Current Status of Hearing Screening in the Neonatal Intensive Care Unit

Shana Jacobs, B.S.

Jackson Roush, Ph.D.

Division of Speech and Hearing Sciences

University of North Carolina School of Medicine

Chapel Hill, NC

Faculty Disclosure

In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation.

This presentation will (not) include discussion of pharmaceuticals or devices that have not been approved by the FDA or if you will be discussing unapproved or “off-label” uses of pharmaceuticals or devices.

Acknowledgements

Karl White, NCHAM State EHDI Coordinators

Background Incidence of SNHL – Well-babies: 1-2:1000– NICU 10-20:1000

Because of the high incidence of permanent hearing impairment in this population, physiologic screening via ABR has occurred in the NICU since the 1980s

More recently OAEs are also used in the NICU – alone or in a combined ABR/OAE protocol

A growing concern for NICU Infants…

Auditory Neuropathy – Dysynchrony– Abnormal neural function at the level of the

VIIIth nerve/brainstem in the presence of normal outer hair cell function

– Incidence is higher than once thought• 25% of NICU infants according to one recent

study (Berg et al, 2005)

– OAE screening alone will not identify AN/AD

Other Challenges in the NICU

Challenges– Ambient noise levels– Transfer before

screening– Difficulties with

tracking, follow-up– Lack of accurate,

efficient reporting procedures

Nurseries in US Hospitals

Level 1 (basic care of well-babies) Level 2 (moderate risk of serious

complications): N=120 Level 3 (specialty and subspecialty care

including life support): N=760

10-15% of newborn population receive care in Level 2 or 3 nursery (Bhatt, 2001; AAP, 2004)

Purpose of this study

To determine the technologies and protocols used for NICU hearing screening in the U.S.

To identify challenges associated with NICU hearing screening

To obtain an estimate of how many infants are being identified with AN/AD

Methodology Survey Instrument

– Electronically distributed– 13 Questions

• Number of Well-Baby and NICU Infants screened• NICU Screening Methods and Protocols• Number of Babies Identified over the past year with AN/AD

– Anonymous once submitted Distribution

– Emailed to State EHDI Coordinators, January, 2006• Used EHDI listserv to contact 51 coordinators (1 per state)

– Two reminder notices sent Returns as of January 30th

– 23/51 (45%)

Please estimate the % of NICU infants discharged prior to screening over the past year

0-2% discharged before screening: 15 (66%) 3-5% discharged before screening: 1 (4%) 6-10% discharged before screening: 3 (13%) >10% discharged before screening: 1 (4%) Unable to estimate: 3 (13%)

If an infant is not screened in the NICU prior to discharge, what is most likely to

happen?

Primary care physician advised of need for initial screen

Family advised of need for initial screen Referral for audiologic assessment

For the first NICU hearing screening, what

technology is used?

OAE: 2 (9%) ABR: 7 (30%) OAE or ABR: 14 (61%)

In your state, who usually conducts the

first NICU hearing screening?

Nurses Hospital Technicians Audiologists

If re-screening is provided in the NICU for infants who fail the first screen, what technology/protocol is most often used?

• 26% - AABR followed by AABR (6/23)• 9% - OAE followed by ABR (2/23)• 9% - OAE followed by OAE (2/23) • 47% - Could be any of the above (11/23)• 9% - Other 2/23

Please indicate the person who is most likely to perform NICU hearing re-screenings in your state?

Nurses Audiologists Hospital Technicians

How many re-screenings are typically performed prior to a referral for

comprehensive audiology evaluation? 57% - 1 re-screening (13/23) 30% - 2 re-screenings (7/23) 0% - 3 re-screenings (0) 0% - More than 3 (0) 13% - Variability in re-screens (3/23)

What are the most significant obstacles or frustrations associated with infant hearing

screening in the NICU in your state? Narrow window of time from when infant is available for

screening to time of transfer; discharge before screening completed

Difficulty tracking children who are transferred from one facility to another (also transfers between nurseries within same hospital)

Hard to ensure follow-up of all infants who fails screening

Failure of some hospitals to report screening results; lack of coordination, uniformity of reporting

Obstacles and frustration (cont’d)

Medical staff may not appreciate the importance of hearing screening; need to give priority to medical concerns

Lack of uniformity in screening protocols Lack of qualified screening personnel

on weekends Excessive ambient noise levels Lack of audiologist availability for follow-

up

Comparison of Eight States

A B C D E F G H

Total

Screened

86,300 69,000 27,000 124,800 50,000 43,000 26,000 14,000

275 160 26 77 100 60 26 12

3.1 2.3 1 1 2 1.4 1 0.9

8 5 6 4 5 3 2 0

3% 3% 23% 5% 5% 5% 8% 0%

Total SNHL

(# per 1000)

AN-AD

Total SNHL Identified (one or both ears)

N=8 States

Total Screened: 440,100

Permanent HL 1.6/1000 % with AN/AD 5%

Conclusions NICU screening protocols vary widely even within some states Some NICUs are using technologies/protocols that will not

identify AN/AD Prevalence estimates of permanent HL consistent with other

reports Infants with AN/AD approximately 5% of all infants identified

with SNHL (unable to compare NICU vs. well-baby screening) Many state EHDI coordinators report frustration with narrow

window of opportunity for screening before discharge

Future Needs

Improved statewide systems for tracking and follow-up

Greater uniformity in statewide screening protocols Further study and more detailed analysis needed to

get an accurate estimate of AN/AD prevalence Follow-up studies needed to determine the natural

history of AN/AD Program managers should be aware of the

advantages of ABR for hearing screening in the NICU

Any questions?