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Author: admin | 06.02.2016 | Category: Ear Drops For Tinnitus

If a clear response to sound is not obtained following two hearing screens, further hearing testing is recommended. Because hearing loss may not be obvious in the first few weeks of life, screening is the first step to identifying and diagnosing hearing loss in babies. Early identification of a hearing loss means a child can begin early intervention and have access to language as early as possible.
The Victorian Infant Hearing Screening Program (VIHSP) screens the hearing of all Victorian newborn babies in their first few weeks of life.
See the Related Links on the left of the screen for more on newborn hearing screening in Victoria. Warning: This website and the information it contains is not intended as a substitute for professional consultation with a qualified practitioner. Auditory Brainstem Response (ABR) audiometry is a neurological test of auditory brainstem function in response to auditory (click) stimuli. More specifically, the test measures evoked potentials generated by a brief click or tone burst (transmitted from an acoustic transducer in the form of an insert earphone or headphone). Although the ABR provides information regarding auditory function and hearing sensitivity, it is not a substitute for a formal hearing evaluation, and results should be used in conjunction with behavioral audiometry whenever possible. Early Hearing Detection & Intervention - Pediatric Audiology Links to Services (EHDI-PALS) is a web-based link to information, resources, and services for children with hearing loss. Idaho Sound Beginnings is a local state run organization (through the Department of Health & Welfare). Idaho's Infant Toddler Program (ITP) coordinates a system of early intervention services to assist Idaho children birth to three years of age who have a developmental delay or who have conditions (such as prematurity, Down Syndrome, hearing loss) that may result in a developmental delay.
The ITP links children with services that promote their physical, mental and emotional development and supports the needs of their families. Children referred to the Infant Toddler Program are assessed to see if they meet program eligibility.
We offer many different hearing tests that will help us diagnose any hearing issues you may have. As shown in slide #17, there are at least five different methods that are frequently used for early identification of hearing loss. We do, however, have other types of information that provide reasonably good evidence about the accuracy of each of these screening techniques.
Until just recently, the most frequent method used in the United States to identify hearing loss in very young children was based on the high-risk indicators recommended by the Joint Committee on Infant Hearing (JCIH). Although such high-risk-based screening programs were the most frequent method used to identify hearing loss in very young children during the late 70's and early 80's, most hospitals are no longer using this approach for two reasons. Although it is not used very often in the United States, another alternative for early identification of hearing loss is to do behavioral assessments of children when they are 7-9 months old. Although often advocated as an alternative for this country, the data on the success of those home-based behavioral screening programs, often called the Home Visitor Distraction Test, is very disappointing. A fourth newborn hearing screening approach is the use of otoacoustic emissions, either transient evoked or distortion product otoacoustic emissions.
The fifth and final technique for newborn hearing screening considered here is the use of automated ABR. Without a screening program, a baby with a hearing loss is often not diagnosed until at least one year of age, sometimes up to three years of age. It also means that families can get appropriate advice and support right from the beginning, giving babies with a hearing loss the best start in life.
It is very unlikely that the baby currently has a hearing loss that would affect early speech or language development. First described by Jewett and Williston in 1971, ABR audiometry is the most common application of auditory evoked responses.
The elicited waveform response is measured by surface electrodes typically placed on the forehead and ear lobes. It is very important to know if an infant has any hearing loss, because early detection and treatment can mean the difference between normal and delayed development.


If eligible, an Individualized Family Service Plan (IFSP) is written that outlines services for the child and their family. What do we know about the accuracy of those methods as a tool for universal newborn hearing screening? For example, Hyde, Riko, and Malizia evaluated 713 high-risk babies who were screened with auditory brainstem response (ABR) prior to hospital discharge, and then were assessed by uninformed diagnosticians when they were an average of almost four years old. About 10% of all children born will exhibit one or more of these indicators, including family history of congenital hearing loss, very low birth weight, congenital malformations of the head and neck, hyperbilirubinemia, etc. First, as shown in slide #21, even though children who exhibit one of the risk factors are at higher risk of having a congenital hearing loss, only about half of all children with congenital hearing loss will exhibit one or more of these indicators. Such programs are used extensively in Europe and have sometimes been advocated for implementation in the U.S. For example, Peter Watkin and his colleagues (slide #24) did a retrospective analysis of over 55,000 children in one geographic district in England. Of the 39 children with severe profound bilateral losses, only 44% were identified from the Home Visitor Distraction Test.
Numerous small-scale studies, such as those summarized in slides #26 and #27, have demonstrated that transient evoked otoacoustic emissions (TEOAE) have a very high rate of agreement with auditory brainstem response. Although several other units are now available, the data in these slides were collected the most widely used AABR equipment produced by Natus Medical. Sponsored by the National Institutes of Health and being coordinated by the University of Washington, this is a multi- centered study which is evaluating the effectiveness of newborn hearing screening using conventional ABR, transient evoked otoacoustic emissions, and distortion product otoacoustic emissions. The screen is performed by trained hearing screeners using valid and reliable technology and is most often done at the baby’s bedside in the days after birth.
It records the response to clicking sounds played through an earpiece placed inside the baby’s ear. The screen is performed by trained hearing screeners using valid and reliable technology and is usually carried out at the baby's bedside in hospital while they are asleep. The amplitude (microvoltage) of the signal is averaged and charted against the time (millisecond).
Even though there are many articles in the literature which use the terms sensitivity and specificity with regard to each of these techniques, there are no studies of universal newborn hearing screening where there are sufficiently large sample sizes and sufficiently good follow up to definitively establish the sensitivity and specificity of any of those techniques. The behaviorally-confirmed hearing status was compared to the results of the hearing screening test.
Since 1974, the JCIH has recommended that infants who exhibit one of these risk indicators be screened for hearing loss using auditory brainstem response. Thus, even if a high-risk-based screening program were to work perfectly, about half of all children with PCHL would be missed. As they operate in Europe, the screening is done by home visitors who are already making routine visits as a part of the well-child health care system. For each of the 171 two- to fifteen-year-old children who had a hearing loss, Watkin and his colleagues determined whether the child was first identified through a home visitor or school-age screening program, a parent, or someone else, such as a doctor or teacher. For children with mild moderate bilateral losses and children with unilateral losses, only 25% and less than 10% were identified with the Home Visitor Distraction Test, respectively. The first large-scale evaluation of otoacoustic emissions in a universal newborn hearing screening program was the Rhode Island Hearing Assessment Program (RIHAP) led by Betty Vohr between 1990 and 1994. As can be seen in slides #30 and #31, four different studies in which results of the Algo1 were compared to conventional ABR show high levels of sensitivity and specificity for the two techniques.
Over 7,000 infants (4,500 NICU babies and 2,600 normal-care nursery babies) were screened prior to discharge using all three of the techniques in random order.
These children are at a much higher risk of language, social and academic delays and impairments later in life. The waveform peaks are labeled (generally 5 peaks) and these waveforms normally occur within a 10-millisecond time period after the stimulus is presented. As summarized in slide #18, most studies which refer to sensitivity and specificity have used very small sample sizes, have focused only on high-risk babies, or have not followed all of the babies who passed the screening test to determine their true hearing status. For this high-risk population, the sensitivity and specificity was 98% and 96% when the ABR screening threshold was set at 40 dB HL and 100% and 91% when the ABR screening threshold level was set at 30 dB HL (see slide #19).


