What are the target timelines for infant hearing screening and intervention in Washington state?

Data Management and Quality Assurance
Managing your program's data is crucial to ensuring the success and quality of your newborn hearing screening program. A good data management system will ensure that no babies are lost to follow-up, as well as help ensure the quality of your program.
Statewide tracking and surveillance
The Washington State Department of Health (DOH), in cooperation with the Centers for Disease Control and Prevention (CDC), developed a statewide EHDDI Tracking and Surveillance system linked to the metabolic screening system. The tracking and surveillance system helps to ensure that all babies are screened for hearing loss prior to one month of age, those that are referred receive diagnostic audiological evaluation by 3 months of age, and those that are diagnosed with hearing loss receive early intervention by 6 months of age.
While Washington state does not mandate universal newborn hearing screening, about 96% of infants are screened before hospital discharge. All birthing hospitals (except two military facilities) and many clinics in Washington report newborn hearing screening results and diagnostic results to EHDDI.
The EHDDI program collaborates with the Early Support for Infants and Toddlers (ESIT) program to determine if infants with hearing loss receive appropriate and timely early intervention services. The ESIT program is Washington state's Part C program that provides services to children birth to 3 years of age who have disabilities, including hearing loss. For updates on this project, please see the EHDDI program website and the ESIT website .
For more information about this project , please contact:
Washington State Department of Health
1610 NE 150th St.
Shoreline, WA 98155
Phone: 206-418-5613 or 888-WAEHDDI (toll-free)
Data management for your hospital
It is important to have a system in place within your hospital to internally manage the data collected from your newborn hearing screening program. This will help you manage your workload and make sure that no babies are missed.
Many larger programs prefer to purchase one of the commercially available software programs, while smaller programs often find simpler, less expensive options sufficient.
We recommend that all hospitals, regardless of size, keep a log sheet or book to manage daily screening needs. This helps ensure that all babies get screened prior to discharge.
Sample spreadsheet for data management (XLS)
Before choosing a data management option, you should consider what data you want to monitor and how much you want the system to do for you.

EHDI National Goals
National Goals, Program Objectives, and Performance Measures for the Early Hearing Detection and Intervention (EHDI) Tracking and Surveillance System
Goal 4. All infants and children with late onset, progressive or acquired hearing loss will be identified at the earliest possible time.
|Program Objectives||Performance Indicators|
|4.1 Risk factors: Each hospital, audiologist and other providers, will identify infants with risk factors for hearing loss and transmit the information to state.|
a. Number and percent of infants with one or more risk factors.
|4.2 Monitoring of at-risk infants. Each state will have a mechanism in place to monitor the hearing status of infants at risk for late onset and progressive hearing loss.|
a. Number and percent of infants with risk factors who are re-screened by 6 months.
|4.3 Acquired hearing loss. Each state will have a mechanism in place to identify and provide follow-up services for infants and children with acquired hearing loss.|
a. Number and percent of infants and children identified with acquired hearing loss.
- Centers for Disease Control and Prevention
National Center on Birth Defects and Developmental Disabilities
Hearing Loss Team
1600 Clifton Road
Atlanta, GA 30333
TTY: (888) 232-6348
- Contact CDC-INFO

Audiological or medical/surgical management, educational and (re)habilitation methods, and child and family support are available strategies for subjects with confirmed hearing loss . Recognised benefits of UNHS are better language outcomes at school age and improved long-term language development [13, 14].
Since the 1999, process and outcome performance indicators and benchmarks were established for Early Hearing Detection and Intervention (EHDI) programs (i.e., identification before 3 months of age and intervention by 6 months of age)  to evaluate progress and determine consistency and stability [16, 17]. In 2007 the JCIH recommended timely and accurate monitoring of relevant quality measures, based on its reviewed performance indicators and benchmarks, as an essential practice for inter-program comparison and continuous quality improvement .
With the aim to verify whether literature reporting experiences on hospital-based UNHS programs include sufficient information to allow inter-program comparisons according to the already available indicators/benchmarks defined by the AAP and JCIH, we performed a systematic review . We found that not all studies reported all the data necessary for calculating the complete proposed set of quality indicators, and that when comparing available data on indicators with corresponding benchmarks, the full achievement of all the recommended targets is an open challenge. We also found substantial heterogeneity in terms of extent of hearing loss (hearing threshold, uni- vs. bilateral hearing loss), criteria for identification of neonates at higher risk of hearing loss, screening tests used, personnel performing the tests, testing environment.
In order to overcome these heterogeneous findings we think it is necessary to optimize the implementation of Universal Newborn Hearing Screening programs with an appropriate application of the planning, executing, and monitoring, verifications and reporting phases. For this reason we propose a conceptual framework that logically integrates these three phases and, consequently, a tool (a check-list) for their rationalization and standardization.
Discussion - The conceptual framework for rationalized and standardized UNHS programs
A planning phase based on indications from guidelines and recommendations, specificities of the local context, benchmarks, reports from verification phase. The Deliver the protocol Action is activated, apart from the first instance, if the benchmarks are not achieved, if guidelines/recommendations are updated, or if the context specificities change. The output of this phase is the protocol for UNHS execution.
An executing phase where the protocol is applied and where data should be generated and managed for monitoring. The outputs of this phase are the raw data for process monitoring.

Am Fam Physician. 1999 Sep 1;60(3):1020.
The Task Force on Newborn and Infant Hearing of the American Academy of Pediatrics (AAP) has issued a new policy statement recommending development of universal newborn hearing screening programs nationwide. The statement, published in the February 1999 issue of Pediatrics, discusses the justifications for universal hearing screening, tracking and follow-up, identification and intervention, evaluation, and other recommendations and issues. The AAP establishes parameters with the goal of ensuring that all newborns with hearing loss be identified.
“Significant hearing loss is one of the most common major abnormalities present at birth and, if undetected, will impede speech, language and cognitive development,” according to the policy statement. The average age for detection of significant hearing loss in the United States is less than 14 months, but the AAP would like to see all newborns screened before they leave the hospital so that treatment can be initiated before these infants are six months old. The policy states that about one to three per 1,000 infants in well-baby nurseries have significant loss of hearing in both ears, and about two to four per 100 infants in the intensive care unit have hearing loss.
The following five essential elements for an effective screening program were identified by the AAP: initial screening with a test having a high degree of sensitivity and specificity; tracking and follow-up; identification; intervention; and evaluation. Guidelines for each of the five essential elements are discussed in the statement. The following guidelines have been excerpted from the section of the guidelines that discusses identification and intervention in a universal neonatal hearing screening program:
The goal of universal screening is that 100 percent of infants with significant congenital hearing loss be identified by three months of age, and appropriate and necessary intervention be initiated by six months of age.
Appropriate and necessary care for the infant with significant hearing loss should be directed and coordinated by the child's physician within the medical home, with support from appropriate ancillary services.
A regionalized approach to identification and intervention for infants with significant hearing loss is essential, ensuring access for all children with significant hearing loss to appropriate expert services. The AAP recognizes that professionals with competency in this area may not be available in every community. The child's physician, working with the state department of health, must ensure that every infant with significant hearing loss is referred to the appropriate professionals within the regionalized system.

The United States Preventive Services Task Force has acknowledged the significant effect that congenital hearing loss has on communication skills psychosocial development and educational progress and have found that early detection of hearing loss improves language development.2 Others also have confirmed that language skills are closely linked to early identification of hearing loss3 and prospects to utilization of early intervention services.4 5 Children with congenital hearing loss who are identified and receive intervention no later than 6 months of age perform up to 40 percentile points higher on language expressive measures and interpersonal adjustment within the school setting.6-9 Such delays may lead to adulthood challenges in education and employment.10 Mandatory infant hearing screening has been recommended by the National Institutes of Health 11 Joint Committee on Infant Hearing (JCIH) 12 and the American Academy of Pediatrics15 in order to initiate the process of hearing loss identification and this screening has been implemented in most says. Newborns who fail their hearing screening or high-risk children undergo an outpatient audiological diagnostic assessment that may take several outpatient encounters in order to obtain definitive diagnosis. Appropriate follow-up through diagnostic and intervention services for children who do not pass a hearing screening or who are diagnosed with hearing loss has become a major national healthcare concern. Disparities in diagnostic and intervention services for some socioeconomic groups are at a high risk of becoming lost to followup.16-18 Patients in rural areas face additional access-to-care barriers that compound these concerns. According to a recent economic statement 19 85 of Kentucky’s 120 counties are considered rural and approximately 1.8 million people Riociguat (BAY 63-2521) live in these counties. Furthermore the Appalachian Riociguat (BAY 63-2521) region of Kentucky which encompasses the eastern and south central portion of the state is considered to be mostly rural based on the 2003 United States Department of Agriculture Rural-Urban Continuum Coding system20 (Beale codes). This Appalachian region is acknowledged nationally as suffering from extreme health disparities and is underserved in healthcare services. The 54 Appalachian counties in Kentucky are plagued by poverty unemployment and a shortage of healthcare. Considering the barriers to any type of care in Appalachia you will find multiple points in the diagnostic and treatment algorithm in which children with hearing loss potentially can be lost to follow up or have a dramatic delay in receiving timely intervention.

How is a hearing test for a baby is done?
It is done in the hospital before the baby is discharged home, by baby’s bedside, in a quiet setting, using a machine to perform a hearing screening. Some leads will be placed at the baby’s forehead and back of the ears, as well as earplugs in both ears for the screening. It will take 15 to 20 minutes to test both ears, and the results are either “Pass” or “Refer”. For babies with the “Refer” result, their parents will be given an appointment date to bring them in for an audiological diagnostic assessment. The appointment date should be within 1 month, or no later than 3 months of age.

The instrument is automated and provides a pass-fail report; no test interpretation by an audiologist is required. Because motion artifact interferes with test results, ABR is best performed in infants and children who are sleeping or, if necessary, sedated.”
Why Is It Important to Have Your Baby’s Hearing Tested?
Because the ability to hear is closely tied to language development, spoken language skills, and social-emotional development, it is extremely important to screen for hearing loss at different stages of your child’s life.
Hearing screening should ideally occur before your baby is discharged from the hospital or birthing center or as soon as possible before one month of age.
Types of Newborn Hearing Screens
Did you know there are different screening methods to determine what your baby hears?
Some of the most common newborn screening tests include:
- Automated Auditory Brainstem Response or Auditory Brainstem Response (AABR). This screening method measures responses from the inner ear as well as the auditory brainstem, testing as sound travels up to the brain. Small earphones are placed over the baby’s ears, while sticker electrodes placed around the ears or her head measure whether there is a response from the baby’s ear and brainstem. If your baby passes this screen, a response from both areas will be noted.
- Auditory Evoked Response (AER). According to a study published in 2015 in The Open Biomedical Engineering Journal22. Paulraj MP, Subramaniam K, Yaccob SB, Adom AH, Hema CR.. Auditory evoked potential response and hearing loss: a review. Open Biomedical Engineering Journal. 2015;9, 17-24. https://doi.org/10.2174/1874120701509010017 by Paulraj and colleagues, a baby’s hearing test using this method involves the use of an electroencephalogram (EEG). The authors report that “EEG-based hearing threshold level determination is most suitable for babies and persons who lack verbal communication and behavioral response to sound stimulation. AER reflects the auditory ability of an individual.”
- Otoacoustic Emissions (OAE). This diagnostic test measures part of the inner ear’s response to sound and is appropriate for babies and children. Soft conductor tips placed in the baby’s ear canal emit quiet clicks while a computer records a soft echo from the ear.

The Maternal Exit Survey and the Maternal CATI Interview will address the following research questions: (1) What are the factors that impede or enable families to follow-up for early hearing evaluation and intervention; (2) What EHDI strategies implemented by hospitals appear to be most successful in reducing loss to follow-up; and (3) Is loss to follow-up associated with maternal characteristics such as parity, age or ethnicity? Both surveys will be available in English and Spanish.
Hearing loss is the most common disorder that can be detected through newborn screening programs. Prior to the implementation of newborn hearing screening, children with hearing loss typically were not identified until 2 to 3 years of age. This is well beyond the period of early language development. Now, with comprehensive EHDI programs, the average age of identification of children with hearing loss has been reduced so that it is now possible to provide interventions for children younger than one year of age. With early identification, children with hearing loss can begin receiving appropriate intervention services that provide the best opportunity for these children to reach their maximum potential in such areas as language, communication, social and emotional development, and school achievement.
Newborn hearing screening is only the first step in the identification of children with hearing loss. Children who do not pass their screening need to be further evaluated to determine if they have hearing loss. The value of newborn hearing screening cannot be realized unless children complete the screening, evaluation, and intervention process. Since recent data indicate that nearly 40 percent of children do not complete the evaluation-intervention process, this project is designed to understand what barriers exist in following through with evaluation and intervention. This evaluation also plans to provide data necessary to develop innovative solutions that can be applied by states, hospitals, and local programs. Results from this collection have the potential to strengthen the EHDI process and minimize social and economic disability among persons born with hearing loss.
By evaluating the policy, structural, personal, and financial factors and barriers associated with loss to follow-up in the EHDI program, this study seeks to identify “best practices” for improving detection, referral to Start Printed Page 57880evaluation and intervention, and adherence to intervention. CDC's plan to publish data and results from this evaluation will help state health officials, other Federal agencies, and other stakeholders to improve the EHDI process-providing direct benefit to infants with hearing loss and their families. The total estimated burden hours are 940.

The surveillance program for early identification of infants and children with late onset (especially in presence of high risk factors) – It is recommended to perform regular surveillance of developmental milestones, auditory skills, parental concerns, and middle-ear status to for all infants, together with an objective standardized screening of global development, at 9, 18, and 24 to 30 months of age or at any time if the health care professional or family has concern . The cooperation among all the involved operators, services and institutions - The identification of the key roles is an essential step for an appropriate management of the entire process and for monitoring purposes.
Monitoring, verifying and reporting
Universality– completeness of universality in both recruitment and follow-up phases;
Timely detection– specification of follow-up deadlines for identification and intervention, and determination of the observed prevalence;
Overreferral – Efficient use of highly specialized care.
Verification of program performance
For each reported indicator a reference benchmark has been identified  which represent a consensus of expert opinion in the field of newborn hearing screening and intervention, and are the minimal requirements that should be attained by high quality EHDI programs. Frequent measures of quality permit prompt recognition and correction of any unstable component of the EHDI process. The JCIH recommends timely and accurate monitoring of relevant quality measures for inter-program comparison and continuous quality improvement .
Reporting of process indicators
This is the output of the Monitor, Verify and Report Activity and it is used to make process results explicit and, as previously reported, as the basis for possible re-planning and/or reorganization.
The proposed framework has been used as a conceptual guidance for building a checklist (Additional file 2) intended to support UNHS program coordinators in the planning, monitoring, reporting and verification.
As reported in the 2007 JCIH Position Statement , regular measurement of performance and routine monitoring of indicators are recommended for inter-programme comparison and continuous quality improvement. With the aim of achieving high quality UNHS programs by achieving AAP and JCIH quality benchmarks, our work proposes a conceptual framework and a checklist. The former is a way to optimize, rationalise and standardise the implementation of UNHS programs by considering all the relevant phases: Planning, executing, and monitoring, verifying and reporting. The latter allows an inter-program comparison by removing heterogeneity in processes description and assessment.
The paper is a contribution toward a standardisation in reporting UNHS experiences which may favour the emerging of best practises.

They also recommend that such screening be performed in all birthing hospitals and coordinated by state departments of health.
How are infants screened?
Hearing tests can be performed while the baby is asleep or quiet and do not require the infant's participation. Sounds (tones or clicks) are played through small earphones and responses to the sounds are automatically measured by electrodes or a probe microphone. Tests are quick, painless, and non-invasive.
- Alexander Graham Bell Association for the Deaf and Hard of Hearing
- American Academy of Audiology
- American Academy of Pediatrics - Early Hearing Detection and Intervention (EHDI)
- American Society for Deaf Children
- American Speech Language and Hearing Association (ASHA)
- Boys Town National Research Hospital
- Center for Disease Control: Early Hearing Detection and Intervention
- Hands and Voices
- Hearing Loss Association of America
- Joint Committee on Infant Hearing
- National Association of the Deaf
- National Center for Hearing Assessment and Management (NCHAM)
- National Institute for Deafness and other Communication Disorders
This is an excellent site with valuable information for parents. They include an unbiased look at communication options for children who are deaf or hard of hearing.

First three years of life are critical for a child to develop speech and language skill. For effective language and communication skill development child need to hear normally. If any hearing impairment is there it should be managed at the earliest.
With modern technologies like Brain-stem evoked response audiometry it is possible to identify hearing-loss within days of birth.
There are certain criteria which needs to pay attention and newborn should be subjected to hearing evaluation:–
1. Parental concern about hearing levels or speech delay in their child
2. Family history of hearing loss
3. History of in-utero (cytomegalovirus, rubella or syphilis) or post natal infections (meningitis)
4. Low birth weight babies
5. Hyper Bilirubinemia
6. Cranio facial deformities or certain syndromes
7. Head injury
8. Recurrent or Persistent otitis media with effusion
9. Exposure to ototoxic drugs

If there is notable hearing loss, no echo or a reduced echo from the ear will be noted.
As your child grows, different methods of hearing tests may be used to determine normal hearing development.
How to Tell if a Baby Needs a Hearing Test
According to the American Academy of Pediatrics (AAP), “the goal is for all babies to have a newborn hearing screening by one month of age, ideally before they go home from the hospital; identified by three months of age and enrolled in early intervention or treatment, if identified as deaf or hard of hearing, by six months of age.”
But how can you tell if your new baby is experiencing hearing loss? The AAP and The American Academy of Audiology recommend seeking a physician’s advice if your child:
- Has a family history or risk factors of childhood hearing loss.
- Had a neonatal intensive care unit (NICU) stay of longer than five days.
- Received intravenous (IV) administration of antibiotics known to cause damage to hearing and/or balance organs.
- Was exposed to infections that occurred before or after birth, such as herpes, rubella, syphilis, toxoplasmosis, or viral or bacterial meningitis.
- Experienced head injury or birth trauma, resulting in damage to the auditory nerve.
- Doesn’t startle at loud noises by one month or turn toward sounds by three to four months of age.
- Doesn’t notice you until he sees you.
- Concentrates on vibrating noises more than other types of sounds.
- Doesn’t seem to enjoy being read to.
- Is slow to begin talking, hard to understand, or doesn’t say single words such as “dada” or “mama” by 12 to 15 months of age.
- Doesn’t always respond when called, especially from another room.
- Seems to hear some sounds but not others. (Some hearing loss affects only high-pitched sounds; some children have hearing loss in only one ear.)
- Has trouble holding their head steady or is slow to sit or walk unsupported. (In some children with hearing loss, the part of the inner ear that provides information about balance and movement of the head is also damaged.)
- Wants the TV volume louder than other members of the family.
Hearing loss can develop over time, even if your baby initially passed their newborn hearing test: It is recommended that children have their hearing screened at different points as they grow.
Who Performs a Baby Hearing Test?

