rograms focused on screening of neonates and
infants for hearing loss often need to be led and supervised by
otolaryngologists. On the face of it, it seems a simple enough task,
that can be well executed with a well-trained team. However, the fact
that – this is not as simple as it looks – was brought home to us when
we agreed to lead the implementation of the Neonatal Hearing Screening
Program in our hospital. Managing such a program requires multiple
skills: being able to calm down a baby, interpreting complex
audiological tests, counseling the parents of a child who has failed the
test, and undertaking data entry and analysis. As specialists in the
field of otolaryngology, we are often theoretically aware of the fact
that 1-5 children out of every 1000 live births are affected by hearing
loss [1]. The fact that delay in identification of hearing loss can have
significant impact on the linguistic and educational outcomes of the
child [2], is what motivated us to accept this task.
As clinicians, we are mostly used to being approached
by patients and parents who are seeking our advice and expertise; the
issue of screening children who are apparently (or mostly) normal can be
rather daunting and challenging. The first step of screening begins much
before the hearing screener is inserted into the ear. It begins with
making the parents aware about the possibility of hearing loss in their
child and its consequent impact not only on the child, but also on the
family and the society in the current time, and in the future. They need
to be informed about the need for the test, the implications of the
result and the future course of investigations. Unless this aspect is
taken care of, the program would be headed towards failure. Parents may
refuse to accept the test. Even when the test has been undertaken, they
fail to bring the child for follow-up and often make decisions based on
hearsay. Hence, the importance of awareness, providing correct and
timely information in a culturally appropriate way and suitable
communication strategies cannot be overstated. The other challenge is
appointing a team of well-trained and qualified personnel to implement
the program. The team must have otolaryngological and audiological
professionals as well as pediatricians, nurses, technicians, and data
entry personnel, and also have an inbuilt strategy to develop linkages
with a variety of other departments such as ophthalmology, neurology and
psychiatry. The need for this diversity is also stated by the World
Health Organization in its guiding principles for neonatal and infant
hearing screening [1]. Due to logistic and financial reasons, a large
team is usually impractical, and team members often need to play
multiple roles like a labor room nurse may have to act as a hearing
technician and a counselor, while an audiological technician may have to
double-up as a data analyst.
Some aspects of the screening program can be
particularly difficult to execute, of which two important are:
1. Follow-up [3]: An unacceptably high
drop-out rate was experienced in the initial phase of implementation of
neonatal hearing screening program in our institute. Many parents did
not return for hearing assessment at the appointed date. This problem
was finally addressed through providing detailed information about
hearing loss, hearing tests, their method, need and implications, to
parents. Further, the protocol was changed to ensure that wherever
repeat testing was required, the appointment was given for the same date
when the parents were scheduled to return for other services such as
immunization. This saved them the expense and trouble of making two
visits to the hospital.
2. Stigma [4] attached to hearing loss and use
of hearing device is the other significant issue that affects the
implementation of the rehabilitative process. When faced with the
diagnosis of hearing loss, many parents refuse to accept it, and at
times, may even blame the person who conveys the news. This attitude is
not easy to overcome, and can only be dealt with by following a
culturally appropriate sensitive approach towards the family. Through
raised awareness, people learn to accept the screening program, hearing
loss and use of devices. Parent support groups can play a leading role
in improving acceptance of hearing loss and hearing devices.
The success of a neonatal hearing screening program
depends on many factors [5], that include
• Effective training and capacity development of
the team members
• Procurement, regular calibration and
maintenance of test machinery
• Evidence-based protocols
• Family centered services with effective
strategy and suitable materials to raise awareness about hearing
loss, its identification and management
• Effective communication with parents
• Effective tracing and follow-up mechanism
• Availability of services for fitting and
maintenance of good quality, reasonably priced hearing devices
• Dependable budget
• Provision of guidance for language development
and education of children identified with hearing loss.
1. Newborn and Infant Hearing Screening: WHO Guiding
Principles For Action, 2009.
2. Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL.
Language of early- and later-identified children with hearing loss.
Pediatrics. 1998;102:1161-71.
3. Gaffney M, Green DR, Gaffney C. Newborn hearing
screening and follow-up: are children receiving recommended services?
Public Health Rep. 2010;125:199-207.
4. Olusanya BO. Follow-up default in a hospital-based
universal newborn hearing screening programme in a low-income country.
Child Care Health Dev. 2009;35:190-8.
5. Hayes D. State programs for universal newborn hearing screening.
Pediatr Clin North Am. 1999;46:89-94.