|Year : 2015 | Volume
| Issue : 2 | Page : 54-58
Results of the first universal newborn hearing screening in Algeria
Farid Boudjenah MD , Mokhtar Hasbellaoui, Omar Zemirli
Department of ENT, Bejaia University Hospital, Bejaia, Algeria
|Date of Submission||02-Feb-2015|
|Date of Acceptance||02-Nov-2015|
|Date of Web Publication||10-Dec-2015|
ENT Department of Bejaia University Hospital, Bejaia, Algeria, Service ORL de l'Hopital Franz Fanon de Bejaia, Bejaia, 06000
Source of Support: None, Conflict of Interest: None
Hearing loss is the most common congenital pathology at birth. Its prevalence increases during the infant period, especially in children at risk. The application of hearing screening in three stages with follow-up of children at risk of developing hearing loss allows to optimize the screening.
The aim of this study was to evaluate the prevalence of hearing loss in the neonatal population and identify newborns at risk and to investigate the best way to support infants with such disability from screening to rehabilitation.
Materials and methods
This prospective study was conducted over a period of 22 months from June 2011 to March 2013, using a systematic screening for deafness in a high-birth-level maternity unit.
Over a period of 22 months, 17 912 live newborn were born in the maternity ward. The application of screening for deafness at birth allowed us to screen 15 382 newborns, with a coverage rate of 85.9%. We chose a three-stage screening protocol. In the first stage, 15 382 newborns were screened by means of analysis of distortion product of otoacoustic emissions (DPOAE). The screening was negative (presence of DPOAE and absence of hearing loss) in 13 467 newborns, and it was positive (absence of DPOAE and a possibility of hearing loss) for 1915 newborns who were addressed to the second stage of the screening protocol for the analysis of DPOAE again after 1 month of birth. In this second stage of screening, 1516 infants were screened in the ENT Department and 399 infants were lost to follow-up. After the second stage of the screening, 76 infants were addressed to the third stage of the screening protocol, which is also called stage of diagnosis. In this last step, 14 children were lost to follow-up and 62 infants were tested for hearing threshold using analysis of auditory brainstem response. Finally, after verification of the results obtained in the third stage using behavioral audiometry and impedance, 49 children showed hearing loss with a hearing threshold greater than 30 dB. The prevalence of neonatal hearing loss in the maternity unit was 3.2%. There were 27 male and 22 female patients, of whom 29 had bilateral hearing loss and 20 children had unilateral hearing loss. In contrast, the study of the risk factors of hearing loss allowed us to identify those who are present among the detected newborns and to calculate the prevalence of hearing loss among newborns admitted in the neonatal ICU, which was 2.14%. The risk factors most associated with deafness are infections with cytomegalovirus and rubella, damage to the nervous system and craniofacial malformations. The rehabilitation of hearing is based on speech rehabilitation and the use a hearing aid, either conventional prosthesis or cochlear implant.
Newborn hearing screening using a three-stage protocol is possible. It allows to detect hearing loss earlier to initiate early hearing and language rehabilitation, the only way to guarantee alignment of children born with hearing impairment or with contracted hearing loss during the neonatal period with their peers with normal hearing.
