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 International Journal of Pediatric Otorhinolaryngology 96 (2017) 4e10

Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology

journal homepage: http://www.ijporlonline.com/

The results of newborn hearing screening by means of transient

otoacoustic emissions e has anything changed over 10 years?
Katarzyna Wroblewska-Seniuk a, *, Grazyna Greczka b, Piotr Dabrowski b, Witold Szyfter b,
Jan Mazela a
a  , Poland
Department of Newborns' Infectious Diseases, Poznan University of Medical Sciences, ul. Polna 33, 60-535 Poznan
b  , Poland
Department of Otolaryngology and Oncological Laryngology, Poznan University of Medical Sciences, ul. Przybyszewskiego 49, 60-355 Poznan

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Universal newborn hearing screening (UNHS) has become the standard of care in many
Received 27 October 2016 countries. The aim of this study was to evaluate the results of UNHS after ten years of the program in
Received in revised form Poland and to compare them with the results of 2003.
14 February 2017
Methods: In the study, we analyze the results of UNHS in the University Hospital in Poznan, Poland.
Accepted 16 February 2017
Available online 21 February 2017
Between 01.01.2013 and 31.12.2013, 6827 children were examined by means of otoacoustic emissions.
Results: Risk factors (RF) were identified in 772 (11.3%) newborns, which is significantly less than 10
years ago (p < 0.05). The most frequent RF were: ototoxic medications, treatment in neonatal intensive
Keywords:
Hearing screening
care unit (NICU) and prematurity < 33 weeks of gestation. In 2003, the most frequent were ototoxic
Congenital hearing deficit medications and prematurity, less frequent was treatment in NICU and more common was low Apgar
Hearing loss score.
Newborn In 51 (6.6%) newborns with RF, the result of OAE was positive either unilaterally or bilaterally. In infants
without RF the result was positive unilaterally in 22 (0.4%) and bilaterally in 14 (0.2%) patients. These
results are significantly lower than in our former study.
The relative risk of positive result was the highest in infants with complex congenital anomalies
(RR ¼ 44.99), craniofacial anomalies (RR ¼ 17.46) and mechanical ventilation for > 5 days (RR ¼ 10.69). In
our previous study, the highest RR of positive test results was in infants with family history, congenital
malformations and low Apgar score.
We found that most predictive as to the final diagnosis was bilaterally positive OAE test. In most patients,
the second check confirmed the diagnosis, independently of RF.
The number of false positive tests at the 1st level of screening is significantly lower now than 10 years
ago, probably due to better staff training.
Conclusions: Long term monitoring and the appropriate management of hearing deficit in children is
essential. UNHS seems to be the most efficient way of finding children who require treatment of hearing
impairment. The prevalence of most risk factors of hearing deficit has significantly changed over the
years. The number of false positive results has significantly decreased over the years thanks to better staff
training.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction
Universal newborn hearing screening is a method that enables
identifying congenital deafness and hearing loss. Over the past two
decades, screening neonates for hearing deficit has become the
* Corresponding author.
E-mail address: kwroblewska@post.pl (K. Wroblewska-Seniuk).
standard of care in many countries all over the world. As a result,
approximately 1e3 infants per 1000 are being identified with
hearing impairment [1].
In Poland in 2002 the group of Polish neonatologists and oto-
rhinolaryngologists, together with The Great Orchestra of Christ-
mas Charity initiated The Polish National Universal Neonatal
Hearing Screening (PNUNHS) program. The program is designed to
evaluate hearing status of all children and consists of three levels.
The first level of hearing screening is performed during the first

http://dx.doi.org/10.1016/j.ijporl.2017.02.021
0165-5876/© 2017 Elsevier B.V. All rights reserved.
 K. Wroblewska-Seniuk et al. / International Journal of Pediatric Otorhinolaryngology 96 (2017) 4e10 5

