Current Status of Hearing Screening in the Neonatal Intensive Care Unit Shana Jacobs, B.S. Jackson Roush, Ph.D. Division of Speech and Hearing Sciences University of North Carolina School of Medicine Chapel Hill, NC

Faculty Disclosure l In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation. l This presentation will (not) include discussion of pharmaceuticals or devices that have not been approved by the FDA or if you will be discussing unapproved or off-label uses of pharmaceuticals or devices.

Acknowledgements l Karl White, NCHAM l State EHDI Coordinators

Background l Incidence of SNHL –Well-babies: 1-2:1000 –NICU 10-20:1000 l Because of the high incidence of permanent hearing impairment in this population, physiologic screening via ABR has occurred in the NICU since the 1980s l More recently OAEs are also used in the NICU – alone or in a combined ABR/OAE protocol

A growing concern for NICU Infants… l Auditory Neuropathy – Dysynchrony –Abnormal neural function at the level of the VIIIth nerve/brainstem in the presence of normal outer hair cell function –Incidence is higher than once thought 25% of NICU infants according to one recent study (Berg et al, 2005) –OAE screening alone will not identify AN/AD

Other Challenges in the NICU l Challenges –Ambient noise levels –Transfer before screening –Difficulties with tracking, follow-up –Lack of accurate, efficient reporting procedures

Nurseries in US Hospitals l Level 1 (basic care of well-babies) l Level 2 (moderate risk of serious complications): N=120 l Level 3 (specialty and subspecialty care including life support): N= % of newborn population receive care in Level 2 or 3 nursery (Bhatt, 2001; AAP, 2004)

Purpose of this study l To determine the technologies and protocols used for NICU hearing screening in the U.S. l To identify challenges associated with NICU hearing screening l To obtain an estimate of how many infants are being identified with AN/AD

Methodology l Survey Instrument –Electronically distributed –13 Questions Number of Well-Baby and NICU Infants screened NICU Screening Methods and Protocols Number of Babies Identified over the past year with AN/AD –Anonymous once submitted l Distribution – ed to State EHDI Coordinators, January, 2006 Used EHDI listserv to contact 51 coordinators (1 per state) –Two reminder notices sent l Returns as of January 30 th –23/51 (45%)

Please estimate the % of NICU infants discharged prior to screening over the past year l 0-2% discharged before screening: 15 (66%) l 3-5% discharged before screening: 1 (4%) l 6-10% discharged before screening: 3 (13%) l >10% discharged before screening: 1 (4%) l Unable to estimate: 3 (13%)

If an infant is not screened in the NICU prior to discharge, what is most likely to happen? l Primary care physician advised of need for initial screen l Family advised of need for initial screen l Referral for audiologic assessment

For the first NICU hearing screening, what technology is used? l OAE: 2 (9%) l ABR: 7 (30%) l OAE or ABR: 14 (61%)

In your state, who usually conducts the first NICU hearing screening? l Nurses l Hospital Technicians l Audiologists

If re-screening is provided in the NICU for infants who fail the first screen, what technology/protocol is most often used? 26% - AABR followed by AABR (6/23) 9% - OAE followed by ABR (2/23) 9% - OAE followed by OAE (2/23) 47% - Could be any of the above (11/23) 9% - Other 2/23

Please indicate the person who is most likely to perform NICU hearing re-screenings in your state? l Nurses l Audiologists l Hospital Technicians

How many re-screenings are typically performed prior to a referral for comprehensive audiology evaluation? l 57% - 1 re-screening (13/23) l 30% - 2 re-screenings (7/23) l 0% - 3 re-screenings (0) l 0% - More than 3 (0) l 13% - Variability in re-screens (3/23)

What are the most significant obstacles or frustrations associated with infant hearing screening in the NICU in your state? l Narrow window of time from when infant is available for screening to time of transfer; discharge before screening completed l Difficulty tracking children who are transferred from one facility to another (also transfers between nurseries within same hospital) l Hard to ensure follow-up of all infants who fails screening l Failure of some hospitals to report screening results; lack of coordination, uniformity of reporting

Obstacles and frustration (contd) l Medical staff may not appreciate the importance of hearing screening; need to give priority to medical concerns l Lack of uniformity in screening protocols l Lack of qualified screening personnel on weekends l Excessive ambient noise levels l Lack of audiologist availability for follow- up

Comparison of Eight States

Total SNHL Identified (one or both ears) N=8 States l Total Screened: 440,100 l Permanent HL1.6/1000 l % with AN/AD5%

Conclusions l NICU screening protocols vary widely even within some states l Some NICUs are using technologies/protocols that will not identify AN/AD l Prevalence estimates of permanent HL consistent with other reports l Infants with AN/AD approximately 5% of all infants identified with SNHL (unable to compare NICU vs. well- baby screening) l Many state EHDI coordinators report frustration with narrow window of opportunity for screening before discharge

Future Needs l Improved statewide systems for tracking and follow- up l Greater uniformity in statewide screening protocols l Further study and more detailed analysis needed to get an accurate estimate of AN/AD prevalence l Follow-up studies needed to determine the natural history of AN/AD l Program managers should be aware of the advantages of ABR for hearing screening in the NICU

Any questions?