Keywords: auditory brainstem response, hearing loss, otoacoustic emissions, rehabilitation, risk factors, screening
|How to cite this article:|
Boudjenah F, Hasbellaoui M, Zemirli O. Results of the first universal newborn hearing screening in Algeria. Adv Arab Acad Audio-Vestibul J 2015;2:54-8
|How to cite this URL:|
Boudjenah F, Hasbellaoui M, Zemirli O. Results of the first universal newborn hearing screening in Algeria. Adv Arab Acad Audio-Vestibul J [serial online] 2015 [cited 2019 May 22];2:54-8. Available from: http://www.aaj.eg.net/text.asp?2015/2/2/54/171521
| Introduction|| |
Neonatal hearing loss is defined as a condition of the neonatal period, characterized by partial or total hearing impairment. It can be unilateral or bilateral. It is the result of a permanent impairment of bone conduction, or absence of the perception of sound, originating from the cochlea or the retrocochlear auditory pathway. This neonatal hearing loss also includes auditory neuropathy and early neonatal infections of the auditory system  . Hearing loss is the most common anomaly at birth , . It is a silent disease characterized by its clinical latency because it is hardly detectable with clinical procedures. Although severe and profound hearing loss can be diagnosed before the age of 30 months, mild and moderate hearing loss are often diagnosed later after the onset of disorder of language articulation or underachievement at school. Usually, it is the parents who first notice this with their children when they frequently respond incorrectly or fail to respond altogether to speeches and sounds. This normally leads to the children being taken to their paediatrician for consultation. This initial consultation of the infantoften occurtoo late whenhis hearing is slight [4-7] . Language difficulties caused by late diagnosis of hearing loss are very difficult to correct after their emergence [8-12]. Hearing screening programmes are applied in many countries worldwide [13-18] , 'thanks', notably, to technological advances on otoacoustic emissions and auditory brainstem response recording [2,19-21]. The aetiologies of neonatal hearing loss are diverse. It may be an anatomical anomaly, biochemical abnormality impeding the transmission of impulses or sound in the auditory pathway, a genetic abnormality, or due to environmental factors , . However, despite diagnosis of the hearing loss aetiology, the treatment is more often applied to the symptom (hearing loss) and its consequences than to aetiologies, leaving the aetiological treatment to prevention. Treatment of neonatal hearing loss is based on three axes , : first, improve the hearing ability of the child by means of primary preventive measures for hearing loss and propose a hearing aid; second, prevent or reduce language disorders; and third, provide the family with ongoing support.
The aim of this study was to evaluate the prevalence of hearing loss in the neonatal population and identify newborns (NB) at risk and to investigate the best way to support infants with such disability from screening to rehabilitation in Algeria.
| Materials and Methods|| |
We conducted a prospective observational study over a period of 34 months from June 2011 to March 2014, using a universal NB hearing screening in a high-birth-level maternity unit. The screening protocol consisted of three phases. The first stage comprised the search for the distortion product of otoacoustic emissions (DPOAE) before the NB were discharged from hospital. The NB who passed the test were discharged, and those who had a positive screening were invited to return after a month for the second phase of testing in the ENT Department for DPOAE.
At this stage, infants with a negative test result were released, and those with a positive screening were referred to the third phase of testing. The third phase of testing, which was conducted in the ENT Department, included a search of auditory brain stem response (ABR) and study of the risk factors of hearing loss described by the Joint Committee on Infant Hearing in 1994 and updated in 2007  . Infants with a hearing that is inferior to 30 dB with risk factors of hearing loss were released from the screening programme, and those presenting risk factors were continued to be monitored with aetiologic research. Infants with an auditory threshold level greater than or equal to 30 dB continued the programme of auditory rehabilitation and aetiological research for a minimum of 12 months. The three phases of the protocol of screening were performed by the ENT medical staff only.
| Results|| |
Over a period of 22 months, 17 912 live NB were colligated in the maternity ward. Only 15 382 NB received hearing screening before being discharged from the hospital. An overall 85.9% of the NB were covered by this research.
In the first phase, 15 382 NB were tested using the analysis of the DPOAE. The screening was negative for 13 467 NB (presence of DPOAE and absence of hearing loss). However, it was positive for 1915 NB (absence of the DPOAE and a possibility of hearing loss). These 1915 NB were invited to attend the second phase of the screening protocol that uses the DPOAE analysis after 1 month of birth. During this first phase of the screening, 794 NB were tested in the neonate intensive care unit (NICU) and the remainder14 588 NB in a normal maternity ward.
During the second phase of the screening, 1516 NB attended the ENT Department. Of them, we noted that 399 NB referred to us did not return to be reviewed. Following the second phase of the screening, 76 NB were invited to attend the third phase of the protocol of screening and diagnosis. In this third phase, 14 children did not respond to our request to return and were lost to follow-up and 62 children passed the test for the threshold of hearing using analysis of brainstem evoked potentials.
