1264-1272.

Davis, A. C., & Wood, S. (1992). The epidemiology of childhood hearing impairment: Factors relevant to planning of services. British Journal of Audiology, 26, 77-90.

Downs, M. P. (1978). Return to the basics of infant screening. In S. E. Gerber & G. T. Mencher (Eds.), Early diagnosis of hearing loss (pp. 129-153). New York: Grune & Stratton.

Feinmesser, M., Tell, L., & Levi, H. (1986). Etiology of childhood deafness with reference to the group of unknown cause. Audiology, 25, 65-69.

Fitzaland, R. E. (1985). Identification of hearing loss in newborns: Results of eight years' experience with a high risk hearing register. The Volta Review, 87, 195-203.

Fortnum, H., Davis, A., Butler, A, & Stevens, J. (December, 1996). Health Service implications of changes in aetiology and referral patterns of hearing-impaired children in Trent 1985-1993. Medical Research Council Institute of Hearing Research, Nottingham, United Kingdom.

Johnson, J.L., Kuntz, N.L., Sia, C.C.J., & White, K.R. (1997). Newborn hearing screening in Hawaii. Unpublished manuscript. Hawaii Department of Health, Zero-to-Three Program, Honolulu, HI.

Kankkunen, A. (1982). Preschool children with impaired hearing. Acta Otolaryngolica, Suppl. 391, 1-124.

Kinney, C. (1953). Hearing impairments in children. Laryngoscope, 63, 220-226.

Lundeen, C. (1991). Prevalence of hearing impairment among school children. Language, Speech, and Hearing Services in Schools, 22, 269-271.

Martin, J. A. M. (1982). Aetiological factors relating to childhood deafness in the European community. Audiology, 21, 149-158.

Mehl, A.L., & Thomson, V. (in press). Newborn hearing screening: The great omission. Pediatrics.

Parving, A. (1985). Hearing disorders in childhood, some procedures for detection, identification and diagnostic evaluation. International Journal of Pediatric Otorhinolaryngology, 9, 31-57.

Prieve, B. (1997). Prevalence data from New York UNHS programs. Personal communication.

Sehlin, P., Holmgren, G., & Zakrisson, J. (1990). Incidence, prevalence and etiology of hearing impairment in children in the county of Vasterbotten, Sweden. Scandinavian Audiology, 19, 193-200.

Sorri, M., & Rantakallio, P. (1985). Prevalence of hearing loss at the age of 15 in a birth cohort of 12,000 children from northern Finland. Scandinavian Audiology, 14, 203-207.

Watkin, P. M., Baldwin, M., & Laoide, S. (1990). Parental suspicion and identification of hearing impairment. Archives of Disease in Childhood, 65, 846-850.

White, K. R., Vohr, B. R., & Behrens, T. R. (1993). Universal newborn hearing screening using transient evoked otoacoustic emissions: Results of the Rhode Island Hearing Assessment Project. Seminars in Hearing, 14(1), 18-29.

Accuracy of Newborn Hearing Screening Methods

Five different techniques are used or frequently suggested for early identification of congenital PCHL: 1) auditory brainstem response (ABR), 2) high-risk indicators followed by ABR, 3) behavioral evaluation when children are 7-9 months old, 4) otoacoustic emissions (OAE), and 5) automated ABR (AABR). All except for behavioral evaluation are used at different hospitals in the United States. Behavioral evaluations of 7- to 9-month-old children are used extensively in other parts of the world. Although many articles report figures for the sensitivity and specificity of these various methods, definitive information about the sensitivity compared to behaviorally confirmed congenital PCHL is not available for any of the methods, with the possible exception of ABR. The reason available data is not definitive is that most studies reporting sensitivity figures have either assumed that all children who pass the initial screen had normal hearing, have only followed a small percentage of the children who passed the initial screen, have compared one screening technique to another screening technique to derive sensitivity figures, or were based on unacceptably small samples or samples of only high- risk babies. There is, however, substantial evidence for the accuracy of some of the techniques as described briefly below.

