Monitoring for newborn hearing screening programmes: an integrative review

Abstracts

In Brazil, hearing loss diagnosis does not occur in early years.  Among various factors that could explain this fact is that the parents do not know well about hearing health for their children, and then do not attend for the follow-up.  This literature review had as main goal to describe how the follow up has been done in Brazil, especially regarding to the audiologic exams, regarding to the follow up by the family, and regarding to educations activities for the health professionals.  In order to achieve that, an integrative review of the literature was done, leaded by the question: How the audiologic follow up has been done for the newborn hearing screening programs?  It was used the the following databases: Lilacs, Medline, IBECS and CidSaúde using combinations of the terms “follow-up studies”, “hearing” and “newborn screening”. Initially, 1130 articles were screened by titles and abstracts. Then, 21 full articles were pre-selected by title and summary.  Twelve articles answered the question of this review.  The results indicated that tests for hearing screening and audiologic were used more Evoked otoacoustic emissions and auditory brainstem response, and behavioral assessment, tympanometry and acoustic reflexes. Three studies reported the presence of educational programs and only one specified professionals realized that, being the nurse what else made these activities. The percentage of families who joined the monitoring varied considerably. It was interesting to see that those recommendations from local and international entities to perform the audiologic, seeking a standard of quality and effectiveness in the programs and the quality of the audiological evaluation.

Hearing; Neonatal Screening; Newborn; Infant

O diagnóstico da perda auditiva no Brasil é tardio. Um dos fatores que pode explicar este fato, mesmo diante de inúmeros programas de triagem auditiva implementados, pode ser a evasão das famílias, não concluindo a avaliação auditiva da criança. Objetivou-se descrever como vem sendo conduzido o acompanhamento audiológico nos Programas de Saúde Auditiva Infantil do Brasil, especialmente em relação aos exames realizados, adesão das famílias ao acompanhamento audiológico e ações educativas desenvolvidas. Realizou-se uma revisão integrativa da literatura, cuja pergunta norteadora foi: como vem sendo conduzido o acompanhamento audiológico nos Programas de Saúde Auditiva Infantil do Brasil? Levantamento nas seguintes bases de dados: Lilacs, Medline, IBECS e CidSaúde, utilizando combinações entre os termos “acompanhamento”, “audição” e “triagem neonatal”. Inicialmente, os 1130 artigos encontrados foram triados por títulos e resumos. Foram lidas na íntegra as 21 publicações pré-selecionadas por título e resumo, constatando-se que 12 artigos respondiam a pergunta desta revisão. Os exames para triagem auditiva e acompanhamento audiológico mais utilizados foram Emissões Otoacústicas e Potencial Evocado Auditivo de Tronco Encefálico, além de avaliação comportamental, timpanometria e reflexos acústicos. Três estudos referiram a presença de ações educativas nos programas e apenas um deles especificou os profissionais que as realizaram, sendo o profissional enfermeiro o que mais efetuou estas atividades. O percentual de famílias que aderiram ao acompanhamento variou consideravelmente. Acredita-se ser interessante observar recomendações de entidades locais e internacionais para realização do acompanhamento audiológico, buscando um padrão de qualidade e efetividade nos programas e a qualidade da avaliação audiológica.

Audição; Triagem Neonatal; Recém-Nascido; Lactente

INTRODUCTION

Newborn Hearing Screening (NHS) allows the detection of possible hearing problems in neonates and infants, enabling the diagnosis of hearing loss before the third month so that intervention can occur before six months of age, as recommended in national and international literature^1,2, in order to avoid significant delays in the language development of these children, if they are not diagnosed^3,4.

Since 1994, the Joint Committee on Infant Hearing (JCIH) has recommended conducting the Universal Newborn Hearing Screening (UNHS), or in other words, hearing screening for all newborn babies², as well as the identification of those who have risk indicators for hearing loss^5,6, fundamental to the existence of the monitoring protocol of at-risk neonates or infants. All these recommendations serve to guide public health actions in order to prevent and educate the public regarding the hearing health care.