Finally, after verification of the results obtained in the third phase of testing protocol using behavioural audiometry and impedancemetry, 49 children showed a hearing loss with a hearing threshold greater than 30 dB. The prevalence of neonatal hearing loss was 3.2% at the ENT Department of Tizi-Ouzou Hospital. From the total of the children tested, 27 were male and 22 were female. Of the 49 children with hearing loss, 29 suffered from bilateral hearing loss and 20 from unilateral hearing loss. In addition, the study of the risk factors for hearing loss allowed us to identify those which are present among the detected NB and to calculate the prevalence of hearing loss among the NB admitted to the neonatal ICU (NICU). The prevalence of hearing loss among the NB hospitalized in the NICU was 2.14%.
The study of the risk factor of hearing loss described by the JCIH and pathologies associated with the NB or parents was carried out by calculating the odds ratio. The results of this study are shown in [Table 1], in which only the factors greater than 1 are shown. The risk factors most associated with hearing loss are infections by cytomegalovirus, rubella, damage to the nervous system and craniofacial malformations. Furthermore, infertility of the couple with treatment by fertilization in vitro (IVF) was found in this study, with an odds ratio of more than 160, indicating its close relationship with hearing loss.
The calculation of the average cost for each child detected taking into account the input of all stakeholders was 226.8 Algerian Dinar (DA), about 20$. The hearing rehabilitation was proposed as soon as the diagnosis of an auditory hearing threshold greater than 30 dB was found. In our study, it was based on speech therapy rehabilitation for all infants (n = 49), a hearing aid with conventional prosthesis for infants with bilateral deafness (n = 29) and a cochlear implantation for children with severe-to-profound bilateral hearing loss (n = 2) [Table 2].
In our series, the size of the cohort was 15 382 NB detected from 17 912 live NB hospitalized in the maternity unit, giving a coverage rate of 85.9%. Screening was conducted using a protocol of two phases for the detection of acoustic otoemissions with 1-month interval followed by a search of the threshold with auditory evoked potentials at 3 months. The rate of attendance of the first phase (% refer) was 12.45% and it was 4.88% in the second phase. Finally, the prevalence of deafness was 3.2 per 1000 births and 2.14% of the NB hospitalized in the NICU.
Speech support is proposed for all children with a hearing loss, even for those with unilateral hearing loss. Bilateral hearing aid is proposed for all NB with bilateral hearing loss as soon as the diagnosis of hearing loss is obtained (most of cases at 3 months). Two children with severe bilateral hearing loss were fitted with unilateral cochlear implantation at 15 months and hearing aid for the other side.
| Discussion|| |
It is essential to use sensitive tests in a universal neonatal screening for hearing loss. Tests using the OAE detection do not have a sensitivity and specificity of 100%  . This deficit is offset by the practice of the test of the first phase as late as possible [26-28] . It is also offset by the repetition of tests at an interval of 2-4 weeks, to reduce the false positives. The rate of positive screening is 15.1% if the test is carried out at 24 h, diminishes to 7.41% if it is carried out within 48 h and it is 3.65 to 4% if it is beyond 48 h (12.5% in our series). The rate of positive screening increases too with the inexperience of the team and decreases with its loyalty , .
We practised the test as late as possible in the NICU, averaging 7 days, but with an average of 21 h in a normal maternity ward. Hospitalization in our maternity ward averaging less than 24 h because of the great number of NB. This high rate of positive screening at the first stage is the most important factor that increases the overall cost of the screening  . This was 226.8 DA for every NB. The prevalence of neonatal hearing loss was one to four per 1000 births and 2 to 5% of births admitted at the NICU ,,,, . This prevalence continues to increase during childhood , . Therefore, we followed up children with hearing loss to detect worsening. We also followed up children with risk factors of hearing loss to detect its possible onset. The risk factors of hearing loss have been well described by the JCIH in 1994 and updated in 2007. Two risk factors found in our study have been described in the literature but not listed in the JCIH paper: IVF and seizures. Convulsions, in the neonatal period, may be due to several causes, including fever, hypothermia, obstetric trauma and metabolic disorders, and may be the start of epilepsy  .