Accuracy of Auditory Brainstem Response for Identification of Congenital PCHL

There is good evidence that Auditory Brainstem Response (ABR) is effective in identifying PCHL in newborns as long as it is used appropriately. Reports of sensitivity for identifying hearing loss are very high (97%-100%), but most are based on small samples of high-risk infants in universal newborn hearing screening programs. Because of the expense and time involved in doing ABR, there are only two known programs in the U.S. who use it as a universal newborn hearing screening technique. There are many programs, however, who screen high-risk infants using ABR.

High-Risk Followed by ABR

Until recently, the most frequent technique for early identification of congenital PCHL was to identify children who exhibited one of the high-risk indicators specified by the Joint Committee on Infant Hearing or to target all children in the neonatal intensive care unit (since a large percentage of these will have one of the JCIH high-risk indicators), and to screen those children with ABR. By targeting screening to this approximately 10% subset of the population, the goal was to keep the cost of screening lower and still identify most of the children. However, because approximately half of children with congenital PCHL do not exhibit any of the risk indicators, many children are missed using this technique. Furthermore, programs have experienced substantial difficulty getting families of children with high-risk indicators to come back for diagnostic evaluations, and consequently, the sensitivity of such programs is very low. If the presence of a high-risk indicator is considered to be a positive screen, the specificity is also very low. With the advent of new screening techniques (OAE and AABR), many high-risk- based early detection programs have been discontinued.

Behavioral Evaluation at 7-9 Months

Although such programs are used primarily in countries where a home health visitor program is already in place, it is sometimes suggested as an alternative here in the U.S. It is also suggested that such evaluations could be done as a part of well-baby care at the doctor's office. Data from well-established programs in other countries which rely on behavioral evaluations at 7-9 months indicate unacceptably low sensitivity. Programs report missing more than half of the children with bilateral sensorineural hearing loss and even higher numbers of children with mild moderate and unilateral losses.

Otoacoustic Emissions

Reported agreement between OAE and ABR testing is high, but there are no studies in which the sensitivity and specificity related to behaviorally confirmed hearing loss can be determined. Early reports of OAE-based newborn hearing screening programs had unacceptably high referral rates for inpatient screening (25%+). Numerous, more recent reports, however, report inpatient referral rates of 5%-8%. There are now dozens of hospital-based universal newborn hearing screening programs using otoacoustic emissions. These programs report identifying 1.5 to 4 PCHL children per thousand (programs unable to track large percentages of referred children are at the lower end of that range, and programs with the most successful follow-up are near the upper range).

Automated ABR

Dozens of hospital-based universal newborn hearing screening programs are using automated ABR to identify children with congenital PCHL. Although there are no data on the sensitivity and specificity of this technique with behaviorally confirmed PCHL, the vast majority of reports which have examined the agreement between AABR and ABR find very high agreement (sensitivity and specificity greater than 95%). AABR-based programs report identifying 2-4 PCHL children per thousand with referral rates of 2%-8% at discharge.

Limitations of Data on Accuracy

Data related to the problems with high-risk indicators and behavioral evaluation of 7- to 9- month-old children are very convincing. The lack of data on sensitivity with behaviorally confirmed PCHL for ABR, OAE, and AABR is concerning, but understandable given the high expense of following all children who pass the initial screening with behavioral evaluations and the fact that other data provide good evidence that most children with congenital PCHL are being identified in these screening programs. Rigorous studies of sensitivity/specificity for universal newborn hearing screening programs using these techniques would certainly be useful, but very expensive to conduct.

References Cited About "Accuracy of Newborn Hearing Screening Techniques"

Barsky-Firkser, L., & Sun, S. (1997). Universal newborn hearing screenings: A three year experience. Pediatrics, 99(6), 1-5.