2e3 days of life, by means of otoacoustic emissions (OAEs). At the before discharge home. Ten years ago, after the first year of the
same time the questionnaire on risk factors of hearing loss is filled PNUNHS program, we analyzed the results of newborn hearing
in (Table 1) [2,3]. screening by means of OAEs in this institution [4]. The aim of this
Children in whom the outcome of OAE is positive, i.e. that new study is to evaluate the results of newborn hearing screening
receive the result ‘refer’ for at least one ear and/or those who have after ten years since the program initiation and to compare them
at least one risk factor of hearing impairment, are referred for with our previous results. We wanted to check if anything changed
further evaluation and final diagnosis to the audiological centers as far as the prevalence of individual risk factors and the frequency
(IInd level of the hearing screening program). of positive results of hearing screening is concerned.
The IIIrd level of program is headed by most advanced audio-
logical centers, which are responsible for ultimate diagnosis,
2. Materials and methods
treatment and rehabilitation of children with hearing impairment
or deafness.
This is a retrospective analysis of the results of neonatal hearing
The program covers children in the entire country. The centers
screening program performed on neonates born at the University
are uniformly equipped with the appropriate devices and have
Hospital in Poznan, Poland between 01.01.2013 and 31.12.2013. All
access to the network terminals which enable them to send the
children were screened by means of otoacoustic emissions (OAEs).
data to the central database. In the database, the demographic data
According to the protocol, healthy neonates were screened in the
of patients, the information on risk factors, the results of all ex-
second or third day of life, whereas infants treated in intensive care
aminations and the information on performed tests and in-
or pathology units e when their general condition was stable. All
terventions are collected and analyzed.
children were tested bilaterally, without any sedation, while
At the moment, there are 407 departments that are responsible
sleeping. If the ‘pass criteria’ of the first test were not achieved, the
for Ist level of hearing screening, 71 centers of IInd level and 23
child was rescreened in the same way on the day of discharge from
centers of IIIrd level of PNUNHS. Since 2002, in the central database
the hospital. The result of the second test was treated as final. The
of PNUNHS 5 133 203 children have been registered, which ac-
screening tests were performed by the personnel trained in the use
counts for about 96% of all children born in Poland during this
of the equipment.
period.
Patient demographic data, risk factors of hearing loss and the
The main presumption of the program is to perform the hearing
results of screening were recorded in the questionnaire. The out-
screening in all newborns prior to hospital discharge and to refer
comes of screening were presented as either ‘positive’ (i.e. hearing
the children in whom the result is positive or who belong to the risk
problem detected) or ‘negative’ (i.e. hearing problem not detected)
group with high susceptibility of hearing loss for further evaluation.
which correspond to ‘refer’ in at least one ear and ‘pass’ in both
It gives a chance for early diagnosis and proper treatment of
ears.
hearing impairment. If there is a supposition of bilateral hearing
Children with positive test result and all children with risk
impairment, the diagnosis should be given by the end of the third
factors of hearing impairment aside from the test results, were
month of life. The program of early intervention, appropriate for the
referred to the outpatient audiology clinic for further evaluation
particular infant, should be implemented by the end of the sixth
within 3 months of life or immediately after hospital discharge.
month (hearing aids, cochlear implants, rehabilitation). All children
They were examined there with otoscopy, had immitance audi-
in need are regularly controlled by audiologist, phoniatrist, speech
ometry measurement performed, were screened once again with
therapist, psychologist and pediatrician. The general purpose of the
otoacoustic emissions and were examined by means of auditory
project is to prevent the adverse consequences of a delayed diag-
brainstem response (ABR) method. We collected the results of the
nosis on speech and language, as well as on cognitive development.
tests performed in the outpatient clinic to assess the accuracy of the
Thanks to the PNUNHS program all newborns have chance for
screening by means of OAEs before discharge from the hospital.
early diagnosis and treatment of hearing deficit and the age when
The STATISTICA 10 package was used for the analysis. Pearson
final diagnosis is given has significantly lowered. The method of
chi-squared test (Ɣ2), test for comparison of proportions, Relative
hearing screening is unified in all departments and the history of
Risk (RR) and 95% confidence intervals (CI) were calculated. A p
children with risk factors or positive result of hearing screening can
value < 0.05 was considered significant.
be monitored.
The University Hospital in Poznan, Poland is one of the biggest
hospitals taking part in the hearing screening program as the Ist 3. Results
level center. Each year more than 6000 children are being born and
treated there and almost all of them are screened for hearing deficit In the analyzed period 6938 children were born in the Univer-
sity Hospital in Poznan. Of this group, 6827 (98.4%) children were

Table 1
The risk factors of hearing loss included in the questionnaire of the Polish National Universal Neonatal Hearing Screening (PNUNHS) program.