Washington State law (WAC 246-760) requires schools to conduct auditory and visual screenings of children each year. All students in kindergarten through third grade, fifth and seventh grade are screened. If your child is not scheduled to be screened this year, you may request a screening if you have concerns by contacting your child’s teacher or emailing firstname.lastname@example.org including your child’s name, school, grade level and teacher.
Parents who DO NOT want their child screened for either vision and/or hearing will need to send a letter to their child’s school each year indicating their child is to be excluded. Please contact the Health Services office at 360-473-1073 if you have any questions. Additional information regarding the vision and hearing screening process is available here.

How Do Doctors Test a Baby’s Hearing?
- A baby’s hearing screening is relatively simple and is important to repeat at different points throughout childhood.
- Symptoms of hearing loss should be promptly reported to your child’s pediatrician.
- Intervention services are available for children who are born deaf or are developing hearing loss.
Though it is rare, babies can be born with a detectable level of hearing loss. A baby’s hearing loss can occur from a variety of conditions, some of which can damage the hearing nerve. According to the National Institute on Deafness and Other Communication Disorders (NIDCD), only 0.2 to 0.3% of babies are born with congenital hearing loss.
Because the most critical time for children to learn language is in the first three years of life, it’s very important to correctly identify babies who have affected hearing.
The CDC recommends that the best way to identify childhood hearing loss is to screen newborns through a universal hearing screening process.
Fortunately, testing a baby’s hearing may seem more complicated than it really is! Screening newborns for hearing loss is probably one of the easiest tests your baby will ever experience.
Baby Hearing Test: What Parents Need to Know
A hearing screening may sound vague or confusing, but it is actually a simple process to determine typical hearing patterns in a newborn.
What Is a Baby Hearing Test?
Newborn hearing screening, or early hearing detection, is a simple method of passing soft sounds or clicks through your baby’s ear and measuring the brain’s response. Referred to as an automated auditory brainstem response (ABR), the test is easy, painless, and generally over after just a few minutes.
Most babies sleep through their hearing screening, which is helpful in providing accurate results since movement can interfere with the recording. As referenced in the American Family Physician Journal11. Bush, Jennifer S.. AAP Issues Screening Recommendations to Identify Hearing Loss in Children. American Family Physician Journal. 2003;67(11), 2409-2413. https://www.aafp.org/pubs/afp/issues/2003/0601/p2409.html, the American Academy of Pediatrics (AAP) recommends that babies be asleep or sedated for their hearing exam:
“The automated auditory brainstem response (ABR) is one objective means of evaluating hearing. It is currently used in many newborn-screening programs, but can be used in children of any age.

Statistics from Altmetric.com
About 1 in 1000 children are born each year with hearing impairment sufficiently severe to compromise speech and language development and communication. There has been much work in recent years to reduce the age of diagnosis and intervention for these children. The paper by Pimperton et al,1 provides important evidence to support the observations of those working clinically with these children, that early identification and habilitation of significant hearing impairment in children pays dividends in terms of education. The cohort of children on whom this paper is based was identified by universal newborn hearing screening before the establishment of NHSP, the national newborn hearing screening programme. The same cohort was studied earlier at an average age of 7.9 years2 when significant benefit in language development was shown in those diagnosed before 9 months of age compared with those identified when older than 9 months. The particular value of this paper is that it has looked at performance in the second decade as well as the first, and there is a paucity of work in this age group. Pimperton et al have highlighted the value of early diagnosis and intervention in establishing good language skills, which underpin later reading comprehension.
Management of deafness in children has seen a significant change in the last 15 years. Prior to newborn hearing screening, the average age of diagnosis of deafness severe enough to compromise speech and language development (moderate-to-profound deafness bilaterally) was 26 months, with hearing aid fitting at 32.2 months.3 Many of these children failed to acquire good speech and oral language. Amplification using hearing aids gave access to sound, but the late start meant that the critical period for good speech and language acquisition was passed. The average reading age of a deaf school leaver was said to be about 8 years, and career and educational opportunities were, as a consequence, limited.
The impetus for change came from the Joint Committee on Infant Hearing, a multidisciplinary American group established in 1969, which first examined the evidence to support early screening and early intervention. Their latest supplement in 2013 presents current evidence.4 The majority of this research has come from the USA. Christine Yoshinaga-Itano, working for the Colorado Early Hearing Detection and Intervention programme, has monitored the identified children, providing excellent research data.

A longitudinal study of deaf and hard of hearing children over a 7-year period identified age-appropriate speech and language development for children whose hearing loss was identified early and who had appropriate intervention, with the best results for those identified within the first 2 months of age. These children were shown to have better social–emotional development because of early and effective intervention.5 Her findings have been supported by others in the USA and also in this country as in this paper by Pimperton et al.
Examining the outcome of interventions for deaf children is difficult because of the many variables—degree of loss, additional needs, quality of intervention as well as the child's aptitude. A longitudinal study has benefit over a cross-sectional study in such a diverse group. It also provides evidence of sustained benefit. Its value in deaf children cannot be underestimated because screening costs and robust evidence of improved educational outcomes demonstrate value for money.
In England, funding for the NHSP from the National Screening Committee of the Department of Health was agreed in March 2000, and the project was established jointly with the Medical Research Council. The programme was rolled out across England over the next few years with 100% coverage (all children being offered screening) achieved by March 2006.
The beginning was a big change for many. It was not just the application of a two-level screen, which in itself was a challenge; it was what followed. Children were being referred from the screen at hours of age, and the specialist diagnostic tests needed were done to the level of expertise required in only a few centres. The knowledge and skills needed to fit hearing aids to tiny babies were also in short supply. The teachers of the deaf providing peripatetic services were used to dealing with deaf toddlers and schoolchildren, but were now expected to cater for the hearing needs of small infants, only a few weeks of age. Only a few medics were adequately trained for the role ahead of them. In short, the learning curve was steep.
NHSP has not been just a screening programme, it had a much broader brief until recently—to ensure identified children were appropriately managed for the first 3 years of life. It has had precise standards of practice and performance with the child and the family at the centre, and it has provided an educational programme for involved professionals. A close working relationship with the National Deaf Children's Society resulted in the development of comprehensive information leaflets and support for parents.

Posts for: February, 2019
A hearing screening is the easiest way to determine if your child is suffering from hearing loss. Thanks to a hearing screening, your pediatrician can determine the degree of hearing loss and how best to help your child hear well again. If your child’s hearing loss goes undiagnosed, it can lead to problems with normal development, learning disabilities, and problems socializing with others.
Your child could be suffering hearing loss from a variety of causes including a family history of hearing problems, infection during pregnancy, or birth complications. Hearing problems can also be caused by middle ear infections, infectious diseases, or even loud noises.
So, how do you know if your child needs a hearing screening? According to the Centers for Disease Control (CDC) these are some of the most common signs and symptoms of hearing loss in babies and children:
- Not turning toward sounds at 6 months
- Not saying single words at 1 year
- Not hearing all sounds
- Not answering to their name
- Delayed or unclear speech
- Difficulty following directions
Hearing screenings are often performed at well-child visits and during school physicals. If your child hasn’t had a hearing screening, and you notice any of the signs and symptoms listed above, you should schedule a hearing screen as soon as possible. Early detection of hearing difficulties leads to early treatment, which is much better for your child.
If your child has hearing difficulties, don’t worry. There are many effective ways to help with hearing loss including:
- State-of-the-art hearing aids, cochlear implants and other hearing devices
- Medications if the hearing loss is caused by an ear infection
- Surgical treatment to correct structural issues which may be causing the hearing loss
- Alternative communication techniques
- Educational and supportive services for the family
A hearing screening is important to the health and well-being of your child. You don’t want your child to miss out on all of the beautiful sounds of life. Your pediatrician can help you schedule a hearing screening to get your child started on the road to hearing well.
Named after the characteristic sound of its notorious coughing fits, whooping cough is an extraordinarily uncomfortable condition that typically manifests itself in babies and in children ages 11 to 18 whose vaccine-provided immunities have begun to fade. In addition to causing several debilitating symptoms, whooping cough also carries the possibility of infant mortality, particularly for patients under 12 months old.

Treatment options may include hearing aids, cochlear implants, or other therapies.
- Cost-Effective: Early detection and treatment of hearing loss can save families and the healthcare system significant costs over time. Delayed diagnosis and intervention may increase healthcare costs and lifelong learning difficulties.
- Peace of Mind: UNHS can provide parents with peace of mind, knowing that their child's hearing has been thoroughly tested and any issues can be addressed early.
In the Nutshell:
- UNHS is a quick and non-invasive screening process that can be done shortly after birth. The test typically takes just a few minutes and is painless for the baby.
- UNHS is essential for all newborns, not just those with a family history of hearing loss or other risk factors. Some babies with hearing loss may not have any obvious signs or symptoms, so screening is necessary to identify those who may benefit from early intervention.
- UNHS is just the first step in ensuring that children with hearing loss receive the support they need. If a baby fails the initial screening, further testing and evaluation will be necessary to determine the extent and type of hearing loss and to develop an appropriate treatment plan.
- UNHS is part of a comprehensive approach to supporting children with hearing loss that includes early intervention services, family support, and ongoing monitoring and follow-up.
- Parents should be aware that even if their child passes the initial screening, you should monitor their hearing and speech development. You should speak with their healthcare provider to determine if further evaluation is necessary if you have any concerns.
What can we do?
The Listening Lab Malaysia provides hearing tests for newborns and infants and gives proper recommendations after diagnosis. We also promote childhood hearing tests such as Tympanometry, Middle Ear Muscle Reflex (MEMR) Test, Auditory Brainstem Response (ABR) Test, Auditory Steady State Response (ASSR) Test, Central Auditory Evoked Potential (CAEP) Test and Otoacoustic Emissions (OAE) Test. Let your child undergo the test in our clinic for proper guidance and planning. Book an appointment today and save money by getting the right treatment plan for your child. You may also contact us through Whatsapp.

Implementation of a universal neonatal hearing screening program may increase demand for qualified personnel to provide age-appropriate identification and intervention services for infants with significant hearing loss. As a result, the AAP recommends the training and education of additional expert care professionals.
The AAP does not recommend a preferred screening method. The statement discusses both evoked otoacoustic emissions and auditory brainstem response to be used either alone or in combination. Both methods, according to the AAP, are easy to perform and are noninvasive.
Copyright © 1999 by the American Academy of Family Physicians.
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I came across a good article in the New York Times which highlights the need for hearing tests for newborns: without them it is difficult to predict what might be wrong if the child is not speaking or reaching other developmental milestones.
Hearing tests are mandatory in 40 states, and routine but optional in the rest. There’s a good reason for the rule:
“We need to identify children early and provide them with hearing tools and training by the time they are 6 months,” said Dr. John Greinwald, a pediatric otologist at Cincinnati Children’s Hospital Medical Center. Studies now confirm that the earlier the intervention, the better the chance that the child will develop listening and language skills.
“If you hear from birth, you learn to listen,” said Anne Oyler, an audiologist for the American Speech, Language and Hearing Association. “More than 90 percent of what babies learn is from incidental listening. If a child isn’t fitted with hearing aids until 2, that is when he or she will have to start learning what sounds are. If we catch kids in the first few months, we don’t see delays and they do beautifully.”
Hearing impairments are pretty common: 1 in 1000 babies are born deaf. The prevalence of this disability is what interested me in pursuing hearing research for my thesis, but also makes it equally distressing when precautions that could aid children in development go unheeded.

Neonatal Hearing DepartmentMaternity Clinic
IASO Maternity Hospital has been performing otoacoustic emissions tests in neonates (screening test) since 1996. It is a simple, quick and harmless test applied in the best maternity hospitals all over the world and offers information about the infant’s hearing (if the infant/child has normal hearing or not). During the test, continuous rhythmical sounds are transmitted to newborns and the sound responses of the ear are recorded via a special appliance linked to a computer. The ideal time to have this test performed is during the first days after birth, because newborns sleep for the most part of the day. The test can also be performed during sleep, so the newborn is not aware of it.
In the event of a positive result, the hearing ability of the patient is normal to a significant extent. The incidence of neonatal hearing loss is 3-4‰ and the incidence of severe hearing loss (deafness) is 1‰. Note that these rates also apply for newborns without hereditary history of hearing loss. The detection of hearing loss during the first weeks, and consequently the opportunity for early intervention, is significantly important for speech development, as well as the intellectual and mental progress in children.
To this end, the otoacoustic emissions test, which is performed on all newborns across the board in medically advanced countries, such as the USA, Western European countries and elsewhere, has been performed on all newborns at IASO for the last twenty years. IASO was the first Maternity Hospital in Greece to universally implement this test and has been the only one that did so for many years. This IASO program is one of the largest worldwide.
In the last fifteen years, a brain stem evoked acoustic responses test is performed in certain cases, for the same reason and indications.
All these are consistent with the guidelines of the World Health Organization. The recording of the screening test remains in the patient file and its results are written down in the child’s personal health booklet (p. 15).

Just Kids Diagnostic and Treatment Center offers hearing screening and assessment for infants, toddlers, preschoolers, school age children and adults.
Screening for newborns is available on-site. The screening is simple and pain free and can be done while the infant is resting. The purpose of hearing screening is to detect hearing loss important to speech development.
School age children should be screened periodically. Adult screening is also available.
For more information, please call 631-924-1000.

Objective. To compare the language abilities of earlier- and later-identified deaf and hard-of-hearing children.
Method. We compared the receptive and expressive language abilities of 72 deaf or hard-of-hearing children whose hearing losses were identified by 6 months of age with 78 children whose hearing losses were identified after the age of 6 months. All of the children received early intervention services within an average of 2 months after identification. The participants' receptive and expressive language abilities were measured using the Minnesota Child Development Inventory.
Results. Children whose hearing losses were identified by 6 months of age demonstrated significantly better language scores than children identified after 6 months of age. For children with normal cognitive abilities, this language advantage was found across all test ages, communication modes, degrees of hearing loss, and socioeconomic strata. It also was independent of gender, minority status, and the presence or absence of additional disabilities.
Conclusions. Significantly better language development was associated with early identification of hearing loss and early intervention. There was no significant difference between the earlier- and later-identified groups on several variables frequently associated with language ability in deaf and hard-of-hearing children. Thus, the variable on which the two groups differed (age of identification and intervention) must be considered a potential explanation for the language advantage documented in the earlier-identified group.
- SD =
- standard deviation •
- df =
- degrees of freedom •
- dB =
- decibels •
- dB HL =
- decibels hearing level •
- CQ =
- cognitive quotient •
- MCDI =
- Minnesota Child Development Inventory •
- MLU =
- mean length of utterance •
- LQ =
- language quotient •
- ANCOVA =
- analysis of covariance
Hearing loss that is bilateral and permanent is estimated to be present in 1.2 to 5.7 per 1000 live births.1–4 The typical consequences of this condition include significant delays in language development and academic achievement.

Apuzzo and Yoshinaga-Itano reported that the first age-of-identification group (ie, those children identified before 3 months of age) had significantly higher language scores than those identified after the age of 2 months despite all children receiving similar intervention programming.
In the Apuzzo and Yoshinaga-Itano29 study, all of the children in the earlier-identified group were diagnosed within the first 2 months of life because they presented with characteristics on the high risk registry for hearing loss. Within that study, there were only a few children without significant cognitive delay identified before 12 months of age despite including the entire sample of young children with hearing loss from a 10-year database of >350 children. Because of the small number of children in the earlier-identified group, the question of whether early identification and intervention was associated with better language scores for all deaf and hard-of-hearing children or only for children who exhibited specific demographic characteristics could not be addressed. Because of the institution of universal newborn hearing screening, within the last few years the number of children identified early with hearing loss who have normal cognitive ability has increased dramatically.
Moeller30 reported a retrospective longitudinal study of 100 deaf and hard-of-hearing children, 25 of whom had been identified before 6 months of age. These children were tested every 6 months until the age of 5 years. Children identified with hearing loss before 6 months of age maintained age-appropriate language skills and had significantly better language skills than those children who were identified after 6 months of age. Similar to the study conducted by Apuzzo and Yoshinaga-Itano,29 Moeller's early identification group consisted primarily of children identified through the high-risk register for hearing loss. Additionally, the earlier- and later-identified groups were not comparable on the full range of demographic variables frequently associated with language ability in deaf and hard-of-hearing children.
The purpose of the present investigation was to compare the language skills of a large group of children whose hearing losses were identified by 6 months of age with children who were identified after the age of 6 months. Because it was hypothesized that the advantage of early identification might vary, the effect was examined within a variety of subgroups formed on the basis of demographic variables frequently associated with language development.