Davis, A., & Wood, S. (1992). The epidemiology of childhood hearing impairment: Factors relevant to planning of services. British Journal of Audiology, 26, 77-90.

Elssmann, S.F., Matkin, N.D., & Sabo, M.P. (1987). Early identification of congenital sensorineural hearing impairment. The Hearing Journal, 40(9), 13-17.

Feinmesser, M., Tell,, L., & Levi, H. (1982). Follow-up of 40,000 infants screened for hearing defect. Audiology, 21, 197-203.

Herrmann, B.S., Thornton, A.R., & Joseph, J.M. (1995). Automated infant hearing screening using the ABR: Development and validation. American Journal of Audiology, 4(2), 6-14.

Hyde, M.L., Riko, K., Malizia, K. (1990). Audiometric accuracy of the click ABR in infants at risk for hearing loss. J Am Acad Audiol, 1, 59-66.

Kennedy, C.R., Kimm, L., Dees, D.C., Evans, P.I.P., Hunter, M., Lenton, S., & Thornton, R.D. (1991). Otoacoustic emissions and auditory brainstem responses in the newborn. Archives of Disease in Childhood, 66, 1124-1129.

Mahoney, T.M., & Eichwald, J.G. (1987). The ups and "downs" of high-risk hearing screening: The Utah statewide program. Seminars in Hearing, 8(2), 155-163.

Mauk, G. W., White, K.R., Mortensen, L.B., & Behrens, T.R. (1991). The effectiveness of screening programs based on high-risk characteristics in early identification of hearing impairment. Ear and Hearing, 12(5),312-319.

McClelland, R. J., Watson, D.R., Lawless, V., Houston, H.G., & Adams, D. (1992). Reliability and effectiveness of screening for hearing loss in high-risk neonates. British Medical Journal, 304, 806-809.

Pappas, D.B., & Schaibly, M. (1984). A two-year diagnostic report on bilateral sensorineural hearing loss in infants and children. American Journal of Otology, 5(5), 339-342.

Plinkert, P.K., Sesterhenn, G., Arold, R., & Zenner, H.P. (1990). Evaluation of otoacoustic emissions in high-risk infants by using an easy and rapid objective auditory screening method. European Archives of Otorhinolaryngology, 247, 356-360.

Watkin, P.M., Baldwin, M., & Laoide, S. (1980). Parental suspicion and identification of hearing impairment. Archives of Disease in Childhood, 65, 846-850.

White, K.R., & Behrens, T.R. (Editors) (1993). The Rhode island Hearing Assessment Project: Implications for universal newborn hearing screening. Seminars in Hearing, 14(1).

White, K.R., Vohr, B.R., Maxon, A.B., Behrens, T.R., McPherson, M.G., & Mauk, G.W. (1994). Screening all newborns for hearing loss using transient evoked otoacoustic emissions. International Journal of Pediatric Otorhinolaryngology, 29, 203-217.

Other References for ABR Accuracy

Alberti, P.W., Hyde, M.L., Riko, K., Corbin, H., & Abramovich, S. (1983). An evaluation of BERA for hearing screening in high-risk neonates. Laryngoscope, 93, 1115-1121.

Fria, T.J. (1985). Identification of congenital hearing loss with the auditory brainstem response. In J .T. Jacobson (Ed.), The auditory brainstem response (pp. 317-336). San Diego, CA: College-Hill Press.

Fritsch, M.H., & Sommer, A. (1991). Handbook of congenital and early onset hearing loss. New York: Igaku-Shoin.

Murray, A., Javel, E., & Watson, C. (1985). Prognostic validity of auditory brainstem evoked response screening in newborn infants. American Journal of Otolaryngology, 6, 120-131.

Pettigrew, A.G., Edwards, D.A., & Henderson-Smart, D.J. (1986). Screening for auditory dysfunction in high risk neonates. Early Hum Dev, 14, 109-120.

