1. The Scientific Basis for
Newborn Hearing Screening

4. Number of Hospitals Doing Universal Newborn Hearing Screening
Number of Programs

5. Status of Universal Newborn Hearing Screening3
Status of Universal Newborn Hearing Screening
in the United States .
Percentage of Births
Screened .
90%+ % %
1 - 20%

6. Conventional ABR 2 Newborn Hearing Screening Prior to 1990!
Too expensive

7. Newborn Hearing Screening Prior to 19902
Conventional ABR !
Too expensive 2
High-Risk Indicators !
50% of children with congenital hearing losses do
not exhibit any high-risk indicators !
Only about 1/2 of those who have a high-risk
indicator make an appointment for further testing
and only 1/2 of those are ever tested

8. How Many Hearing Impaired* Children were at High Risk as Infants?49 %
Feinmesser et al. (1982) 54 %
Pappas & Schaibly (1984) 48 %
Elssmann et al. (1987) 43 %
Watkin et al. (1991) 50 %
Mauk et al. (1991) 50
100
* Limited to children with permanent bilateral hearing loss
>
50 dB

9. Newborn Hearing Screening Prior to 19902
Conventional ABR !
Too expensive 2
High-Risk Indicators !
50% of children with congenital hearing losses do not exhibit any
high-risk indicators !
Only about 1/2 of those who have a high-risk indicator make an
appointment for further testing and only 1/2 of those are ever tested 2
Home-Based Behavioral Screening
Programs !
Requires very expensive infrastructure !
Not as successful as widely believed

10. Percentage of Children with Permanent Hearing
Loss Identified by the Infant Distraction Test
Performed at 8 Months of Age 50 40 30 20 10
Severe/Profound
Mild/Moderate
Bilateral
Bilateral
Unilateral
(n = 39)
(n = 72)
(n = 60)
Watkin, P. M., Baldwin, M., & Laoide, S. (1990). Parental suspicion and identification of hearing impairment.
Archives of Disease in Childhood,
65,

11. Newborn Hearing Screening 1990-1993,
Healthy People 2000 Goals ,
Effectiveness of Automated ABR demonstrated ,
RIHAP and others demonstrate the effectiveness of
TEOAE-based universal newborn hearing screening ,
NIH Consensus Conference in March 1993

12. NIH Consensus Panel The consensus panel concluded that all
Early Identification of Hearing Impairment in Infants and Young Children
March, 1993
The consensus panel concluded that all
infants should be screened for hearing
impairment...this will be accomplished most
efficiently by screening prior to discharge
from the well-baby nursery. Infants who fail
... should have a comprehensive hearing
evaluation no later than 6 months of age.

13. Comprehensive Hearing
NIH Recommended Screening Protocol
OAE Screening Prior
ABR
Comprehensive Hearing
Evaluation Before 6
Months of Age
to Hospital
Fail
Screening
Fail
Discharge

14. Statements Endorsing Early Detection of Hearing Loss
The Department of Education, in collaboration with the Department of Health and
Human Services, should issue federal guidelines to assist states in implementing
improved [hearing] screening procedures for each live birth.
Commission on Education of the Deaf, 1988
Reduce the average age at which children with significant hearing impairment are
identified to no more than 12 months.
Healthy People 2000 Report, 1990
All hearing impaired infants should be identified and treatment initiated by 6 months of
age. In order to achieve this ... the consensus panel recommends screening of
all
newborns ... for hearing impairment prior to hospital discharge.
NIH Consensus Statement, 1993
The 1994 [JCIH] Position Statement endorses the goal of universal detection of infants
with hearing loss ... [and] recommends the option of evaluating infants before
discharge from the newborn nursery.
Joint Committee on Infant Hearing, 1994
Universal detection of infant hearing loss requires universal screening of all infants.
American Academy of Pediatrics, 1998

15. Good work, but I think we might need just a little more
Implementing Universal Newborn Hearing Screening Programs
out
Then a
miracle
occurs
Start
Good work,
but I think we might
need just a little more
detail right here.

16. The Solution? ?

17. Issues to be Considered In Deciding Whether
Universal Newborn Hearing Screening Should Be the
Method of Choice in Detecting Hearing Loss? I.
Prevalence of Congenital Hearing Loss
II.
Consequences of Neonatal Hearing Loss
III.
Effects of Earlier Versus Later Identification and Intervention
IV.
Accuracy of Newborn Hearing Screening Methods V.
Efficiency of Existing Early Detection Programs
VI.
Costs of Newborn Hearing Screening
VII.
Has Hospital-based Hearing Screening Become the Standard of
Care?

