Early hearing detection and intervention

Unidentified children who are deaf or hard of hearing may have delayed speech and language development that can interfere with daily functioning. Unidentified hearing loss also places a cost burden on families and the healthcare system, with the lifetime educational cost of hearing loss estimated in 2007 at $115,600 per child.¹

As such, early screening for hearing loss is now mandated by 41 states, the District of Columbia, and Guam, all of which have passed statutes or regulatory guidance on ways to identify infants with hearing loss.¹ In addition, The US Preventive Services Task Force, the Recommended Uniform Screening Panel (US Department of Health and Human Services Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children), and the Joint Committee on Infant Hearing (JCIH) have recommended hearing loss screening in all newborns.

More: Hearing loss and the pediatrician

To help ensure that infants receive early screening, Early Hearing Detection and Intervention (EHDI) programs are now established in all jurisdictions within the United States. Based on evidence-based public health approaches, EHDI programs focus on both early screening of newborns as well as continual follow-up through tracking and surveillance with the coordinated help from public health agencies, clinical service providers, and families.¹

The importance of follow-up is highlighted by the prevalence of hearing loss throughout childhood because of, for example, late onset hearing loss or acquired hearing loss. In light of this, the American Academy of Pediatrics (AAP), along with the JCIH, recommends that newborns and children be monitored for hearing loss and additional hearing screening during early childhood within a medical home.¹ In 2002, the AAP published a policy statement to help clarify the concept and operational definition of the medical home.²

In 2006, with support from the AAP, the National Center for Hearing Assessment and Management (NCHAM), and the Center for Childhood Deafness at Boys Town National Research Hospital in Nebraska conducted a national survey of primary care physicians to examine their knowledge, skills, and practices in participating in an EHDI program within a medical home.³ Results of the survey showed important gaps in knowledge among the physicians surveyed, including knowing when and where to refer infants for follow-up procedures; implementing surveillance for late-onset hearing loss; understanding the role of genetics in hearing loss; and familiarity with cochlear implants and criteria for candidacy.

In 2012-2013, a second survey was undertaken to gauge the progress made in improving physician understanding and skill since the 2006 survey.⁴ Rachel St. John, MD, director of the Family-Focused Center for Deaf and Hard of Hearing Children, Children’s Medical Center/University of Texas Southwestern Medical Center, Dallas, presented the latest results of this survey at the recent AAP National Conference and Exhibition in Washington, DC.

This article provides a summary of St. John’s presentation, highlighting the gaps in knowledge that persist despite ongoing programs and efforts to ensure that hearing loss is correctly identified and treated in all infants and children. Key components of an effective EHDI program in the medical home setting will be described and resources provided to facilitate a clear and, hopefully, easy way for primary care physicians, pediatricians, and others to implement hearing loss screening within a continuum of care.

Gaps in screening for hearing loss in children

In the 2012-2013 updated survey, primary care providers across 24 states were surveyed about their understanding and attitudes regarding newborn hearing screening and follow-up.⁴ The survey included questions regarding knowledge of the current standards of practice recommended by the AAP known as the EHDI “1-3-6” timeline (Table 1) and the role of the medical home in hearing loss screening (Table 2).

Of the 2172 (11.5%) responders, 53.8% were pediatricians followed by 27.4% family practice physicians, 7.2% otolaryngologists, 3.1% neonatologists, and 0.6% obstetrician/gynecologists. Most responders practice in a metro area (56.5%) and were in private practice or community clinic (81.8%). Table 4 lists key gaps in knowledge that remain since the 2006 survey.

The survey also found that 29% of providers reported performing newborn hearing screening in their office, although few of those (only about 23%) used objective screening methods such as otoacoustic emissions.

NEXT: Guidelines for rescreening in the medical home

Importantly, most of these 29% providers who do rescreening in their office rarely or never report results to their state EHDI coordinator, which goes against recommended policy, according to St. John.

These results highlight one of the key gaps found in the study, namely, a lack of knowledge of methods recommended for follow-up of in-office newborn hearing screening. Table 5 provides a detailed list of recommendations for providers who perform in-office newborn hearing screening.⁵ Note, although it is not prohibited to conduct the initial hearing screening in the office setting, the AAP always encourages initial screening in the hospital.

Next: Otoacoustic emissions hearing screening update and review

Resources to better adhere to EHDI

A number of resources are easily available to pediatricians and other healthcare providers to better adhere to EHDI:

·      Familiarity with the “1-3-6” model: St. John highlighted this resource as the most critical for providers to understand and implement (Table 2). The survey showed that physicians are not uniformly familiar with these recommendations, she said, and that familiarity with the recommendations will help providers address a delay in the development of hearing loss; understand the etiology of the hearing loss and need for further follow-up assistance by referral to subspecialists; and awareness of the risk of late-onset hearing loss.

·      AAP EHDI Tools: St. John encouraged providers to take advantage of tools on the AAP EHDI website to help in clinical decision making. See bit.ly/hearing-screening-EHDI-tools. Table 5 lists several tools for pediatric primary care practice physicians.

·      Connect with state EHDI Coordinators: St. John emphasized that providers who do newborn screening need to report results to the state. See a list of state EHDI coordinators at www.infanthearing.org/status/cnhs.php.

St. John ended her talk by encouraging pediatricians and physicians to spread the word about EHDI to residents (eg, through such venues as noon lectures, grand rounds, specialty rotations) and other staff physicians (eg, through grand rounds, state and national conferences).

REFERENCES

1. Gaffney M, Eichwald J, Gaffney C, Alam S; Centers for Disease Control and Prevention (CDC). Early hearing detection and intervention among infants-hearing screening and follow-up survey, United States, 2005-2006 and 2009-2010. MMWR Surveill Summ. 2014;63 suppl 2: 20-26.

2. Medical Home Initiatives for Children With Special Needs Project Advisory Committee; American Academy of Pediatrics. The medical home. Pediatrics. 2002;110(1 pt 1)):184-186. Available at: http://pediatrics.aappublications.org/content/pediatrics/110/1/184.full.pdf. Accessed December 16, 2015.

3. Moeller MP, White KR, Shisler L. Primary care physicians’ knowledge, attitudes, and practices related to newborn hearing screening. Pediatrics. 2006;118(4):1357-1370. Available at: http://www.infanthearing.org/ncham/publications/Moeller%202006%20Pediatrics.pdf. Accessed December 16, 2015.

4. White K, Behl D, Levine J, et al. Meeting the needs of physicians in support of EHDI. National Center for Hearing Assessment and Management, Utah State University, NCHAM Webinar Series. Available at: http://www.infanthearing.org/resources_home/events/physicians-in-support-of-ehdi.html. Presented February 22, 2015. Accessed December 16. 2015.

5. American Academy of Pediatrics Task Force on Improving Newborn Hearing Screening, Diagnosis, and Intervention. Guidelines for rescreening in the medical home following a “do not pass’ newborn hearing screening. April 2014. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/PEHDIC/Documents/Rescreening_Guidelines.PDF. Accessed December 16, 2015.

Ms Nierengarten, a medical writer in Minneapolis, Minnesota, has over 25 years of medical writing experience, authoring articles for a number of online and print publications, including various Lancet supplements, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.