Riko, K., Hyde, M.L., & Alberti, P.W. (1985). Hearing loss in early infancy: incidence, detection and assessment. Laryngoscope, 95, 137-145.

Shimizu, H., Walters, R.J., Proctor, L.R., Kennedy, D.W., Allen, M.C., & Markowitz, R.K. (1990). Identification of hearing impairment in the neonatal intensive care unit population: Outcome of a five-year project at the Johns Hopkins Hospital. Seminars in Hearing, 11(2), 150-160.

White, K. R., Vohr, B. R., & Behrens, T. R. (1993). Universal newborn hearing screening using transient evoked otoacoustic emissions: Results of the Rhode Island Hearing Assessment Project. Seminars in Hearing, 14(1), 18-29.

Other References for High Risk Indicator Accuracy

Epstein, S., & Reilly, J. S. (1989). Sensorineural hearing loss. Pediatric Clinics of North America, 36, 1501-1520.

Gerber, S.E. (1990). Review of a high risk register for congenital or early-onset deafness. Br J Audiol, 24, 347-356.

Smith, R.J.H., Zimmerman, B., Connolly, P. K., Jerger, S. W., & Yelich, A. (1992). Screening audiometry using the high-risk register in a level III nursery. Arch Otolaryngol Head Neck Surg, 118, 1306-1311.

Other References for Behavioral Evaluation Accuracy

Barr, B. (1980). Early detection of hearing impairment. In I. G. Taylor & A. Markides (Eds.), Disorders of auditory function (Vol. III, pp. 33-42). New York: Academic Press.

Bentzen, O., & Jensen, J. H. (1981). Early detection and treatment of deaf children: A European concept. In S.E. Gerber & G.T. Mencher (Eds.). Early management of hearing loss, (pp. 85-103). San Francisco: Grune & Stratton.

Haggard, M. P. (1990). Hearing screening in children--State of the art(s). Archives of Disease in Childhood, 65, 1193-1198.

Parving, H. H. (1987). Detection of hearing impairment in early childhood. Scand Audiol, 16, 187-192.

Scanlon, P. E., & Bamford, J. M. (1990). Early identification of hearing loss: Screening and surveillance methods. Archives of Disease in Childhood, 65, 479-485.

Smith, R.J.H., Zimmerman, B., Connolly, P. K., Jerger, S. W., & Yelich, A. (1992). Screening audiometry using the high-risk register in a level III nursery. Arch Otolaryngol Head Neck Surg, 118, 1306-1311.

Other References for OAE Accuracy

Daemers, K., Dirckx, J., Van Driessche, K., Somers, T., Offeciers, F. E., & Govaerts, P. J. (1996). Neonatal hearing screening with otoacoustic emissions: an evaluation. Acta oto-rhino-laryngologica belg., 50, 203-209.

Huynh, M. T., Pollack, R. A., & Cunningham, R.A.J. (1996). Universal newborn hearing screening: Feasibility in a community hospital. The Journal of Family Practice, 42(5), 487-490.

Maxon, A.B., White, K.R., Culpepper, B., & Vohr, B.R. (1997). Maintaining acceptably low referral rates in TEOAE-based newborn hearing screening programs. Journal of Communication Disorders, 457-475.

Watkin, P. M. (1996). Neonatal otoacoustic emission screening and the identification of deafness. Archives of Disease in Childhood, 74, F16-F25.

Other References for AABR Accuracy

Hall, J. W., Kileny, P. R., Ruth, R. A., & Kripal, J. P. (1987). Newborn auditory screening with ALGO-1 vs. conventional auditory brainstem response. Asha, 29, 120.

Jacobson, J. T., Jacobson, C. A., & Spahr, R. C. (1990). Automated and conventional ABR screening techniques in high-risk infants. Journal of the American Academy of Audiology, 1, 187-195.