The Labor Day campaign is called that because more babies are born around this time of year than any other. The campaign is designed to remind parents to have their newborn babies' hearing screened.
The Hispanic/Latino/Latina community does not receive sufficient healthcare information. Outreach to this community includes efforts to disseminate information in Spanish about hearing screenings, follow-through visits, and how medical professionals can help increase the number of infants who return for hearing screening evaluations. The campaign will also use the Hispanic/Latino/Latina media services to provide information that will reach their communities. Another focus is to make information available in the Combined Health Information Database (CHID) so that resources are available to healthcare professionals who work with these communities.
18.104.22.168 Performance Measures
- Increase knowledge about the importance of hearing screening and follow through for under-represented groups to ensure improved communication, occupational, and financial outcomes for these children.
- Increase knowledge of professionals about the importance of follow through after hearing screening for appropriate interventions.

Trends in Amplification. 1999;4(2), 51-60. https://doi.org/10.1177/108471389900400205 in order to evaluate for hearing loss and gain a better understanding of your baby’s ears.
Intervention Options After Your Baby Hearing Test
If your baby has been diagnosed with hearing loss of any sort, you’ll want to start looking into intervention services as soon as possible to reduce any developmental delay in your baby.
As you work to identify options with your child’s healthcare team, consider such ideas as:
Working with a speech-language pathologist (SLP) can help identify valuable strategies for learning to communicate with your little one experiencing hearing loss. Your baby is most likely to show spoken language development at a rate similar to a baby without hearing loss when diagnosed early.
Sign language is a valuable tool to enhance communication with pre-verbal and non-verbal children of all ages.
Many devices, such as a frequency modulation (FM) system, are available to help children who lose hearing abilities maximize sounds heard or communicate with hearing individuals.
According to the American Speech-Language-Hearing Association, assistive hearing devices like hearing aids can be used successfully for babies and very young children. Professionals at the American Academy of Audiology report that cochlear implants can also be used in children and that “cochlear implants are an option when benefit from hearing aids is limited and should not be viewed as a last resort.”
A child’s hearing ability can change over time. Because hearing loss in a young child can significantly impact their development and communication skills, performing regular screening tests allows for early intervention services if a child demonstrates hearing loss.
- Bush, Jennifer S. (2003). AAP Issues Screening Recommendations to Identify Hearing Loss in Children. American Family Physician Journal. 67(11), 2409-2413. https://www.aafp.org/pubs/afp/issues/2003/0601/p2409.html
- Paulraj MP, Subramaniam K, Yaccob SB, Adom AH, Hema CR. (2015). Auditory evoked potential response and hearing loss: a review. Open Biomedical Engineering Journal. 9, 17-24. https://doi.org/10.2174/1874120701509010017
- Singh G, Archana G. (2008). Unraveling the mystery of vernix caseosa.

The Centers for Disease Control and Prevention (CDC) publishes a list of information collection requests under review by the Office of Management and Budget (OMB) in compliance with the Paperwork Reduction Act (44 U.S.C. Chapter 35). To request a copy of these requests, call the CDC Reports Clearance Officer at (404) 371-5983 or send an e-mail to email@example.com. Send written comments to CDC Desk Officer, Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503 or by fax to (202) 395-6974. Written comments should be received within 30 days of this notice.
Assessment of State Early Hearing Detection and Intervention Programs (EHDI): A Program Operations Evaluation Protocol—New—National Center on Birth Defects and Developmental Disabilities (NCBDDD), Centers for Disease Control and Prevention (CDC).
Background and Brief Description: Every year, an estimated 12,000 newborns are diagnosed with permanent hearing loss, a condition that if not identified and treated early can lead to impaired functioning and development. CDC's role in the detection, diagnosis, and treatment of early hearing loss through the “Early Hearing Detection and Intervention Program” (EHDI) is of vital importance for families of newborns and infants affected by hearing loss. Nonetheless, recent data indicate that only 60 percent of the newborns that fail hearing screening are evaluated by the recommended 3 months of age.
The evaluation will involve an integrative evaluation approach that encompasses the following activities, conducted in Arkansas, Massachusetts, Michigan, Utah, and Virginia: (1) A 10-minute survey of 3,000 mothers whose newborns have been screened (the “Maternal Exit Survey”); and (2) a 20-minute computer-assisted telephone interviewing (CATI) survey of 1,000 mothers of newborns who have been referred for additional hearing evaluation (the “Maternal CATI Interview.”) To complete these interviews, it is expected that 5,000 will be contacted. The overall burden on all contacted women is expected to be approximately 940 hours.

Hearing Screening Associates is a full-service company that offers an all-inclusive service for screening the hearing of newborn infants. The concept covers everything from personnel and testing to equipment to reporting and billing.
The Newborn Hearing Screening Technician performs mandated hearing screening tests for newborn infants, provides education to parents pertaining to the relevance of hearing screening and early intervention, and records patient information and hearing screen results. The screener is responsible to conduct these hearing screening tests prior to patient discharge supporting patient care goals and objectives. This part-time position is based in a busy Newborn Nursery / NICU hospital setting.
Conducts newborn hearing screenings on all infants in the nursery and NICU prior to discharge from the hospital, coordinates post-discharge follow up care as needed utilizing appropriate procedures and computer technology.
Works directly with nursing staff, patients, and parents to communicate relevance of hearing screening and early intervention to support positive outcomes; provide screening results to parents. Must be able to analyze and communicate responses to problem situations in a manner consistent with the company and customer's needs.
Maintain and use hearing screening equipment, assist with database management.
Interacts as needed with various hospital departments; Performs duties in accordance with the policies and procedures of HSA, hospitals, and respective departments.
Upholds the code of conduct and compliance policies.
Upon completion of HSA/Hospital training; has thorough knowledge of procedural variables and instrumentation in the application of Otoacoustic Emissions Assessment, Transient Emissions, and Automated Auditory Brainstem Response (AABR) testing.
All other duties as assigned.
High School Diploma or General Education Degree (GED) required.
One (1) or more years of healthcare or childcare training/experience, or related college curriculum is a plus.
Possess basic computer skills.
Ability to attend all company provided training.
Willingness and ability to learn and operate hearing screening equipment.
Must be able to move or lift up to 15 pounds.
Employment is contingent upon the following:
Clear seven (7) year background check
Verifiable prior employment including title and dates of hire
Must pass Drug Test
Bloodwork required to verify immunization Titers
Vaccinations as required by hospitals, including Flu Vaccine
Hearing Screening Associates is an Equal Opportunity / Affirmative Action employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, sex, national origin, disability, or protected veteran status.

Listening Stars : Parent Infant Program (0-18 Months)
Early Intervention plays a vital role.
Early diagnosis is the key to successful early intervention. Babies who are detected early can access further testing quickly and parents can access support and information. Children whose problems are identified early & begins with early intervention strategies before six months of age, have the best chance of developing age appropriate speech and language.
As Babies begin to learn things right from the time they are in the womb of their mother. It is advised not to waste critical time. Critical Period for developing the ability for spoken language is from 0-3 years. At that stage, the brain has the maximum neural Plasticity. The child too must learn early to grow up with the hearing aids/cochlear implant (CI) and accept them easily. Most importantly, children learn to make use of their residual hearing and acquire speech and language faster if they start earlier. Starting at an older age, not only slows down the ability to learn and speak, it can severely jeopardise.
The programme is especially for Babies/ Infants diagnosed with any developmental delays. It provides them early training to identify and understand the sounds around them.
Baby Developmental Milestones
The following milestones can be used as a guide to monitor child’s development as he/she grows:
Birth –Eighteen Months Old
- Localizes sound source with accuracy
- Discriminate angry & Friendly vocal tones
- Appears to enjoy listening new words
- Understands more simple instruction
- Enjoys sounds making toys & objects.
- Awakes easily to loud, sudden noises
Our early intervention program is a multi-disciplinary approach with emphasis on assisting the child to reach their full potential. The services are individualized to each child’s need and integrate many disciplines such as Audiologist, Speech Pathologists, Special Educator, Psychologists, Occupational Therapists, Early childhood Specialist & Music therapist.
Schedule an appointment for your child today!

Service Provider Qualifications
Infants and babies who are deaf or hard of hearing generally are eligible for early intervention services. The goal of these services is to ensure that deaf and hard of hearing infants, toddlers, and children develop age-appropriate language, social skills, and cognitive skills. Qualified, specialized early intervention personnel are necessary to help achieve this goal. The Joint Committee on Infant Hearing1 recommends that:
All individuals who provide services to infants with hearing loss should have training and expertise in auditory, speech, and language development; communication approaches for infants with hearing loss and their families (eg, cued speech, sign language systems including American Sign Language); and child development.
The Conference of Educational Administrators of Schools and Programs for the Deaf recommends that:
[Early intervention] providers should be credentialed by the early intervention system in the state in which they work. Minimally, they must have education and experience with the 0-3 population and have a degree in Deaf Education. They should know about the acquisition and development of spoken and signed language in children who are deaf and hard of hearing. They should possess the training and skills necessary to help children develop age appropriate language. They should be skilled in working with families from diverse backgrounds.
According to the Joint Committee on Infant Hearing, early interventionists for deaf and hard of hearing infants and toddlers and their families should be able to provide families with:
The Joint Committee on Infant Hearing also states that early interventionists should also be able to:
Families should seek out early intervention programs that have professionals with these qualifications or advocate within their early intervention system to obtain these professionals.
1 Members of the Joint Committee include: American Academy of Audiology, American Academy of Pediatrics, American Speech-Language-Hearing Association, Council on Education of the Deaf (CED member organizations include Alexander Graham Bell Association for the Deaf and Hard of Hearing, American Society for Deaf Children, Association of College Educators - Deaf and Hard of Hearing, Conference of Educational Administrators of Schools and Programs for the Deaf, Convention of American Instructors of the Deaf, and National Association of the Deaf), and Directors of Speech and Hearing Programs in State Health and Welfare Agencies.
Conference of Educational Administrators of Schools and Programs for the Deaf. (2006). Position on Early Intervention Programs for Children with Hearing Loss. www.ceasd.org
Joint Committee on Infant Hearing. (2000).

• Absence of startling response to a sudden loud noise
• Absence of response to familiar voices in older infants, when spoken out of the infant’s view
• If a child is not using voice or speech to ask, seek attention or call out
Assessment Techniques for Hearing Loss
Hearing tests for infants are carried out objectively. Auditory Brain Stem response test uses electrodes placed on the infant’s head with a sound-generator inserted into the external ear, to record the responses of the auditory nerve to a sound. Otoacoustic emissions test records the echo of the sound given out via the speakers into the ear, wherein the absence of the echo confirms hearing loss.
Initial Steps towards Intervention
The first step towards the intervention program is to provide the suitable amplification for the child diagnosed with hearing loss using a hearing aid or cochlear implant. The goal of the intervention program should be to help the child to learn to communicate, maximize the use of residual hearing and interact with the society. Everyone in the family and immediate surroundings of the child becomes a contributor in the intervention program.
The team of professionals in the intervention program includes Otolaryngologist, Audiologist, Speech and Language therapist, primary care physician and psychologist if required. They can help in deciding whether the child can be helped to develop verbal language skills, use of sign language or any other means of communication. This decision is based on the overall cognitive skills, physical ability and intelligence of the hearing impaired child.
Auditory Training after Amplification
Children or adults with severe or profound hearing loss may still be able to hear some low frequency sounds and this hearing ability in them is called residual hearing. It is very important to preserve and use this residual hearing in the intervention program. Amplification with hearing aid or cochlear implant will help the child hear the sounds while the Auditory training sessions will help the child differentiate, discriminate and identify the sounds he or she hears. The auditory training can be extended to speech sound discrimination and identification, ultimately helping the child to improve on verbal communication skills.
Critical Period of Language Learning
A child with normal hearing learns to use verbal communication and spoken language during the critical period for language development, before two years of age. During this development, almost 80 percent of first language is learnt by the child, building up the vocabulary thereafter. Studies have shown that if this period is missed for language learning, the language development may not be as natural.

The DOH Department Circular on the Guidelines for Universal Newborn Hearing Screening Program (UNHSP) Implementation was released last March 31, 2014 to all health leaders and stakeholders including hospitals, health providers and patients across the country.
The Department of Health- Family Health Office (DOH-FHO) and the Newborn Hearing Screening Center- National Institute of Health, UP-Manila (NHSC-NIH-UPM) developed guidelines for the implementation of Universal Newborn Hearing Screening Program (UNHSP) which will serve as a comprehensive guide and reference material for service providers and health workers who are engaged in the provision of newborn hearing screening, be it actual screening, training of health workers, or application of intervention strategies. Included in the circular are the roles guidelines of service providers for a clearer delineation and discharge of their functions.
In the circular are the Universal Newborn Hearing Screening Act 2009 and Manual of Operations for Republic Act 9709. You may download a copy here.

Each state sets their own eligibility requirements, so depending on the type and/or severity of the hearing loss, some D/HH children may not be eligible to receive Part C services.
NOTE: Refer a child diagnosed D/HH even if
- You are unclear about eligibility for a specific case, or
- The child is three (3) years of age or older.
Even if the family is found to be ineligible for services, the EI case coordinator will be able to share other resources with the family.
To locate your EI program, contact
The Early Childhood Technical Assistance Center or your state EHDI program.
- Provider’s legal obligation (2011 Part C regulations:§ 303.302) (pg. p.60141)
- National Center on Hearing Assessment and Management [8.16 MB, 8 pages]
- Part C of the Individuals with Disabilities Education Act (IDEA)
- American Speech-Language and Hearing Association
- The Early Childhood Technical Assistance Center
- Individualized Family Service Plan (IFSP)
- The Early Intervention / IFSP Process [20.1 KB, 1 page]
Other helpful resources
Centers for Disease Control and Prevention Hearing Screening and Follow-up Survey

Children learn speech and language from listening to others. The first few years are particularly critical to development. When a hearing loss exists a child does not get the full benefit of language learning experiences. A hearing loss may be temporary, progressive or permanent but left unnoticed, delays in speech and language learning can occur.
KidsAbility Infant Hearing Screening Information During COVID-19
During the Covid19 pandemic, newborn screening in the hospital and in the community has been temporarily suspended in order to protect the safety of newborns, families, staff and the greater community. The Ministry of Health is working with the regional partners to identify when services will resume and which services will be considered a priority in the first phase of re-opening. To date, we have no direction for screening but certainly understand the concerns of parents. Further information will be provided as soon as it is available.
Who can tell me if my child has a hearing impairment?
Newborns - Birth to 4 months
All parents of babies born in Ontario are offered a free hearing screening for their newborn before they leave the hospital.
If your baby was not screened and is not yet 4 months of age call ErinoakKids Client Services Intake Centre at 1-877-374-6625 to arrange a community screening assessment through the Central West Infant Hearing Program.
Toddlers – 4 to 12 months
If your physician or other professional is concerned that your child may have a permanent hearing loss or has risk factors for this diagnosis, then he may call ErinoakKids Client Services Intake Centre at 1-877-374-6625 to arrange an audiology assessment through the Central West Infant Hearing Program.
Preschoolers – One year of age to school entry
Children may be assessed by a local Audiologist on referral from a family physician. Any child identified with a permanent hearing loss may receive ongoing audiology services from the Central West Infant Hearing Program. You can call directly after receiving the diagnosis for your child of a permanent loss.
Do I wait for a hearing assessment before getting help for my child’s speech and language development?
If you feel your baby is having difficulty learning to communicate or interact with others Contact Us. KidsAbility works in partnership with other service providers to support you and your child as you learn about your child’s developmental needs and navigate through systems of support.
What services are available once my child is diagnosed with a hearing impairment?1.

The National Deaf Children's Society has celebrated a long-running campaign that has seen 36,000 babies receive hearing screen tests with a champagne reception in the House of Commons.
The reception celebrated the first anniversary of the Newborn Hearing Screening Programme, which has been piloted in 23 sites across England.
The organisation fought for 10 years to get free tests.
The programme allows babies' hearing to be tested within days of birth.
Previously, babies were not tested until they were six to eight-months old.
Susan Daniels, chief executive of the National Deaf Children's Society, said: "The programme revolutionises the identification of deafness and is the first step in changing the lives of babies born deaf in the UK. It is important that we ensure the newborn screening is available to all parents by 2004 and that all the support services are in place."

Referring Deaf or Hard of Hearing Children to Early Intervention
Early Intervention for Children who are Deaf or Hard of Hearing
Did you know that providers, such as audiologists, otolaryngologists, and pediatricians have a legal obligation to make a referral to the state’s Early Intervention (EI) program as soon as possible, but no later than seven calendar days after the child has been identified with a permanent hearing loss?
Developmental risk and early intervention
Children who are born deaf or hard of hearing (D/HH) are at risk for developmental delay because they may lack early exposure to an accessible language. However, data reported to the Centers for Disease Control and Prevention show that some D/HH children were not documented as having received early intervention services. In addition, some D/HH children may be born with other conditions that also can result in developmental delays. Referring D/HH children to early intervention as soon as possible will help ensure that they can reach their full potential. Early Intervention represents the goal of the entire Early Hearing Detection and Intervention (EHDI) process. To realize the benefits of early identification, intervention services need to be
- Targeted, and
In addition, intervention services for D/HH children need to be implemented promptly and in a family-centered manner. If a family refuses your referral to intervention services, be sure to document the parents’ decision.
What is Early Intervention (EI)?
EI is a system of services available to children under the age of three who are eligible and may have a developmental or language delay [284KB, 16 pages], disability, or special health condition that is likely to lead to non-typical development. Evaluation and service coordination are provided free of charge.
If a child isn’t developing as expected in certain areas, the family may be able to receive early intervention services from the state’s lead agency that works with families and children with different developmental needs. EI services are developmental services that are
- Selected in collaboration with the parents; and
- Usually provided at no cost (some Federal or State laws provide for a system of payments by families, including a schedule of sliding fees).