Despite of the importance of having intervention as early as possible, the diagnosis of hearing loss in Brazil is tardy, occurring around the age of 3-4 and taking up to two years to complete⁷. One of the factors that may explain this late identification, even with numerous implemented hearing screening programmes, could be the families’ lack of adhesion. In other words, they do not attend the audiological monitoring when there is referral, and consequently, do not complete the hearing evaluation of the child. Thus, it is necessary to realise audiological monitoring and observe how this is being conducted in Child Hearing Health Programmes in Brazil, so that this reality can be changed.

The need to ensure auditory monitoring of infants with risk indicators comes from the increased possibility of late onset or progressive hearing loss in these individuals. Some factors may contribute to this monitoring, bringing improvements to the effectiveness of the child hearing health programme, such as investment in guidance to families about the importance of listening to language development, to improve their adherence to audiological monitoring and consequently provide the diagnosis of possible hearing loss^1,4,8. In certain cases, even without the presence of risk indicators, the family should return to the programme after hearing screening for other hearing tests of the child in order to complete the diagnosis.

Considering this context, some proposals may be used for greater involvement of the various health professionals in Child Hearing Health Programmes, for greater awareness of the risk indicators that may be related to hearing loss, highlighting educational activities. Thus, it is recommended to invest in the transformation of the knowledge of professionals who deal with newborns and infants, so they may act as a multiplier of knowledge for the families, besides identifying the need for referral to a hearing evaluation service. Educational programmes have proven to be useful for subsidizing practices directed to health professionals, making them agents of individual and collective changes in the families’ bio psychosocial context. Therefore, these professionals assume the role of facilitators of the population’s health education process^9,10.

Thus, it is important to investigate the audiological monitoring in Child Hearing Health Programmes. For that reason, it was decided to carry out an integrative review, aiming to describe how audiological monitoring is being conducted in Child Hearing Health Programmes in Brazil, especially addressing the tests conducted, the adherence of families to audiological monitoring and developed educational actions.

METHODS

This study consists of an integrative literature review, a method that allows the incorporation of evidence into practice and aims to gather and synthesize research results on a defined topic or issue in a systematic and orderly fashion, helping to further the knowledge about the investigated topic¹¹. The elaboration of the integrative review followed six stages: preparing the guiding question, 2) searching or sampling the literature, 3) data collection, 4) critical analysis of the included studies, 5) discussion of the results and 6) presentation of the integrative review¹².

To achieve the objective of this review, the following guiding question was prepared: how is audiological monitoring being conducted in the Child Hearing Health Programmes in Brazil?

For the article survey in the literature, an online search was conducted in January 2013 in the following databases: Latin American and Caribbean Centre on Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE), Spanish Bibliographic Index on Health Sciences (IBECS) and Literature on Healthy Cities / Municipalities (CidSaúde).

In the article search all possible combinations between the free term “monitoring” and controlled descriptors “hearing” and “neonatal screening” were used, found via Descriptors in Health Sciences (MeSH). The search results by combining descriptors (“hearing” and “newborn screening” and “monitoring”, “hearing” and “newborn screening”, “hearing” and “monitoring”, “newborn screening” and “monitoring”) according to the database can be seen in Table 1.

Table 1
Publications found from the combination of descriptors, according to the database. Recife, 2013

Descriptors	Lilacs	Ibecs	Medline	CidSaúde	Total of publications
“hearing” and “newborn screening” and “monitoring”.	6 articles	0 articles	10 articles	0 articles	16
“hearing” and “newborn screening”.	72 articles	14 articles	841 articles	0 articles	927
“hearing” and “monitoring”.	83 articles	1 article	40 articles	0 articles	124
“newborn screening” and “monitoring”.	25 articles	0 articles	38 articles	0 articles	63
TOTAL	186 articles	15 articles	929 articles	0 articles	1.130

After the search, 1130 publications were identified, of which 186 were found in the LILACS, 15 in IBECS, 929 in MEDLINE and none in CidSaúde.

