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Targeted screening for hearing impairment in neonates: A prospective

observational study

Article  in  Indian Journal of Otology · January 2018

DOI: 10.4103/indianjotol.INDIANJOTOL_10_18

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Volume 24 / Issue 1 / January - March 2018

Indian Journal of Otology

Indian Journal of Otology • Volume 24 • Issue 1 • January - March 2018 • Pages 1-***

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Ÿ An Indexed International Journal
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Dr. M. K. Taneja
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 Original Article

Targeted Screening for Hearing Impairment in Neonates:

A Prospective Observational Study
Jehangir Allam Bhat, Rajesh Kurmi, Santosh Kumar, Roshan Ara, Amit Kumar Mittal
Department of Paediatrics, Kurji Holy Family Hospital, Patna, Bihar, India

Abstract
Background: The aim of this study is to estimate the incidence and determine the risk factors predictive of hearing impairment in newborn by
targeted hearing screening. Methods: This was a prospective, observational study conducted over a period of 1 year. We screened high‑risk
neonates for hearing impairment admitted to the Neonatal Intensive Care Unit using evoked otoacoustic emissions (EOAEs) and brainstem
auditory evoked response (BAER). Babies who tested refer on EOAE were subjected to BAER urgently. Babies having an abnormality on
BAER where confirmed as hearing impaired for this study. Results: A total of 195 high‑risk babies comprising males (95 = 48.7%) and
females (100 = 51.3%) were screened. Fifteen neonates (7.69%) tested refer in the initial screening procedure, i.e., EOAE, who then underwent
BAER and out of these 15 (7.69%) neonates, 12 (6.15%) had abnormal BAER, i.e., hearing impairment. The significant individual risk factors
in neonates with hearing impairment were stigmata and/syndrome associated with hearing loss, craniofacial anomalies, and hyperbilirubinemia
and Apgar score <4 at 1 min and <6 at 5 min. Hearing impairment increased from 0.917% for one risk factor, 6.66% for two risk factors,
10.52% with three risk factors, 28.57% with four risk factors, and 25% with five risk factors. Conclusions: In this study, the incidence of
hearing impairment was 7.69%. Stigmata and/syndrome associated with hearing loss, craniofacial anomalies, and hyperbilirubinemia and
Apgar score <4 at 1 min and <6 at 5 min are significant risk factors for hearing loss, hearing loss increased as risk factors increase.

Keywords: Evoked otoacoustic emissions, hearing impairment, high‑risk screening, newborn screening, risk infants, universal screening

Introduction improved outcomes for children who have congenital hearing

Screening is one of the most important methods of early
diagnosis of treatable diseases in children and hearing loss is
an important treatable disease of childhood.[1] The prevalence
of bilateral hearing loss is substantial, particularly in neonates
admitted to the Neonatal Intensive Care Unit  (NICU) who
frequently present with risk factors for hearing loss. The
prevalence of significant bilateral hearing loss in this group is
1%–3%, which is 10 times higher than that in the well‑baby
nursery population. [2] Furthermore, early intervention
in hearing‑impaired children  (aged 6  months or earlier)
improved their language and speech outcomes as well as
their socioemotional development.[3‑5] The congenital hearing
loss has been recognized for decades as a serious disability
for affected children, with a delay in diagnosis of 2 years or
more being the rule rather than the exception.[6] In 1993, the
National Institutes of Health recommended that every newborn
infant have a hearing test performed in the first few months
of life.[7] Yoshinaga‑Itano et  al.[8] revealed the significantly
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loss and received early intervention when compared to a cohort
of similar children who did not receive the benefit of early
screening and detection. Similarly, independent of specific
screening protocols and measures of screening follow‑up
success, affected infants who were born in a hospital with
an established screening program had significantly improved
outcomes when compared to those who were born in hospitals
that did not screen.[9]
Hearing screening can be done by two ways
Targeted (high risk) – In targeted hearing screening high‑risk
newborns are screened. High-risk newborn criteria are
defined by the Joint committee on infant hearing, year 2007
statement.[10]
Address for correspondence: Dr. Jehangir Allam Bhat,
Department of Paediatrics, Kurji Holy Family Hospital, Patna, Bihar, India.
E‑mail: ajaalam333@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non-commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Bhat JA, Kurmi R, Kumar S, Ara R, Mittal AK.
10.4103/indianjotol.INDIANJOTOL_10_18 Targeted screening for hearing impairment in neonates: A prospective
observational study. Indian J Otol 2018;24:42-6.