STEP 1: Parents will be asked if they want to consent to hearing screening
Hearing screening is not mandatory but is a medical recommendation. Parents or legal guardians can decline hearing screening. However, before making a final decision please speak with a health care provider about the pros and cons of this decision.
STEP 2: The Infant Hearing Program performs the hearing screen and expanded hearing screening is offered as an option if it is recommended that the baby have an appointment with an audiologist
Based on a baby’s hearing screening results, the Infant Hearing Program might recommend that the baby have an appointment with an audiologist for a hearing assessment. If so, the baby is eligible for expanded hearing screening and the Infant Hearing Program hearing screeners will discuss this option with parents/legal guardians.
Once a parent or legal guardian has had their questions answered and has enough information to make a decision, the hearing screener will document the choice for expanded hearing screening. The selection will be recorded on the hearing screening form, along with the name of the person providing consent and the hearing screener who provided the information. The last page of the hearing screening form (parent education page) will be torn off and the selection recorded and provided to the parent or legal guardian for their records.
STEP 3: If the parent/guardian consents to expanded hearing screening, the Infant Hearing Program screening form is sent to Newborn Screening Ontario and the test is performed
The Infant Hearing Program sends the screening form to Newborn Screening Ontario (NSO) to notify NSO to perform the hearing loss risk factor blood spot screen. If a baby passes their hearing screen, they will not be eligible for the hearing loss risk factor blood spot screen
Results from the hearing loss risk factor blood spot screen should be available within a week once NSO is notified to perform the screen.
Newborn Screening Ontario and the Infant Hearing Program have collaborated toprovide screening for hearing loss risk factors. The dried blood spot is already available for many babies so it is painless to have the hearing loss risk factor blood spot screen. As well, testing for congenital cytomegalovirus needs to be performed on a blood sample taken during the first 3 weeks of life. In most cases the dried blood spot is taken in the first week of life and sent to Newborn Screening Ontario for newborn blood spot screening.

Universal Early Hearing Detection
Course Language: English
Universal Early Hearing Detection: Making a difference one baby at a time
Instructor:Dr. Judith A. Marlowe, PhD, FAAA, CCC-A, Executive Director Audiology & Professional Relations, Natus Medical Incorporated
294 STUDENTS ENROLLED
This educational session reviews the criteria for mass screening programs, illustrates how screening every newborn for hearing satisfies these requirements, outlines professional guidelines, recommendations, and benchmarks for effective and efficient EHDI programs, and summarizes evidence supporting the significant benefits of early detection and intervention.

Yoshinaga-Itano, who is a Professor at the University of Colorado at Boulder in the Department of Speech, Language and Hearing Sciences, also advocates the globalization of infant hearing screening as Chair of the Joint Committee on Infant Hearing (JCIH). A JCIH policy statement, updated in 2007, sets criteria for these programs, and most countries look to it as the standard but tailor it for their area and culture, she says.
Yoshinaga-Itano has been trotting around the globe for more than 20 years, doing humanitarian work and setting up programs in China, Mexico, and Southeast Asia, including Thailand and the Philippines. Most recently, she and her team worked with audiometric technicians in the rural area of Luoyang, about an hour outside Xian, one of China's ancient capitals. Most technicians in China are trained by manufacturers because no professional audiology program exists there yet, so the technicians typically have big gaps in their knowledge, she admits. During her time there, the team worked with newborns and children between the ages of 2 and 6, and showed technicians how to do secondary levels of testing, checking hearing aids and fitting children for new ones. Most of the children already fitted with hearing aids were underamplified, she says.
“When you're working side-by-side with 10 teachers and technicians at a school, you see right away what they don't understand,” Yoshinaga-Itano says. “But they learned fast and we saw dramatic changes in how they did basic fittings, identification and basic principles of intervention. We also noticed that once we got people trained in an area of China, other people from nearby areas were coming to learn from them. It created a ripple effect in the region.”
With more than a billion people in China, the challenges of reaching the majority of the population are staggering, but Yoshinaga-Itano credits newer automated technology as a big leap forward in bringing newborn screening to needy populations that previously had no access to testing and follow-up care.
Now it's possible to screen newborns just about anywhere in the world, she says. Costs have declined, devices are more portable, and digitization and battery-operated instruments have made screenings more accessible because administrators don't have to rely on local electricity, which isn't available everywhere. And with automated equipment, those with lower skill levels can be trained to use it in remote regions, she adds.

(2018, December 20) | Useful to early interventionists, lead agencies, and Parent Centers on screening during evaluation of an infant or toddler for hearing loss or deafness.
This Dear Colleague letter from OSEP responds to a question about the evaluation process for an infant or toddler suspected of being deaf or hard of hearing to determine eligibility for early intervention services under Part C of IDEA. The inquirer also sought guidance on the applicable evaluation timelines and required protocols.
In answering the writer’s questions, OSEP explains in concise detail what the IDEA requires. Included in the discussion is the need for parental consent before evaluating a child suspected of having a disability or developmental delay, what that evaluation must involve (including a family-directed assessment to identify the family’s resources, priorities, and concerns and the supports and services necessary), andhow each state’s policies are a factor to be considered. The letter also answers questions such as:
May a previous hearing screening (such as a newborn hearing screening outcome or a hearing screening result provided by an Early Head Start program or a health care provider) meet the Part C evaluation requirements?
How can Part C programs ensure that a hearing screening or evaluation is completed in a timely manner when a child is determined to be eligible for Part C services based on an established condition?
If an initial evaluation has begun and the child requires treatment to resolve any temporary medical conditions before the hearing evaluation can be completed, how should Part C programs ensure that the child remains actively in the eligibility determination process if the hearing evaluation requires more than 45 days to complete?
The 4-page Dear Colleague letter is available in PDF, at:
SOURCE ARTICLE: Center for Parent Information and Resources
Give us a call at (727) 523-1130 or (800) 825-5736 or request a callback by clicking below.

Language development is impacted if there is any loss in the ability to hear.
Even a mild hearing loss can dramatically effect a child’s language development. Early identification of hearing loss is key to providing appropriate intervention services to promote language development.
Guam EHDI works to assure that all babies born on Guam get screened for hearing loss by 1 month. If a baby does not pass their hearing screen, a Diagnostic Audiological Evaluation (DAE) will be conducted by 3 months of age. A baby with hearing loss will be enrolled in early intervention services by 6 months of age.
If you have concerns about your baby’s hearing, discuss this with your baby’s doctor, or contact Guam Early Intervention System (GEIS) at (671) 300-5776 to schedule a FREE hearing screening.
For more information on the Newborn Hearing Screening Program please call (671) 735-2466.

El cribratge universal de la hipoacúsia. Incorporació i implementació del Programa de cribratge en els centres i serveis de la xarxa pública i privada amb atenció maternoinfantil
Introduction: A screening programme for hearing loss is being implemented within the Catalan Public Hospital Network since 2010. In 2015 Decree 4/2015, of 13 January, was approved to extend a universal screening coverage. To implement it, different sessions were conducted for coordination and training was offered to a hundred percent of private healthcare centers. Objective: The objective is to assess the Early Hearing Loss Detection Programme through the process indicators and results describing the innovation with the recent addition of private centers (Decree 4/2015, of 13 January). Methods: Descriptive study of process indicators and results of the Early Hearing Loss Detection Programme in Catalonia record since the beginning – in 2010 – to 2015. Description of the extension process in the private centers network. Results: The number of screened newborns has passed from 9,178 (2010) to 44,632 (2015), which represents a 386% increase. In 2015, this represents a coverage of 91,7%. 468 cases were diagnosed (from 2010 to 2015) and 110 were diagnosed in 2014. In 2015 80 newborns were diagnosed with hearing loss (provisional data). Conclusions: The Programme presents good coverage in the Catalan Public Hospital Network, whilst in the private health network it is being fostered as a universal coverage public health programme. This initiative promotes that all the cases of newborns diagnosed with hearing loss are reported by private birth centers to the record, while public birth centers keep mantaining good coverage and reporting. There is good interaction among the different agents involved in the screening.
Hearing loss; Screening; Automated evoked potentials; Registry
Prats B, Fernandez-Bardon MR, Cabezas-Peña C. El cribratge universal de la hipoacúsia. Incorporació i implementació del Programa de cribratge en els centres i serveis de la xarxa pública i privada amb atenció maternoinfantil. Butll Epidemiol Catalunya.

Early Intervention for Hearing Impairment
Early intervention is a term used for the process of identifying conditions in children that may cause delays in development of physical skills, cognitive skills, communication, adaptive skills and social and emotional development. The main focus of early identification and early intervention for a child with hearing loss is on developing communication skills, both verbal and sign language, to the maximum possible extent. Further, if hearing impairment is associated with other disorders like mental retardation, blindness, cerebral palsy, etc., the intervention program addresses those needs also.
Hearing impairment is detrimental to the normal speech and language development in such children. While speech and language are innate skills of human beings, these skills develop only by hearing, listening and incorporating the use of words, intonations, voice variations, and the patterns in which words are strung together to form expressions.
Why Early Intervention?
The American Academy of Pediatrics recommends a hearing screening to be done for every baby a few weeks after birth, and also follow-up visits up to two years of age. With modern technology of manual and automatic hearing testing routines, congenital hearing loss is being identified in children before they are 3 months of age. Identification of hearing impairment is possible by looking into the risk factors, responses of the baby to sounds around and seeking professional help when the risks and signs indicate a hearing problem.
Risk Factors for Hearing Loss
Some of the important risk factors associated with hearing loss can be listed and an informal screening can help in determining whether to look out for signs of hearing impairment. The risk factors include:
• Family history of hearing impairment
• Prenatal infections in the mother like rubella, herpes simplex and toxoplasmosis
• Abnormal development of the structures in head and neck region like cleft palate, atresia (absence of pinna), etc
• Premature birth
• Medications given in neonatal period
• Syndrome associated with hearing loss like Waardenburg, neurofibromatosis, etc
• Recurrent infections in the ear, nose and throat
• Infections like meningitis, measles, mumps, etc
• Head trauma
Certain symptoms may be noticed by the mother or primary caregiver of the baby that can call for a detailed hearing assessment to be done.

Washing your hands often, especially after wiping a young child’s nose, mouth or tears or changing diapers is important, said Stephanie Browning McVicar, co-author and director of the Cytomegalovirus Public Health Initiative at the Utah Department of Health. “What is also essential, though, is not sharing food, drink or utensils, particularly with young children, while pregnant.”
The bill also requires all infants who fail two hearing screens to be tested for CMV within three weeks of birth unless a parent declines the test.
By using that time frame, health providers are able to distinguish between congenital CMV and CMV acquired after birth, which is rarely associated with health problems. The screening parameters also are designed to identify infants who do not have any symptoms but are most at risk for hearing loss.
The researchers used Utah Department of Health and Vital Records data to assess whether 509 asymptomatic infants who failed hearing tests between July 1, 2013 and June 30, 2015 underwent CMV screening and the results of that screening.
They found that 62 percent of these infants were tested for CMV and three-quarters were screened within the three-week time frame. Fourteen of those infants were CMV positive and six had hearing loss. Of the infants who were tested more than 21 days after birth, seven were CMV positive and three had hearing loss.
The researchers conclude that because these infants had no signs of infection, it is “highly likely” they would not have been diagnosed later as having congenitally acquired CMV. Identification of CMV-positive infants increased opportunities to watch their health more closely and intervene, when needed, more quickly. They also found more infants received timely diagnostic hearing tests after the law took effect.
“This result has major implications for all children who fail their newborn hearing screening since speech and language outcomes depend upon early hearing loss diagnosis,” said Albert Park, co-author and chief of the U’s pediatric otolaryngology division. “CMV infected infants with hearing loss may benefit from antiviral therapy.

A conceptual framework for rationalized and standardized Universal Newborn Hearing Screening (UNHS) programs
- Carlo Giacomo Leo†1, 2Email authorView ORCID ID profile,
- Pierpaolo Mincarone†3,
- Saverio Sabina1,
- Giuseppe Latini1 and
- John B. Wong2, 4
© Leo et al. 2016
Received: 22 December 2015
Accepted: 4 February 2016
Published: 12 February 2016
Congenital hearing loss is the most frequent birth defect. The American Academy of Pediatrics and the Joint Committee on Infant Hearing established quality of care process indicators for Universal Newborn Hearing Screening starting from 1999. In a previous systematic review of Universal Newborn Hearing Screening studies we highlighted substantial variability in program design and in reported performance data. In order to overcome these heterogeneous findings we think it is necessary to optimize the implementation of Universal Newborn Hearing Screening programs with an appropriate application of the planning, executing, and monitoring, verifications and reporting phases. For this reason we propose a conceptual framework that logically integrates these three phases and, consequently, a tool (a check-list) for their rationalization and standardization.
Our paper intends to stimulate debate on how to ameliorate the routine application of high quality Universal Newborn Hearing Screening programs. The conceptual framework is proposed to optimize, rationalise and standardise their implementation. The checklist is intended to allow an inter-program comparison by removing heterogeneity in processes description and assessment.
KeywordsUniversal Newborn Hearing Screening Checklist Quality improvement UNHS
Sensorineural hearing loss is one of the most frequently occurring permanent congenital defects at birth with a prevalence of 0.1–0.3 % for newborns [1–4] (2–5 % in presence of audiological risk factors) . Its late diagnosis could negative influence language, learning and speech development with lifelong consequences [6–11]. Universal Neonatal Hearing Screening (UNHS) programs were developed in several countries to identify the majority of newborns with hearing impairment. UNHS programs adopt, as screening tests, otoacoustic emissions (OAEs) and/or automated auditory brainstem response (aABR) testing. Those who are positive at tests are referred to full audiological diagnosis.

How we do it: Employment of listeningdevelopment criteria during assessment of infants who use cochlear implants Brittan A Barker 1, Maura H Kenworthy 2, Elizabeth A Walker 2 1
Louisiana State University, USA, 2University of Iowa, USA
There are currently no formal, standardized procedures for assessing speech processing and perception during infancy. This lack of tools makes interpretation of infant data challenging. This article describes how our clinical research center established listening-development criteria for infants with cochlear implants. The listening-development criteria incorporate programming, audiometric, and parent-report measures to estimate adequate audibility of the speech signal prior to the infants’ inclusion in research protocols. This paper operationally defines the listening-development criteria, discusses its importance, and presents data from 10 infants who met the listening criteria on average after 6 months of device use. Keywords: Cochlear implants, Infant, Audibility, Assessment, Speech perception
In 2000, the Food and Drug Administration approved implantation in infants 12-months-old and older. Today many centers are even implanting children as young as 6-months-old (Waltzman and Roland, 2005). However, the field still lacks a complete understanding of programming issues that contribute to the ability to detect and process sound in these very young children. Much of this gap in knowledge is due to the fact that there are currently no formal, standardized procedures for assessing speech processing and perception during infancy. Our clinical research center established listening-development criteria for infants with cochlear implants (CIs) to address this challenge. The listening-development criteria incorporate programming, audiometric, and parent-report measures to estimate adequate audibility of the speech signal prior to inclusion in research protocols evaluating their listening development. These criteria and the method of their employment are described within.
Why is adequate audibility in infants with CIs important? Adequate audibility of the speech signal is crucial for spoken language learning. Years of research examining speech perception and spoken language development in typically developing infants and children with hearing aids support this notion (e.g. Jusczyk, 1997; Stelmachowicz et al., 2000). There is a dearth Correspondence to: Brittan A Barker, PhD, Department of Communication Sciences & Disorders, College of Humanities & Social Sciences, Louisiana State University, 63 Hatcher Hall, Baton Rouge, LA 70803, USA.

Students, left to right, Kami DeFee, 5, Cadence Elliott, 5, and Lucas McCaslin, 4, assembled a stick man on the floor of their preschool classroom with the help of teacher Elizabeth Anderson, at right, on Tuesday, September 7, 2021 at the Spokane HOPE Center for Deaf and Hard of Hearing Children in Spokane, Washington. It was the first day of the school year for students receiving services through the center, typically those aged 12 months to five years. The nonprofit has contracts with Washington State and local school districts to help children with hearing problems, but reimbursement only covers about a third of the cost. The rest of the funds come from grants, donations and general fundraising. In October they will have their annual Hoedown for HOPE fundraiser. (Jesse Tinsley/The Spokesman-Review)
From birth to age 3, HOPE teachers conduct hour-long home visits where they provide parents with methods to teach their child to speak.
When the toddler is ready, they move on to HOPE Preschool at 1821 E. Sprague Ave. It’s where he learns socialization skills and builds on what he’s learned in the so-called ‘Birth to 3 Years’ program.
Each teacher works with up to 30 families at any one time and provides assistance to schools in the Spokane and Spokane Valley areas. Recently, the school was asked to help more rural areas, Driscoll said.
Even after sending children to kindergarten classes, HOPE teachers are checking in with families as they navigate the “traditional” school system, said Laurel Graham, an early intervention provider.
“We also continue with this empowering role,” Graham said. “I have a parent who is nervous about his grandson going to preschool because he will be the first child with cochlear implants, so we were just thinking for his son in particular s ‘He was stressed.”
Parents also need to know the gear and lingo of the community, said Amy Hardie, HOPE’s director of education.
Hardie said it’s so they can advocate for their own child as they enter school, often in a classroom where a teacher may not have that knowledge.
“It’s an important part of the process, so we need to make sure our kids are self-advocates for their gear, and if they know their battery isn’t working, they can tell their friends,” said Bold.