18. Reported Prevalence Rates of Bilateral Permanent Childhood
Hearing Loss (PCHL) in Population-based Studies
4.0
3.5 12
3.0
2.5 8
Prevalence per 1,000
2.0 9 3
1.5 4 7 5
1.0 2 11 10 .5 1 6 20 25 30 35 40 45 50 55 60 65
dB Threshold Level (loss criterion)
1. Barr (1980), n = 65,000
7. Parving (1985), n = 82,265
2. Downs (1978), n = 10,726
8. Sehlin et al. (1990), n = 63,463
3. Feinmesser et al. (1986), n = 62,000
9. Sorri & Rantakallio (1985), n = 11,780
4. Fitzland (1985), n = 30,890
10. Davis & Wood (1992), n = 29,317
5. Kankkunen (1982), n = 31,280
11. Fortnum et al. (1996), n = 552,558
6. Martin (1982), n = 4,126,268
12. Watkin et al. (1990), n = 51,250

19. Percentage of Sensorineural Hearing Losses Which Are Unilateral
# of Hearing Impaired
Author (year) Children in Sample % Unilateral
Kinney (1953)
1307
48%
Brookhauser, Worthington
1829
37%
& Kelly (1991)
Watkin, Baldwin, & Laoide (1990)
171
35%

20. II. Consequences of Neonatal Hearing Loss2
Severe/Profound PCHL Losses 2
Mild Bilateral and Unilateral PCHL Losses 2
Fluctuating Conductive Loss

21. Reading Comprehension Scores of Hearing and Deaf Students
10.0 '
9.0 ,
Deaf '
8.0 '
Hearing '
7.0 '
6.0 '
Grade Equivalents
5.0 '
4.0 '
3.0 ' , , , , , , ,
2.0 , , , ,
1.0 8 9 10 11 12 13 14 15 16 17 18
Age in Years
Schildroth, A.N., & Karchmer, M.A. (1986).
Deaf children in America
. San Diego: College Hill Press.

22. Effects of Unilateral Hearing Loss
Normal Hearing
Unilateral Hearing Loss
Keller & Bundy (1980)
Math
(n = 26; age = 12 yrs)
Language
Peterson (1981)
Math
(n = 48; age = 7.5 yrs)
Language
Bess & Thorpe (1984)
Social
(n = 50; age = 10 yrs)
Math
Blair, Peterson & Viehweg (1985)
(n = 16; age = 7.5 yrs)
Language
Math
Culbertson & Gilbert (1986)
(n = 50; age = 10 yrs)
Language
Social
Average Results
0th
10th
20th
30th
40th
50th
60th
Math = 30th percentile
Percentile Rank
Language = 25th percentile
Social = 32nd percentile

23. Effects of Mild Fluctuating Conductive Hearing Loss
Teele, et al., 1990 )
194 children followed prospectively from 0-7 years. )
Days child had otitis media between 0-3 years assessed during normal visits to physician. )
Data on intellectual ability, school achievement, and language competency individually
measured at 7 years by "blind" diagnosticians. )
Results for children with less than 30 days OME were compared to children with more than
130 days adjusted for confounding variables.
Effect Size for
Outcome Measure Less vs. More OME
WISC-R Full Scale
.62
Metropolitan Achievement Test
Math
.48
Reading
.37
Goldman Fristoe Articulation
.43
Teele, D.W., Klein, J.O., Chase, C., Menyuk, P., Rosner, B.A., and the Greater Boston Otitis media Study Group (1990).
Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years.
The Journal
of Infectious Diseases ,
162 ,

24. III. Effects of Earlier Versus Later Identification and Intervention2
Prospective randomized trials have not been done. 2
Most existing evidence is weakened by: )
potential for selection bias. )
lack of long-term follow-up to assess "wash-out" effect. )
small sample sizes. )
subjective assessments of outcomes.

