International Journal of Pediatric Otorhinolaryngology (2003) 67S1, S193—S196

The newborn hearing screening programmein England

Adrian Davis*, Sally Hind

Medical Research Council, Institute of Hearing Research, University of Nottingham, Nottingham NG72RD, UK

KEYWORDSNeonatal hearingscreening;Screening programme;Patient centredscreening;Multi-disciplinaryworking

Summary Following a systematic review of the role of neonatal hearing screening inthe identification of hearing impaired and deaf children in 1997, the Department ofHealth in England commissioned a national programme of newborn hearing screeningin 2001 and has linked a systematic evaluation to the first 23 sites in the implemen-tation of that policy. It is anticipated that all areas of England will participate inthe programme by 2004/2005. It is expected that other regions of the UK will alsoaim for implementation by this date. In addition to successful advocacy by the twomajor consumer organisations, there were three key elements linked to the decisionto implement newborn hearing screening which were primarily evidence based andalso driven by two significant service developments. The evidence base showed thatnewborn hearing screen was considerably more effective and efficient than the infantdistraction test used in many areas and that there was a high probability that earlyintervention increased the potential for better language and communication. Theconcern over raised anxiety for those parents whose babies need differential assess-ment as a result of the screen is reduced by the low number of referrals and increasedefficiency of assessment when national protocols are used for screening and assess-ment. The introduction of family friendly hearing services (FFHS) provides a context inwhich the health, education, voluntary and social services can work together to pro-vide an equitable and seamless service throughout the year for hearing impaired anddeaf children and their families. Currently, 22 areas with 110,000 births per annum,have been selected for implementation, some of whom use a pilot community-basedmodel for screening. A major barrier to rapid progress has been a lack of evidenceconcerning elements of the screening process, e.g. equipment, IT systems, trainingat all levels. It is anticipated that a further 20—40 areas with an additional 150,000birth per annum will be brought into the programme by end of 2002/2003. The aims,protocols, training programme and evaluation of the NHS Newborn Hearing ScreeningProgramme are presented with a view to highlighting the research needed to improvespecification of large scale screening programmes.© 2003 British Association for Paediatric Otorhinolaryngology. Published by ElsevierIreland Ltd. All rights reserved.

∗Corresponding author. Tel.: +44-1159-223431;fax: +44-1159-518503.

E-mail addresses: adrian@ihr.mrc.ac.uk (A. Davis),sally@ihr.mrc.ac.uk (S. Hind).

Following a systematic review of the role ofneonatal hearing screening in the identification ofhearing impaired and deaf children in 1997, theDepartment of Health in England commissioned anational programme of newborn hearing screening

0165-5876/$ — see front matter © 2003 British Association for Paediatric Otorhinolaryngology. Published by Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijporl.2003.08.024

S194 A. Davis, S. Hind

in 2001, and has linked a systematic evaluation tothe first 23 sites in the implementation of that pol-icy. The programme will evolve through feedbackfrom the evaluation team, sites and from parents.It is anticipated that all areas of England and theother regions of the UK will participate in the pro-gramme by April 2005.

In addition to successful advocacy by the twomajor consumer organisations, there were threekey elements linked to the decision to implementnewborn hearing screening which were primarilyevidence based and also driven by two significantservice developments.

Firstly, the evidence base showed that newbornhearing screen was considerably more effectiveand efficient than the existing universal hearingscreen: the Infant Distraction Test, and that therewas a high probability that early intervention in-creased the potential for better language andcommunication. Evidence for the value of earlyidentification of hearing impairment is accruing in

Fig. 1 Parent information pathway.

the USA, e.g. [1,2]. A study conducted in the TrentRegional Health Authority UK, produced substan-tial data on cognitive performance of children withmoderate—severe permanent hearing impairmentand indicators of quality of family life (QoFL).Linear regressions controlling for potentially con-founding variables, e.g. age, severity, presence ofserious other disability, showed age at first fittingof hearing aids as a significant predictor of verbaland non-verbal reasoning and overall IQ, and ageat diagnosis as a significant predictor of workingmemory, i.e. digit span. It is possible that veryearly cochlear implantation may lead to betteroutcomes too.

Secondly, the concern over raised anxiety forthose parents whose babies need differential as-sessment as a result of the screen is reduced bythe low number of referrals associated with atwo-stage screen, e.g. [3] and increased efficiencyof assessment when national protocols are used forscreening and assessment.