Also, screening programs that only test infants who present with one or more risk factors for hearing loss are typically testing only ∼50% of children who actually have a hearing loss.1 ,3 ,41 ,42 These factors have resulted in an average age of identification of 11 to 19 months for children with known risk factors for hearing loss2 ,17 42–44 and 15 to 19 months for children without apparent risk.17 ,43 ,44
Taken as a group, previous and present research findings suggest that the first year of life, especially the first 6 months, is critical for children with hearing loss. When hearing loss was identified and treated by this time, several independent researchers have reported that, as a group, children demonstrated average language scores that fell within the normal range when they were 1 to 5 years old.28 ,30 This finding is encouraging and suggests that early identification and subsequent intervention is associated with improved language development in deaf and hard-of-hearing children. If this is the case, it is critical that all infants with hearing loss be identified by 6 months of age and receive early intervention; universal newborn hearing screening would be an excellent vehicle for achieving this goal.
This study was supported by the National Institutes of Health (contract number NO1-DC-4–2141), Maternal and Child Health, the Colorado Department of Education, the University of Colorado-Boulder, and the Colorado Department of Public Health and Environment.
We wish to acknowledge the contributions of following individuals to this project: Arlene Stredler-Brown, Mah-rya Apuzzo, Deborah DiPalma, Amy Dodd, Colette Roy, Joan McGill Eden, Kathy Watters, Colorado Home Intervention Program regional coordinators, Colorado Home Intervention Program parent facilitators, and the participating families.
- Received August 5, 1997.
- Accepted June 22, 1998.
Reprint requests to (C.Y.-I.) University of Colorado-Boulder, CDSS Building, Campus Box 409, Boulder, CO 80309.
- Watkins P,
- Baldwin M,
- McEnery G
- Northern JL,
- Hayes DH
- Geers A,
- Moog J
- ↵Webster A. Deafness, Development, and Literacy. London, England: Methuen and Company Ltd; 1986
- ↵Allen TE. Patterns of academic achievement among hearing impaired students: 1974 and 1983.

Newswise - A new study of Colorado birth records shows that infants with low Apgar scores - the widely used measure of newborn health - are 10 times less likely to receive an initial hearing loss screening than babies with normal Apgars. Low-weight babies also are four times more likely to go untested. In both cases, these babies are at greater risk for the most common birth defect: hearing loss.
"While the data do not suggest why these babies are missed, we can clearly conclude that clinical measures showing poor health are strongly associated with both missed screening and risk of hearing loss," said lead study author Mathew Christensen, Ph.D.
Christensen is the program evaluator at the Colorado Department of Public Health and Environment. He and his colleagues analyzed more than 200,000 state birth records from January 2002 to December 2004.
The study appears online and in the December issue of the American Journal of Preventive Medicine.
Ninety-eight percent of the infants received hearing screening a day or so after birth, but the 2 percent who did not undergo screening were likely to be those who needed it most. Moreover, of those who had a positive test - indicating loss of hearing - 18 percent did not receive timely follow up, which is a function of individual hospitals' outreach programs.
Such tests are the standard of care in the United States and 42 states require them, according to the Web site of the National Center for Hearing Assessment and Management.
Study co-author Vickie Thomson, Ph.D., director of newborn screening programs at the Department of Public Health and Environment, said that newborns' hearing is tested while they are resting or asleep and involves sending a signal of clicks and then measuring the reaction of the inner ear or brain to the sounds. Testing usually occurs four hours or more after birth or the next day.
Thomson said that her experience as an audiologist leads her to conclude that many small or low-Apgar babies could be too involved in other procedures or discharged too soon for clinicians to perform the test.
Karl White, Ph.D., director of the National Center for Hearing Assessment and Management at Utah State University, said this finding is not surprising but is important: "Basically, it says sick babies are less likely to get screened."
According to the researchers, studies show that intervention by age of six months results in a return to near-normal ability to develop speech and language.

doi:10.1136/adc.2008.151092.View ArticlePubMedGoogle Scholar
- NIH. Consensus development conference statement - early identification of hearing impairment in infants and young-children - 1–3 March 1993. Int J Pediatr Otorhinolaryngol. 1993;27(3):215–27.View ArticleGoogle Scholar
- American Academy of Pediatrics Task Force on Newborn and Infant Hearing. Newborn and infant hearing loss: Detection and intervention. Pediatrics. 1999;103(2):527–30.View ArticleGoogle Scholar
- Busa J, Harrison J, Chappell J, Yoshinaga-Itano C, Grimes A, Brookhouser PE, et al. Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120(4):898–921. doi:10.1542/peds.2007-2333.View ArticleGoogle Scholar
- Mincarone P, Leo CG, Sabina S, Costantini D, Cozzolino F, Wong JB, et al. Evaluating reporting and process quality of publications on UNHS: a systematic review of programmes. BMC Pediatr. 2015;15(1):86. doi:10.1186/s12887-015-0404-x.PubMed CentralView ArticlePubMedGoogle Scholar
- Bureau International d’Audiophonologie. BIAP Recommendation 02/1 bis. 1996. http://www.biap.org/index.php?option=com_content&view=article&id=5%3Arecommandation-biap-021-bis&catid=65%3Act-2-classification-des-surdites&Itemid=19&lang=en. Accessed 11/07/2014.
- World Health Organization. Primary Ear And Hearing Care Training Resource. Advanced Level., Geneva. 2006. http://www.who.int/pbd/deafness/activities/hearing_care/advanced.pdf. Accessed 11/07/2014.
- Clark JG. Uses and abuses of hearing loss classification. Asha. 1981;23(7):493–500.PubMedGoogle Scholar
- National Institutes of Health.

Objectives: This study examined the ability of click auditory brainstem response (ABR) undertaken below the age of 6 months (from expected date of delivery) to differentiate between conductive and sensorineural hearing loss (SNHL), using the latency of wave V measured 20 dB above threshold.
Design: Subjects were recruited if they had an ABR threshold of ≥ 40 dB nHL and ≤ 70 dB nHL in one or both ears measured below the age of 6 months and they had also attended follow-up appointments for behavioral assessment of their hearing in which the type of hearing loss had been confirmed. Forty-five children (84 ears) with SNHL, 82 children (141 ears) with temporary conductive hearing loss (TCHL), and 5 children (10 ears) with permanent conductive hearing loss (PCHL) were recruited. The differences between mean wave V latencies measured 20 dB above ABR threshold were examined using the independent t-test for the groups of cases with SNHL, TCHL, and PCHL. Signal-detection theory was used to examine the relationship between sensitivity and specificity when the latency of wave V 20 dB above threshold was used to identify the presence of SNHL. Receiver operating characteristics were generated and the coordinates of the curve examined for the best compromise between sensitivity and false-alarm rate. The specificity, positive predictive value, and probability of missing a true case were determined for the most promising criteria.
Results: There were significant differences between the two groups with SNHL and TCHL. The mean latency of wave V 20 dB above threshold was 1 msec shorter in those with SNHL compared with those with TCHL. There were significant differences between children with PCHL and SNHL but no difference between those with PCHL and TCHL. When a criterion of < 7.6 msec was chosen to predict the presence of SNHL the test sensitivity was 0.98, test specificity 0.71, and positive predictive value was 0.66. Nine out of 10 of those with a latency 20 dB above threshold of < 7.0 msec had an SNHL.
Conclusions: The latency of wave V 20 dB above threshold measured using click ABR is a useful indicator of the type of hearing loss in babies referred from newborn hearing screening.

Alexandria, VA – A new review of medical databases shows that neonatal hearing loss, already one of the most common birth disorders in the United States, is especially prevalent among Hispanic-Americans and those from low-income households, according to the April 2009 issue of Otolaryngology-Head and Neck Surgery. The wide-ranging study focused on hearing loss in newborns (neonates), children, and adolescents.
The authors also note serious flaws in the collecting of data on pediatric hearing loss, resulting in a fractured body of knowledge that is hindering a more complete evaluation of the problem's scope.
The researchers found that the average instance of neonatal (younger than one month old) hearing loss was 1.1 per 1,000 infants screened. The number varies from state to state, with cases being most prevalent in Hawaii (3.61 per 1,000), followed by Massachusetts and Wyoming.
When looking at children as a larger group (combining neonatal through adolescent), the research indicates that compared to other ethnic groups, Hispanic-American children in all subgroups (Mexican-American, Cuban-American, and Puerto Rican) show a higher prevalence of hearing loss, with a similar prevalence existing in children in low-income households. The authors note that it is unclear whether instances of hearing loss actually increases as children grow older, adding particular weight to the neonatal results.
The authors conclude that in addition to the statistics presented, there exists a real need to establish a more unified system for the collection of regional and national health data. They note that within the existing databases, data collection methodologies are not standardized; the authors suggest creating multi-institutional national data repositories in an effort to standardize the information as it is collected. This could include a neonatal hearing loss screening registry within the Universal Newborn Screening Programs.
Approximately two to four of every 1,000 children in the United States are born deaf or hard-of-hearing. Studies have shown that early diagnosis of hearing loss is crucial to the development of speech, language, cognitive, and psychosocial abilities. One in every four children born with serious hearing loss does not receive a diagnosis until age three or older, making early hearing screening a necessary step for ensuring a healthy life for a child.

Auditory maturation and congenital hearing loss in NICU infants
Rijping van het auditieve systeem en congenitaal gehoorverlies bij NICU kinderen
The number of preterm births has increased over the past decades as a result of increasing maternal age and in vitro fertilization (1). At the same time the survival of preterm infants has increased due to advances in perinatal and neonatal care. For example, antenatal corticosteroids for women with threatened preterm delivery, high-frequency oscillatory ventilation and inhaled nitric oxide have now become standard therapy (1). Unfortunately, these improvements sometimes come at a price. Neonatal intensive care unit (NICU) survivors have an increased risk of neurodevelopmental impairment, such as cerebral palsy, cognitive delay, blindness and deafness (2). Infants admitted to the NICU have an increased risk of congenital (present at birth) and acquired hearing loss compared to infants admitted to the well-baby nursery (3). Multiple risk factors have been associated with congenital hearing loss (Table 1) (4). Many of these risk factors occur in daily NICU care. The increased knowledge of the etiology of congenital hearing loss has put the emphasis not only on treating, but also on preventing congenital hearing loss. For example, bilirubin serum levels are kept within a very strict range in NICU infants. While prevention may not always be possible, the increased awareness has resulted in earlier diagnosis and careful counseling. Between 2002 and 2006 the universal newborn hearing screening (UNHS) program was introduced in the Netherlands. This has resulted in earlier identification and referral of infants with congenital hearing loss. Several studies have shown that early and adequate intervention of infants with congenital hearing loss minimizes future problems with speech and language development (5-6). Treatment before the age of six months results in better speech and language development at school age.
|Keywords||NICU, congenital hearing loss, deafness, infants, maturation|
|Promotor||J.B. van Goudoever (Hans) , R.J.

Procedures, guidelines and reports
The documents in this section have been developed by the NSU for health professionals providing services in or associated with the Universal Newborn Hearing and Early Intervention Programme (UNHSEIP).
The workforce development strategy and action plan (the Strategy) addresses the development of the newborn hearing screening and audiology workforce required for the implementation of the UNHSEIP. It recognises that the effective delivery of the UNHSEIP requires a multidisciplinary team.
In this section
The purpose of the National Policy and Quality Standards is to document the operational policy and quality standards of practice for providers of services within the Universal Newborn Hearing Screening and Early Intervention Programme (UNHSEIP)
The Universal Newborn Hearing and Early Intervention Programme(UNHSEIP) carries out a two stage regime using aABR technology with the BERAphone equipment, to screen for hearing loss. This is introduced below.
The NSU recommends that the parents and guardians of all babies born in New Zealand are offered newborn hearing screening for their babies.
Reports into quality improvements for the UNHSEIP programme

Permanent childhood hearing loss can be congenital, delayed-onset, progressive, or acquired in nature. Congenital hearing loss refers to hearing loss that is present at birth and is often identified through a newborn hearing screening conducted shortly after birth. While estimates vary, some hearing loss in childhood is delayed-onset or progressive in nature. As a result, it is important to provide audiologic monitoring over time for children who are considered to be "at risk" for hearing loss. In addition, some mild hearing losses as well as auditory neuropathy may not be identified through newborn hearing screening due to the current limitations of the test equipment or testing methodology used.
Hearing is critical to speech and language development, communication, literacy, and learning. Early identification and intervention of hearing loss can lessen the impact on a child's development (Sininger, Grimes, & Christensen, 2010; Yoshinaga-Itano, Baca, & Sedey, 2010). The Joint Committee on Infant Hearing (JCIH, 2007) recommends that
- all children be screened for hearing loss no later than 1 month of age,
- hearing and medical evaluations be completed no later than 3 months of age,
- infants with confirmed hearing loss are fit with amplification (if the family chooses and if appropriate) within 1 month of diagnosis,
- early intervention services begin no later than 6 months of age.
Note: The scope of this content is limited to the diagnosis and management of permanent hearing loss for children from birth through 5 years of age from an audiological perspective. Resources for hearing screening and habilitation, as well as hearing loss for school-age and adult populations, are under development.
Families who are actively involved in the assessment and treatment process achieve better outcomes (DesJardin, 2006). It is paramount that audiologists incorporate family-centered practice into the identification and treatment of young children who are deaf or hard of hearing; family-centered activities include
- engaging the family and using the child's toys from home in various aspects of the evaluation and therapy sessions,
- suspending judgment and building rapport with the family about their needs and interests,
- matching re/habilitation with the family needs and goals,
- recognizing the family's rights regarding informed consent and confidentiality.
The goal of family-centered practice is to create a partnership with the family so that the family fully participates in all aspects of the child's care.

The typology and the number of tests, and the healthcare setting in which performing the examinations (before or after the discharge) – The program needs to be well balanced for sensitivity, specificity, coverage of the population and costs per subject identified. E.g., Kennedy et al.  reported to have changed their protocol using unilateral failure on aABR, rather than bilateral failure on Transient Evoked OAEs (TEOAEs) testing, as the second step; this change was associated with a reduction in the screen-failure rate from 2.4 % (95 % CI 2.2–2.6) to 1.3 % (1.1–1.5) of babies screened. The presence of specific protocol for neonates at higher risk (e.g., aABR for NICU staying in NICUs for more than 5 days instead of TEOAEs)  - Such neonates, in fact, are at risk of having neural hearing loss (auditory neuropathy/auditory dyssynchrony) which is not detectable with TEOAEs. The set of examinations for the full audiological evaluation – E.g., the one recommended by the JCIH . The tasks to be performed to increase the percentage of enrolment and to reduce the lost to follow up (neonates referred to further examinations that do not show at the planned appointments) - With reference to the former, it has to be noted that specific actions should be done for an appropriate communication with families creating the conditions for an informed consent. With reference to the latter, a survey conducted in USA  shows that only 62 % of all newborns who need a diagnostic evaluation actually did it and, out of them, only 52 % by the age of 3 months (as recommended by the JCIH). The lost to follow-up at all stages of the EHDI process continues to be a serious concern also for the World Health Organization (WHO)  that states the importance, for its success, of monitoring and implementing all the phases of the screening (responsibilities, training, information campaign, procedures of quality assurance).

At the time, this statement was reasonable in that before Bess and Paradise's commentary, studies examining the effects of early identification and subsequent intervention either defined early identification as before 18 months (rather than 6 months) of age26 or did not specify the number of children identified by the age of 6 months.27 Nevertheless, in one of these older studies, White and White26 reported significantly better language scores for a group of severely and profoundly deaf children whose average age of identification was 11.9 months (with an average age at intervention of 14 months) as compared with children with the same degree of hearing loss whose average age of identification was 19.5 months (with an average age at intervention of 26 months).
Since the publication of Bess and Paradise's commentary, Robinshaw28 described 5 young children with severe and profound hearing loss whose deafness was confirmed between 3 and 5 months of age. All of the children wore hearing aids by the age of 6 months. Robinshaw compared her deaf children with 5 normally-hearing control children and to data from a previous study involving 12 children with severe and profound hearing loss whose average age of identification was 2 years, 3 months. She found that the earlier-identified children acquired vocal communicative and linguistic skills at an age similar to the 5 normally-hearing control children and well before the deaf children who were identified later. Her investigation supports the value of early identification followed by immediate amplification; however, the group of children studied was small, only children with severe and profound hearing loss were included, and no data from standardized assessments were presented. In addition, the only treatment consistent across all 5 children was the early fitting of amplification. The frequency of additional early intervention varied among children.
Apuzzo and Yoshinaga-Itano29 responded to Bess and Paradise's25 concerns more directly. They compared language ability at 40 months of age across four age-of-identification groups: 1) 0 to 2 months, 2) 3 to 12 months, 3) 13 to 18 months, and 4) 19 to 25 months. The hearing loss of the children in each of the groups ranged from mild to profound and all of the children received ongoing intervention services from the same program shortly after their hearing loss was identified.

This question will hopefully be addressed in an upcoming NIH funded clinical trial that our group will be conducting to compare hearing, speech and language outcomes in CMV infected infants.”
The researchers suggest, based on their analysis of the data, that screening compliance could be increased by focusing educational and outreach efforts on certain groups who were less likely to get their infants screened for congenital CMV: less educated mothers, babies not born in a hospital and infants who received hearing tests later than 14 days after birth.
Other co-authors of the study include Cathleen D. Zick, professor in the Department of Family and Consumer Studies at the University of Utah, and Jill Boettger, CMV data coordinator at the Utah Department of Health.
The full study can be found here.