Van Straaten, H.L.M., Groote, M. E., & Oudesluys-Murphy, A. M. (1996). Evaluation of an automated auditory brainstem response infant hearing screening method in at risk neonates. Eur J Pediatr, 155, 702-705.

Von Wedel, H., Schauseil-Zipf, U., & Doring, W. H. (1988). Horscreening bei Neugeborenen and Sauglingen. Laryng. Rhinol. Otol., 67, 307-311.

Efficiency of Existing
Universal Newborn Hearing Screening (UNHS) Programs

Although hundreds of hospital-based UNHS programs are now operating in the U.S., there are a number of issues related to the operation of those programs which should be considered in deciding whether to recommend the implementation of such programs for all children born in the U.S.

Coverage and Referral Rates

Questions are often raised about whether it is practicable to conduct a universal newborn hearing screening program in a busy hospital environment with relatively short stays. In addition, the relatively high referral rates reported for some early UNHS programs raised concerns about whether universal screening was feasible. More recent data demonstrates that most hospitals with UNHS programs (regardless of the technology) are able to screen 95%+ of all newborns prior to discharge. Referral rates are under 10% in most cases, with the lowest rates coming from hospitals using both OAE and AABR in a two-stage, inpatient screening protocol. The fact that so many different protocols is being used is significant (see Table 1).

Table 1 SCREENING PROTOCOLS Protocols Used in Universal Newborn Hearing Screening Programsa Screening Procedure Before Hospital Discharge After Hospital Dischargeb Number of Programs TEOAE TEOAE and ABRc 44 DPOAE DPOAE 5 AABR AABR 24 AABR TEOAE 2 TEOAE and ABRc ______ 5 TEOAE and AABRc ______ 2 DPOAE and ABRc ______ 1 TEOAE ______ 4 DPOAE ______ 3 AABR ______ 28 ABR ______ 2

Effects of UNHS on Age of Identification

There is clear evidence that the implementation of UNHS substantially lowers the age at which children with congenital PCHL are identified.

Effects on Parents

There is substantial literature showing that certain types of newborn screening programs (e.g., screening for cystic fibrosis) can be disruptive and anxiety provoking for parents. Although there is limited evidence on this question for newborn hearing screening programs, the available evidence suggests that most parents are supportive of newborn hearing screening programs. There are feelings of confusion, shock, anger, and concern among a few parents who have a normal-hearing infant who does not pass the initial screen, but these feelings are not nearly so frequent or as strong as they are in other newborn screening programs for conditions such as cystic fibrosis. Whether false positives in newborn hearing screening result in long-term negative effects for parents or for the relationship between parents and the infant has not been adequately investigated.

Difficulties with Follow-up

Many universal newborn hearing screening programs are experiencing difficulty getting all or most of the babies referred from the screening program to complete the diagnostic process and be enrolled in intervention. Attrition rates of as high as 60% between the initial referral and a diagnostic confirmation are not unusual. Such high attrition rates are a problem for UNHS programs regardless of the type of equipment (OAE- or ABR-based) or protocol (one- or two- stage initial screen) used. Even though many more infants with PCHL are being identified as a result of UNHS programs, attrition during the follow-up and diagnostic process is a significant problem.

Limitations of Existing Data

Evidence for the feasibility and practicality of UNHS is quite strong, but evidence concerning secondary effects for parents and family members is only beginning to emerge and is based on small samples or anecdotal reports from operational programs. It is clear that many programs are experiencing difficulties with attrition during the follow-up and diagnostic process, but the factors associated with or contributing to these difficulties are not well documented, nor has there been much work in developing and evaluating solutions.

References Cited About "Efficiency of Current UNHS Programs"

Barringer, D.G., & Mauk, G.W. (1997). Survey of parents' perceptions regarding hospital-based newborn hearing screening. Audiology Today, 9(1), 18-19.

Clayton, E.W. (1992). Screening and treatment of newborns. Houston Law Review, 29(1), 85-148.