The rationale for this approach was that by focusing on a subset of the population which was at higher risk, hospitals would be able to afford to use auditory brainstem response, whereas most people did not believe hospitals could afford to use ABR to screen all infants.
Secondly, high-risk-based screening programs found that it was very difficult to get parents to come back for the necessary diagnostic evaluations. More than a third of the children were missed by both the nine-month and the school-age screening program. So even with home visitors who were specifically trained to do that type of behavioral assessment in a home setting and were given a great deal of support and monitoring to do it well, most of the children are being missed. As shown in slide #28, of the first cohort of 1,850 infants from well-baby and special-care nurseries, 11 were identified with sensorineural hearing loss. A frequent problem is that studies that have allegedly examined the sensitivity and specificity of a particular screening technique have done that by comparing one screening technique to another screening technique. For example, in 1987, Mahoney and Eichwald reported the results of the Utah- based high-risk screening program over a seven-year period (1978 to 1984). If such home visitors are unable to do behavioral screening at nine months of age, it is very unlikely that it can happen as a part of the routine in a busy doctor's office.
Because ABR screening was also done with each of these babies, the study showed that there was very high agreement between TEOAE screening and auditory brainstem response.
Even though the results do not provide information on the sensitivity for determining hearing loss since behavioral evaluations of all the children were not done, given what we know about the accuracy of conventional ABR, these data provide convincing evidence about the accuracy of automated ABR. All of the behavioral assessments were completed in October 1997, and final results from the study are expected to be available by April 1998. In other words, instead of comparing otoacoustic emissions in a screening program to behaviorally confirmed hearing loss, a study might compare otoacoustic emissions to conventional ABR. From a UNHS program at Saint Barnabus Medical Center in New Jersey, over a three-year period with more than 5,000 babies screened each year, an average of 3.3 infants per thousand were identified with a congenital hearing loss and referred into intervention programs. During that time, the JCIH indicators were incorporated into the legally required birth certificate, so they were reported for every child. Furthermore, four of the babies would have been missed if screening had only been done with high-risk infants or with babies in the NICU.
As summarized in slide #33, these data will provide us with more definitive information than we have had about the true sensitivity and specificity of ABR and evoked otoacoustic emissions.
Thus, data are not available to definitively establish the sensitivity and specificity of any of the techniques. Sedation was not used, the referral rate for further diagnostic testing at the time of hospital discharge was 3.1%, and most screening was done by audiologists within 24 hours of the baby's birth. It's important to note, however, that the screening methods used in this study are now five years old, so even though the study will provide important information about the underlying mechanism, the equipment used with each of these techniques is quite different today than at the time data were collected for this study. As summarized in slides #22 and #23, only about half the parents whose children had a high-risk indicator ever made an appointment for a diagnostic evaluation, and only about half of those parents completed the evaluation. If we assume that all of the original passes had normal hearing, then the sensitivity in this study was 100%, and the specificity was 95% (slide #29). Parenthetically, it is important to note that newborn hearing screening equipment continues to evolve quite rapidly. Whether ABR or EOAE is used, the equipment is becoming faster and more accurate with each passing year.
The last five years have seen dramatic changes in both AABR and EOAE equipment, and it is safe to predict that similar advances will happen during the next five years. Even though complete follow-up data is not available for any of the programs, it is clear, based on the very small number of children identified, that such programs have very low sensitivity; and given the relatively high number of children exhibiting risk factors, such programs also have very low specificity.



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