NEWBORN HEARING (Screening)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 9/30/11

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
The U.S. Preventive Services Task Force (USPSTF) recommends screening for hearing loss in all newborn infants.

Evidence Rating: B (Recommended/Moderate Certainty)
The USPSTF concludes that there is moderate certainty that the net benefit of screening all newborn infants for hearing loss is moderate.1
CDC Recommendation
The CDC supports the USPSTF's recommendation that all newborn infants should have their hearing screened at birth.

Evidence Rating: Observational Studies, Expert Opinion
The CDC recommendation for screening at birth is based on evidence from observational studies that children who receive intervention services for hearing loss before the age of 6 months develop significantly better language skills.2,3 This is supported by expert opinion of those who care for children with hearing loss and parents of children with hearing loss, who report that children with hearing loss detected as infants have better language skills than older siblings with later-diagnosed hearing loss.

Back to top


The Value of Prevention

Economic Burden of Condition/Disease
Many people with hearing loss need long-term services. The average lifetime cost for one person with early-childhood-onset bilateral moderate-to-profound hearing loss is estimated to be $383,000 (in year 2003 dollars).8 It is estimated that the lifetime cost for all people with congenital hearing loss who were born in 2000 will total $1.9 billion (in year 2003 dollars).6 These costs include both direct and indirect costs. Direct medical costs, such as doctor visits, prescription drugs, and inpatient hospital stays, make up 7% of these costs. Non-medical expenses, such as home modifications and special education, make up 24% of the costs. These estimates do not include other expenses, such as hospital outpatient visits, sign language interpreters, and family out-of-pocket expenses.
Workplace Burden of Condition/Disease
Indirect costs of hearing loss, which include the value of lost wages when a person either cannot work or is limited in the amount or type of work possible, make up 69% of total costs.6
Economic Benefit of Preventive Intervention
The economic benefits of newborn hearing screening include reduced special education costs associated with improved hearing and language and also lower social and community services. A study from England reported that average education costs among 7 to 9 year-old children with bilateral hearing loss were lower by 22% among children born in districts with universal newborn hearing screening.7
Estimated Cost of Preventive Intervention
The cost of screening for hearing loss depends on the location (inpatient or outpatient setting), provider type, and the screening instrument used. In 2004, the private-sector reimbursement of screening for hearing loss in the hospital (recommended setting) averaged $84 if billed and paid separate from the labor and delivery charge; approximately 95% of paid claims fell within the range of $0 to $200.8 If the screening was missed before discharge or needed to be repeated on an outpatient basis, the average private-sector cost was $98 (in this scenario 95% of paid claims fell within the range of $0 to $235).8 Both figures include the cost of staff time, consumables, and the cost of the equipment. When screening is billed as a part of labor and delivery charges the incremental cost is lower.

Estimated Cost of Treatment
The cost of treatment will vary widely depending on the type and severity of the hearing loss and the kinds of interventions chosen.
Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
Screening programs detect up to 3 children with hearing loss for every 1,000 infants screened. Assuming an average cost of $30 taken from the literature, the cost per infant detected may be as low as $10,000. In comparison to other preventive interventions and to commonly accepted cost-effectiveness benchmarks, newborn hearing screening is cost-effective. The cost-effectiveness of early detection depends on long-term outcomes. To the extent that improved language leads to lower special education costs and to improved learning potential, the monetary benefits of screening are likely to exceed the costs.9 The savings in special education costs are likely to exceed the costs of screening within 5 years.7