Maxon, A.B., White, K.R., Culpepper, B., & Vohr, B.R. (1997). Maintaining acceptably low referral rates in TEOAE-based newborn hearing screening programs. Journal of Communication Disorders, 457-475.

Parving, A., & Salomon, G. (1996). The effect of neonatal universal hearing screening in a health surveillance perspective - a controlled study of two health authority districts. Audiology, 35, 158-168.

Tluczek, A., Mischler, E. H., Farrell, P. M., Fost, N.,Peterson, N. M., Carey, P., Bruns, W. T., & McCarthy, C. (1992). Parents' knowledge of neonatal screening and response to false-positive cystic fibrosis testing. J Dev Behav Pediatr, 13(3), 181-6.

Uzcategui, C. A. D. (1977). Refer rate and parental anxiety in newborn hearing screening in the state of Colorado. Unpublished doctoral dissertation, University of Colorado at Boulder, Colorado.

Watkin, P.M., Beckman, A., & Baldwin, M. (1995). The views of parents of hearing impaired children on the need for neonatal hearing screening. British Journal of Audiology, 29, 259-262.

Other References Related to Efficiency

Becker, S. (1976). Initial concern and action in the detection and diagnosis of a hearing impairment in a child. Volta Review (February-March), 105-115.

Feldman, W. (1990). How serious are the adverse effects of screening? Journal of General Internal Medicine, 5(September/October Supplement), 550-553.

Fyro, K., & Bodegard, G. (1987). Four-year follow-up of psychological reactions to false positive screening tests for congenital hypothyroidism. Acta Paediatr Scand, 76(1), 107-14.

Goldstein, R., & Tait, C. (1971). Critique of neonatal hearing evaluation. J Speech Hear Disord, 36(1), 3-18.

Hampton, M., & Lavizzo, B. (1974). Sickle cell "nondisease." American Journal Dis. Child, 128 (July), 58-61.

Rothemberg, M.B., & Sills, E.M. (1968). Iatrogenesis: The PKU anxiety syndrome. J. Amer. Acad. Psychiatry, 7, 689-692.

Sorenson, J.R., Levy, H.L., Mangione, T.W., & Sepe, S.J. (1984). Parental response to repeat testing of infants with "false-positive" results in newborn screening program. Pediatrics, 73(2), 183-187.

Consequences of Neonatal Hearing Loss

There is substantial and convincing evidence that moderate or worse bilateral PCHL has serious negative consequences for children's development, success in school, and later success in life. In recent years, there has been increasing evidence that mild bilateral, unilateral, and fluctuating conductive losses can also have serious negative consequences for children. The preponderance of the evidence indicates that hearing loss of any severity or type has negative consequences for children's development.

Limitations of the Data

The most difficult aspect of estimating the consequences of hearing loss is controlling for all of the confounding variables that may affect the outcomes between groups of hearing- impaired children and groups of normal-hearing children.

References Cited About "Consequences of Hearing Loss"

Bess, F., & Tharpe, A. (1984, August). Unilateral hearing impairment in children. Journal of Pediatrics, 74(2), 206-216.

Blair, J., Peterson, M., & Viehweg, S. (1985). The effects of mild hearing loss on academic performance among young school age children. Volta Review, 87(2), 87-94.

Culbertson, J., & Gilbert, A. M. (1986). Children with unilateral sensorineural hearing loss: Cognitive, academic, and social development. Ear and Hearing, 7(1), 38-42.

Keller, W. D., & Bundy, R. S. (1980). Effects of unilateral hearing loss upon educational achievement. Child Care Health and Development, 6, 93-100.

Peterson, M. E. (1981). The effects of mild hearing loss on academic performance among school-age children. Master's thesis, Utah State University, Logan.

Schildroth, A.N., & Karchmer, M.A. (1986). Deaf children in America. San Diego: College Hill Press.