1. Family history of hearing loss

2. Craniofacial anomalies
3. Complex congenital anomalies associated with congenital hearing loss
4. Congenital infections (TORCH infections)
5. Low birth weight (<1500 g)
6. Premature birth (weeks < 33)
7. Hyperbilirubinemia
8. Ototoxic medications (including but not limited to aminoglycosides used in multiple courses or in combination with loop diuretics such as furosemide)
9. Bacterial meningitis
10. Low Apgar score - 0e4 at 1 min
11. Low Apgar score - 0e6 at 5 min
12. Mechanical ventilation for at least 5 days
13. Intensive care >7 days
6 K. Wroblewska-Seniuk et al. / International Journal of Pediatric Otorhinolaryngology 96 (2017) 4e10
examined by means of the otoacoustic emissions in the neonatal
hearing screening program. The exam was not performed in 111
newborns due to various reasons: 86 of them died, other were
either transported to other institutions in first hours of life or their
mothers did not sign consent to perform the exam.
Positive result of the screening test was obtained in 51 (0.75%)
children bilaterally and in 36 (0.53%) children unilaterally. In 6740
children the result of the screening was negative. When comparing
these results with the results obtained in our former study [5], we
found that the number of positive results is significantly lower (test
for comparison of proportions (Chi2(1) ¼ 177.173; p < 0.0001)
unilaterally and (Chi2(1) ¼ 60.244; p < 0.0001) bilaterally) (Fig. 1).
Hearing deficit was finally diagnosed in 33 infants e in 8 unilat-
erally and in 25 bilaterally.
Risk factors were identified in 772 (11,3%) of newborns. This
result is significantly lower than the one from 10 years ago
(Chi2(1) ¼ 8.445; p ¼ 0.0037) (Fig. 1). The most often risk factors
were: administration of ototoxic medications, treatment in the
intensive care unit for more than 7 days and prematurity <33
weeks of gestation (Table 2). In 2003 similarly, the most often risk
factor were administration of ototoxic medications and prematu-
rity, however less frequent was treatment in the intensive care unit
and more frequent was low Apgar score (Fig. 2). There are signifi-
cant differences in the prevalence of most individual risk factors
between the two studies (test for comparison of proportions)
(Table 2). Significantly more frequent risk factors in infants born in
2013 were: treatment in the intensive care unit, TORCH infections,
family history of hearing impairment and craniofacial congenital
anomalies. On the contrary such risk factors as: the use of ototoxic
medications, prematurity and low Apgar scores were observed less
frequently than 10 years ago (Table 2, Fig. 2).
In 51 (6.6%) newborns with risk factors of hearing deficit, the
result of OAE was positive unilaterally (14 patients e 1.8%) or
bilaterally (37 patients e 4.8%). In infants without risk factors the
positive test result was received unilaterally in 22 (0.4%) and
bilaterally in 14 (0.2%) patients. All these results are significantly
lower (test for comparison of proportions; p < 0.01) than in our
former study [5], where the OAE test was positive in almost 25% of
infants with risk factors e 120 (16.2%) unilaterally and 63 (8.5%)
bilaterally. In infants without risk factors the positive test result was
received respectively in 99 (2%) patients unilaterally and in 74
(1.5%) bilaterally. Similar relationship was also observed in most
cases when analyzing subgroups with different number of risk
factors (Table 3).
Fig. 1. The main results of hearing screening program in the Poznan University Hospital in 2003 and 2013.
Most commonly neonates had one risk factor (n ¼ 324). The
prevalence of positive test results was not directly proportional to
the number of observed risk factors, similarly as in the group
analyzed in 2003 (Table 3).
The relative risk of positive test results was the highest in infants
with complex congenital anomalies (RR ¼ 44.99). High relative risk
was also connected with craniofacial congenital anomalies
(RR ¼ 17.46) and mechanical ventilation form more than 5 days
(RR ¼ 10.69) (Table 4).
In our previous study on the contrary we observed the highest
relative risk of positive test results in infants with positive family
history, congenital malformations and low Apgar score, however
the numerical values of those results were much lower.
The prevalence of most risk factors was statistically higher in
infants with positive than in those with negative test results. We
also observed that in children with bilaterally positive screening
test, complex congenital anomalies were diagnosed statistically
more often than in those with unilaterally positive or negative
screening test. The prevalence of other risk factors did not differ
between the group with unilateral and bilateral positive test result.
These results are generally similar to those presented in our earlier
study.
All children with positive screening results or with at least one
risk factor for hearing impairment were referred to the outpatient
clinic for further evaluation (IInd level of hearing screening pro-
gram). Out of 832 referred children, 618 (74,3%) turned up to be
assessed during the observation period. According to the protocol,
they were examined once again with otoacoustic emissions and
then had otoscopy and immitance audiometry measurement per-
formed and were examined by means of auditory brainstem
response method. The final diagnosis was based on the results of
OAE and ABR test. These results are much higher than in the pre-
vious analysis, where only about 24% of children referred for
reevaluation turned up to be assessed.
In Table 5 we present the final results of the exams performed at
the second level of hearing screening program. We found that most
predictive as to the final diagnosis was the situation when OAE
screening test at the Ist level was bilaterally positive. In almost 60%
of these children, the examination at the IInd level of screening
confirmed the initial diagnosis, independently of the presence or
absence of risk factors. On the contrary, all cases of unilaterally
positive OAE test revealed to be false positive results and in chil-
dren with risk factors only, in whom the result of OAE test was
negative, the percentage of positive results at the second level of
 K. Wroblewska-Seniuk et al. / International Journal of Pediatric Otorhinolaryngology 96 (2017) 4e10 7