Of this total, only articles that met the following criteria were included: articles published in Portuguese, English and Spanish; articles published up to the year 2012, without a minimum time limit; articles approaching the audiological monitoring of neonates and infants in a Child Hearing Health Programme in Brazil. Excluded were: studies that addressed only the monitoring in intervention stages or in cases of diagnosed hearing loss; publications that were not original research articles, such as informal case reports, book chapters, dissertations, theses, reports, news, editorials, unscientific texts. Articles that appeared in more than one database were counted only once.

The titles and abstracts of 1130 articles were read to verify their suitability for inclusion criteria, and thus their suitability to the study’s theme. From this pre-selection, 21 articles remained, which were then read in their entirety in order to measure their suitability to the theme of audiological monitoring in a Child Hearing Health Programme in Brazil. After reading the full texts, it was ascertained that 12 items responded to the question posed in this review. It is worth noting that at this stage of the selection meetings were held between the study’s authors to clarify doubts regarding the inclusion or exclusion of studies. This procedure aimed to reduce bias in selection, giving it greater safety and accuracy.

To assess the methodological rigor of the 12 selected studies, the adapted version of the Critical Appraisal Skills Programme (CASP) was used, composed of 10 items: objective, methodological adequacy, presentation of theoretical and methodological procedures, sample selection, data collecting procedure, the relationship between researcher and subjects, consideration of ethical aspects, data analysis procedure, presentation of results and significance of the research. For each item cited, a value of 0 (zero) or 1 (one) was assigned, with the end result being represented by the sum of the scores, with a maximum score of 10 points¹³.

The selected articles were classified according to the scores: level A – 6 to 10 points (good methodological quality and reduced bias) or level B – up to 5 points (satisfactory methodological quality, but with increased risk of bias). At the end of the evaluation, all studies were classified as level A, and remained in the sample.

After the classification process, the data collection for these 12 selected articles was carried out, and the following information extracted: the database where it was indexed; title, authors, journal, year of publication, language; article’s objectives; population or entity studied; level of evidence; methodological characteristics; audiological monitoring information. This was followed by a discussion on the selected studies for this integrative review presentation.

The results are part of the review of 12 original research articles that met the review criteria and were of good quality and methodologically rigorous. All selected publications have quantitative methodology.

The articles were also classified according to the 7 Levels of Evidence¹⁴, with 2 of them falling into evidence level 4 and the 10 remaining into level 6.

In Figure 1 the characteristics of the articles selected for this integrative review are presented.

LITERATURE REVIEW

Among the findings on the characteristics of the Hearing Health programmes described in the articles, the following issues for discussion were identified: tests performed to assess hearing, adherence to audiological monitoring and educational activities that promote audiological monitoring.

Tests performed for screening and audiological monitoring in the programmes referred to in this review’s articles were principally the TEOAE and the BAEP, although also cited were Imitanciometry, CER, DPOAE and Behavioural Audiometry.

The Multidisciplinary Hearing Health Committee (COMUSA) outlines some recommendations, one of which refers to methods of hearing assessment, such as the indication of hearing loss identification through hearing screening with sensitive and specific methods, recommending the use of electrophysiological (BAEP) and/or electroacoustic (EOAE register– by Transient Stimulus or Distortion Product) measures¹⁵.

The Otoacoustic Emissions test (OAE) is highly sensitive, faster than the BAEP, taking approximately one minute per ear, simple, easy to apply and interpret and has been highly recommended for NHS. The downside is that it does not identify retrocochlear changes, common in Intensive Care Unit (ICU) neonates, and suffers greater interference in case of disorders of the external ear (e.g. vernix) and middle ear (e.g. otitis). The association of the two screening procedures (OAE and BAEP) in the NICU has already been recommended by the National Institute of Health for babies who obtain result ‘failure’ in the OAE, before hospital discharge¹⁶.

In its latest publication, JCIH (2007) recommended the inclusion of BAEP in neonates who remain in the NICU for more than 5 days, associated with the OAE exam². The two-step protocol, with OAE + BAEP in automatic equipment, has the advantage of identifying retrocochlear alterations, thus more suitable for high-risk populations. This association brings disadvantages as the higher cost and longer for NHS, about 10 minutes¹⁶.