Teele, D.W., Klein, J.O., Chase, C., Menyuk, P., Rosner, B.A., and the Greater Boston Otitis media Study Group (1990). Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years. The Journal of Infectious Diseases, 162, 685-694.

Other References Related to "Consequences of Hearing Loss"

Coplan, J., et al. (1982). Validation of an early milestone scale in a high-risk population. Pediatrics, 70, 77-83.

Davis, J. M., Elfenbein, J., Schum, R., & Bentler, R. A. (1986). Effects of mild and moderate hearing impairments on language, educational, and psychosocial behavior of children. Journal of Speech and Hearing Disorders, 51, 53-62.

Greenberg, M. T., & Kusche, C. A. (1989). Cognitive, personal, and social development of deaf children and adolescents. In M. C. Wang, M. C. Reynolds, & H. J. Walberg (Eds.), handbook of Special Education (Vol. 3): Low incidence conditions. New York: Pergaman Press.

Klee, T. M., & Davis-Dansky, E. (1986). A comparison of unilaterally hearing-impaired children and normal-hearing children on a battery of standardized language test. Ear and Hearing, 7, 27-37.

Lyon, D. J., & Lyon, M. E. (1982). Early detection of hearing loss. Canadian Journal of Public Health, 73, 410-415.

Oyler, R. F., Oyler, A. L., & Matkin, N. D. (1988). Unilateral hearing loss: Demographics and educational impact. Language, Speech, and Hearing Services in the Schools, 19, 191-200.

Quigley, S. P. (1978). The effects of early hearing loss on normal language development. In F. N. Martin (Ed.), Pediatric audiology (pp. 35-63). Englewood Cliffs, NJ: Prentice-Hall.

Parving, A. (1992). Intervention and the hearing-impaired child--an evaluation of outcome. International Journal of Pediatric Otorhinolaryngology, 23, 151-159.

Ramkalawan, T. W., & Davis, A. C. (1992). The effects of hearing loss and age of intervention on some language metrics in young hearing-impaired children. British Journal of Audiology, 26, 97-107.

Riko, K., Hyde, M. L., & Alberti, P. W. (1985). Hearing loss in early infancy: incidence, detection and assessment. Laryngoscope, 95, 137-45.

Riko, K., Hyde, M. L., Corgin, H., Fitzhardinge, P. M. (1985). Issues in early identification of hearing loss. Laryngoscope, 95, 373-381.

Benefits of Earlier Identification and Intervention

A key question in deciding whether to recommend universal newborn hearing screening is whether children who are identified earlier and given intervention do better than those who are identified later. For obvious reasons, it is not practical to identify hearing-impaired children early and randomly assign them to receive intervention or not to receive intervention. Thus, there are no prospective clinical trials which can be used to address this question. However, there are a number of retrospective studies in which children have been categorized into groups who were identified early or identified later, matched on relevant variables, and assessed on developmental outcomes and success in school-related areas. There are also a number of studies in which the correlation between age of identification and developmental outcomes have been assessed.

Data from these studies consistently show that children who are identified early and given intervention (including amplification, as well as educational intervention) do better than children who are identified later.

Limitations of Available Evidence

Studies which have addressed this question are generally based on small sample sizes in which a group of early identified children are matched with children who are identified later. In such studies, children with more severe hearing losses are likely to be identified early, and late- identified children are more likely to be included if they have more severe language deficits. Most of the studies do not follow the children into the elementary school years. The nature of the early intervention program provided is often not clearly described, and outcome measures are not as strong as desirable.

References Cited About "Benefits of Early Identification"

Apuzzo, M. L., & Yoshinaga-Itano, C. (1995). Early identification of Infants with Significant Hearing Loss and the Minnesota Child Development Inventory. Seminars in Hearing, 16(2), 124-139.

Moeller, M.P. (1997). Personal communication, moeller@boystown.org.

Watkins, S. (1987). Long term effects of home intervention with hearing-impaired children. American Annals of the Deaf, 132, 267-271.

