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Nelson HD, Bougatsos C, Nygren P. Universal Newborn Hearing Screening: Systematic Review to Update the 2001 U.S. Preventive Services Task Force Recommendation [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Jul. (Evidence Syntheses, No. 62.)

Cover of Universal Newborn Hearing Screening: Systematic Review to Update the 2001 U.S. Preventive Services Task Force Recommendation

Universal Newborn Hearing Screening: Systematic Review to Update the 2001 U.S. Preventive Services Task Force Recommendation [Internet].

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4Discussion

Summary of Review Findings

Evidence addressing the 3 key questions in this review is summarized in Table 6.

Table 6. Summary of Evidence.

Table 6

Summary of Evidence.

A good-quality community-based cohort study of both high and average risk children with PCHL indicated that those who had early versus late confirmation and those who had UNHS versus none had better language scores at age 8 years.33 In this study, 67% of children undergoing UNHS had confirmation of impairment by age 9 months compared to 27% of those not undergoing UNHS. In contrast, a fair-quality community-based cohort study of children with hearing impairment who did not undergo UNHS indicated no relationship between age at diagnosis and language, speech, and reading measures at age 7 to 8 years.35 Few children were diagnosed by age 6 months in this cohort.

These studies provide stronger evidence for the long-term benefits of UNHS than previous studies.3, 4 Although previous studies were consistent in reporting improved outcomes for children diagnosed early versus late, all had important methodologic limitations.3, 4 The use of large community-based birth cohorts providing prospectively collected data, blinded assessments of validated outcome measures, and adjustment for confounders improves the internal validity and generalizabilty of the cohort studies.33, 35

A good-quality nonrandomized trial of a large birth cohort of both high and average risk newborns indicates that infants identified with PCHL through UNHS have significantly earlier referral, diagnosis, and treatment than those identified in other ways.17, 18 These findings are corroborated by multiple descriptive studies of ages of referral, diagnosis, and treatment including reports of UNHS program follow-up measures,10, 20, 46 historical comparisons,16, 66, 67 and comparisons between screened and nonscreened children.47, 48

The most impressive follow-up measures come from the most recently published studies, potentially reflecting refinements in screening techniques, system and process improvements, incorporation of UNHS as a routine practice, and increasing commitment to implementing successful programs in response to practice and policy changes. In the first phase of a national UNHS program in the U.K., well infants had a median age of first follow-up at age 4 weeks, diagnosis at 10 weeks, enrollment in education services at 10 weeks, and hearing aid fitting at 14 weeks.19 Data from populations not undergoing UNHS indicate age of diagnosis typically between 15 to 24 months with treatment following several months later.16, 47, 48, 66, 67 In the absence of UNHS, children with more severe hearing impairment are generally diagnosed and treated earlier than children with less severe impairment.47, 66, 68

Limited follow-up data exist specifically for high risk infants who could be identified by targeted screening. Approximately half of infants with PCHL identified by UNHS have risk factors for hearing impairment.10, 1720 Patients of NICUs undergoing UNHS had slightly later ages of confirmation and treatment compared to well infants in the U.K. study,19 potentially relating to the complexity of co-existing health problems.

Since the previous review, efforts have been made to study both the short and long-term effects of UNHS on a variety of outcomes including negative emotions, parental worry and anxiety, and attitudes toward infants. Recent cohort studies indicate no significant differences in measures of concern, anxiety, and parental attitudes for families with newborns who pass versus those who do not pass the newborn screening test. No studies addressed the adverse effects of a child with PCHL being screened or diagnosed late.

Other studies indicate that usual parental reactions to an initial non-pass on the screening test include worry, questioning, and distress. Negative emotions resolve for most parents when a diagnostic test is provided with a normal result. Although some parents show residual worry months after a normal test, most concern improves over time. Parents of children with confirmed hearing loss show greater levels of frustration and confusion than those parents of normal hearing children. These parents may need increased support and comfort during the screening process and at the time of diagnosis. Information on the screening test, timely access to appropriate follow-up testing and intervention, and integrated and individualized family services and support within the healthcare system have been linked to a positive UNHS experience for parents.

Hearing screening programs are generally well accepted and tolerated by the parents of newborns and have demonstrated cost-effectiveness.69 With legislation for UNHS being enacted in most U.S. states over recent years, screening practices and procedures have become routine in the postpartum hospital setting. Technicians and parents have become more comfortable with the routine practice of UNHS and show less anxiety about such procedures then when they were first introduced (Personal communication [written] October 6, 2003).24

Less has been published about the adverse effects of early interventions. To fully address this question, studies would compare adverse outcomes between children initiating treatment at age 6 months as current practice standards advise versus those initiating treatment later. Currently available studies comparing early versus late interventions focus on benefits. Now that practice standards exist, it may be difficult to conduct adequate comparison studies of early versus late initiation of treatment to evaluate both benefits and adverse effects.

A major limitation of the application of the key studies in this update in the U.S. is that they were conducted outside the U.S. Although the method of screening and the inpatient maternity experience are likely similar, the processes of referral, follow-up, and treatment would be expected to differ. Differences can be attributed to many factors such as dissimilar health care systems, practice patterns, coverage, access, educational systems, and populations. Currently, there is no standard method in the U.S. to track children through these processes to ultimately obtain language outcomes on a birth cohort as done in the U.K. study,33 although approaches to do so are being piloted. Factors influencing follow-up and treatment in the U.S. would need to be considered as well as exposure to UNHS when determining long-term outcomes.

Future Research

More studies of long-term functional outcomes related to UNHS are needed to support the findings of the U.K. study.33 Other functional outcomes, such as school performance, social interactions, and quality of life, may be more relevant to children and their families and future research should include these also. Studies conducted among different populations with dissimilar health systems would help determine the generalizability of the U.K. results. Research from UNHS programs can be utilized to identify best practices and guide process and quality improvement efforts. Standardization of nomenclature, methods, and measures would allow collaborative research nationally and internationally.

Conclusions

Universal newborn hearing screening is recommended as a practice standard by professional organizations and is mandated in 39 U.S. states.21 Screening techniques have high performance characteristics and can be performed on a sleeping newborn in less than 5 minutes. False positive rates have been reduced by using 2-step screening and repeat screening for newborns failing to pass the first test. Screening has been implemented as routine newborn care in many U.S. hospitals and rates of refusals are low. The feasibility of screening in the context of community practice has been demonstrated for average risk newborns with short lengths of stay as well as high risk patients in NICUs. Methods of referral, diagnosis, and treatment are more variable than screening, and are dependent on system processes, insurance coverage, community practice, and social and economic barriers, among other influences.

Results of this review indicate that infants identified with PCHL through UNHS have significantly earlier referral, diagnosis, and treatment than those identified in other ways. Although the clinical community has acknowledged the significance of early treatment for many years, evidence of its effect on long-term functional outcomes has been limited. New data on improved language outcomes at school age strengthen the case for UNHS, but are also dependent on effective methods of referral, follow-up, and treatment. As these needs are being addressed with ongoing projects, further research will be required to demonstrate effectiveness for the entire process that UNHS initiates.

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