25. Yoshinaga-Itano, et al., 1996 6
Compared language abilities of hearing-impaired children identified
before 6 months of age (n = 46) with similar children identified after 6
months of age (n = 63). 6
All children had bilateral hearing loss ranging from mild to profound,
and normally-hearing parents. 6
Language abilities measured by parent report using the Minnesota
Child Development Inventory (expressive and comprehension scales)
and the MacArthur Communicative Developmental Inventories
(vocabulary). 6
Cross-sectional assessment with children categorized in 4 different
age groups.
Yoshinaga-Itano, C., Sedey, A., Apuzzo, M., Carey, A., Day, D., & Coulter, D. (July 1996).
The effect of early
identification on the development of deaf and hard-of-hearing infants and toddlers
. Paper presented at the
Joint Committee on Infant Hearing Meeting, Austin, TX.

26. Expressive Language Scores for Hearing Impaired
Children Identified Before and After 6 Months of Age 35 30 25
Language Age in Months 20 15 10
Identified BEFORE 6 Months 5
Identified AFTER 6 Months
13-18 mos
19-24 mos
25-30 mos
31-36 mos
(n = 15/8)
(n = 12/16)
(n = 11/20)
(n = 8/19)
Chronological Age in Months

27. Vocabulary Size for Hearing Impaired Children
Identified Before and After 6 Months of Age
300
250
200
Vocabulary Size
150
100
Identified BEFORE 6 Months 50
Identified AFTER 6 Months
13-18 mos
19-24 mos
25-30 mos
31-36 mos
(n = 15/8)
(n = 12/16)
(n = 11/20)
(n = 8/19)
Chronological Age in Months

28. Watkins, 1987 6
Comparisons made among 3 groups of bilaterally hearing-impaired
children (n = 23 in each group)
Group #1:
Received average of 9 months home intervention
before 30
months age, followed by preschool intervention.
Group #2:
Attended preschool beginning at an average of 36 months.
Group #3:
Received no home intervention and no preschool intervention. 6
Children matched on hearing severity (PTA ~ 85 dBHL), presence of
other handicaps, and analysis of covariance used to adjust for age at
post test, age of mother, SES, and number of childhood middle ear
infections. 6
Data collected by uninformed, trained examiners when children were 10
years old.
Watkins, S. (1987). Long term effects of home intervention with hearing-impaired children.
American Annals of the Deaf ,
132 ,
Watkins, S. (1983).
Final Report: work scope of the Early Intervention Research Institute
, Logan, Utah: Utah State
University.

29. Effects of Earlier Intervention
(Watkins, 1989)
Read
Math
Vocabulary
No EI or Preschool
Articulation
Childrens Developmental Outcomes
Preschool
Is Understood
EI<9 mos +Preschool
Understands
Social
Behavior 20 40 60 80
100
Percentile Scores

30. Boys Town National Research Hospital Study of Earlier vs. Later)
129 deaf and hard-of-hearing children assessed 2x each year. )
Assessments done by trained diagnostician as normal part of early intervention program. 6
Identified <6 mos (n = 25) 5
Identified >6 mos (n = 104) 4
Language Age (yrs) 3 2 1
0.8
1.2
1.8
2.2
2.8
3.2
3.8
4.2
4.8
Age (yrs)
Moeller, M.P. (1997).
Personal communication ,

31. IV. Accuracy of Newborn Hearing Screening Methods,
How many children with hearing loss are identified? ,
How many children with hearing loss are missed?

32. Sensitivity of Various UNHS Techniques)
Although various rates of sensitivity are reported, there are
no studies of UNHS with sufficient sample sizes to
definitively establish sensitivity for any of the techniques. )
Weakness with existing studies of "sensitivity" 2
Small sample sizes. 2
One screening technique compared to another screening
technique (e.g., OAE vs. ABR). 2
All screening passes are not followed. 2
Samples include only high-risk babies.