The terms seizure and convulsion are interchangeably used by the American Academy of Paediatrics  even if the seizures are treated as a symptom in the literature  . IVF is an infertility treatment. It is also called medically assisted procreation, or reproduction technologically assisted by the CDC of Atlanta. It consists of the manipulation of sperm and eggs in the laboratory and the relocation of the ovule fertilized in the womb of the woman. This definition does not include artificial insemination, in which only the sperm are handled and injected into the woman's uterus  .
This medically assisted reproduction was implicated in brain injuries and sensorineural desorders ,, .
Strömberg and colleagues reported that children born of IVF were three times more at risk for neurological pathology compared with the general population. In our study, three NB were the result of an IVF. One of them suffered from hearing loss.
It is accepted now that rehabilitation of hearing should be early and bilateral within 3 to 6 months of age to have the best results on language disorders [8-12] . However, if the rehabilitation of bilateral hearing loss reached consensus, that of unilateral hearing loss still raises discussions. Most researchers prefer a monitoring only, others propose to neither monitor nor track the individuals concerned with unilateral hearing loss, and some propose a hearing aid.
Indeed, a restoration of the binaural hearing with specific help at school and in the family environment for an infant with hearing loss can improve the performance at school  . In our study, we have proposed speech rehabilitation and monitoring of all children with a unilateral hearing loss and advice for parents.
| Conclusion|| |
Neonatal screening of hearing loss using a protocol of three phases is possible. It allows detection of hearing loss early to apply an adapted auditory rehabilitation early to guarantee alignment of children born with a hearing loss or contracted a hearing loss during the neonatal period with their peers with normal hearing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Joint Committee on Infant Hearing, year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics Vol. 120 No. 4 October 2007, pp. 898-921
Finitzo T, Crumley WG. The role of the pediatrician in hearing loss. From detection to connection. Pediatr Clin North Am 1999; 46
White K. Twenty years of early hearing detection and intervention (EHDI): where we′ve been and what we′ve learned (2010). ASHA audiology virtual conference.
Arehart K, Yoshinaga-Itano C, Thomson V, Gabbard SA, Brown S. The status of universal newborn screening, assessment, and intervention systems in 16 States. American Journal of Audiology, 1998; 7
Harrison M, Roush J. Age of suspicion, identification, and intervention for infants and young children with hearing loss: a national study. Ear Hear 1996; 17
Kile J. Identification of hearing impairment in children: a 25-year review. Transdisciplinary J 1993; 3
Elssmann SA, Matkin ND, Sabo MP. Early identification of congenital sensorineural hearing impairment. Hear J 1987; 40
Yoshinaga-Itano C. Efficacy of early identification and early intervention. Semin Hear 1995; 16
Yoshinaga-Itano C. Levels of evidence: universal newborn hearing screening (UNHS) and early hearing detection and intervention systems (EHDI). J Commun Disord 2004; 37
Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL. Language of early- and later-identified children with hearing loss. Pediatrics 1998; 102
Yoshinaga-Itano C, Coulter D, Thomson V. The Colorado Newborn Hearing Screening Project: effects on speech and language development for children with hearing loss. J Perinatol 2000; 20
Spivak L,Datzell L, Berg A, Bradley M, Cacace A. The New York City universal newborn hearing screening demonstration project: in-patients outcome measures. Ear Hear 2000; 21
Joint Committee on Infant Hearing. Position statement; principles and guidelines for early hearing detection and intervention programs. Pediatrics 2000; 106
Grill E, Hessel F, Siebert U, Schnell-Inderst P, Kunze S, Nickisch A, Wasem J. Comparing the clinical effectiveness of different new-born hearing screening strategies. A decision analysis. BMC Public Health 2005; 5
Narayana J. Neonatal screening for deafness by OEAP among children at risk, at level III of the 2001 to 2004 Béclère Hospital Maternity. Thesis for graduation of State French.