Alvarenga et al proposed the Model Project of Newborn Hearing Health, which consists of performing UNHS in two steps, test and retest, using EOAE. It also ensures an orientation period about the importance of performing NHS, with the mother still in bed, before hospital discharge. The screening is preferably performed before discharge and retest (audiological monitoring), on the day the Guthrie Test is performed at the maternity hospital¹⁷.

COMUSA further states that, in cases of a ‘failure’ result using the OAE method, it is recommended to use the automatic BAEP before hospital discharge, and/or on the return for retesting, as it can decrease the number of unnecessary referrals for diagnosis. Normal responses in automatic BAEP in both ears should be regarded as satisfactory screening. However, this committee also recommends guidance to parents or guardians in order to emphasize that, in the case of suspected difficulties in the development of auditory skills, a quality hearing care service should be sought immediately¹⁵.

The identification of hearing loss programmes enable diagnosis and intervention over a decisive period for the development of speech. However, for the goals of such programmes to be achieved, the adherence of families at all stages of this process is essential¹⁸.

Different quality indicators are proposed for the Child Hearing Health Programmes, such as the rates of family adhesion and non-adherence. The JCIH proposed/recommended that for a programme to be considered of quality, screening should be performed on at least 95% of newborns, and among those who obtain the result “failure”, at least 90% must undertake hearing evaluation by the third month of life².

However, the authors have shown great difficulties due to high dropout rates of families at various stages of the hearing health programme, although existing programmes seek to follow these recommendations and achieve these indices^7,19.

In a survey conducted in Massachusetts, in the United States, 11% of children who obtained a ‘failure’ result in hearing screening did not complete audiological monitoring, i.e. did not return for follow-up¹⁹. In a study conducted in Italy, there was a loss of 255 (16.46%) of the newborns who did not return to complete the audiological evaluation²⁰.

A study on the reasons for non-attendance at infant audiological follow-ups pointed to a number of aspects: low parental education, financial difficulties in bringing the child for evaluation, confusion around different postnatal appointments and referrals, and the fact that the mother has more children and observes infant’s reactions to sounds in daily life. It is also suggested that mothers’ lack of knowledge regarding the right of their children to screening and the impact of deafness on children’s speech and language development contribute to the non-adherence. Thus, it is believed that several factors can act as influencers on the adhesion of families of infants to screening programs²¹.

In another study, the socioeconomic and demographic factors found for mothers who did not complete the scheduled hearing screening were: mothers who had less than high-school education, who were from low-income families and lived in rural areas outside the city of Recife²².

There is a clear need for studies that assess demographic and socioeconomic conditions and relate these aspects to the results found in auditory screenings performed in maternity hospitals. Additionally, it is recognised how important are studies that investigate causes and solutions related to the unfavourable socioeconomic conditions identified in the population participating in this type of study²³.

Few programmes cited the adoption of hearing health education as a routine practice, which could work to enhance adherence to audiological monitoring, while the parents or guardians would be empowered in relation to care for the hearing health of their child.

Health promotion underpins a new approach in the context of public health, a radical model of health education, which prioritizes the breaking-down of verticality in the professional-user relationship and recognizes the user as a bearer of knowledge about the health-disease-care process²⁴.

Empowerment includes promoting awareness and providing information on health and life skills, enabling individual autonomy to make their own choices. The word carries the notions of different fields of knowledge, such as social sciences and health, and is associated with alternative ways of working with social realities²⁴.

Regarding the professional who conducted health education hearing family members, most were in the Nursing area, confirming the findings in the literature.

Research suggests that the orientation of the doctor or nurse about the need for the exam seems to have motivated mothers to seek the service of hearing evaluation, even if the mother does not quite know what test was taken and what it was for. This behaviour can be justified by the fact that we still live in a society where doctors and some health professionals enjoy much prestige, and their guidelines are followed without question. The effective participation of professionals who make up the hospital staff in the programme can ensure the information to parents regarding the procedures for conducting the screening, highlighting the role of the nursing sector which, in general, is very close to the mothers and babies during their stay in hospital. The programmes can benefit greatly from this partnership²⁵.