Table 2
The prevalence of risk factors of hearing impairment in the study group (2013) with comparison of proportions from group (2005) [4].

Risk factor Year 2013 Year 2003 Comparison of proportions Chi2 95% CI p-value
(n ¼ 6938) (n ¼ 5601)

n % n %

Ototoxic medications 476 6.86 436 7.78 3.890 [-0.0066; 1.8568] 0.0486
Treatment in intensive care unit (>7 days) 331 4.77 194 3.46 13.263 [0.6013; 2.0124] 0.0003
Prematurity (<33 Hbd) 238 3.43 256 4.57 10.643 [0.4396; 1.8536] 0.0011
Mechanical ventilation (>5 days) 213 3.07 160 2.86 0.473 [-0.4034; 0.8140] 0.4915
Very low birth weight (<1500 g) 178 2.57 170 3.04 2.533 [-0.1202; 1.0727] 0.1115
Low Apgar score (<4 in first or <6 in fifth minute) 162 2.33 274 4.89 60.571 [1.8898; 3.2486] <0.0001
TORCH infection 123 1.77 36 0.64 31.675 [0.7446; 1.5191] <0.0001
Family history of hearing impairment 96 1.38 53 0.95 4.881 [0.0396; 0.8148] 0.0271
Craniofacial congenital anomaly 63 0.91 20 0.36 14.205 [0.2639; 0.8385] 0.0002
Complex congenital anomalies 40 0.58 NA NA e e e
Hyperbilirubinemia treated with exchange transfusion 3 0.04 8 0.14 3.663 [-0.0143; 0.2412] 0.0556
Bacterial meningitis 1 0.01 4 0.07 3.033 [-0.0208; 0.1711] 0.0816

NA e not available.

Fig. 2. The risk factors identified in screened children in 2003 and in 2013.

Table 3
The OAE test results in relation to the number of observed risk factors and the results of the test for comparison of proportions with the group from 2003 (p value).

Number of risk factors Number of children Positive test result

Unilaterally Bilaterally

N % p N % P

0 6166 22 0.4 <0.0001 14 0.2 <0.0001

1 324 4 1.2 <0.0001 11 3.4 0.0016
2 152 2 1.3 <0.0001 7 4.6 0.4178
3 95 0 0.0 0.0001 6 6.3 0.5763
4 66 0 0.0 0.0041 2 3.0 0.0556
5 85 6 7.1 0.1877 5 5.9 0.4974
6 28 2 7.1 0.4805 3 10.7 0.8682
7 22 0 0.0 0.0007 3 13.6 0.4420

screening was very low (1.8%).
Hearing deficit was diagnosed also in 2 patients who did not
have OAE test performed after birth and were referred directly to
the second level of hearing screening program. One of these chil-
dren did not have OAE test performed as he was discharged from
the hospital in the first day of life. He had no risk factors of hearing
deficit and was diagnosed with mild hearing deficit of mixed type.
The second child did not have OAE test performed because of
the congenital defect of external ears (microtia). He was finally
diagnosed with moderate conductive hearing deficit.
The character and the severity of the hearing deficit in all chil-
dren are shown in Table 6.
When comparing these results to those from 10 years ago, in
children with risk factors only, the proportion of children with
positive results at the second level significantly decreased
(p < 0.01) and in those with the positive result of the screening test,
8 K. Wroblewska-Seniuk et al. / International Journal of Pediatric Otorhinolaryngology 96 (2017) 4e10

