COMMENTARY

Screen and Intervene: Improving Outcomes in Congenital Hearing Loss

William T. Basco, Jr., MD

Disclosures

December 14, 2017

Hearing Loss, Screening, and Outcomes

Bilateral permanent hearing loss affects 1-2/1000 newborns.[1] Research suggests that children identified as having bilateral permanent hearing loss will have better language outcomes with earlier intervention, but the supporting data have been retrospective and observational.[1] The real question of whether universal newborn hearing screening (UNHS) results in the desired cascade of earlier identification of hearing loss, prompt treatment, and improved language outcomes is still largely unanswered. Whether the benefits of early treatment vary with the degree of hearing loss or the timing of intervention is also unknown.

Ching and colleagues[1] evaluated a cohort of children to determine whether an intervention (hearing aid fitting or cochlear implantation) and the timing of that intervention improve language outcomes among children with different degrees of hearing loss. This study compared 50 children with hearing loss with a comparison group of 120 similar children with normal hearing. Children with hearing loss were those who had hearing aids or cochlear implants placed before age 3 years.

Language outcomes were assessed at age 5-6 years. The evaluators were all speech pathologists who were blinded to the intervention for each child as well as the severity of the child's hearing loss. Outcome measures included receptive and expressive vocabulary and language, performance in reading, mathematics, letter knowledge, speech production, functional auditory behavior, social skills, behavior problems, and health-related quality of life. The analyses accounted for birth weight, sex, degree of hearing loss, nonverbal IQ, disabilities, and other socioeconomic and demographic factors that might be associated with the outcomes. Using the outcomes from all assessments, a "global language score" was created to serve as the primary outcome.

Children with hearing impairment who were exposed to UNHS received a hearing aid at a mean of 9.1 months versus 19.1 months for infants who had not been screened, a significant difference. The median difference in the age at intervention was even greater (5.1 months for hearing-screened infants vs 21.3 months for nonscreened infants). Overall, 55.7% of the screened infants with hearing loss were fitted with a hearing aid before age 6 months compared with only 19.1% of those who had not been screened. Similarly, cochlear implants were placed earlier in hearing-impaired children who had been screened.

For the main outcome of interest, there was a strong association between earlier hearing augmentation and better language outcomes. In fact, even after accounting for personal and demographic variables, a large proportion of the variation in outcome was tied to the age at hearing augmentation. Similarly, the use of cochlear implants had large effect sizes on language outcomes. Furthermore, the benefits of early treatment were more substantial in children with more significant hearing loss.

These findings identified a strong positive effect of early intervention on language function at 5 years in children with hearing loss. These data suggest that UNHS is associated with earlier intervention with hearing aids or cochlear implants, and earlier age at intervention is associated with better language outcomes.

Viewpoint

As acknowledged by the investigators, this study does not directly tie UNHS to better speech and language outcomes in children with hearing loss. Not every hearing-impaired child who was screened early received early intervention. Conversely, not every child with hearing loss who was not screened received delayed intervention. Nevertheless, UNHS clearly allows an earlier age of intervention for most of the children who require intervention, so we may just have to take it on faith that it indirectly relates to hearing outcomes.

It's also worth ending with a quick review of the suggested hearing screening sequence endorsed by the American Academy of Pediatrics. First, all infants should complete UNHS by 1 month of age, and abnormalities should be confirmed by 3 months of age. The goal is to get children into treatment by 6 months of age.

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