Another important aspect to be considered in Child Hearing Health Programmes is the identification of risk indicators. The identification of risk indicators in newborns and infants treated at a NHS service becomes important for their monitoring, enabling audiological monitoring and targeting preventative actions and promoting hearing health⁶.

The JCHI recommends hearing screening for all newborn babies, as well as the identification of those who have risk indicators for hearing loss, which is fundamental for the protocol for monitoring the neonate or infant at risk, given the possibility of late-onset or progressive hearing loss^2,5,6.

CONCLUSION

Audiological monitoring is being carried out in various ways, but with some commonalities amid the studied Infant Hearing Health Programmes.

The most-used tests for hearing screening and audiological monitoring were OAE and BAEP, and in some cases, behavioural assessment, tympanometry and acoustic reflexes were used. The order in which these tests were included in the programmes also varied, while the situations that required monitoring were the result of ‘failure’ in the screening test and/or the presence of risk indicators for hearing loss.

Families were invited to the audiological monitoring stage at the time of screening. In addition, few took advantage of other hospital activities to promote the returns for audiological monitoring, which would work as a strategy to ensure the family’s return to the programme, saving time and taking advantage of a single return to the health centre for multiple purposes.

Few studies have reported the importance or the presence of educational programmes in the Child Hearing Health Programme that could be very useful to improve adherence to audiological monitoring, while elucidating the real need to detect hearing loss and provide intervention as soon as possible. Only one study specified the professionals who conducted educational actions, with nurses being those who most often performed these activities.

The percentage of families who adhered to the audiological monitoring varied considerably in the publications found, meaning this fact may be due to the difference found in the operating of the programmes in question, which were different from each other, as well as those aspects of the study population.

It would be interesting to observe the suggestions and recommendations of local and international entities to conduct audiological monitoring of neonates and infants, so that they seek not only a standard of quality and effectiveness in the programmes, but also the quality of the audiological evaluation, ensuring detection of hearing loss as early as possible. However, each programme can change in order to adapt their actions to the population it serves and its location.