Back to top


Condition / Disease Specific Information

Epidemiology of Condition/Disease
Hearing loss affects up to 5 per 1,000 children, depending on the particular study. Congenital hearing loss represents about 50-60% of these figures. About 20% of children with congenital hearing loss have another condition at birth. Hearing loss, even loss that is mild in magnitude or unilateral (only one ear affected), can affect a child's potential to develop speech, language, social skills, and school performance.4 Hearing loss may be present at birth or may occur later.
Condition/Disease Risk Factors
About 40% to 60% of hearing loss is due to genetic or gene-environment factors. The causes of hearing loss for many children are poorly defined and infants may have no identifiable risk factors to prompt targeted screening. However risk factors for hearing loss may be present in some infants and young children. Some of these risk factors include a family history of permanent childhood hearing loss; infections such as bacterial meningitis, in utero cytomegalovirus (CMV), herpes, toxoplasmosis, and rubella; admission to the neonatal intensive care unit (NICU) for more than 5 days and other factors as identified by the Joint Committee on Infant Hearing.5

Back to top


Preventive Intervention Information

Preventive Intervention: Purpose of Screening
Screening newborn infants for hearing loss identifies most children with congenital hearing loss prior to the onset of language development, allowing their parents to access services much earlier than otherwise. In the absence of screening, the majority of children with congenital hearing loss do not receive a diagnosis until 2 to 3 years of age, by which point language development is usually seriously delayed.11 The average adult who has been deaf or hard of hearing since early childhood reads at only a 4th grade level.12 The average language development score of children who are deaf or hard of hearing in the absence of early identification is two standard deviations below the mean.3

Certain children have later-onset or progressive hearing loss that cannot be detected during the newborn period. Clinicians and parents should be alert to hearing, speech, language, or developmental delay and should have children tested for hearing loss if they are concerned about delays regardless of previous hearing screenings.
Benefits and Risks of Intervention
With screening, most cases of hearing loss can be detected prior to 3 to 4 months of age. With early identification, parents have the opportunity to communicate with their child beginning early in infancy. This aids language development for the child and strengthens the parent-child bonding. Research suggests that most preschool-age children with hearing loss will have language development within the normal range if intervention beginnings by 6 to 12 months of age.2,3 It is widely believed that this will lead to improved school performance and occupational success.9 Long-term outcome studies of newborn hearing screening in England have confirmed that newborn hearing screening is associated with improved language ability and reduced costs of schooling.7,13,14

The main risk of screening is that false-positive results can lead to additional screening or evaluation, incurring unnecessary costs and inconvenience for families and providers. The expected number of newborns who do not pass the hearing screen is 40 per 1,000 births, of which 3 will have hearing loss. Following and re-testing the remaining 37 incur costs and challenge follow-up systems. On the other hand, a number of surveys of families whose children screened positive for hearing loss found that most parents support hearing screening and consider the inconvenience to be minor compared to the benefits of early recognition.15
Initiation, Cessation, and Interval of Screening
Hearing screening for newborn infants is mandated in many jurisdictions, and the United States Preventive Services Task Force recommends it for all infants.

Since hearing loss may develop or first become apparent later, infants and children should also be screened when a clinician, parent or caregiver suspects that language or developmental delay may be related to hearing loss. Physicians should be encouraged to see that patients at high risk for late-onset or progressive hearing loss be screened or receive a full diagnostic evaluation in accordance with recommendations set forth by the Joint Committee on Infant Hearing (JCIH).5

In addition, an infant who does not pass a newborn screening should get a diagnostic audiological evaluation no later than 3 months of age.7 Regardless of whether or not an infant passed the newborn hearing screen, all infants' hearing abilities should be monitored according to the American Academy of Pediatrics (AAP) pediatric periodicity schedule.5
Intervention Process
Hospital-based screening programs should use physiologic measures of screening to screen neonates and infants for hearing loss. These measures include Otoacoustic Emissions (OAE) and automated Auditory Brainstem Response (ABR) testing. Both screening technologies are easily performed in neonates and infants. All infants who do not pass the hearing screening should be referred to an audiologist with experience and expertise in testing the hearing of infants and young children for an audiologic diagnostic evaluation.5 This evaluation requires a test-battery approach to cross-check results of multiple physiologic and developmentally-appropriate behavioral measures. Early audiologic assessments rely on physiologic measures of auditory function including: ABR, OAE, acoustic immittance measures, and acoustic reflexes.16