A monitoring, reporting and verifying phase where the Monitor action is activated periodically or upon request to aggregate data and build performance indicators. The verification is made comparing indicators with benchmarks and a report is generated with an analysis of reasons for possible deviations which can push for a redefinition of the protocol and/or for a re-organization of its execution. Reports can be used also for disseminating purposes.
A more detailed description of the single phases follows in the following sections (note that the EXECUTING UNHS PROGRAM phase is out of the scope of our work and will not be discussed further).
Planning UNHS program
In order to deliver a protocol it necessary to define the target and the processes.
Definition of the target
Two elements are of importance: the definition of hearing loss and the identification of criteria used to define newborns at higher risk of hearing loss. Hearing threshold and uni- vs. bilateral have an impact in the number of neonates going through testing and evaluations, the number of infants admitted to therapy, the rate of newborns with hearing loss with early diagnosis and treatment, the number of neonates that could erroneously be evaluated as with no hearing deficits. These two parameters are fundamental for inter-program comparison. Several classifications of Hearing Loss have been formulated [19–21] which brings in the definition of the levels of severity (see Additional file 1). It is therefore necessary to make the choice explicit also for their impact on the typology of treatment/rehabilitation. We have previously observed that, in the lack of standardization, several thresholds have been applied in UNHS programs (26 to 40 dB HL).(6) Newborns with risk factors for neonatal hearing loss have about a 10 fold probability for hearing deficits with respect to the overall population [1, 2]. Criteria for higher audiological risk have been defined by several subjects (JCIH , the US National Institutes for Health - NIH , ASHA ) or are chosen directly by program coordinators (e.g., Clemens et al. ).
The audiological risk criteria are relevant for that: specific audiological risk may require a specific screening protocol; the timing and number of hearing re-evaluation (surveillance) for infants at risk should be customized and individualized depending on the relative likelihood of a subsequent delayed onset hearing loss.
Definition of the processes
Activities, detailed actions, decision nodes, workflows, roles, environmental conditions have to be identified and specified. More specifically key issues are reported.

In: Schildroth AN, Karchmer MA, eds. Deaf Children in America. Boston, MA: College-Hill Press; 1986:161–206
- Holt JA
- ↵Quigley SP. Environment and communication in the language development of deaf children. In: Bradford LJ, Hardy WG, eds. Hearing and Hearing Impairment. New York, NY: Grune and Stratton; 1979:287–298
- Elssmann S,
- Matkin N,
- Sabo M
- ↵Mehl AL, Thomson V. Newborn hearing screening: the great omission. Pediatrics. 1998;101(1). URL: http://www.pediatrics.org/cgi/content/full/101/1/e4
- Ross M
- American Academy of Pediatrics
- ↵US Department of Health and Human Services. Healthy People 2000. Public Health Service, DIIHS Publication No. 91–50213: Washington, DC: US Government Printing Office; 1990
- ↵NIH Consensus Statement. Identification of Hearing Impairment in Infants and Young Children. Bethesda, MD: NIH; 1993;11:1–24
- American Academy of Audiology
- Bess FH,
- Paradise JL
- White SJ,
- White REC
- ↵Moeller MP. Early intervention of hearing loss in children. Presented at the Fourth International Symposium on Childhood Deafness; October 9–13, 1996; Kiawah Island, SC
- ↵Stredler-Brown A, Yoshinaga-Itano C. F. A. M. I. L. Y assessment: a multidisciplinary evaluation tool. In: Roush J, Matkin N, eds. Infants and Toddlers With Hearing Loss. Baltimore, MD: York Press; 1994:133–161
- ↵Calhoun D. A Comparison of Two Methods of Evaluating Play in Toddlers. Ft Collins, CO: Colorado State University; 1987. Thesis
- ↵Ireton H, Thwing E. The Minnesota Child Development Inventory.

The test must be timely. The first bloodspot test should be done between 24 and 36 hours of age or prior to discharge from the hospital. For some disorders, false negative results can occur with later testing. The second screen should be done at the first outpatient visit between 5 and 10 days of age.
The hearing test is done in the hospital and any re-screening should be done within 2 weeks and diagnostic testing should be done as soon as possible following the failed outpatient scree. Completing diagnostic testing before three months of age ensures that testing can be done without anesthesia or sedation.
The Arizona screening panel includes:
- 6 amino acid disorders
- fatty acid oxidation disorders
- 9 organic acid disorders
- Biotinidase deficiency
- Classic galactosemia
- Congenital Hypothyroidism
- Congenital Adrenal Hyperplasia
- 3 hemoglobin diseases
- Cystic Fibrosis
- Hearing loss
The incidence in the population is rare, but the potential devastating results and the high costs of treating undiagnosed infants is thought to justify the mass screening. Hearing loss is the most common approximately 2-4 per 1000 births,
Arizona Newborn Screening Program Guidelines-August 2010

Commercially available software
If your hospital has a large number of births, we recommend that you purchase one of the commercially available software programs. In addition to tracking data, these software programs can generate regular reports and follow-up letters to families and physicians.
There are several software products that are currently commercially available for newborn hearing screening data management:
Some of these companies can be used for managing all aspects of a statewide newborn screening program, such as hearing screenings, birth defect information, and metabolic tests.
Hospitals with smaller numbers of births may find that the software included with the equipment they purchase to be sufficient. Some of the hospitals even find a simple logbook or excel spreadsheet to be adequate.
What data should you monitor
The number of births your hospital has will generally dictate how you decide to track and monitor your data. You should be able to easily obtain the following information:
- Overall refer rate. How many babies were screened, how many babies passed, and how many referred.
- Refer rates for individual screeners. This tells you how well each screener is doing.
- Infants that were missed prior to discharge. You will need to follow-up and make sure these infants obtain a hearing screening.
- Infants that need to return for a re-screen. You will need to make sure these infants return for their follow-up re-screen appointments.
- Infants that need a diagnostic audiologic evaluation. You will need to follow-up with the infant's parents or pediatrician to ensure that they scheduled a diagnostic evaluation.
The Department of Health sends hospitals monthly reports with these screening statistics. Some hospitals find these reports to be sufficient for data management purposes. As mentioned above, each hospital, regardless of size, should keep its own record of hearing screenings, be it a log sheet, book, or electronic record, to manage daily screening needs.
Quality assurance guidelines
The following guidelines serve as a good baseline by which to monitor your program:
- Within three months of initiating a hearing screening program:
- Maintain a referral rate no higher than 8% for the initial screening.
- If the hospital performs outpatient rescreening, maintain a referral rate no higher than 4%.
- Within six months of program initiation, screen a minimum of 95% of infants prior to discharge or before 1 month of age.
- The benchmark for percent of infants lost after not passing the initial screen should be 10% or less.

Objective To examine the incidence of pediatric congenital hearing loss and the timing of diagnosis in a rural region of hearing healthcare disparity. the timing of diagnostic screening. Results In Kentucky during 2009-2011 there Riociguat (BAY 63-2521) were 6 970 newborns who failed hearing screening; the incidence of newborn hearing loss was 1.71 per 1000 births (1.28/1000 in Appalachia and 1.87/1000 in non-Appalachia). 23.8% of Appalachian newborns compared with 17.3% of non-Appalachian children failed to obtain follow-up diagnostic testing. Children from Appalachia were significantly delayed in obtaining a final diagnosis of hearing loss compared with children from non-Appalachian regions (p=0.04). Conclusion Congenital hearing loss in children from rural regions with hearing healthcare disparities is usually a common problem and these children are at risk for any delay in the timing of diagnosis which has the potential to limit language and social development. It KIR3DL3 is important to further assess the causative factors and develop interventions that can address this hearing healthcare disparity issue. With an incidence of approximately 1.4 per 1000 newborns screened1 hearing loss is the most common neonatal sensory disorder in the United States. The sense of hearing is usually important during the early years of life for the development of speech language and cognition. Hearing impairment in early child years Riociguat (BAY 63-2521) can result in lifelong learning delay and disability; however early identification and intervention can prevent educational and interpersonal effects.

Monday, May 8, 2017, 2:00 – 2:15 p.m. EDT
Using a Multi-Modal Approach to Support Children with Hearing Loss
Karen Latimer, Assistive Technology Specialist, Delaware Assistive Technology Initiative, Center for Disabilities Studies
Karen Latimer email@example.com
Link to webinar: https://ncham.adobeconnect.com/bhsm/
Via Washington State Department of Early Learning's Early Support for Infants and Toddlers Program:
Coffee Break webinars last 15 minutes! How cool is that?
May is Better Hearing and Speech Month! In celebration, OSEP’s Early Childhood Assistive Technology Model Demonstration grantees and Center on Technology and Disability is partnering with the Office of Head Start’s Early Childhood Hearing Outreach (ECHO) Initiative to join the American Speech-Language-Hearing Association (ASHA) in celebrating this year’s theme “Communication: The Key to Connection.” Throughout the month of May, ASHA partners with national and local stakeholders to engage in a multifaceted public education campaign to raise awareness about the critical need to intervene early when young children are identified with communication disorders. The Coffee Break Webinars will focus on raising awareness about the use of assistive technology and the importance of frequent hearing screenings. Please join the Coffee Break webinar series to learn more about assistive technology and hearing screening. There is no pre-registration to join the webinars.

Summary of the National Institutes of Health consensus: early identification of hearing impairment in infants and young children. Am J Otol. 1994;15(2):130–1.Google Scholar
- American Speech-Language-Hearing Association. Guidelines for the identification of hearing impairment in at risk infants age birth to 6 months. Asha. 1988;30(4):61–4.Google Scholar
- Clemens CJ, Davis SA, Bailey AR. The false-positive in universal newborn hearing screening. Pediatrics. 2000;106(1):5. doi:10.1542/peds.106.1.e7.View ArticleGoogle Scholar
- Kennedy C, Kimm L, Thornton R, Davis A. False positives in universal neonatal screening for permanent childhood hearing impairment. Lancet. 2000;356(9245):1903–4. doi:10.1016/s0140-6736(00)03267-0.View ArticlePubMedGoogle Scholar
- Shulman S, Besculides M, Saltzman A, Ireys H, White KR, Forsman I. Evaluation of the Universal Newborn Hearing Screening and Intervention Program. Pediatrics. 2010;126:S19–27. doi:10.1542/peds.2010-0354F.View ArticlePubMedGoogle Scholar
- World Health Organization. Newborn and infant hearing screening - Current issues and guiding principles for action: outcome of a who informal consultation held at WHO headquarters, Geneva, Switzerland. WHO. November 2009. http://www.who.int/blindness/publications/Newborn_and_Infant_Hearing_Screening_Report.pdf.

Despite the many similarities between the two groups, there were two identified variables on which the groups differed, ie, age of identification (and subsequent intervention) and cognitive ability. Differences in the participants' cognitive abilities were controlled statistically in all analyses. Thus, the remaining variable (age of identification and subsequent intervention) must be considered as a possible explanation for the language differences noted at 1 to 3 years of age.
To provide the most solid evidence that early identification and subsequent intervention impacts later language ability, a controlled, prospective investigation with random assignment to early- versus late-identified groups and treatment versus no-treatment groups might be proposed. Presently, such a study is not feasible for several reasons. First, random assignment to groups based on time of identification is not possible in an increasing number of states because of recent legislative mandates to screen the hearing of all newborns. Even in those states without universal hearing screening programs, parental cooperation for such a study is likely to be quite low. Under the Individuals with Disabilities Education Act, families are entitled to a timely evaluation if they suspect their child has a disability. Once parents become suspicious that their child has a hearing loss, it is unlikely they would be willing to delay an evaluation even if they previously had consented to being placed in a late-identification group.
Soliciting participation in a study that might result in assignment to a no-treatment (or delayed-treatment) group also is likely to meet with substantial parental resistance. This is because, in addition to timely assessment, the Individuals with Disabilities Education Act stipulates the provision of prompt intervention services after a disability is identified. It is likely that most parents would not be willing to delay these federally-guaranteed services for their child in the interest of research.
Because of the obstacles to randomly assigning children to early- and late-identification/intervention groups, the topic of early identification and intervention must be explored through descriptive studies using naturally occurring groups of children. The results of such descriptive studies become more powerful when they are replicated by a variety of different researchers with independent samples of children. Such is the case with the present question. The language advantage reported in this study for children who were identified earlier is consistent with several previous studies on the early identification of hearing loss. White and White,26Robinshaw,28 Moeller,30 and Apuzzo and Yoshinaga-Itano29 all have reported significantly better language scores for children whose hearing losses were identified earlier.

Information for Hearing Screening Professionals
To operate smoothly, your program will need screeners and a program coordinator. You will need to make sure you have coverage of all shifts so that no babies are missed prior to discharge.
The program coordinator is often an OB or nurse manager. Sometimes this person is a consulting audiologist.
This person will oversee the screening program, train the screeners, monitor referral rates, and ensure that follow-up is obtained for infants who do not pass the hearing screening.
The program coordinator often also assists with performing the hearing screenings. Generally speaking, your program coordinator will need to commit 2–6 hours per week per thousand births to manage and coordinate your program.
See a sample job description for program coordinators (PDF).
The screeners will be responsible for performing the hearing screenings. Your screening staff should have a low turnover rate and be reliable. It is important not to have too many screeners.
The fewer screeners you have, the more practice each screener will get, the better and faster they will be at screening. Limiting the number of screeners also ensures that screeners take responsibility for the program.
Your screeners can be:
- Nurses/nursing aides
- Lactation consultants
- OT/PT personnel
- Technicians hired and trained specifically for screening
See a sample job description for screeners (PDF).
Training Your Screeners
Your screeners will need to be trained in:
- Operation of equipment
- Proper communication of screening results
- Education of parents about hearing screening
- Infection control procedures
- Baby handling skills
Your screeners should also be evaluated at regular intervals to help ensure the ongoing quality of your program. Annual competencies are recommended. The National Center for Hearing Assessment and Management (NCHAM) has created a free and interactive web-based Newborn Hearing Screening Training Curriculum that can be used by programs to complete annual screener competencies.
It is recommended that you use a checklist when training screeners to ensure adequate skills in all aspects of the screening process.
A separate checklist for communication of the screening results is recommended as well, due to the importance of proper communication of the screening results and what they really mean.

Republic Act 9709 or the Universal Newborn Hearing Screening and Intervention Act of 2009 gives hope in the early prevention of the development of congenital hearing disabilities in newborn babies in the Philippines.
In the research forum on hearing impairment, “Understanding the Silent World of the Hearing Impaired,” organized by the Metro Manila Health Research and Development Consortium (MMHRDC) and the Philippine Council for Health Research Development of the Department of Science and Technology (PCHRD – DOST), held at De La Salle University, Manila on November 18, 2011, the importance of having newborns screened for risks of developing hearing disabilities because of congenital anomalies was addressed. Dr Charlotte Chiong, Assistant Director for the Philippine National Ear Institute and a strong advocate of the law, spoke on the importance of the implementation of RA 9709.
“As hearing impairment is an invisible disability, majority of the people do not fully understand the implications of hearing loss and its consequences on the deaf person,” Dr. Chiong said. “For those parents who are not fully aware of such early detection and intervention programs, most of the time they settle and give up on their child’s hearing disability altogether.”
RA 9709, which was signed and approved by President Gloria Macapagal-Arroyo on August 12, 2009, mandates that every newborn infant in the country undergo the Universal Newborn Hearing Screening (UNHS) before they reach their third month of age. The law compels parents, health practitioners and medical institutions to provide the necessary procedures to detect risks of developing congenital hearing loss in children in the future. Infants who were born in hospitals should be screened before they are discharged; while newborn babies who were born at home should be screened before the third month after birth.
According to Dr. Chiong, “Hearing impairment poses a great deal of consequences that mainly affects the individual’s communicative and linguistic skills, as well as social and educational competencies. One of the goals of UNHS is to prevent these repercussions through early identification and intervention by allowing the child to develop normal speech and have an improved quality of life alongside their hearing peers.”
In the Philippines about 8 babies are born deaf every day while three babies are born with hearing impairment every three hours. Through the RA, every newborn baby in the country gains access to all the necessary medical screening as well as medical intervention for congenital hearing defects.

Give us books, pamphlets, phone numbers, support groups, anything that will be helpful to us in understanding our child's hearing loss and where to find help. If we ask a question, and you don't have the answer, help us find the resource where we can find the answer. As children and parents grow, their choices and need for information grows.*Hands & Voices (2007) How difficult would it be to do this?
12 Intervention (cont.) Goal #3: Assist parents in their ability to establish an effective language learning environment for their child…*Strategies: (*Spencer, P. (2003) Sensitivity to infant visually aware and responsive to opt. to interact…treat behavior as intentional…expect com. Topic responsiveness follow childs lead Talking to infant melodic & repetitive Use visual & tactical cues… pointing & stroking
13 Intervention (cont.) Goal #3: Strategies (cont.) Exaggerated facial expression Establish mutual eye gaze moving into childs line of vision Commenting on what the child is doing & feeling associating language with actions Expanding on childs communicative behavior providing more conventional communicative models Waiting for the child to look up Producing short utterances, w/ repetition, of single signs or words Pointing or tapping objects being discussed…
14 Intervention (cont.) Goal #3: Strategies (cont.) Moving interesting objects up to face Tapping the child to signal look at me Attempting to prolong the interaction for as many turns as possible Use action orientated vs. naming activities Provide opportunities for parents of newly identified children to talk with parents of older children who are d/hh + observe the parents interacting with their children How difficult would it be to do this?
15 Intervention (cont.) Goal #4: [provided by the participants] Strategies:
16 Resources Communication Choice Decision Wisconsins babies & hearing: An interactive notebook for families with a young child who is deaf or hard of hearing - Building blocks for communication. Web Site: National Center for Hearing Assessment & ManagementNational Center for Hearing Assessment & Management (www.infanthearing.org/familysupport/wisconsin/index.html)www.infanthearing.org/familysupport/wisconsin/index.html
17 Resources (cont.)

