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- Indian J Otolaryngol Head Neck Surg
- v.75(Suppl 1); 2023 Apr
- PMC10188711
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Indian J Otolaryngol Head Neck Surg. 2023 Apr; 75(Suppl 1): 16–22.
Published online 2022 Aug 19. doi:10.1007/s12070-022-03138-6
PMCID: PMC10188711
PMID: 37206804
Aneena K. Siddique,
1 Renuka S. Melkundi,2 Arunraj Karuppannan,3 Siddaram Patil,2 and N. Sreedevi4
Author information Article notes Copyright and License information PMC Disclaimer
Abstract
The studyestimated the prevalence of hearing impairment in high-risk neonates and effect of high-risk factors on the hearing. A hospital-based cross sectional study was conducted on 327 neonates with high-risk factors. All the high-risk babies were screened using TEOAE and AABR followed by diagnostic ABR testing. Six (2%) of high-risk neonates werefound to have bilateral severe sensorineuralhearing loss. Risk factors associated with hearing impairment include multiple risk factors of Preterm delivery, hyperbilirubinemia, congenital anomalies, neonatal sepsis, viral or bacterial infection, positive family history of hearing loss and prolonged NICU stay. Further, the inclusion of AABR along with TEOAE has been shown to be a useful tool in reducing false-positive rates and identifying hearing loss.
Keywords: Hearing loss, High-risk neonates, TEOAE- Transient evoked otoacoustic emissions, AABR- Automated auditory brainstem response, ABR- Auditory brainstem response
Introduction
Hearing is one of the important five senses required for normal speech and language development. Children with limited speech and language face many problems including poor social, educational, emotional, and economic well-being. Congenital hearing loss affects between 1.2 and 5.7 out of every 1000 live births [12]. Early identification of hearing loss and timely rehabilitation with the right resources improve their hearing and communication skills. Hearing tests such as otoacoustic emission (OAE) and automatic auditory brainstem response (AABR) are generally recommended for newborns. These tests are non-invasive and require minimal patient cooperation. The OAEs will assess the outer hair cell functioning, while AABR measures the functional integrity of the auditory pathway. OAE shows 67% sensitivity and 98% specificity [25], while AABR has been reported to have a sensitivity of 94% and a specificity of 64% [11]. To avoid false-positive outcomes, screening tests based on TEOAE and AABR have been utilized in major screening programmes. Combined physiological tests (OAE and AABR) show high sensitivity (86%) and specificity (96%) than individual auditory measures, reducing false-negative (1.3%) and false-positive (0.3%) responses [24]. The Joint Committee on Infant Hearing [6, 7] and other guidelines such as AAP recommend that all babies undergo newborn hearing screening using either the AABR or OAE and or both the tests before discharge from the hospital. However, the revised JCIH guidelines (2019) suggested the use of OAE and AABR to avoid missing the auditory neuropathy spectrum disorders (ANSD).
Apart from that, several studies have shown that the risk factors are the major indicators for hearing loss that need continuous monitoring of auditory and language skills [3, 6]. Risk factors include newborn stayed in NICU for more than five days, assisted ventilation, low Apgar score, pre-term babies, craniofacial anomalies, ototoxic drug exposure, In Utero-infection, Neonatal Sepsis, gestational age and meningitis [4, 6, 20]. In addition, family history of hearing loss and consanguineous marriages are associated with greater risk of hearing loss [5, 9, 15, 23], and its prevalence varies with regions and countries [19, 20].
The lack of knowledge on risk factors associated with congenital hearing loss by either parents or health providers often limit the early diagnosis and rehabilitation. Ravi et al. [19] surveyed to explore the knowledge and attitude of mothers towards newborn hearing screening in Karnataka. Mothers were unaware of the risk factors, for example, neonatal hyperbilirubinemia, delayed birth cry, convulsion, low birth weight, ototoxic medication, and measles that could cause hearing loss. Seventy-five percent of the population agreed that there is a treatment for hearing impairment. Only 56% of the population was aware that children with congenital hearing loss could have the same educational opportunities as their peers, with early detection and intervention.