42 © 2018 Indian Journal of Otology | Published by Wolters Kluwer - Medknow

 Bhat, et al.: Target hearing screening in neonates
Universal newborn hearing screening : All newborn are
screened for hearing impairment.
Techniques used to assess hearing of infants should be capable
of detecting hearing loss of this degree in infants by the age of
3 months and younger. Of the various approaches to newborn
hearing assessment currently available, two physiologic
measures (brainstem auditory evoked response [BAER] and
evoked otoacoustic emissions [EOAEs]) show good promise
for achieving this goal.
BAER has been recommended for newborn hearing assessment
for almost 15 years and has been successfully implemented
in both risk register and universal newborn hearing screening
programs, follow‑up studies of infants screened by this
technique demonstrate acceptable identification of infants
with hearing loss.
EOAEs have been introduced for risk register and the assessment
of newborn hearing. Follow‑up studies of infants screened by
this technique are limited but suggest that EOAEs can identify
infants with hearing loss of approximately 30  dB HL and
greater. Hearing loss of 30 dB HL and greater in the frequency
region important for speech recognition (approximately 500
through 4000 Hz) will interfere with the normal development
of speech and language.[11]
Methods
A hospital‑based prospective, observational study was
conducted in the Department of Pediatrics, Kurji Holy Family
Hospital Patna, Bihar which is a tertiary care referral hospital
for children from June 2015 to May 2016. All neonates who
were delivered in this hospital or outside who came to this
hospital for further management who had below mentioned
any risk factors as defined by the Joint committee on infant
hearing. Year 2007 statement as follows.[10]
1. The family history of hereditary childhood sensorineural
hearing loss
2. Intrauterine infections (TORCH)
3. Craniofacial anomalies, including those with morphologic
abnormalities of the pinna and ear canal
4. Birth weight <1500 g
5. Hyperbilirubinemia at a serum level requiring exchange
transfusion
6. Ototoxic medications, including but not limited to the
aminoglycosides, used for more than 5 days or multiple
courses or in combination with the loop diuretics
7. Bacterial meningitis
8. Apgar scores of <4 at 1 min or <6 at 5th min
9. Needing mechanical ventilation for more than 5 days
10. Stigmata or other findings associated with a syndrome
known to include sensorineural and/or conductive hearing
loss.
Ethical committee clearance was given by the Hospital Ethical
Committee. Informed consent was obtained from the parents and
the guardians after explaining to them the purpose of this study.
Indian Journal of Otology  ¦  Volume 24  ¦  Issue 1  ¦  January-March 2018
Exclusion criteria
a. Consent not obtained
b. Active ear infections
c. Severe multiple anomalies are incompatible with life.
Neonates with one or more of the above risk factors were
screened for hearing impairment before the age of 3 months using
a two‑stage screening protocol which consisted of a preliminary
screening with EOAE. Participants who were referred during the
first screening with EOAE were subjected to further screening
with BAER to confirm the presence of hearing loss.
Results
A total of 195 high‑risk babies comprising (95 = 48.7%) males
and  (100  =  51.3%) females were screened. Twelve hearing
impairment cases were found. Out of them 4  (33%) and
8 (67%) were female. Hearing impairment had no significant
statistical relationship with gender (P = 0.199) [Table 1].
Occurrence of risk factors in increasing order of frequency was
ototoxic medications (65.1%), birth weight <2500 mg (48.2%),
and Apgar scores of  <4 at 1  min or  <6 at 5th  min  (22.6%).
These three were major risk factors. The percentage of other
risk factors was as follows: bacterial meningitis  (14.4%),
hyperbilirubinemia requiring exchange transfusion (13.6%),
TORCH infection  (3.6%), craniofacial anomalies including
those with morphologic abnormalities of the pinna and ear
canal (2.1%), and stigmata or other findings associated with a
syndrome known to include sensorineural and/or conductive
hearing loss (2.1%) [Table 2].
Fifteen (7.69%) neonates tested refer in the initial screening
procedure i.e. EOAE who then underwent BAER and out of
these 15 (7.69%) neonates, 12 (6.15%) had abnormal BAER,
i.e., hearing impairment.
The significant individual risk factors in neonates with hearing
impairment were stigmata and/syndrome associated with
hearing loss  (P  =  0.02), craniofacial anomalies  (P  =  0.02),
hyperbilirubinemia (P = 0.012), and Apgar score <4 at 1 min
and <6 at 5 min (P = 0.006). Since newborn screened were
having multiple risk factors, confounding of risk factors might
have occurred, to overcome the confounding all statistically
significant risk factors were analyzed using multivariate
logistic regression as shown in Table  3 which proved
craniofacial anomalies, hyperbilirubinemia, Apgar score  <4
at 1  min and  <6 at 5  min, and stigmata and/or syndrome
associated with hearing loss as independent risk factors.
Table 1: Gender distribution of study neonates with
hearing loss (n=12)
Refer EOAE, n (%) Hearing loss, n (%)
Male 6 (40) 4 (33)
Female 9 (60) 8 (67)
Total 15 (100) 12 (100)
P=0.199. Association between gender and hearing loss. EOAE: Evoked
otoacoustic emission
43
 Bhat, et al.: Target hearing screening in neonates