33. Accuracy of ABR for Newborn Hearing Screening
Hyde, Riko, and Malizia (1990) )
713 at-risk infants screened with ABR prior to hospital discharge. )
Children evaluated by "blind" examiners at mean of 3.9 years of age (range 3-8years). )
Results based on 1367 ears with reliable ABR and pure tone thresholds.
Hearing Status
Hearing Status
Impaired
Normal
Impaired
Normal 44 57
Refer 45
125
Refer
ABR Screen (40
ABR Screen
dBHL)
(30 dBHL) 1
1265
1197
Pass
Pass
Sensitivity = 98%
Sensitivity = 100%
Specificity = 96%
Specificity = 91%
Hyde, M.L., Riko, K., & Malizia, K. (1990). Audiometric accuracy of the click ABR in infants at risk for hearing loss.
J Am Acad Audio l, 1 ,

34. Accuracy of ABR for UNHS
Saint Barnabus Medical Center, NJ )
15,749 infants born from 1/1/93 to 12/31/95 screened with Nicolet Compass
ABR system without sedation. )
Normal care nursery babies screened at 35 dB HL; NICU and High Risk
screened at 40 dB HL and 70 dB HL. )
Screening done by audiologists, usually within 24 hours of birth. )
Babies with a High Risk Indicator who passed initial screen were
re-evaluated at 6 months.
# and %
# and %
PCHL # and
Births
Screened
Referred
Prevalence
16,229
15.749
485 52
(97%)
(3.1%)
3.3/1000
Barsky-Firkser, L., & Sun, S. (1997). Universal newborn hearing screenings: A three year experience.
Pediatrics , 99
(6), 1-5.

35. What Percentage of Hearing Impaired
Children were High Risk as Infants?
49%
Feinmesser et al. (1982)
54%
Pappas & Schaibly (1984)
48%
Elssmann et al. (1987)
43%
Watkin et al. (1991)
50%
Mauk et al. (1991)
50%
Mehl & Thomson (1998) 0%
50%
100%

36. Accuracy of High Risk Based UNHS Programs
Mahoney and Eichwald (1987) 2
Program operational from 2
JCIH indicators incorporated into legally required birth certificate. 2
Computerized mailing and follow-up, and free diagnostic assessments at regional
offices and/or mobile van. 2
Program now discontinued because: )
parents only made appointments for about 1/2 the children who had a risk
indicator. )
only about 1/2 of the children with an appointment showed up. )
of difficulty obtaining accurate information from hospitals for some risk
indicators.
Mahoney, T.M., & Eichwald, J.G. (1987). The ups and "downs" of high-risk hearing screening: The Utah statewide program.
Seminars in Hearing , 8
(2),

37. Results of Birth Certificate Based High Risk Registry to
Identify Hearing Loss in Utah ( )
Births, 283,298
Live Births with High
Risk Indicators
24,082 (8.5%)
Parent Response
No Response
12,699 (52.7%)
11,383 (47.3%)
Appointments for
No Concern
Diagnostic Evaluation
5,254 (41.4%)
7,445 (58.6%)
Diagnostic Evaluation
Broken
Completed
Appointments
5,644 (75.8%)
1,801 (24.2%)
Summary:
23.4% of live births with high-risk indicators completed a diagnostic evaluation;
.36 SNHL per 1000 identified.
Mahoney, T.M., & Eichwald, J.G. (1987). The ups and "downs" of high-risk hearing screening: The Utah statewide
program.
Seminars in Hearing , 8
(2),

38. Accuracy of Home-Based Behavioral Screening
Watkin, Baldwin and Laoide, 1990* )
Retrospective analysis of 171 hearing impaired children to determine how
they were identified. )
Hearing loss first noticed by:
Home visitor or Other than Parent
School Screening Parent (e.g., teacher, doctor, etc.)
Severe/profound 18 10 11
Bilateral (n = 39)
(46%)
(26%)
(28%)
Mild/Moderate 51 14 7
Bilateral (n = 72)
(71%)
(19%)
(10%)
Unilateral 34 18 8
(57%)
(30%)
(13%)
*Parental suspicion and identification of hearing impairment.
Archives of Disease in Childhood,
65,

39. Percentage of Hearing Impaired Children in Watkin, et
al. (1990) Identified by Home Screening at 7-9 Months
of Age 50 40 30 20 10
Severe/Profound
Mild/Moderate
Bilateral
Bilateral
Unilateral
(n = 39)
(n = 72)
(n = 60)

40. Newborn Hearing Screening
Accuracy of OAE-Based
Newborn Hearing Screening
Plinkert et al. (1990)
Sample:
95 ears of high-risk infants
Comparison:
TEOAE vs. ABR (
>
30 mean age = 9 weeks)
Results:
TEOAE compared to ABR: sensitivity = 90%;
specificity = 91%
Plinkert, P.K., Sesterhenn, G., Arold, R., & Zenner, H.P. (1990). Evaluation of otoacoustic emissions in high-risk infants by
using an easy and rapid objective auditory screening method.
European Archives of Otorhinolaryngology ,
247 ,