Table 4
The relative risk of positive test results connected with single risk factors.

Risk factor Number of infants (n ¼ 6938) Number of infants with positive result of the screening test Relative risk of hearing deficit (RR)

Ototoxic medications 476 34 8.71

Treatment in intensive care unit (>7 days) 331 24 7.60
Prematurity (<33 Hbd) 238 16 6.34
Mechanical ventilation 213 22 10.69
(>5 days)
Very low birth weight (<1500 g) 178 14 7.28
Low Apgar score 162 14 8.02
(<4 in first or <6 in fifth minute)
TORCH infection 123 3 1.98
Family history of hearing impairment 96 2 1.68
Craniofacial congenital anomaly 63 12 17.46
Complex congenital anomalies 40 18 44.99
Hyperbilirubinemia 3 0 0
Bacterial meningitis 1 0 0

Table 5
The results of audiologic evaluation at the second level of hearing screening program.

The result of OAE at the first level Children examined at the second level Final diagnosis of hearing deficit at the second level of
of hearing screening program of hearing screening program hearing screening program

Unilaterally Bilaterally

N % N %

OAE negative þ risk factors 547 4 0.7 6 1.1

OAE positive unilaterally 18 0 0 0 0
OAE positive unilaterally þ risk factors 10 0 0 0 0
OAE positive bilaterally 11 1 9.1 4 36.4
OAE positive bilaterally þ risk factors 26 3 11.5 13 50.0
No OAE test 1 0 0 1 100
No OAE test þ risk factors 5 0 0 1 20.0

Table 6
The character and the severity of hearing deficit in the analyzed group of children.

Severity of the hearing deficit Mild Moderate Severe Profound

40 dB 41-70 dB 71-90 dB >90 dB
Character of the hearing deficit

Unilateral sensorineural hearing deficit 1 1 0 0

Unilateral conductive hearing deficit
Unilateral mixed hearing deficit
Bilateral sensorineural hearing deficit
Bilateral conductive hearing deficit
Bilateral mixed hearing deficit
2 3 0 0
1 0 0 0
2 7 2 1
5 7 0 0
1 0 0 0