Since there is a lack of awareness about the necessity of neonatal hearing screening and risk factors of hearing impairment. It is necessary to document the information about the high-risk factors and determine the prevalence of hearing loss in those high-risk neonates. Also, the reported risk factors of hearing loss vary among studies and several other conditions. A better understanding of the high-risk factors of hearing loss would prevent this disabling and highly prevalent disorder. Therefore, the purpose of this study is to estimate the prevalence of hearing impairment in high-risk neonates in the Kalburagi region of Northern Karnataka and delineate the possible risk factors associated with hearing impairment.
Materials and Method
This is a cross-sectional prospective clinical trial carried out in a tertiary care hospital in the Kalaburagi district of Northern Karnataka. A total of 327 high-risk infants born between January and June 2021 were included in the study. Of these, 170 (52%) babies were male and 157 (48%) were female. The risk factors considered in this study are listed in Appendix 1 and the information about the presence of risk factors was collected from the parents/care-givers and medical records. The distribution (percentage) of these risk factors is shown in Table Table1.1. In addition, 152 (46%) infants had a single high-risk factor, and 175 (54%) infants had multiple risk factors, i.e. presence of two or more risk factors.
Table 1
Distribution of pre-natal, natal and post-natal risk factors in neonates
| Risk factors (n = 327) | No | Percentage (%) | |
|---|---|---|---|
| Pre-natal | Family history of hearing loss | 6 | 1.8 |
| Elderly pregnancy | 7 | 2.1 | |
| Gestational diabetes | 7 | 2.1 | |
| Gestational Hypertenstion | 17 | 5.2 | |
| History of abortion | 17 | 5.2 | |
| Gestationalviral/Bacterial infection | 2 | 0.6 | |
| Rh incompatibility | 1 | 0.3 | |
| Natal | Low birth weight | 113 | 34.6 |
| Preterm | 74 | 22.6 | |
| Hyperbilirubinemia | 82 | 25 | |
| Delayed birth cry | 46 | 14 | |
| Neonatal Asphyxia | 70 | 21.4 | |
| Meconium Aspiration | 15 | 4.6 | |
| Prolonged NICU stay | 151 | 46 | |
| Post- natal | Congenital anomalies | 11 | 3.4 |
| Viral/ bacterial infection | 7 | 2.1 | |
| Hypoglycemia | 2 | 0.6 | |
| Neonatal Sepsis | 7 | 2.1 | |
| Neonatal convulsion | 16 | 4.9 |
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All of these newborns had a hearing test before discharge. Transient click-evoked OAE (TEOAE) and chirp-evoked Automated Auditory Brainstem Response (AABR) were administered with Maico Easyscreen OAE + AABR screener. Neonates failed in AABR test or both the TEOAE and AABR tests were considered as ‘REFER’ and had undergone detailed diagnostic Auditory Brainstem Response (ABR) [RMS Medulla 201 BERA AEP System] within a month to confirm the hearing loss. The protocol followed and the parameters considered for recording TEOAE, AABR and detailed ABR are provided in Table Table22.
Table 2
Stimulus parameters for Screening and Diagnostic test tools
| Stimulus | Non-linear clicks |
|---|---|
| I. TEOAE screener | |
| Click rate | 50–80/sec |
| Stimulus intensity | 60dB peSPL to 83dB peSPL auto in-ear calibration |
| Frequency region | 1–4kHz |
| Passing criteria | SNR of > 4dB in three out of four frequency bands with a reproducibility of 50% or greater (Default setting) |
| II. AABR screener | |
| Stimulus type | CE-Chirps |
| Intensity | 35dB nHL |
| Click rate | 88–92.5/s (Default) |
| Transducer | Insert receiver IP30 |
| Electrode montage | Horizontal Montage (Inverting—Test ear mastoid Non-inverting—Forehead; Common Ground—Non-test ear mastoid) |
| III. Diagnostic ABR | |
| Stimulus type | 100µs Clicks |
| Intensity | Varied from90to30 dBnHL |
| Click rate | 11.1/s |
| Transducers | ER-3A insert earphones |
| Polarity | Rarefaction |
| Averages | 1500 |
| Filter setting | 30–1500Hz |
| Electrode montage | Horizontal Montage (Inverting—Test ear mastoid; Non-inverting—Forehead; Common Ground—Non-test ear mastoid) |
| Interpretations | Waveforms were recorded at various intensities, beginning at 90 dBnHL. At each intensity, two replications were obtained, and peaks I, III, and V were marked wherever they appeared |
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All the neonates included in the study were tested in a sound-treated room of the Audiology department- GIMS hospital, in the presence of parents/caregivers, preferably when the baby was sleeping with all precautionary measures. Ethical approval of the study was obtained from the institutional review board of GIMS, Kalaburagi. Consent from parents or caregivers has been obtained.