41. Kennedy et al. (1991) Sample:
370 infants (223 NICU, 61 normal nursery with risk
factors, and 86 normal lnursery with no risk factors
Comparison:
TEOAE, ABR (
>
35 dB), and Automated ABR (
>
35 dB)
all at 1 month vs. behaviorally confirmed hearing
loss, mean age = 8 months
Results:
TEOAE identified same 3 infants with sensorineural
hearing loss as ABR and automated ABR
Kennedy, C.R., Kimm, L., Dees, D.C., Evans, P.I.P., Hunter, M., Lenton, S., & Thornton, R.D. (1991). Otoacoustic emissions
and auditory brainstem responses in the newborn.
Archives of Disease in Childhood , 66 ,

42. Rhode Island Hearing Assessment Project (RIHAP)
1850 infants (normal and special care) screened prior to hospital discharge with TEOAE and ABR )
Referrals for either TEOAE or ABR were rescreened at 3-6 weeks and referred for diagnosis as
necessary
Fail TEOAE
Fail ABR
NICU
High-Risk
Failed test, Present in NICU, Risk Factor Present
Passed Test, Not in NICU, Risk Factors Absent
White, K.R., & Behrens, T.R. (Editors) (1993). The Rhode island Hearing Assessment Project: Implications
for universal newborn hearing screening.
Seminars in Hearing , 14
(1).

43. 11 79 1643 Accuracy of TEOAE 2-Stage Screen* RIHAP Screen
Sensorineural Loss
Hearing Status
Impaired
Normal 11 79
Refer
RIHAP
Screen
1643
Pass
"Sensitivity" = 100%
"Specificity" = 95%
*Note: Analysis is based on heads. Infants initially screened but lost to follow-up
or rescreen because of parent refusal, lost contact, or repeated broken
appointments (> 3) are not included.
White, K.R., Vohr, B.R., Maxon, A.B., Behrens, T.R., McPherson, M.G., & Mauk, G.W. (1994). Screening all
newborns for hearing loss using transient evoked otoacoustic emissions.
International Journal of Pediatric
Otorhinolaryngology , 29 ,

44. Accuracy of Automated ABR
Hall, Kileny, Ruth, & Kripal (1987)
Jacobson, Jacobson, & Spahr
(336 ears)
(1990) (447 ears)
Conventional ABR
Conventional ABR
Refer
Pass
Refer
Pass 18 11 33 17
Refer
Refer
ALGO I
ALGO I
307
397
Pass
Pass
Sensitivity = 100%
Sensitivity = 100%
Specificity = 97%
Specificity = 96%

45. Accuracy of Automated ABR
(continued)
Von Wedel, Schauseil-Zipf and
Hermann et al. (1995)
Doring (1988) (100 ears)
(304 ears)
Conventional ABR
Conventional ABR
Refer
Pass
Refer
Pass 8 4 42 6
Refer
Refer
ALGO I
ALGO I 2 86
256
Pass
Pass
Sensitivity = 80%
Sensitivity = 98%
Specificity = 96%
Specificity = 100%

46. Accuracy of Automated ABR Summary of 4 Studies
(1187 ears)
Conventional ABR
Refer
Pass
101 38
Refer
ALGO I 2
1046
Pass
Sensitivity = 96%
Specificity = 98%
Herrmann, B.S., Thornton, A.R., & Joseph, J.M. (1995). Automated infant hearing screening using the ABR: Development
and validation.
American Journal of Audiology , 4
(2), 6-14.

47. NIH Study: Identification of Neonatal Hearing Impairment
Multi-Center Study Based at University of Washington 2
Null Hypothesis: ABR, TEOAE, and DPOAE are equally effective for newborn hearing
screening. 2
7178 infants (4510 NICU and 2668 normal nursery) screened prior to discharge with
ABR, TEOAE, and DPOAE in random order. 2
Screening results will be compared with ear specific VRA at 8-12 months.* 2
Other issues investigated: !
Influence of co-existing medical factors on characteristics of OAE and ABR. !
Optimum stimulus and recording parameters for OAE. !
Time and cost-efficiency of ABR and OAE. !
Influence of external and middle ear status, test environment, and tester
characteristics.
Data collection completed October, 1997; data expected to be reported April 1998.