One in every 350 babies is born deaf or hard of hearing in Minnesota each year (approximately 200 total). Nationally, CDC data show 1.4 out of every 1000 infants screened at birth (range 0-4.6 per 1000 screened) have some degree of hearing loss. This makes hearing loss one of the most common conditions present at birth. This prevalence rises to 5 per 1000 children with hearing loss by ages 3-17, due to children developing or identified with hearing loss later in childhood. The majority of babies who are deaf or hard of hearing are born to hearing parents and most often, they have no experience with hearing loss.
The degree of hearing loss is measured in decibels (dB). For children, a slight hearing loss ranges from 16-25 dB, a mild hearing loss ranges from 26 dB to 40 dB, moderate from 41 to 55 dB, moderately severe from 56 to 70, severe 71 to 90 dB, and a profound hearing loss > 90 dB HL. The degree of hearing loss can be the same or different in each ear.
A child with a mild high frequency hearing loss will have trouble hearing and understanding soft speech, speech from a distance, and speech with background noise. With moderate hearing loss the child will have difficulty with conversations even at close distances. An audiogram, which is a graph, illustrates the type, degree, and configuration of hearing loss. To understand more about audiograms, visit American Speech-Language-Hearing Association: The Audiogram.
Early intervention has a positive impact on language and child development. We know that children who do not receive early intervention services may have communication difficulties. These children may also face educational, psychological, and social challenges. This is why it is important to identify hearing loss as early as possible.
Minnesota's Early Hearing Detection and Intervention (EHDI) Program works to ensure that every baby who does not pass hearing screening has timely and appropriate follow-up. This includes an audiologic evaluation (hearing test) if needed. If a child is identified with hearing loss, Minnesota's EHDI program helps families access appropriate and timely intervention, statewide services, and needed resources.
For more information about hearing loss, visit Minnesota's Early Hearing Detection and Intervention (EHDI) Program. Other helpful information can be found at: CDC Hearing Loss in Children, Babyhearing.org, Minnesota Hands and Voices, and the American Speech-Language-Hearing Association.

In the present investigation, and in all four studies documenting a language advantage for the earlier-identified group, children received early intervention services shortly after their hearing losses were identified. It is unlikely that language differences of the magnitude documented in these studies would occur simply by identifying hearing loss early; early identification alone is unlikely to result in improved outcomes if it is not followed by early intervention.
Research on school-aged children with severe-to-profound hearing losses indicates a 40-point discrepancy between performance intelligence scores (mean of 100) and verbal intelligence scores (mean of 60)9 ,39 ,40; even academically successful deaf students demonstrate a 20-point discrepancy. It is interesting that a cognitive-language quotient discrepancy was already present by 3 years of age in the later-identified children in this study, raising the possibility that the cognitive-linguistic gap previously reported in school-aged children may have its roots in the first year of life.
In the four previous investigations that have noted better language skills in early-identified children, the average age of identification for the early group was below 12 months of age (with three of the four studies defining early identification as before 3 to 6 months of age). In the present study, there was no significant difference in language scores between four subgroups of later-identified children who were divided sequentially according to age of identification (from 7 months to greater than 25 months of age). This may explain the results of a previous study that examined the contribution age of intervention makes to later language ability and failed to find any significant contribution.27 In that study, 91% of the children began intervention some time before 3 years of age. Specific information regarding the distribution by age of intervention was not provided; however, unless a large proportion of the children began intervention in the first 6 months of life, this study is consistent with the results of the present investigation. That is, the present findings, and the pattern that has emerged from previous studies, suggest that for an earlier-identified group to demonstrate significantly better language skills than a later-identified group, identification must truly occur early (ie, within the first 6 months of life).
Before the advent of universal newborn hearing screening programs, identifying hearing loss by 6 months of age was rarely accomplished. Parents generally do not suspect a hearing loss until their child fails to meet important speech and language milestones at 1 to 2 years of age.

"It's also created a strong partnership between the state laboratory, practitioners, and medical experts at OHSU."
The screening itself is performed when the infant is only a few days old. Small drops of the baby's blood are collected on special filter paper, which is sent to the state lab in Portland where tests are done.
The lab tests the blood for pheynlketornuria phenylketonuria (PKU), Maple Syrup Urine Disease, sickle cell disease, hypothyroidism, galactosemia, biotinidase deficiency, hypothyroidism, and MCD, which screens for congenital adrenal hyperplasia (CAH), and several urea cycle, fatty, amino and organic amino, organic, and fatty acid disorders (including MCAD)and congenital adrenal hyperplasia (CAH). During the past 18 months these disorders have been detected, and disease prevented, in 72 Oregon newborns, Skeels said.
The March of Dimes also recommends that newborns be tested for hearing loss. In 2000, the Oregon legislature passed a bill requiring all hospitals with more than 200 births per year to screen babies for hearing loss.
Twenty-four other states require newborn hearing screening. Oregon's program is overseen by DHS, according to Skeels.
Information about newborn screening is on the Web at www.dhs.state.or.us/publichealth/nbs/index.cfm; to learn more about newborn hearing
go to www.dhs.state.or.us/publichealth/pch/hearing/index.cfm

Furthermore, early intervention and preschool providers and parents should regularly conduct observational checks of the child’s listening ability through the HA (e.g., Ling 6 sound test), which may put them in a position to notice threshold shifts or HA malfunction and make immediate referrals to the audiologist.
- Adjust HA gain to account for the decline in the sound level in the ear canal as the child experiences normal physical growth (McCreery et al. 2015a, this issue, pp. 24S–37S).
- Carefully monitor the outcomes of all CHH, but exercise special vigilance with regard to children with moderate-to-severe HL, who are at the greatest risk for language (Tomblin et al. 2015a, this issue, pp. 76S–91S) and auditory delays (McCreery et al. 2015b, this issue, pp. 60S–75S).
- Consider also that it may be especially important to carefully monitor and support caregiver–child interactions for dyads from lower SES backgrounds as well as caregivers who have children with moderate-to-severe HL (Ambrose et al. 2015, this issue, pp. 48S–59S).
- Provide additional support to caregivers from lower SES backgrounds related to the achievement of consistent HA use (Walker et al. 2015, this issue, pp. 38S–47S). This might include regular hands-on training with the HAs and provision of access to appropriate parent-to-parent support experiences.
These suggested practice shifts have costs associated with them. The practicalities of limited or no reimbursement, limitations in staff time, and economic barriers for families may represent major barriers to implementation. In light of these issues, we have sought to highlight populations at greater risk (moderate-to-severe losses and lower SES backgrounds) and suggest that any needs associated with children in these groups be considered priorities for intervention. Furthermore, past experience with CHH suggests there are costs associated with not making the suggested practice shifts, in terms of failing to prevent the impact of HL on literacy, socialization, and employment (Bess et al.

Realistic Timelines for Developing Speech and Language
Parent Priorities: At Time of Diagnosis (Mild-Moderate Hearing Loss) l Causes of Hearing Loss l Understanding the Audiogram l Learning to Listen and Speak / Understanding the Ear and Hearing l Coping with Emotional Aspects / Communication Options
Parent Priorities: A Few Months Later (Mild-Moderate Hearing Loss) l Learning to Listen and Speak l Realistic Timelines for Developing Speech and Language l Responsibilities of Early Intervention Agencies l Legal Rights of Children with Hearing Loss
Parent Priorities: A Few Months Later (Mild-Moderate Hearing Loss) l Opportunities to Interact with Other Parents There are other families out there that can and will support you and your decisions without making judgments. Find us. Speak to other parents, they will help you heal
Mild to Moderate At DiagnosisA Few Months Later 1.Causes of Hearing Loss 2.Understanding the Audiogram 3.Learning to Listen and Speak and Understanding the Ear and Hearing 4.Coping with Emotional Aspects and Communication Options 1. Learning to Listen and Speak 2. Realistic Timelines for Developing Speech and Language 3. Responsibilities of Early Intervention Agencies 4. Legal Rights of Children with Hearing Loss and Opportunities to Interact with Other Parents
Advice for (Entry Level) Providers from Families l Form a relationship with the family l Include other children in the family l Be an intuitive listener l Provide information regarding typical development as well as hearing loss l Please dont always be so overly energetic l Keep up to date on the newest stuff Rice & Lenihan 2005
Listening is the Recurring Theme "Many a man would rather you heard his story than granted his request." Phillip Stanhope, Earl of Chesterfield "I remind myself every morning: Nothing I say this day will teach me anything. So if I'm going to learn, I must do it by listening." Larry King
Top 10 Things Parents Want Us to Hear l with apologies to Dave… Adapte d from Roush and Matkin, 2004
#10 Talk to us… but listen too l If youre new at this (and even if youre not) theres a tendency to talk too much.

Hearing screening of newborns is a prerequisite for the early intervention and support needed by hearing impaired children. Early intervention is beneficial for the children's speech, educational, social and emotional development.
This has always been the main argument in favour of the universal newborn hearing screening programmes, first implemented in the 1990's and still being introduced around the world. Uruguay is among the countries currently preparing to offer hearing screening of all newborns. The first reports about the long-term effects of these programmes have been issued. They conclude that hearing screening works as advertised.
Vlandern: 85 percent in mainstream schools
In the Vlandern region of Belgium, all newborns have been hearing screened since 1998. The vast majority of newborns found to have hearing loss in screenings between 1998 and 2003 made it into mainstream schools, according to a recent evaluation of these children's speech and educational development.
85 percent of the children five and a half years of age or older and with no other disability than hearing loss go to mainstream schools. Among those, whose hearing loss was treated with a cochlear implant, 79 percent attend mainstream schools.
The researchers behind this study concluded that early intervention in hearing impaired children may improve language outcomes and subsequent school and occupational performance.
USA: Screening benefits speech development
In the United States, hearing screenings became common practice following a recommendation made by the US Preventive Services Task Force in 2001. By 2006, 46 of the 50 states had hearing screening programmes.
A new report, based on a survey of scientific articles about hearing screening, published since 2002, confirmed that children with hearing loss who had universal newborn hearing screening have better language outcome at school age than those not screened.
In particular, the ability to listen and understand speech is supported by early intervention following hearing screening. Children whose hearing loss was identified early, and children who had hearing screenings as newborns were found at 8 years of age to be better at listening and understanding speech than those whose hearing loss was discovered late and children who had not been hearing screened. No difference was found between the two groups in terms of speech ability and language.
Sources: International Journal of Pediatric Otorhinolaryngology; Pediatrics; www.infanthearing.org

Idaho's Infant Toddler Program (ITP) coordinates a system of early intervention services to assist Idaho children birth to three years of age who have a developmental delay or who have conditions (such as prematurity, Down Syndrome, hearing loss) that may result in a developmental delay.
The ITP links children with services that promote their physical, mental and emotional development and supports the needs of their families. These can include therapeutic, educational, and supportive services, such as:
- Family education
- Speech therapy
- Occupational therapy
- Service coordination
- Family training
- Home visits
- Health services
Children referred to the Infant Toddler Program are assessed to see if they meet program eligibility. If eligible, an Individualized Family Service Plan (IFSP) is written that outlines services for the child and their family. This plan is reviewed every six months. At three years of age, ITP assists with the child's transition to a developmental preschool program or other community services.
Hearing Loss is the most common birth disorder in newborns. It affects how your baby perceives sound and is able to communicate with you and the world. 90% of infants with hearing loss are born to hearing parents. Please don't wait. Much can be done if hearing loss is identified early.
ZERO TO THREE is a national nonprofit organization that provides parents, professional and policy makers the knowledge and the know-how to nurure early development.
Neuroscientists have documented that our earliest days, weeks and months of life are a period of unparalleled growth when trillions of brain cell connections are made. Research and clinical experience also demonstrate that health and development are directly influenced by the quality of care and experiences a child has with his parents and other adults.
That is why at ZERO TO THREE our mission is to ensure that all babies and toddlers have a strong start in life.
We know that as babies, the way we are held, talked to and cared for teache us about who we are and how er are valued. This profuondly shapes who we will become.
Early experiences set a course for a lifelong process of discovery about ourselves and the world around us. Simply put, early experiences matter. We encourage you to learn more about very young children, early development and the work of ZERO TO THREE by exploring our site.

Marcus Riccelli (D-Spokane), whose daughter, Bryn, was born last July at Providence Sacred Heart Medical Center & Children's Hospital in Spokane.
Thirty days after Bryn's birth, Riccelli received a call that there was an abnormality on her screening. The screening would have to be redone, a worrisome prospect given that some of the disorders can sicken and kill children within the first few days or weeks of life.
"For me, it was a true feeling of powerlessness," Riccelli said. "I don't want any other parent to feel that."
It turned out that Bryn did not have one of the 28 rare disorders that Washington screens for and she is in good health today. The problem was that there had not been enough blood in the initial sample, meaning it had to be retaken.
Riccelli said the Journal Sentinel investigation put the scope of the problem into perspective for his fellow lawmakers.
"It was helpful to be able to say that this isn't just a state problem, it's a national problem," he said.
A pending regulation in Oregon will require newborn screening samples to arrive at the lab no more than five days after collection, but preferably within 24 to 48 hours. The change is expected to become final within a few weeks.
About half of the country has regulations that require hospitals to send blood samples for testing within 24 hours of collection, although those regulations often are not followed or enforced.
In addition to Arizona and Washington state, health officials in Wisconsin and Nevada have said they will post hospitals' newborn screening performance online in coming months. This is the only way prospective parents would be able to tell if the hospital where their baby will be born promptly sends newborn screening samples to state labs.
In June, the Journal Sentinel requested newborn screening data from every U.S. state and the District of Columbia. Twenty-four states and Washington, D.C., would not release information identifying hospital names. Many cited patient privacy, even though children's names and outcomes of tests were not requested. Other states, including Wisconsin, initially said releasing such information would be adversarial to hospitals or might reveal their business practices.
Since last year, four additional states released newborn screening to the Journal Sentinel, including South Carolina, which ranked among the worst in the nation, underscoring the need for transparency.
Hospitals in all states have been urged by the American Hospital Association and often their own health departments to review newborn screening protocols and performance.

Because a hearing loss is not visible, it is often overlooked and can go undetected for some time. Surprisingly, an educationally significant hearing loss may go undetected in a child as late as six years of age, even with the most advance medical techniques available(Schwartz,2). Below is a checklist of milestones from the Bill Wilkerson Center that your child should be accomplishing at various ages:
|3 to 6 months
||Enjoys rattles and other sound making toys
Responds to pleasant tones by cooing
Stops playing and appears to listen to sounds or speech
Watches a speaker’s face
Begins to turn head toward sounds that are out of sight
|Laughs out loud
Cries differently for pain,hunger, and discomfort
Coos-produces an assortment of oohs, ahs, and other vowel sounds
|6 to 9 months
||Responds to soft levels of speech and other sounds
Temporarily stops action in response to “no”
Turns head directly toward voices and interesting sounds
Begins to understand routine words when used with a hand gesture( e.g. bye-bye or up)
|Babbles-repeats consonants-vowel combinations such as ba-ba-ba
Makes a raspberry sound
Makes sounds with rising and falling pitches
|9 to 12 months
||Follows simple directions presented with gestures (e.g. give it to me, come here)
Responds to his or her own even when spoken quietly
Will turn and find sound in any direction
|Vocalizes to get attention
Produces a variety of speech sounds (e,g,m,b,d) in several pitches
|12 to 18 months
||Knows the names of familiar objects, persons, pets
Follows routine directions presented without gestural or visual cues (e.g.

In the future it would be useful to utilize objective measures (i.e. electrical stapedial reflex threshold and electrical compound action potential measures) in conjunction with behavioral measures to produce appropriate speech processor MAPs and more accurate listening criteria. It would also be important to examine long-term data on listening criteria to determine the accuracy and stability of these measures in addition to the factors associated with satisfaction.
Acknowledgments The authors would like to thank Tanya VanVoorst, Greta Stamper, and Kathryn Engelhardt for gathering listening-development criteria data. We would also like to thank all the infants and their families who contributed to these criteria.
References ASHA 2004. Cochlear implants. Technical report. Barker B.A., Tomblin J.B. 2004. Bimodal speech perception in infant hearing aid and cochlear implant users. Archives of Otolaryngology — Head and Neck Surgery, 130: 82–86. Estabrooks W. 1998. Appendix C: Auditory-verbal ages and stages of development. In: Estabrooks W. (ed). Cochlear Implants for Kids. Washington, DC: Alexander Graham Bell Association for the Deaf. Hogan C.A., Turner C.W. 1998. High-frequency audibility: benefits for hearing-impaired listeners. Journal of the Acoustical Society of America, 104: 432–441. Houston D.M., Pisoni D.B., Kirk K.I., Ying E.A., Miyamoto R.T. 2003. Speech perception skills of deaf infants following cochlear implantation: A first report. International Journal of Pediatric Otorhinolaryngology, 67: 479–495. Humes L.E., Watson B.U., Christensen L.A., Cokely C.G., Halling D.C., Lee L. 1994. Factors associated with individual differences in clinical measures of speech recognition among the elderly. Journal of Speech and Hearing Research, 37: 465–474. Jusczyk P.W. 1997. Discovery of Spoken Language. Cambridge, MA: MIT Press. Miyamoto R.T., Houston D.M., Kirk K.I., Perdew A.E., Svirsky M.A. 2003. Language development in deaf infants following cochlear implantation.