it significantly increased (p < 0.01). This confirms that the number
of false positive and false negative tests at the Ist level of screening
program is significantly lower than earlier.
The children with the diagnosis of hearing deficit at the second
level of screening program were further referred to the audiology
clinic for control tests and to start treatment and rehabilitation (IIIrd
level of UNHS).
4. Discussion
Early identification and diagnosis of hearing impairment in in-
fants is of crucial importance as it increases the chance of appro-
priate speech and language development and reduces
socioemotional problems. When hearing loss is missed in the
neonatal period, it is usually not identified until the child is about
24e30 months old. This may have a profound impact on speaking
ability as well as later school performance, as the most “sensitive
period” of brain growth and language acquisition in the first few
months of life is lost [5e10]. It is known that the decline in language
learning aptitude due to hearing deficit is related to the changes at
neural level. The absence of appropriate linguistic input during the
early period of life has a direct impact on the neural pathways in the
brain that support language [11]. What is important, the structural
and functional changes in brain resulting from early linguistic
deprivation can be reversed to some extent by electrical stimula-
tion of the auditory pathway by a cochlear implant. The best effects
can be achieved when this intervention is done early in life, thanks
to the brain plasticity [11,12].
The only possibility to identify children with permanent hearing
impairment at the earliest time of life is universal newborn hearing
screening. Nowadays in many countries this procedure is the
standard of care, however the programs of hearing screening differ
between the regions. In some countries, screening programs based
on risk factors have been implemented. However permanent
childhood hearing impairment is still one of the most common
congenital disorders and in many cases, is not associated with any
risk factors [13]. It has been proven that the screening protocols
based on JCIH risk factors identify only 50e75% of infants with
hearing loss [14]. Similar is the result of our study were out of 11
children without any risk factors who had bilaterally positive OAE
test, 5 (36.4%) were finally diagnosed with hearing deficit. They
accounted for more than 15% of all children diagnosed with hearing
 K. Wroblewska-Seniuk et al. / International Journal of Pediatric Otorhinolaryngology 96 (2017) 4e10
deficit in the study group. Some investigators recommend universal
hearing screening unilaterally, some recommend for the additional
assessment only those children who did not pass bilaterally [15],
because the consequences of unilateral hearing deficit are not well
established. It is noteworthy that in our study, all unilaterally
positive results of OAE screening were false positives. It seems
however, that to be most efficient and reliable the hearing
screening program should be applied in all newborns, and should
be performed bilaterally.
Hearing impairment was diagnosed in 33 children of our study
group (0.48%) and severe or profound hearing deficit in 3 children
(0.04%). These numbers are higher than in other studies [1], how-
ever these results are not from the general population but from one
hospital only, in which there is a big neonatal intensive care unit
and many premature babies and infants with other pathologies are
born and treated. More than 11% of children of the study group had
at least one risk factor of hearing loss.
Otoacoustic emissions are used as a first-line technique for
neonatal hearing screening in most protocols as they are non-
invasive, time saving and easy to apply [16]. OAE testing can be
performed by a technician or a nurse and does not involve an
audiologist. It is worth to stress that screening by means of OAE
detects both conductive and sensorineural hearing loss, while
auditory brain stem response, used at the second level of screening
protocol, is the gold standard for diagnosing sensorineural deficit
[16]. It is recommended by the Joint Committee on Infant Hearing
to use OAE in healthy neonates, while infants admitted to NICU
should be screened with OAE as well as with ABR, due to the higher
prevalence of auditory nerve dysfunction in this group [2,16]. That
explains why NICU treatment for more than 7 days is treated as a
risk factor for hearing loss requiring additional diagnostic tests.
It should be highlighted that many infants do not show up for
reevaluation even if the result of the screening test is positive or if
they have risk factors of hearing impairment. The same issue is
underlined by other authors [17]. However, it is well known that in
many cases, especially after hypoxic events and in children with
very low birth weight, the hearing loss is delayed and/or progres-
sive. The 2007 Joint Committee on Infant Hearing position state-
ment clearly says that infants who pass the neonatal screening but
have a risk factor should have at least one diagnostic audiology
assessment by 24e30 months of age [2]. Some experts recommend
that children with congenital CMV infection, a family history of
hearing deficit and with malformations and syndromes associated
with hearing loss should undergo audiological follow-up every 4e6
months during their first two years of life and then annually by 6
years of age [18]. Neonates treated with ototoxic drugs should be
evaluated once during the first 3 months of life [18]. The same
applies to the children with positive result of the OAE test.
In our study, more than 25% of children were lost to follow up.
We think that at least some of them were eventually diagnosed and
treated in institutions that do not take part in the national program
of hearing screening and that is why they are missing, but at the
same time we suppose that some parents simply ignored the risk of
hearing deficit and did not keep the scheduled appointments for
their baby's further assessment. We should emphasize, however,
that this result is much better than it was 10 years ago when only
about 25% of referred infants were later examined in the IInd level
centers. This is probably due to the fact that the program is
nowadays better organized, there are clear instructions for Ist level
departments about referring children to follow-up and instructing
parents on where to go for the audiological assessment. IInd level