Watkins, S. (1983). Final Report: 1982-83 work scope of the Early Intervention Research Institute. Logan, Utah: Utah State University.

Yoshinaga-Itano, C., Sedey, A., Apuzzo, M., Carey, A., Day, D., & Coulter, D. (July 1996). The effect of early identification on the development of deaf and hard-of-hearing infants and toddlers. Paper presented at the Joint Committee on Infant Hearing Meeting, Austin, TX.

Other References Related to "Benefits of Earlier Identification"

Clark, T. C. (1979). Language development through home intervention for infant hearing-impaired children. Unpublished doctoral dissertation, University of North Carolina, Chapel Hill. (University Microfilms International No. 80-13, 924).

Levitt, H., McGarr, N. S., & Geffner, D. (1987). Development of language and communication skills in hearing- impaired children. ASHA Monographs Number 26. American Speech-Language-Hearing Association, Rockville, MD.

Markides, A. (1986). Age at fitting of hearing aids and speech intelligibility. British Journal of Audiology, 20, 165-168.

Northern, J. L., & Downs, M. P. (1984). Hearing in children (3rd ed.). Baltimore, MD:

Williams & Wilkins. Strong, C. J., Clark, T. C., & Walden, B. E. (1994). The relationship of hearing-loss severity to demographic, age, treatment, and intervention-effectiveness variables. Ear & Hearing, 15, 126-137.

Strong, C. J., Clark, T. C., Johnson, D., Watkins, S., Barringer, D. G., & Walden, B. E. (1994). SKI*HI home-based programming for children who are deaf or hard of hearing: Recent research findings. Infant-Toddler Intervention, 4(1), 25-36.

Cost Efficiency of Newborn Hearing Screening

A number of cost-related studies have been done about newborn hearing screening. A few are cost-effectiveness studies in which the costs of two alternative screening protocols are computed and compared to the effects of each protocol. Most are cost estimates in which the costs of a particular protocol are computed without trying to compare that protocol to another. A third type of cost study, cost-benefit analysis, in which the outcomes of a screening program are assessed and assigned a monetary value and compared to the costs of the program, has not been done. Although people frequently ask whether newborn hearing screening is cost beneficial, such studies do not exist.

Although there are several published articles about the costs of newborn hearing screening programs, most of these report results of analyses with outdated technology, are based primarily on hypothetical assumptions about costs and time necessary for various procedures, are incomplete economic analyses, or only consider some of the components or activities associated with early hearing detection and intervention. In spite of these deficiencies, those studies do provide some general information about the costs associated with newborn hearing screening. There are no cost studies which have been done well enough to draw conclusions about the cost effectiveness of different protocols or the cost benefit associated with universal newborn hearing screening.

References Related to the Costs of Newborn Hearing Screening

Grosse, S. (September, 1997). The costs and benefits of universal newborn hearing screening. Paper presented to the Joint Committee on Infant Hearing, Alexandria, VA.

Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon, P.R., Sia, C.C.J., & Blackwell, P.M. (1993). Implementing a statewide system of services for infants and toddlers with hearing disabilities. Seminars in Hearing, 14(1), 105-119.

Maxon, A. B., White, K. R., Behrens, T. R., & Vohr, B. R. (1995) Referral rates and cost efficiency in a universal newborn hearing screening program using transient evoked otoacoustic emissions (TEOAE). Journal of the American Academy of Audiology, 6, 271-277.

Stevens, J.C., Hall, D.M.B., Davis, A., Davies, C.M., & Dixon, S. (1997). The costs of early hearing screening in England and Wales. Unpublished manuscript, Royal Hallamshire Hospital, Sheffield, England.

Weirather, Y., Korth, N., White, K. R., Downs, D., Woods-Kershner, N. (1997). Cost analysis of TEOAE-based universal newborn hearing screening. Journal of Communication Disorders, 447-493.

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