48. V. Efficiency of Existing UNHS Programs2
Coverage and Referral Rates 2
Effects on Parents 2
Follow-up

49. Births Per Year, Percent of Babies Screened, and
Reported Referral Rates of Universal Newborn
Hearing Screening Programs
Percent Babies
Reported Pass
# of
Average Births
Screened Before
Rate at
Hospitals
Per year
Discharge
Discharge a
OAE-Based Programs 64
2140
94.9
91.6% b 56
1348
96.2
96.0%
ABR-Based Programs
120
1767
95.5
93.7%
All Programs a
55 of 64 OAE-based programs were TEOAE, 9 were DPOAE b
54 of 56 ABR-based programs were automated ABR
White, K.R., Mauk, G.W., Culpepper, N. B., & Weirather, Y. (1997). Newborn hearing screening in the United States:
Is it becoming the standard of care? In L. Spivak (Ed.),
Neonatal hearing screening
. Thieme: New York.

50. Possible Adverse Effects for Parents of
Various Hearing Screening Results )
False-Positive 2
Adversely affect parent-child bonding (e.g., rejection or over-protection). 2
Anger, resentment, or confusion when child is confirmed normal. 2
Lingering concerns about whether child's hearing is normal. )
False Negative 2
Inappropriate confidence that child hears normally, thus delaying
identification. )
True Positive 2
Emotional stress during time of emerging parent-child relationship. 2
Incomplete or inaccurate information may be used to make future
reproductive decisions.
Adapted from Clayton, E.W. (1992). Screening and treatment of newborns.
Houston Law Review , 29
(1),

51. Parents’ Perceptions of Screening
Questionnaires administered by nurses to 169 babies born between 6/1/94 and 7/15/94.
Question
% Answering Yes
If you were in a hospital where you had to give your
98%
permission to have your baby's hearing screened,
would you give it?
If this screening were conducted for a fee of
71%
approximately $30, would you be willing to pay it?
Do you believe that any anxiety caused by your baby
88%
not passing the hearing screening would be
outweighed by the benefits of early detection if a
hearing loss was found to be present?
Barringer, D.G., & Mauk, G.W. (1997). Survey of parents' perceptions regarding hospital-based newborn hearing
screening.
Audiology Today , 9
(1),

52. Parents' Views About Newborn Hearing Screening
Watkin, Beckman, and Baldwin, 1995 2
208 parents of children with sensorineural hearing loss (average age of
child = 12.3 years) answered written questionnaires. 2
None of the children participated in a newborn hearing screening program. )
58% wished their child had been identified earlier. )
Only those whose children's impairments were mild or who
were confirmed in the first 18 months of life were satisfied with
the age of confirmation. )
89% preferred having a newborn hearing screening program
instead of what they had.
Watkin, P.M., Beckman, A., & Baldwin, M. (1995). The views of parents of hearing impaired children on the need for
neonatal hearing screening.
British Journal of Audiology , 29 ,

53. Hearing Loss Identified
Parent's Reaction
Constructive
Grief
Action
Denial
Depression
Acknowledgment
Anger
Guilt
Parental
Adjustment
Parental
Expectation
Disability Model
Cultural Model
of Learning
of Learning
Language & Communication

54. "...the 'harm-benefit ratio' of not implementing a universal newborn
hearing screening program is
better documented than the
alleged dangers of implementing
such a program."
White & Maxon, 1995, p. 208

55. VI. Cost Efficiency of Newborn Hearing Screening,
What does early detection and intervention
cost ? ,
Is protocol A more
cost-effective
than protocol B? ,
Is early hearing detection and intervention
cost-beneficial ?