Table 2: Distribution of risk factors in neonates with normal hearing after EOAE followed by brainstem evoked response
audiometry and hearing loss after evoked otoacoustic emissions followed by brainstem auditory evoked response
Risk factor n (%) Normal hearing after Hearing loss after P OR
EOAE followed by EOAE followed by
BAER (n=183), n (%) BAER (n=12), n (%)
Familial hearing loss 4 (2.18) 4 (2.185) 0 ‑ ‑
Torch infection 7 (3.6) 6 (3.278) 1 (8.33) 0.364 2.682 (0.296‑24.273)
Craniofacial anomalies 4 (2.1) 2 (1.092) 2 (16.66) 0.020 18.1 (2.305‑142.123)
Birth weight <1500 g 94 (48.2) 88 (48.087) 6 (50) 0.987 1.080 (0.336‑3.472)
Hyperbilirubinemia 26 (33.1) 21 (11.475) 5 (41.66) 0.012 5.510 (1.604‑18.935)
Ototoxic medication 127 (65.1) 116 (63.387) 11 (91.66) 0.060 6.353 (0.802‑50.303)
Apgar score <4 at 1 min and <6 at 5 min 44 (22.6) 37 (20.218) 7 (58.33) 0.006 5.524 (1.659‑18.396)
Mechanical ventilation >5 days 16 (8.2) 14 (7.650) 2 (16.66) 0.257 2.414 (0.481‑12.115)
Stigmata and/or syndrome associated with hearing loss 4 (2.1) 2 (1.092) 2 (16.66) 0.020 18.10 (2.305‑142.123)
Meningitis 28 (14.4) 25 (13.661) 3 (25) 0.385 2.107 (0.534‑8.316)
OR: Odds ratio, EOAE: Evoked otoacoustic emission, BAER: Brainstem auditory evoked response

Table 3: Multivariate logistic regression analysis of significant risk factors for hearing loss
Risk factors Coefficient P OR 95% CI
Lower Upper
Craniofacial anomalies 3.104 0.020 22.286 1.585 313.304
Hyperbilirubinemia 1.819 0.012 6.165 1.424 26.696
Apgar score <4 at 1 min and <6 at 5 min 1.895 0.006 6.655 1.498 29.553
Stigmata and/or syndrome associated with hearing loss 3.818 0.020 45.505 3.436 602.668
OR: Odds ratio, CI: Confidence interval