Auditory Brainstem Response (ABR) is a test that checks the brain's response to sound and is measured by placing electrodes on the head to record the brain's response to sound. Older babies, as well as those who do not routinely sleep well after eating, frequently require sedation to attain accurate ABR test results.16 Otoacoustic Emissions (OAE) is a test that checks the inner ear response to sound and is measured by placing a very sensitive microphone in the ear canal to measure the ear's response to sound. For infants in the well-baby nursery, either type of instrument can be used alone or in sequence for most infants.5,7 Evidence is mixed as to what instrument or method is most effective in accurately identifying children with hearing loss, but most instruments seem to have an adequate level of sensitivity and specificity.16 However separate protocols are recommended for infants admitted to the neonatal intensive care unit (NICU) for more than 5 days. These infants are to have auditory brainstem response testing included as part of their screening. For infants who do not pass automated auditory brainstem response testing in the NICU, referral should be made directly to an audiologist for rescreening and, when indicated, comprehensive evaluation. For all infants (NICU or well infant) who are readmitted to a hospital in the first month of life in which there are conditions associated with hearing loss, a repeat hearing screening is recommended before discharge.5
Treatment Information
Health benefits should include provisions for rescreening, diagnostic, surveillance, and treatment services.

Infants with a diagnosed hearing loss should receive appropriate services no later than 6 months of age, including medical services, early intervention services (i.e., Part C services or other state approved intervention services), and audiologic services.5,17

According to the Joint Commission on Infant Hearing year 2007 position statement:

Every infant with confirmed hearing loss should be referred for an otolaryngology medical evaluation to determine the etiology of hearing loss, to identify related physical conditions, and to provide recommendations for treatment as well as referral for other services, including genetics evaluation and counseling. Every infant with a confirmed hearing loss should also have an evaluation by an ophthalmologist to document visual acuity and rule out concomitant or late-onset vision disorders such as Usher syndrome. Indicated referrals to other medical subspecialists, including developmental pediatricians, neurologists, cardiologists, and nephrologists, should be facilitated and coordinated by the primary health care professional.5
The clinician should refer families to a source of information about qualified early intervention service providers and the state Universal Newborn Hearing Screening (UNHS)/Early Hearing Detection and Intervention (EHDI) program. In many states, clinicians are required to report children with hearing loss to the state program.

Back to top


Strength of Evidence

The level of evidence supporting the recommendations contained in this section is described below.

Evidence-Based Research:

U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: B (Recommended/Moderate Certainty)
  • The U.S. Preventive Services Task Force (USPSTF) recommends screening for hearing loss in all newborn infants. The USPSTF concludes that there is moderate certainty that the net benefit of screening all newborn infants for hearing loss is moderate.1
Recommended Guidance:

Centers for Disease Control and Prevention (CDC)
Strength of Evidence: Observational Studies
  • " Even prior to the USPSTF recommendation, the CDC found evidence to support universal newborn hearing screening at birth based on evidence from observational studies that children who receive intervention services for hearing loss before the age of 6 months develop significantly better language skills.2,3
The Joint Committee on Infant Hearing (JCIH)
Strength of Evidence: Expert Opinion
  • The Joint Committee on Infant Hearing (JCIH) endorses early detection of and intervention for infants with hearing loss to maximize linguistic competence and literacy development for children who are deaf or hard of hearing. The hearing of all infants should be screened at no later than 1 month of age. Those who do not pass screening should have a comprehensive audiological evaluation at no later than 3 months of age. Infants with confirmed hearing loss should receive appropriate intervention at no later than 6 months of age from health care and education professionals with expertise in hearing loss and deafness in infants and young children. Regardless of previous hearing-screening outcomes, all infants with or without risk factors should receive ongoing surveillance of communicative development during well-child visits in the medical home.5
National Institutes of Health (NIH)
Strength of Evidence: Expert Consensus
  • An NIH Consensus Development Conference Statement on Early Identification of Hearing Impairment in Infants and Young Children recommended that universal newborn hearing screening be implemented.18