56. Actual Costs of Operating a Universal
Newborn Hearing Screening Program
Cost
Personnel
$ 60,654
Screening Technicians (avg. 103 hrs./week)
Clerical (avg. 60 hrs./week)
Audiologist (avg. 18 hrs./week)
Coordinator (avg. 20 hrs./week
Fringe Benefits
(28% of Salaries)
16,983
Supplies, Telephone, Postage
12,006
Equipment
5,575
Hospital Overhead
(24% of Salaries)
14,557
TOTAL COSTS
$110,775
Cost Per Infant Screened = $110, ,253 = $26.05 :
Maxon, A. B., White, K. R., Behrens, T. R., & Vohr, B. R. (1995) Referral rates and cost efficiency in a universal newborn
hearing screening program using transient evoked otoacoustic emissions (TEOAE).
Journal of the American Academy
of Audiology , 6 ,

57. CDC Cost Study (1997) 2
Multi-center pilot UNHS cost study using 6 hospitals (one
each in CO, GA, LA, TN, UT, and VA). 2
Cost estimates based on self-report questionnaires with site
visits to 4 of 6 sites. 2
Standardized estimates used for equipment and overhead
costs.
Grosse, S. (September, 1997).
The costs and benefits of universal newborn hearing screening
. Paper presented to the Joint
Committee on Infant Hearing, Alexandria, VA.

58. Results of CDC Cost Study
3 Hospitals
3 Hospitals
Cost category
using TEOAE
using AABR
Staff time
$13.04
$10.73
Equipment
0.91
2.63
Supplies
0.51
9.33
Overhead
3.49
3.34
Total Cost
$17.96
$26.03
(Range)
($15-$22)
($22-$30)
Initial refer rate 8% 2%
Screening minutes per child
31.4
42.9
Audiologist minutes per child
17.0
5.4

59. Prevalence of Various "Screenable" Diseases Among Newborns4
3.5 3
Incidence of Disease
2.5 2
1.5 1
0.5
Permanent
Hearing Loss
PKU
Hypothyroidism
Sickle Cell
3.0/1000
.10/1000
.25/1000
.20/1000
Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon, P.R., Sia, C.C.J., & Blackwell, P.M. (1993). Implementing a statewide
system of services for infants and toddlers with hearing disabilities.
Seminars in Hearing
, 14(1),

60. Cost of Identifying Infants with Various Diseases Using
Current Screening Protocols in Rhode Island
$50,000
$40,000
Cost Per Infant Identified (1990 Dollars)
$30,000
$20,000
$10,000 $0
Permanent
Hearing Loss
PKU
Hypothyroidism
Sickle Cell
($8,683)
($40,960)
($40,960)
($40,960)
Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon, P.R., Sia, C.C.J., & Blackwell, P.M. (1993). Implementing a statewide
system of services for infants and toddlers with hearing disabilities.
Seminars in Hearing
, 14(1),

61. Cost of Educating Children with Hearing Loss in Various Settings
$40,000
$35,000
$30,000
Annual Cost
$25,000
$20,000
$15,000
$10,000
$5,000 $0
Regular Classes
Self-Contained Classes
Residential Programs
($3,383)
($9,689)
($35,780)
Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon, P.R., Sia, C.C.J., & Blackwell, P.M. (1993). Implementing a statewide
system of services for infants and toddlers with hearing disabilities.
Seminars in Hearing
, 14(1),

62. VII. Establishing a Standard of Care,
Expectations for a reasonable practitioner under
similar circumstances ,
Guidelines and standards ,
Availability of technology

63. A physician ... impliedly represents that he
possesses ... that reasonable degree of learning and
skill ... ordinarily possessed by physicians in his
locality.... [It is the physician's] duty to use
reasonable care and diligence in the exercise of his
skill and learning ... [he must] keep abreast of the
times ... departure from approved methods and
general use, if it injures the patient, will render him
liable.
Pike v. Honsinger, 1898

64. Guidelines and Standards,
Healthy People 2000 ,
NIH Consensus Conference ,
Joint Committee on Infant Hearing ,
Joint Commission on Accreditation of Health
Organizations

65. STANDARD OF CARE ... when does a guideline become a standard? The
answer is when an inexpensive and reliable device
comes onto the market, the technology and concept
of which have already been adopted by a group
who specialize in the concept ... A guideline
becomes a standard of care when the device behind
the guideline is available and readily usable as a
practical matter by members of other medical
specialities who have cause and reason to consider
its use.
Wm H. Ginsburg, Jr.,
Annals of Emergency
Medicine
, 1993, 22 ,

66. What are the Objections to Hospital-based Universal Newborn
Hearing Screening? ,
It's too hard to do it in the newborn nursery. ,
It's too expensive / Insurance won't pay for it. ,
Pediatricians can do it easier as a part of well-baby
care. ,
There's no evidence that earlier is better. ,
It's not mandated.