The newborn hearing screening programme in England S195

Thirdly, the Trent study showed that early iden-tification was associated with an adverse impacton QoFL in families where the services providedwere perceived to be of poor quality. The intro-duction of family friendly hearing services (FFHS)provides a context in which the health, education,voluntary and social services can work togetherto provide an equitable and seamless service forhearing impaired and deaf children and their fami-lies. Hence, major innovations in services are beingdeveloped to complement the newborn hearingscreening programme to promote more favourableoutcomes for children identified with permanenthearing impairment. Prior to the introduction ofthis programme, education in England was man-dated to work with over 2 year olds only, and didnot provide year round cover. The Department forEducation and Skills, working with the Royal Na-tional Institute for Deaf people, has now producednew strategies for working with the under 2 yearolds, and to provide year round cover. Other initia-tives include Early Excellence Centres which aimto promote multi-disciplinary input to assessmentand habilitation.

To ensure an equitable service, national proto-cols have been developed, and supporting parent in-formation (written leaflets, video, verbal dialogue)produced with the help of appropriate profession-als and parents. Fig. 1 provides a flowchart of theparent information pathway. The main model of de-livery is hospital based and uses a two-stage screen,

AppropriateChild Healthsurveillance

Automated Auditory Brainstem Response AABR

Stage 2Stage 2

Audiologyfollow up and

Team involvement

Hearing test:Click ABR

Bi-lateral within 4 wksUni-lateral within 4 wkspriority given to bi-lateral cases

Missed orincomplete

NO CLEARresponseon 1 orboth ears

CLEAR response

on both ears

Threshold NOT raised

Thresholdraised

Automated OtoAcoustic Emissions AOAE (up to 2 attempts)

Complete Screen in OPD or Community by 4-6 wks

Stage1Stage1 Missed or incomplete

AABR in OPD orCommunity by 4-6 wksNO CLEAR

response on one orboth ears

OrOAE inappropriate

CLEARresponseon both ears

Fig. 2 National protocol for ‘well’ babies.

i.e. TOAE followed by AABR if no clear response/sat TOAE. Fig. 2 shows the protocol flowchart for‘well’ babies. Babies who are in neonatal intensivecare for more than 48 h have BOTH screens irrespec-tive of outcome of TOAE. Where possible, all babiesare screened at the bedside in the presence of themother.

The mission statement of the NHS Newborn Hear-ing Screening Programme also has three main ele-ments:

• to enable high quality parent-child interaction inthe first months of life for all children;

• to empower parents of hearing impaired childrenconcerning communication options;

• to put in place an evaluative culture of serviceprovision.

The major aims of the programme are:

• to identify 90% of children with bilateral moder-ate to profound permanent childhood hearing im-pairment within 8 weeks of age and 100% by 24weeks of age;

• to begin an agreed habiliative programme withthe family and child as soon as possible followingconfirmation of permanent hearing impairment;

• to enable follow up of those children with unilat-eral or mild hearing impairment and those at highrisk of progressive impairments at an appropriateage.

S196 A. Davis, S. Hind

Currently, 23 areas with 110,000 births per an-num, have been selected for implementation; fourof which use a pilot community-based model forscreening. The community-based model follows thesame basic two-stage screen but the first screen isconducted in the community within the first 24 daysof age, and in some areas the second screen is con-ducted in the audiology clinic.

Implementing a national screening programmehas not been without its problems. A major bar-rier to rapid progress has been a lack of evidenceconcerning elements of the screening process, e.g.equipment, IT systems, training at all levels. Theseproblems are now largely being overcome, and itis anticipated that a further 20—40 areas with anadditional 150,000 birth per annum will be broughtinto the programme by the end of 2002/2003.

The aims, protocols, training programme andevaluation of the NHS Newborn Hearing Screen-

ing Programme serve to highlight research neededto improve specification of large scale screeningprogrammes. Research teams will need to work incollaboration with other international screeningteams, ORL and audiology to explore outcomes andimpact of different interventions.

References

[1] C. Yoshinaga-Itano, A.L. Sedey, D.K. Coulter, A.L. Mehl, Lan-guage of early- and later-identified children with hearingloss, Pediatrics 102 (November (5)) (1998).

[2] P.M. Moeller, Early intervention and language developmentin children who are deaf and hard of hearing, Pediatrics106 (September (3)) (2000).

[3] C. Kennedy, L. Kimm, R. Thornton, A. Davis, False posi-tives in universal neonatal screening for permanent child-hood hearing impairment, Lancet 356 (December (9245))(2000).