centers are also better prepared for these consultations. At the
beginning of the program the IInd level centers were overloaded
and insufficient, which resulted in parents' frustration and caused
that some of them headed for other institutions [19]. At that time,
9
most challenging was the fact that the risk factors were not well
defined and many children were unnecessarily directed for audio-
logical examination [19]. Nowadays the criteria when the child
needs further evaluation are much more precise. Another reason
for overloading the IInd level was also the high number of false
positive results [19]. Currently false positive results are rare as we
have more reliable equipment and staff performing the screening
test is well qualified and trained. In the hospital, there is a group of
five nurses and technicians whose only duty is to perform hearing
screening and report the results to the central database. They are all
continuously trained, they know the techniques and the equipment
very well and they have enough time to find optimal moment and
condition to perform the screening. In agreement with the learning
curve the percentage of positive results in 2013 is five times lower
than in 2003. Consequently, significantly less children are now
referred for further controls. There is also a statistically significant
increase in the number of children with positive result of the
hearing screening in whom the test at the second level was also
positive, that confirms the lower number of false positive results.
The prevalence of risk factors of hearing impairment in our
study group was significantly lower than in the population
analyzed 10 years before (11.3% vs. 13%). Similar frequency of risk
factors was observed by other authors [20,21]. Additionally, the
prevalence of individual risk factors has also changed over the
years. Significantly more often we find nowadays such risk factors
as treatment in the intensive care unit, TORCH infections, family
history of hearing impairment and craniofacial congenital anoma-
lies. On the contrary such risk factors as: the use of ototoxic med-
ications, prematurity and low Apgar scores were observed less
frequently than 10 years ago. However, we think that although
statistically significant, these differences are clinically negligible.
It is difficult to explain the reasons for changes in the prevalence
of single risk factors. It seems that less often observed low Apgar
scores are due to better perinatal care and to the fact that new
resuscitation techniques have been introduced over the years.
Fewer children are being born in poor state and even if born in bad
condition, thanks to quick respiratory support they receive better
Apgar scores.
Less frequent use of ototoxic medications is probably connected
with fewer and shorter use of antibiotics accordingly to the newest
recommendations for clinical management in postnatal period.
On the other hand, we observed that in our group significantly
more children have been treated in NICU for more than 7 days,
which is another risk factor of hearing impairment. Firstly, this is
probably due to the fact, that non-invasive ventilation is widely
used even in late preterm and term infants with respiratory prob-
lems and secondly, because more very preterm infants with
extremely low birth weight survive and are treated in NICU.
As far as TORCH infections are considered, it seems that they are
more often diagnosed nowadays, while their actual prevalence has
not changed.
Similarly, as before, we found that most children had only one
risk factor of hearing deficit. In the present analysis, we observed
also that the more risk factors exist, the higher is risk of the positive
result of the OAE test, which seems to be rational. As mentioned
before, this is probably due to the conjuncture of more precise
definitions of risk factors and better performance of screening test
by our staff. Understandably, most at risk of hearing impairment
seem to be infants with 5 and more risk factors, where the inci-
dence of positive OAE test results is more than 10%.
In accordance with the results of other studies, the highest
relative risk of positive hearing screening we observed in infants
with complex congenital anomalies and craniofacial anomalies. It is
well known that genetic defects are responsible for about half of
the cases of hearing impairment [22e25]. There are many specific
10 K. Wroblewska-Seniuk et al. / International Journal of Pediatric Otorhinolaryngology 96 (2017) 4e10
congenital syndromes that are associated with hearing loss [25],
but also isolated malformations of the pinnae, such as preauricular
skin tags and/or ear pits may be associated with a higher preva-
lence of hearing deficit [26]. Cleft palate also is associated with an
increased prevalence of conductive hearing loss [27].
Nearly all risk factors were observed statistically more often in
children in whom the screening test was positive than in those with
negative result. This is analogous to the data that we obtained in
our former study and to the results of other authors [28e31]. That
confirms also that risk factors of hearing deficit should be taken
into consideration when diagnosing hearing impairment in
children.
5. Conclusions
1. Long term monitoring for hearing loss and the appropriate
management of hearing deficit in children with risk factors is
essential.
2. Universal hearing screening seems to be the most efficient way
of finding children who require treatment of hearing
impairment.
3. The prevalence of most risk factors of hearing deficit has
significantly changed over the years. Significantly more often we
found now such risk factors as treatment in the intensive care
unit, TORCH infections, family history of hearing impairment
and craniofacial congenital anomalies, while the use of ototoxic
medications, prematurity and low Apgar scores were observed
less frequently than 10 years ago. The children with risk factors
require additional diagnostic tests in the first months of life.
4. The number of false positive results has significantly decreased
over the years thanks to better staff training.
Acknowledgements
We would like to acknowledge The Great Orchestra of Christmas
Charity Foundation - initiator and co-founder of Polish Universal
Neonatal Hearing Screening Program and all people who contrib-
uted to our work by performing screening tests in infants and
submitting data to the database.
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