Hearing impairment increased from 0.917% for one risk factor,
6.66% to two risk factors, 10.52% with three risk factors,
28.57% with four risk factors, and 25% with five risk factors.
As the number of risk factors per neonate increased, the
probability of being hearing impaired also increased as shown
in Table 4.
Discussion
The prevalence of bilateral hearing loss is substantial,
particularly in neonates admitted to the NICU who frequently
present with risk factors for hearing loss. The prevalence of
significant bilateral hearing loss in this group is 1%–3%,
which is 10 times higher than that in the well‑baby nursery
population. Furthermore, early intervention in hearing‑impaired
children (aged 6 months or earlier) improved their language and
speech outcomes as well as their socioemotional development.
It seems reasonable to include hearing screening into routine
programs. Thus, screening in a population at risk as performed
in the present study can only be regarded to be the first step
toward a universal screening.
In this study, 195 at risk neonates were screened for hearing
impairment using EOAE and who fail the EOAE test were
screened by BAER. Fifteen neonates tested refer to the initial
screening procedure, i.e., EOAE who then underwent BAER
and out of these 15 (7.69%) neonates, 12 (6.15%) had abnormal
BAER, i.e., hearing impairment. This implies a 50‑fold
increase in hearing impairment in high‑risk neonates. Similar
results have been obtained in the studies done by Zamani
et al.[1] (8%) and Maisoun and Zakzouk[12] (13.5%).
In this study, there was not much statistically significant
difference among male and female neonates regarding
hearing (P = 0.199) [Table 1] impairment which is consistent
with most of the prior studies such as Al‑Meqbel and
Al‑Baghli[13] Maqbool et al.[14]
In this study, use of ototoxic medications, birth weight <2500 g,
Apgar scores of  <4 at 1  min or  <6 at 5 th   min, and
hyperbilirubinemia were the major risk factors occurring in
65.1%, 48.2%, and 22.6% at 33.3% risk neonates, respectively
which is consistent with the study conducted by Zamani et al.[1]
and Meyer et al.[15] In the study by Christiane Meyer et al.,
12 ototoxic medication and birth weight  <1500  g were the
major risk factors. A higher percentage of hyperbilirubinemia
requiring exchange transfusion in the study is due to poor
follow‑up of neonates with blood group incompatibilities and
a higher percentage of home deliveries and poor accessibility
to pediatricians.
Apgar score  <4 at 1  min and  <6 at 5  min  (P  =  0.006),
stigmata and/or syndrome associated with hearing loss
(P  =  0.020), craniofacial anomalies  (P  =  0.020), and
hyperbilirubinemia (P = 0.012) were significant independent
clinical risk factors for predicting hearing impairment in
high‑risk neonates [Tables 2 and 3]. Al‑Meqbel and Al‑Baghli[13]
found premature birth (gestational age ≤34 weeks), positive
family history of hearing loss, hyperbilirubinemia, severe