REFERÊNCIAS

• ¹
  Comitê Brasileiro sobre Perdas Auditivas na Infância (CBPAI). Recomendação 01/99 do Comitê Brasileiro sobre Perdas Auditivas na Infância. Jornal do Conselho Federal de Fonoaudiologia. 2000;3(7):5-6.
• ²
  Joint Committee on Infant Hearing (JCIH). Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Pediatrics. 2007;120(4):898-921.
• ³
  Colozza P, Anastasio ART. Screening, diagnosing and treating deafness – the knowledge and conduct of doctors serving in neonatology and/or pediatrics in a tertiary teaching hospital. São Paulo Med J. 2009;127(2):61-5.
• ⁴
  Sígolo C, Lacerda CGF. Da suspeita à intervenção em surdez: caracterização deste processo na região de Campinas/SP. J Soc Bras Fonoaudiol. 2011;23(1):32-7.
• ⁵
  Amado BCT, Almeida EOC, Berni PS. Prevalência de indicadores de risco para surdez em neonatos em uma maternidade paulista. Rev CEFAC. 2009;11:18-23.
• ⁶
  Griz SMS, Silva ARA, Barbosa CP, Menezes DC, Curado NRPV, Silveira AK, et al. Indicadores de risco para perda auditiva em neonatos e lactentes atendidos em um programa de triagem auditiva neonatal. Rev CEFAC. 2011;13(2):281-91.
• ⁷
  Berni PS, Almeida EO, Amado BC, Almeida Filho N. Triagem auditiva neonatal universal: índice de efetividade no reteste de neonatos de um hospital da rede pública de Campinas. Rev CEFAC. 2010;12(1):122-7.
• ⁸
  Cristobal R, Oghalai JS. Hearing loss in children with very low birth weight: Current review of epidemiology and pathophysiology. Arch. dis. child. fetal neonatal ed. 2008;93:462-8.
• ⁹
  Alvarenga KF, Bevilacqua MC, Martinez MANS, Melo TM, Blasca WQ, Taga MFL. Proposta para capacitação de agentes comunitários de saúde em saúde auditiva. R Atual. Cient. Pró-fono. 2008;20(3):171-6.
• ¹⁰
  Paschoal AS, Mantovani MF, Méier MJ. Percepção da educação permanente, continuada e em serviço para enfermeiros de um hospital de ensino. Rev Esc Enferm USP. 2007;41(3):478-84.
• ¹¹
  Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na Enfermagem. Texto & contexto enferm. 2008;17(4):758-64.
• ¹²
  Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein. 2010;8(1 Pt 1):102-6.
• ¹³
  Public Health Resource Unit, The University of Kent, Critical Appraisal of the Journal Literature. Critical Appraisal Skills Programme (CASP) - Evaluation tool for quantitative studies. England: Public Health Resource Unit; 2006.
• ¹⁴
  Galvão CM. Níveis de Evidência. Editorial. Acta paul. enferm. 2006;19(2):5.
• ¹⁵
  Lewis DR, Marone SAM, Mendes BCA, Cruz OLM, Nóbrega M. Comitê Multiprofissional em Saúde Auditiva – COMUSA. Braz J Otorhinolaryngol. 2010;76(1):121-8.
• ¹⁶
  Angrisani RMG, Suzuki MR, Pifaia GR, Testa JR, Sousa EC, Gil D et al. PEATE automático em recém nascidos de risco: estudo da sensibilidade e especificidade. Revista CEFAC. 2012;14(2):223-33.
• ¹⁷
  Alvarenga KF, Gadret JM, Araújo ES, Bevilacqua MC. Triagem auditiva neonatal: motivos da evasão das famílias no processo de detecção precoce. Rev Soc Bras Fonoaudiol. 2012;17(3):241-7.
• ¹⁸
  Fernandes JC, Nozawa MR. Estudo da efetividade de um programa de triagem auditiva neonatal universal. Cien Saude Colet. 2010;15(2):353- 61.
• ¹⁹
  Liu CL, Farrell J, MacNeil JR, Stone S, Barfield W. Evaluating loss to follow-up in newborn hearing screening in Massachusetts. Pediatrics. 2008;121(2): 335-43.
• ²⁰
  De Capua B,  Costantini D,  Martufi C,  Latini G,  Gentile M,  De Felice C. Universal neonatal hearingscreening: the Siena (Italy) experience on 19700 newborns. Early Hum Dev. 2007; 83(9):601-6.
• ²¹
  Fernandes JC. Estudo da efetividade de um programa de Triagem Auditiva Neonatal Universal [Dissertação]. Campinas (SP): Universidade Estadual de Campinas, Faculdade de Ciências Médicas; 2005.
• ²²
  Griz S,  Mercês G,  Menezes D,  Lima ML. Newborn hearing screening: an outpatient model. Int J Pediatr Otorhinolaryngol. 2009;73(1):1-7.
• ²³
  Griz SMS, Barbosa CP, Silva ARA, Ribeiro MA, Menezes DC. Aspectos demográficos e socioeconômicos de mães atendidas em um programa de triagem auditiva neonatal. Rev. Soc. Bras. Fonoaudiol. 2010(b);15(2):179-83.
• ²⁴
  Brites LS, Souza APR, Lessa AH. Fonoaudiólogo e agente comunitário de saúde: uma experiência educativa. Rev Soc Bras Fonoaudiol. 2008;13(3):258-66.
• ²⁵
  Munhoz SRM. Um programa de triagem auditiva neonatal: efetividade e ações educativas. [Dissertação]. Piracicaba (SP): Universidade Metodista de Piracicaba, Programa de Pós-Graduação em Educação; 2007.

Mailing address: Adriana Ribeiro de Almeida e Silva Rua Conselheiro Nabuco, 115A – Casa Amarela Recife – PE – Brasil CEP: 52070-010 E-mail: [e-mail]

Conflict of Interest: Non-existent

Publication Dates

• Publication in this collection
  may-jun 2014

History

• Received
  31 Jan 2013
• Accepted
  20 May 2013