Back to top


Summary Plan Description

Covered Screening
Hospital-based hearing screening is a covered benefit for all newborns. Newborns who are not screened in the hospital, or who require further screening, may be screened in an outpatient setting. Screening may include the use of the following tests:
  • Automated audiologic screening
  • Auditory Brainstem Response (ABR)
  • Otoacoustic Emissions (OAE)
Diagnostic audiological evaluation is a covered benefit for all infants and children who do not pass initial screening tests.
Initiation, Cessation, and Interval
Screening is covered for all newborns during the first 3 months of life. Additional screening is provided for all children, as determined medically necessary. Diagnostic audiological evaluation is covered, as medically necessary.

Back to top


CPT Codes

Newborn Hearing (Screening)
92585 Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive
92586 Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited
92587 Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)
92588 Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)

Back to top


Other Information and Resources

Business Group Resource(s)

CDC Resource

Other Resources:

Back to top


Author(s)

Grosse S. Newborn hearing evidence-statement: screening. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health. 2006. Updated 2011.

Back to top


References

  1. U.S. Preventive Services Task Force. Screening for newborn hearing. Summary of recommendations. Rockville, MD: Agency for Healthcare Research and Quality; 2001. Available at: http://www.ahrq.gov/clinic/uspstf/uspsnbhr.htm. Accessed May 29, 2009.
  2. Yoshinaga-Itano C, Gravel JS. The evidence for universal newborn hearing screening. Am J Audiol. 2001;10:62-4.
  3. Moeller M. Early intervention and language development in children who are deaf and hard of hearing. Pediatrics. 2000 Sep;106(3):1-9.
  4. Centers for Disease Control and Prevention. Hearing Loss, Data and Statistics. Available at: http://www.cdc.gov/ncbddd/hearingloss/data.html . Accessed August 14, 2011.
  5. Joint Committee on Infant Hearing. Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Pediatrics. 2007;120(4):898-921.
  6. Centers for Disease Control and Prevention. Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment-United States, 2003. MMWR. 2004;53(3):57-9.
  7. Schroeder L, Petrou S, Kennedy C, et al. The economic costs of congenital bilateral permanent childhood hearing impairment. Pediatrics. 2006;117:1101-1112.
  8. Thomson Reuters. 2004 MarketScan® Commercial Commercial Claims and Encounters Database. 2005.
  9. Keren R, Helfand M, Homer C, McPhillips H, Lieu TA. Projected cost-effectiveness of statewide universal newborn hearing screening. Pediatrics. 2002;110:855-64.
  10. Morton, C and Nance, W. Newborn Hearing Screening — A Silent Revolution. The New England Journal of Medicine. 2006; 354: 2151-2164.
  11. Mehl AL, Thomson V. Newborn hearing screening: the great omission. Pediatrics. 1998 Jan;101(1):E4.
  12. Traxler CB. Measuring up to performance standards in reading and mathematics: Achievement of selected deaf and hard-of hearing students in the national norming of the 9th Edition Stanford Achievement Test. J Deaf Stud Deaf Educ. 2000;5:337-348.
  13. Grosse SD, Ross DS. Cost savings from universal newborn hearing screening. Pediatrics. 2006;118:844-45.
  14. Kennedy CR, McCann DC, Campbell MJ, et al. Language ability after early detection of permanent childhood hearing impairment. N Engl J Med. 2006;354:2131-41.
  15. Clemens CJ, Davis SA, Bailey AR. The false-positives in Universal Newborn Hearing Screening. Pediatrics. 2000;106(1):e7 (5 pages).
  16. Gifford, K, Holmes, M and Bernstein, H. Hearing Loss in Children Pediatrics in Review. 2009; 30(6): 207-216.
  17. Centers for Disease Control and Prevention. National EHDI goals. Available at: http://www.cdc.gov/ncbddd/ehdi/nationalgoals.htm. Accessed July 11, 2008.
  18. National Institutes of Health. Early identification of hearing impairment in infants and young children. NIH Consensus Statement. 1993;11:1-24.