44 Indian Journal of Otology  ¦  Volume 24  ¦  Issue 1  ¦  January-March 2018

 Bhat, et al.: Target hearing screening in neonates
Table 4: Hearing loss (evoked otoacoustic emissions
abnormal cases who undergone brainstem auditory
evoked response) in relation to the number of risk
factors present (n=195)
Number of Normal EOAE Abnormal Hearing loss
risk factors (n=183), EOAE (n=15), (n=12),
present n (%) n (%) n (%)
One (n=109) 107 (98.16) 2 (1.83) 1 (0.917)
Two (n=45) 42 (93.33) 3 (6.66) 3 (6.66)
Three (n=19) 16 (84.21) 3 (15.78) 2 (10.52)
Four (n=14) 10 (71.42) 4 (28.57) 4 (28.57)
Five (n=8) 5 (62.5) 3 (37.5) 2 (25)
EOAE: Evoked otoacoustic emission
perinatal asphyxia, ototoxic medication, and syndromes
associated with hearing loss as a significant risk factors for
hearing impairment. Meyer et al.[15] have reported craniofacial
anomalies, familial hearing disorders, and bacterial meningitis
as significant factors associated with pathologic BAER. Kumar
et al.[16] have reported major risk factors are NICU admission,
LBW, hypoxia, and jaundice. Gouri et  al.[17] found low
Apgar Score and family history of SNHL as an independent
risk factor. Similar findings were reported by Maisoun and
Zakzouk[12] and Chan et al.[18]
In this study, four neonates had a family history of hearing
loss, none had hearing impairment [Table 2]. This may be due
to smaller sample size and lack of proper hearing impairment
evaluation of neuro‑handicapped children in our set up.
In this study, two out of the four neonates who had craniofacial
anomalies had EOAE refer and another two were EOAE PASS.
On BAER testing, of these refer neonates, both have abnormal
BAER, i.e., hearing loss. On univariate regression analysis and
Chi‑squared testing (Fisher’s exact test), a value of P = 0.002
was derived which is statistically significant [Tables 2 and 3].
Similar findings have been reported by Srisuparp et al.[19]
In this study, EOAE response was recorded in five out of
26 neonates with hyperbilirubinemia as risk factor. On
BAER testing, all neonates had an abnormal response
(Hearing loss). On Chi‑squared (Fisher’s exact test), a value
of P = 0.012 was derived which proved hyperbilirubinemia as
a statistically significant independent risk factor for hearing
impairment [Tables 2 and 3]. In this study conducted by Zamani
et al.,[1] hyperbilirubinemia was the main cause of hearing loss.
In this study, as shown in Table 2, eight neonates out of 44,
who had low Apgar score as the risk factor had referred EOAE
response initially, but one neonate had normal BAER and seven
had an abnormal response, i.e., hearing impairment which is in
accordance with an earlier study conducted by Gouri et al.[17]
Another risk factor which has statistical significance as
an independent risk factor in the study is stigmata and/or
syndrome. Two out of the four neonates who had stigmata
and/or syndrome EOAE refer and another two were EOAE
PASS as shown in Tables  2 and 3. On BAER testing, of
Indian Journal of Otology  ¦  Volume 24  ¦  Issue 1  ¦  January-March 2018
these refer neonates, both have abnormal BAER, i.e., hearing
impairment. On univariate regression analysis and Chi‑squared
testing (Fisher’s exact test), a value of P = 0.02 was derived
which is statistically significant.
In this study, aminoglycosides were used for more than 5 days
in 127 neonates making up 65% of the total study infants. This
high percentage could be attributed to the high risk of sepsis in
our NICU. Of these 127 neonates, aminoglycoside use was the
only risk factor in 51 neonates, and one showed EOAE RERER
response which also had BAER abnormality so had hearing
loss. Of 76  cases who had other risk factors present besides
aminoglycosides, 12 had EOAE refer response. On BAER
testing, of these 12 cases, 10 had hearing loss confirmed as shown
in Table 2. In spite of being risk factor present in majority of
cases who had hearing loss 11 out of 12, it is not an independent
significant risk factor for hearing impairment  (P  =  0.06). It
could be due to a higher percentage of cases  (65%) having
aminoglycoside as a risk factor and the use of aminoglycosides
in appropriate dosages given at proper intervals such that the drug
concentration in blood remained below the toxic level. Similar
findings have been reported by Meyer et al.[15]
In this study, risk factor such as meningitis  (P  =  0.385),
intrauterine infection  (TORCH)  (P  =  0.364), birth
weight  <1500, (P  =  0.987), and mechanical ventilation
(P = 0.257) were not statistically significant risk factors for
hearing impairment [Table 2].
Hearing impairment increased from 0.917% for one risk factor,
6.66% for two risk factors, 10.52% with three risk factors,
28.57% with four risk factors, and 25% with five risk factors
[Table 4]. As the number of risk factors per neonate increased,
the probability of being hearing impaired also increased which
is in accordance with the study conducted by Srisuparp et al.[19]
and Zamani et al.,[1] and Maqbool et al.[14]
Conclusions
The study data indicate a high incidence of hearing impairment
in NICU graduates and a change in the pattern of risk factors
for neonatal hearing loss. Apgar score  <4 at 1  min and  <6
at 5 min, stigmata and/or syndrome associated with hearing
loss, craniofacial anomalies, and hyperbilirubinemia were
significant independent clinical risk factors for predicting
hearing impairment in high‑risk neonates. This study was the
first step toward implementing the hearing screening program
in our hospital and could help in meta‑analysis of the studies
on hearing screen; hence, that hearing screening could be
implemented throughout the country.
Acknowledgment
The authors are highly thankful to the hospital administration,
the paramedical staff of the pediatric department, hospital
statistician, and computer operators for helping in conducting
this research.
Financial support and sponsorship
Nil.
45
 Bhat, et al.: Target hearing screening in neonates
Conflicts of interest
There are no conflicts of interest.
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Indian Journal of Otology  ¦  Volume 24  ¦  Issue 1  ¦  January-March 2018