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Online-EHDI Case 1 (Part 1 Answers to Questions)

Case 1: A Healthy Newborn That Does Not Pass the Hearing Screen


Part 1

History: Jamiel Sweager comes for his first well child visit at 2 weeks of age. He was a 7 lb 8 oz baby boy, born at term to a 27 year old woman after an uncomplicated pregnancy, labor, and delivery. His parents report that they are worried because they were told in the hospital that Jamiel failed his newborn hearing screening bilaterally. They are confused about why this test was done in the first place and what they should do now. Mrs. Sweager becomes very tearful during the visit as the discussion proceeds.
1. What would you tell them about Universal Newborn Hearing Screening (UNHS)?

• It is a state law in Pennsylvania, passed in 2001.
• The prevalence of permanent, significant hearing loss is approximately 1 to 6 per 1000 children born at term and higher in children born prematurely or experiencing complications in the newborn period.
• Untreated significant hearing loss can have adverse effects on speech, language,cognition and psychosocial functioning. Early treatment significantly reduces these adverse effects. Thus, it is extremely important to make an early diagnosis of hearing loss and provide effective therapy. []
• Parental and professional observations frequently do not detect clinically significant hearing loss.
i. Targeted screening that evaluates only children with risk factors for hearing loss identifies only about ½ of the children with significant hearing loss.
ii. In the past, before the passage of laws regarding Universal Newborn Hearing Screening (UNHS), the average age of detection of hearing loss was 24 months of age or older
• Advances in technology allow for accurate, inexpensive objective hearing screening without the child needing to make a voluntary response. []
Hearing screening uses one of two techniques:
i. Evoked otoacoustic emissions (Evoked OAEs)
ii. Automated auditory brainstem response (Automated ABR or aABR).
iii. Evoked OAEs are quicker, less expensive and less invasive but lead to more false positives than automated ABRs.

2. What are the steps in Universal Newborn Hearing Screening (UNHS)?

• Newborns are screened in the hospital. If at discharge, the infant has “not passed” the screening in either ear then a “referral” is made.
• Parents, the child’s physician, the Department of Health, and the professional to whom the child is referred to all receive information about the results of the tests.
• If a referral has been made, the infant may return to the hospital where he or she was born for a second screening, or may be referred immediately to an audiologist for a second screening or diagnostic testing. The second screening should occur before the child is 1 month of age.
• If at the second testing session, the child passes the OAEs or aABRs in both ears and the audiologist or tester is confident of the results, no further testing is needed unless concerns arise.
• If the child does not pass the OAEs or aABRs again, then a diagnostic ABR is conducted. The diagnostic ABR uses many stimuli so that the threshold for responses can be determined at a range of frequencies. Definitive testing should occur by 3 months of age.
• If a hearing loss is identified, the child will most likely require hearing aids and also enrollment in Early Intervention. This step should occur before the child is 6 months of age. [Flow sheet on UNHS]

3. What would you advise them to do at this time?

• It is very important that the parents follow up on the recommendations provided in the hospital for a second screening or definitive testing.
• If they are uncertain about the recommendations for the second screening, then assist them in calling the hospital for clarification.
• A helpful tip is that if they are scheduled for an ABR, suggest they hold off feeding the baby until they arrive for testing. Hopefully the child will sleep after feeding for the testing.

4. How would you respond to Mrs. Sweager’s emotions?

• Mother’s often show intense emotional reactions in the aftermath of a delivery.
• Many women, as many as 20% or more in some studies, experience post-partum depression in the 3 months after delivery. A rare minority experience postpartum psychosis.
• The news that a child may have a health issue of any type can also lead to grief and guilt in new parents.
• Early recognition and treatment of postpartum depression may have a positive impact on mother-infant attachment and the subsequent social and emotional development of this infant.
• It is important to acknowledge and assess Mrs. Sweager’s feelings at this time. It is important to inquire about the causes of her crying. It is also important to ask about eating, sleeping, social contact, and feelings of hope versus hopelessness to get a sense of whether she may be becoming depressed. The Edinburgh Postpartum Depression Scale is a validated measure that can be useful in this setting for determining the severity of depression.
• If Mrs. Sweager’s scores suggest post-partum depression, the news of her child’s potential hearing loss represents one other stressor. A referral to her own physician is imperative.

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