Kaye CI, Accurso F, La Franchi S, Lane PA, Northrup H, Pang S, et al
., Committee on Genetics. Introduction to the newborn screening fact sheets. Pediatrics 2006; 118
Olusanya BO, Wirz SL, Luxon LM. Community-based infant hearing screening for early detection of permanent hearing loss in Lagos, Nigeria: a cross-sectional study. Bull World Health Organ 2008; 86
Davis AC. The prevalence of hearing impairment and reported hearing disability among adults in Great Britain. Int J Epidemiol 1989; 18
Bonfils P, Francis M, Aidan D, Avan P, Parat S, Boissinot C, et al
. Deafness in the neonatal period: the basics of screening. Arch Pediatr 1995; 2
Kemp DT, Ryan S. Proschel emission tests in neonatal screening programs. Acta Otolaryngol 1991; 482
Mason S, Davis A, Wood S, Farnsworth A. Field sensitivity of targeted neonatal hearing screening using the Nottingham ABR Screener. Ear Hear 1998; 19
Morton CC, Nance WE. Newborn hearing screening - a silent revolution. N Engl J Med 2006; 354
Petit C. Genes responsible for human heriditary deafness; Synphony of a thousand. NAT Genet 1996; 14
Committee A, second report: prevention of hearing impairment. Resolution of the 48th World Health Assembly; WHA 48.9. HBK Res., Vol. III (3rd ed.), 1.16.15 (twelfth plenary meeting, 12 May 1995) Geneva: WHO; 1995. Available in English at: http://www.who.int/pbd/publications/wha_eb/wha48_9/en/.
Mehl AL, Thomson V. Newborn hearing screening: the great omission. Pediatrics 1998; 101
Clemens CJ, et al
. The false-positive in universal newborn hearing screening. Paediatrics 2000; 106
Clemens CJ, Davis SA. Minimizing false-positives in universal newborn hearing screening: a simple solution. Pediatrics 2001; 107
Owen M, Webb M, Evans K. Community based universal neonatal hearing screening by health visitors using proschel emissions. Arch Dis Child Fetal Neonatal Ed 2001; 84
Vohr BR, Oh W, Stewart EJ, Bentkover JD, Gabbard S, Lemons J, et al
. Comparison of costs and referral rates of 3 universal newborn hearing screening protocols. J Pediatr 2001; 139
Gracey K. Current concepts in universal newborn hearing screening and early hearing detection and intervention programs. Adv Neonatal Care 2003; 3
Benito Orejas JI, Ramirez Cano B, Morais Pérez D, Fernández-Calvo JL, Almaraz Gomez A. Results of applying a universal protocol for early detection of hypoacusia in newborn infants for 42 months. Acta Otorhinolaringol Esp 2008; 59
Meyer C, Witte J, Hildmann A, Hennecke KH, Schunck KU, Maul K, et al
. Neonatal screening for hearing disorders in infants at risk: incidence, risk factors, and follow-up. Pediatrics 1999; 104
Fortnum HM, Summerfield AQ, Marshall DH, Davis AC, Bamford JM. Prevalence of permanent childhood hearing impairment in the United Kingdom and implications for universal neonatal hearing screening: questionnaire based ascertainment study. BMJ 2001; 323
Weichbold V, Nekahm-Heis D, Welzl-Mueller K. Universal newborn hearing screening and postnatal hearing loss. Pediatrics 2006; 117
NI Wolf, T Bast, R. Surtees. Epilepsy in inborn errors of metabolism. Epileptic Disord 2005; 7
PAA: American Academy of Pediatrics. Difference between seizure and convulsion (2009). American Academy of Pediatrics. Available at: http://www.healthychildren.org
. [Last accessed on 2013 Jul 9].
Strömberg B, Dahlquist G, Ericson A, Finnström O, Köster M, Stjernqvist K. Neurological sequelae in children born after in-vitro
fertilisation: a population-based study. Lancet 2002; 359
Fiona S, Eve B, Eva A. Cerebral palsies: epidemiology and causal pathways. Mac Keith press 2000;151:67-83. Distributed by Cambridge University Press.
Kuppler K, Lewis M, Evans AK. A review of unilateral hearing loss and academic performance: is it time to reassess traditional dogmata? Int J Pediatr Otorhinolaryngol 2013; 77
[Table 1], [Table 2]