Statistical Analysis
The statistical analyses were performed using the IBM Statistical Package for Social Sciences (SPSS) version 20. The frequency of risk factors associated with hearing loss was studied using descriptive statistics. The Chi-squared test was used to determine the significant associationbetween therisk factors and hearing loss.
Results
In the present cross-sectional study conducted at GIMS hospital, all 327 neonates had one or more high-risk factors. All neonates underwent TEOAE and AABR screening as a preliminary test. Out of 327, 299 (91%) neonates passed TEOAE in both ears while 28 (9%) failed in either one of the ear or in both ears. All the babies underwent AABR screening to avoid chances of missing out auditory neural disorders and false positive response. Neonates shown as ‘PASS’ in TEOAE screening, i.e. 299 (91%) were also shown ‘PASS’ in AABR as well. Out of 28 (9%) neonates who were ‘REFER’ in TEOAE screening, 22 (7%) were ‘PASS” and 6 (2%) were ‘REFER’ bilaterally in AABR results, as shown in Fig.1.
Fig. 1
Graphical representation of a TEOAE results b AABR results c Diagnostic ABR results
Neonates who failed in AABR screening 6 (2%) were subjected for detailed testing using diagnostic ABR to confirm hearing loss. All neonates failed in AABR found to have bilateral severe sensorineural hearing loss, indicating a prevalence rate of 2%. Of the 6 (2%) neonates, 4 were males and 2 were females. Neonates identified with hearing loss, had multiple risk factors such as premature delivery, low birth weight, hyperbilirubinemia, Neonatal sepsis, Neonatal asphyxia, congenital anomalies, Family history of hearing loss and meningitis. All neonates identified as hearing loss were kept in the neonatal intensive care unit for more than7days.
A Chi-square test was performed to see if there was an association between each risk factor in neonates with normal hearing and hearing impairment. Table Table33 shows chi-square test results for possible risk factors that include family history, hyperbilirubinemia, preterm birth, neonatal sepsis, birth defects, post-viral or bacterial infections, and prolonged stay in the NICU were significantly associated with hearing loss (p < 0.05). Multiple risk factors for the neonates and/or mothers were significantly associated with hearing loss (p < 0.05).
Table 3
Significant association of risk factors for neonates with and without hearing loss
| Risk factors | Normal hearing | Hearing loss | p value | |
|---|---|---|---|---|
| Pre-natal | Family history of Hearing loss | 5 | 1 | 0.01* |
| Elderly pregnancy | 7 | 0 | 0.71 | |
| Gestational Hypertension | 17 | 0 | 0.56 | |
| Gestational diabetes | 7 | 0 | 0.71 | |
| History of Abortion | 16 | 1 | 0.20 | |
| Rh incompatibility | 1 | 0 | 0.89 | |
| Viral/bacterial infection | 2 | 0 | 0.85 | |
| Natal | Low birth weight | 119 | 4 | 0.14 |
| Hyperbilirubenemia | 84 | 4 | 0.03* | |
| Delayed birth cry | 44 | 2 | 0.17 | |
| Preterm delivery | 70 | 4 | 0.01* | |
| Neonatal asphyxia | 68 | 3 | 0.57 | |
| Meconium Aspiration | 16 | 0 | 0.09 | |
| Prolonged NICU stay | 148 | 6 | 0.01* | |
| Post-natal | Congenital anomalies | 4 | 1 | 0.02* |
| Viral/bacterial infection | 6 | 1 | 0.01* | |
| Neonatal convulsions | 16 | 0 | 0.57 | |
| Neonatal Sepsis | 4 | 4 | 0.001* | |
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*Significant association,p < 0.05
Discussion
Hearing loss is often identified at later stages of life beyond a child's critical age, where there are delays in the expected speech and language milestones. However, early identification and intervention of a hearing impairment is critical for hearing, speech, and language development. Current research shows that the prevalence of hearing loss in high-risk children is 2%. In the literature, the reported prevalence of neonatal hearing loss ranges from 1 to 8 per 1000 births in India [1, 16]. A study by Jose et al. [8] in Kerala reports a prevalence of 0.9% in high-risk neonates. Another study performed by Paul et al. [17] showed that the prevalence of hearing impairment in high-risk infants was 1.03%.
