NEWBORN HEARING (Screening)
Clinical Preventive Service Recommendations
U.S. Preventive Services Task Force RecommendationThe 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 RecommendationThe 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.
The Value of Prevention
Economic Burden of Condition/DiseaseMany 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/DiseaseIndirect 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 InterventionThe 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 InterventionThe 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 TreatmentThe 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 InterventionScreening 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
Condition / Disease Specific Information
Epidemiology of Condition/DiseaseHearing 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 FactorsAbout 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
Preventive Intervention Information
Preventive Intervention: Purpose of ScreeningScreening 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 InterventionWith 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 ScreeningHearing 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 ProcessHospital-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 InformationHealth 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.5The 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.
Strength of EvidenceThe level of evidence supporting the recommendations contained in this section is described below.
Summary Plan Description
Covered ScreeningHospital-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:
Initiation, Cessation, and IntervalScreening 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.
Other Information and Resources
Business Group Resource(s)
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.