In the screening test, the present study showed 9% referral rate using TEOAE, while with the inclusion of AABR showed a reduction of referral rate to 2%. Likewise, many studies have reported false-positive OAE results when TEOAE was administrated in early days of birth [2, 5, 8]. Kaveh et al. [10] reported an increased rate of false-positive OAE response, ranging from 2.5 to 8% in the universal newborn hearing screening. This may be due to debris from the ear canal, position of the infant, ambient noise, and myogenic interference [10, 18, 22].
The major risk factors for hearing impairment reported in literature are congenital infections and craniofacial abnormalities. Studies suggest that toxoplasma gondii, congenital rubella virus, cytomegalovirus, and herpes simplex virus are the main congenital infections that cause hearing loss [6, 13]. In addition, neonatal hyperbilirubinemia, low birth weight, family history of hearing loss, asphyxia at birth, and prolonged stay in the neonatal intensive care unit (NICU) are also considered high risk factors causing hearing loss [5, 20]. Similar observation was seen in the current study. Risk factors such as family history of hearing loss, hyperbilirubinemia, preterm birth, prematurity, prolonged NICU stay, birth defects, post viral/bacterial infection and sepsis were significantly associated with hearing loss. Hajare et al. [5] reported that in the prolonged NICU, increased hyperbilirubinemia and mechanical ventilation were the main risk factors for congenital hearing loss. Gestational age is also an important factor to take into account because premature babies are more susceptible to hearing loss than term babies [4, 7, 20]. Nagapoornima et al. [16] reported that 25% in Karnataka had a family history of deafness due to mutations in the GJB2 gene.
In this study, all infants identified with hearing loss had more than one high-risk factor and prolonged intensive care hospitalization. High-risk infants were more likely to have hearing loss than healthy infants [2, 5, 14]. However, studies have reported that infants without risk factors were also reported to have hearing loss [5, 17, 21]. Ideally, all neonates with or without high-risk factors should undergo newborn hearing screening. Early identification and intervention of a hearing loss will help improve communication skills during the critical age period.
Conclusion
The study showed that high-risk babies having multiple risk factors are more prone to hearing loss. Inclusion of AABR along with TEOAE have proven to be a useful tool in identifying infant hearing impairment and in reducing the false positive rates. Raising awareness among parents at the primary level by educating them about a healthy pregnancy, as this can contribute to the overall health and well-being of the unborn baby. Such awareness will reduce the risk of having a child with hearing loss significantly. In addition, newborn screening helps to identify hearing loss and initiate appropriate interventions as early as possible, thereby reducing the complications from hearing loss. The results of this study will help to raise awareness and sensitize all professionals and the public about the risk factors and focus of hearing screening at birth.
Acknowledgements
Thanks to the Gulbarga Institute of Medical Sciences, Kalaburagi, Government of Karnataka; and the All India Institute of Speech and Hearing, Mysuru under the Ministry of Health and Family Welfare, Government of India for their support.
Appendix 1
Funding
No funding.
Declarations
Conflict of interest
The authors declare that there is no conflicts of interest.
Consent for publication
Consent was obtained for publication.
Ethical approval
Ethical approval was obtained from GIMS institutional ethical committee.
Consent to participate
Consent was obtained from the participants.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Aneena K. Siddique, Email: moc.liamg@59k.aneena.
Renuka S. Melkundi, Email: moc.liamg@akuneridnuklem.
Arunraj Karuppannan, Email: moc.liamg@nuraluhan.
Siddaram Patil, Email: moc.liamg@92litapmaraddisrd.
N. Sreedevi, Email: ni.erosymhsiia@ivedeers.
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