South Carolina operates an early hearing detection and intervention program called First Sound. This is how it works:
- South Carolina hospitals that birth an average of 100 or more babies per year screen each newborn baby for hearing and send the results to DHEC.
- Infants who do not pass the initial hearing screening in the hospital are referred for rescreening; this should be performed by the time the infant is one month old. The rescreening may be done at the birth hospital or at an audiologist's (hearing specialist) office.
- Whenever an infant does not pass the rescreening, we refer them/their family to a participating audiologist for a diagnostic hearing evaluation; this should be performed before the baby is three months old.
- If the audiologist confirms hearing loss, we then refer the infant and their family to Babynet . This should be done by six months of age. Babynet will work with the family to get the infant the hearing intervention services needed.
DHEC also tracks infants for three years if they pass their hospital screening but are at high risk for developing hearing loss.
If your infant has not been screened for hearing loss or if you are a health care provider wishing to refer an infant to First Sound, contact us at (803) 898-0708. Fax: 803-898-4453
Facts about Newborn Hearing Loss
- Hearing loss occurs in newborn infants more frequently than any other health condition for which newborn infant screening is required. Studies show that hearing loss occurs in approximately 2-4 out of 1,000 babies.
- Hearing is vitally important to development of language skills. Infants begin developing speech and language from the moment they are born. Eighty percent of the language ability of a child is established by the age of 18 months.
- Without early hearing detection and intervention programs like First Sound, hearing loss is often not identified until children are 18 months to 3 years of age.
- Children with hearing loss who do not receive early intervention and treatment may require extensive (usually publicly funded) special education services.
- Early detection of hearing loss in a child and early intervention and treatment has been demonstrated to be highly effective.
- Universal screening/detection of hearing loss in infants before three months of age, with appropriate intervention no later than six months of age, is endorsed by the major speech-language-hearing associations in the U.S. as well as the American Academy of Pediatrics.

Program Updates Power Point
presentation (OSPI and ESIT, 8/10, PDF)
This Power Point provides a summary of changes of the Early Support for Infants
and Toddlers program and Indicator B-12.
Early Support for Infants and
Toddlers FFY 08 APR Data (ESIT, 8/10, PDF)
This chart outlines Washington State Part C Annual Performance Report (APR)
Fast Facts About the Early
Support for Infants and Toddlers Program (ESIT, 8/10, PDF)
This handout provides an overview of Part C services delivered in Washington
Providing Early Support Services for Infants and Toddlers (ESIT, 8/10, PDF)
This document provides information for school districts about providing Part C
services directly using school district staff.
Intervention/Individualized Family Service Plan (IFSP) Process
(NECTAC, 2006, PDF)
This chart outlines the IFSP process from initial referral to transition into
Part B services.
Challenge and Change by Greg Abell (8/10, PDF)
This Power Point examines the elements of effective teaming and dynamics of
Electronic Data Management System by Bob Morris (8/10, PDF)
This Power Point describes the electronic Data Management System (DMS) and
provides information to school districts about accessing Part C reports and
Individualized Family Service Plans (IFSPs) on the DMS.
Supporting Infants and Toddlers with Sensory Impairments by Dr. Nancy Hatfield
This Power Point provides information about infants and toddlers with hearing
loss and/or visual impairment.

(2011);32:605–616
Fitzpatrick E. M., Olds J., Gaboury I., et al. Comparison of outcomes in children with hearing aids and cochlear implants. Cochlear Implants Int. (2012);13:5–15
Gumperz J. J., Kaltman H., O’Connor M. C.Tannen D.. Cohesion in spoken and written discourse: Ethnic style and the transition to literacy. In Coherence in Spoken and Written Discourse. (1984) Norwood, NJ Arnold:3–19
Joint Committee on Infant Hearing (JCIH). Joint Committee on Infant Hearing (JCIH). . Principles and guidelines for early hearing detection and intervention [Position statement]. (2007) Retrieved from www.jcih.org/posstatements.htm
Jones C., Launer S.Seewald R. C., Bamford J. M.. Pediatric fittings in 2010: The Sound Foundations Cuper project. In A Sound Foundation Through Early Amplification: Proceedings of the 2010 International Conference. (2011) Chicago, IL Phonak.:187–192
McCreery R. W., Bentler R. A., Roush P. A.. Characteristics of hearing aid fittings in infants and young children. Ear Hear. (2012);34:701–710
McCreery R. W., Walker E. A., Spratford M., et al. Longitudinal predictors of aided speech audibility in infants and children. Ear Hear. (2015a);36:24S–37S
McCreery R. W., Walker E. A., Spratford M., et al. Speech recognition and parent-ratings from auditory development questionnaires in children who are hard of hearing
. Ear Hear. (2015b);36:60S–75S
Moeller M. P., Hoover B., Peterson B., et al. Consistency of hearing aid use in infants with early-identified hearing loss. Am J Audiol. (2009);18:14–23
Moeller M. P., Tomblin J. B.. An introduction to the outcomes of children with hearing loss study. Ear Hear.

Good hearing is essential for speech and language development and plays an important part in a child’s social and emotional growth. It is important that parents are aware of their child’s hearing from the moment their child is born.
A child’s hearing can be affected by many things. Some newborns run a high risk of hearing loss due to hereditary or prenatal complications including rubella, syphilis, low birth weight, and meningitis. Toddlers and preschool children may acquire hearing loss with earaches, colds, running ears, upper respiratory infections, or allergies.
Signs of Hearing Loss
- Does not pay attention or react to loud noises around the house
- Has had frequent ear infections and /or fluid draining from the ears
- Has trouble locating sounds
- Speaks loudly
- Has unclear speech
- Stops early babbling
If you are concerned about or suspect a hearing problem, or if you notice any of the signs listed above, see your doctor as soon as you can and ask about a hearing test.
The BC Early Hearing Program
BC Early Hearing Program through the Abbotsford Public Health Unit provides newborn hearing screening, diagnosis and intervention upon birth. Service open to all babies in BC, the test is covered by BC Medical (MSP). Screening conducted in hospital before baby and mother are discharged, or at local public health unit with a hearing clinic. The Health Unit provides service for entry-level school age screening and sales, fitting, and maintenance of hearing equipment and assistive listening devices. They also provide eye and ear examinations and vision and hearing screening services to children of school age.
Abbotsford Public Health Unit
Hours of operation: Mon - Fri, 8:30 a.m. - 4:30 p.m.
For more information on having your newborn's hearing checked visit Fraser Health's webpage.
For a complete list of local audiologists, refer to the ‘Audiologists’ and ‘Hearing Analysis’ sections of the Yellow Pages.

Email: [email protected]
© W.S. Maney & Son Ltd. 2011 DOI 10.1179/146701010X486543
of research, however, exploring audibility of the speech signal in children with CIs. This is likely due to the fact that there is currently no documented method — behavioral or objective — to measure audibility of the implant’s electric signal in its user. Understanding which aspects of the speech signal are audible by the CI user is important. However, it is particularly important for the infant CI user who has limited language skills, and is therefore unable to provide reliable feedback. The literature focusing on people with hearing loss consistently illustrates that audibility of the speech signal affects spoken language perception (Hogan and Turner, 1998), production (Moore and Bass-Ringdahl, 2002), and comprehension (Vermeulen et al., 2007). This appears to hold true across the lifespan from early childhood (Rvachew et al., 1999) to later adulthood (Humes et al., 1994). It stands to reason that audibility would be equally important in infancy when language acquisition begins. We believe that researchers and clinicians should have an understanding of each infant’s access to the speech signal prior to assessing speech perception and spoken language development. Without knowledge of infant CI users’ audibility, such assessments will likely be in vain and result in equivocal infant data (Barker and Tomblin, 2004) and an unclear path for aural habilitation. As our center’s first step in gaining an understanding of audibility via CIs we established listening-development criteria for infant users. We currently use these criteria to ensure speech audibility in infant CI users prior to
Cochlear Implants International
Barker et al.
Listening-development criteria for infant cochlear implant users
the evaluation of their speech perception skills and listening development.
The listening-development criteria At our clinical research center we currently monitor each infant’s listening development using the succeeding listening criteria. Each infant’s listening skills are typically assessed during clinical follow-up visits at 1-month- and 2-months-post-initial stimulation and every 2 months thereafter until the infant reaches the listening criteria. When an infant meets the listening-development criteria, the following standards are satisfied: (1) a plateau is noted in the infant’s MAP (i.e.

These delays are apparent for both children with mild and moderate hearing loss5–7 as well as for those whose losses fall in the severe and profound ranges.8–11 Despite advances in hearing aid technology, improved educational techniques, and intensive intervention services, there has been virtually no change in the academic statistics of this population since the systematic collection of national data >30 years ago.12 ,13 These data indicate that the average deaf student graduates from high school with language and academic achievement levels below that of the average fourth-grade hearing student.14 ,15 Similarly, for hard-of-hearing children, achievement is also below that of their hearing peers with average reading scores for high school graduates at the fifth-grade level.15 These limitations in reading have a pervasive negative impact on overall academic achievement.16
Many professionals in both health care and special education have supported early identification of hearing loss and subsequent intervention as a means to improving the language and academic outcomes of deaf and hard-of-hearing individuals.4 17–20 In 1994, the Joint Committee on Infant Hearing21 released a position statement endorsing the goal of universal detection of infants with hearing loss as early as possible, preferably by 3 months of age. This position statement was endorsed by the American Academy of Pediatrics. This priority is in concert with the national initiative Healthy People 2000,22 the National Institutes of Health Consensus Statement,23 and the position statement of the American Academy of Audiology.24 All of these position statements support the need to identify all infants with hearing loss. Both the Joint Committee on Infant Hearing and the American Academy of Audiology recommend accomplishing this goal by evaluating all infants before discharge from the newborn nursery.
Despite widespread support for universal newborn hearing screening, this mandate has been challenged by Bess and Paradise25partly on the grounds that “no empirical evidence … supports the proposition that outcomes in children with congenital hearing loss are more favorable if treatment is begun early in infancy rather than later in childhood (eg, 6 months vs 18 months)”.

Help Me Grow Washington
Help Me Grow Washington connects families to the health and development resources needed to give ALL kids the best start.
Two Ways to Get Started Today!
Call our friendly and knowledgeable staff at the Help Me Grow Washington Hotline 1-800-322-2588 to learn about developmental screening for your child and the Ages and Stages Questionnaire, or you can get started right now. It's easy and there is no cost involved!
What does Help Me Grow Washington offer families?
- Free developmental screening for all kids under 5
(no waiting lists or income requirements)
- Community resources like parenting classes, medical clinics and food banks
- Referrals for further evaluation and early intervention services
- Activities and games that support healthy growth and learning
How Can Developmental Screening Help My Child?
Developmental screening is important for ALL kids! 1 in 6 kids has a developmental delay, but only 30% of those kids are detected through parent observations and regular checkups. Often, the signs are hard to see, even for a professional.
Screening all kids regularly is the best way to catch delays early, when intervention is most effective. Even for families with kids developing on track, screening is a fast, flexible and fun way to learn about what’s coming next and what you can do to encourage healthy growth!
The Ages and Stages Questionnaire
To screen kids Help Me Grow Washington uses a survey tool called the Ages and Stages Questionnaire (ASQ). Developmental screening cannot give you a diagnosis; however it can show you if your child is developing more slowly than kids in the same age group.
The ASQ covers 5 areas of development:
- Communication – how kids use language
- Gross Motor – how kids move their bodies
- Fine Motor – how kids use their hands
- Problem Solving – how kids interact with their world
- Personal-Social – how kids calm themselves down

Early detection can make a big difference in the lives of children with hearing loss.
Early intervention in a stimulating environment – even during infancy – can help expand your child’s development.
Boston’s Bobby Moakley celebrates on top of Copper Mountain during the No Barriers Summit from June 23-26. The college sophomore returns to Colorado as keynote speaker for the No Barriers “What’s Your Everest?” event in Keystone this weekend, July 22-23.
The inner ear processes low-frequency sounds, important for speech and music perception, differently to high-frequency sounds, new research has found.
The Catalyst Center, the National Center for Health Insurance and Financing for Children and Youth with Special Health Care Needs is hosting a webinar –
Date: Wednesday, July 27, 2016
Time: 9:30 to 10:30 a.m. PT
12:30 to 1:30 p.m. ET
Looking for ways to improve reading comprehension? Find recommendations for teaching foundational reading skills to students in kindergarten through 3rd grade. Each recommendation includes implementation steps and solutions for common obstacles. Download the guide at:
When Tameka Goldsmith looks at her son’s accomplishments—and she has filled plastic bins with report cards and photos of his travels, certificates and copies of the kind words teachers wrote about him on scholarship applications—she remembers what doctors said about Kyree before he ever started kindergarten.
They said he’d never speak—that, because of his autism and hearing loss, he’d never function in a regular classroom.
We know that time management is always a challenge in busy hearing screening programs. We can’t make the days longer (summer solstice is past!), but in the spirit of the 4th of July, we can offer greater freedom in learning opportunities to meet your upcoming training needs.

[ 1985 c 213 § 33.
Severability—1967 ex.s. c 102:
See note following RCW 43.70.130
Rules and regulations—
Visual and auditory screening of pupils: RCW 28A.210.020

Automatic auditory brainstem response
American Academy of Pediatrics
Early hearing detection and intervention
Joint Committee on infant hearing
Neonatal intensive care unit
Evoked otoacoustic emissions
Transiently evoked OAEs
Universal Newborn Hearing Screening
Our work has been complemented by the contribution of Roberto Guarino (National Research Council, Institute of Clinical Physiology) who collaborated in representing the framework of the screening processes.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- BarskyFirkser L, Sun S. Universal Newborn Hearing Screenings: a three-year experience. Pediatrics. 1997;99(6):e4. doi:10.1542/peds.99.6.e4.View ArticleGoogle Scholar
- Mehl AL, Thomson V. The colorado newborn hearing screening project, 1992–1999: on the threshold of effective population- based universal newborn hearing screening. Pediatrics. 2002;109(1):8. doi:10.1542/peds.109.1.e7.View ArticleGoogle Scholar
- Vartiainen E, Kemppinen P, Karjalainen S. Prevalence and etiology of bilateral sensorineural hearing impairment in a finnish childhood population. Int J Pediatr Otorhinolaryngol. 1997;41(2):175–85.View ArticlePubMedGoogle Scholar
- US Center for Diseases Control and Prevention. Summary of 2009 National CDC EHDI Data2009
- Norton SJ, Gorga MP, Widen JE, Folsom RC, Sininger Y, Cone-Wesson B, et al. Identification of neonatal hearing impairment: a multicenter investigation. Ear Hear. 2000;21(5):348–56.

In addition, a vision screening is required for 1st, 3rd, 5th and 7th graders.
Code 53A-11-201 (1996) also requires each local school board to implement rules as prescribed by the Department of Health for vision, dental, abnormal spinal curvature, and hearing examinations of students attending the district’s schools. Code 53A-11-203 (2010) requires children entering school under the age of eight to have a vision screening. Each school district may conduct free vision screening clinics for children aged 3 1/2 to 8. The statute also authorizes districts to provide free vision screening for children ages 8 and older, establishes guidelines for administering a free vision screening programs, and establish penalties for a violation of certain provisions related to free vision screenings.
16 VSA 1422 (2009) requires periodic hearing and vision screening of school-aged children screening by primary care providers and school districts based on research-based guidelines developed by the commissioner of health in consultation with the commissioner of education. Each year in grades 1, 2, 3, 5, 7,and 9 and any pupil who appears to have defective vision or appears to be need for test.
Code 22.1-273 (1995) calls for the principal of each school identified by the school board to ensure the testing of sight and hearing of relevant pupils unless it was included as part of the examination required in Code 22.1-270 (2004).
RCW 28A.210.020 (1971) requires all school boards to provide vision and hearing screening for their students.
WAC 246-760 Schools shall conduct auditory and visual screening of children:
(1) In kindergarten and grades one, two, three, five, and seven; and
(2) For any child showing symptoms of possible loss in auditory or visual acuity referred to the district by parents, guardians, or school staff.
(3) If resources permit, schools shall annually screen children at other grade levels.
Personnel conducting the screening must use a Snellen test chart for screening for distance central vision acuity. Either the Snellen E chart or the standard Snellen distance acuity chart may be used as appropriate to the child’s age and abilities. The test chart must be properly illuminated and glare free. Other screening procedures equivalent to the Snellen test may be used only if approved by the state board of health.

Satisfying the listening-development criteria After establishing these criteria we wanted to determine the rate at which infants satisfy these listeningdevelopment criteria. We predicted that there would be great variability in the rate at which the infants satisfied the listening-development criteria. This prediction echoes the individual differences that dominated other spoken language perception and production measures across pediatric CI users for the past 20 years (ASHA, 2004). We looked at the rate of criteria satisfaction in 10 children (7 males) with profound, bilateral sensorineural hearing loss (SNHL). All the infants were born to hearing parents and were identified as having SNHL within the first year of life. The infants’ ages at the time of surgery for placement of their CI devices ranged from 11 to 21 months with an average age at implantation of 15 months (SD = 2.76 months). All the infants were followed longitudinally as part of a comprehensive, CI center study. American English was the primary language spoken in each child’s home (i.e. English was spoken more than 50% of the time in the infant’s listening environment). Infants and toddlers had no known visual abnormalities. The individual profiles are presented in Table 1.
Individual outcomes Table 1 illustrates the variability in CI experience at which the infants satisfied the listening-development criteria. Note that these infants met the listening criteria on average after 6.4 months of device use (SD = 2.5 months).
Discussion We found that there are vast individual differences in the rate at which it takes an infant to reach the proposed listening criteria. Infants needed as few as 2 months to as many as 10 months of device experience before meeting the listening criteria. These data suggest that although many researchers and clinicians are quick to begin testing infant CI users shortly after initial stimulation (e.g. Houston et al., 2003; Miyamoto et al., 2003), it may be beneficial to require that listening criteria be met prior to assessment. Such criteria are likely to ensure adequate audibility of the speech signal, resulting in more valid measures of infant speech perception. Secondly, it is possible that adequate speech audibility in these very young children may also contribute to
Barker et al.

The card is supposed to be sent within 24 hours to a lab for testing.
About one in every 800 babies is born with a potentially severe or deadly condition that can be treated and managed if the child is properly tested. These babies often appear healthy at birth but can become extremely sick within days. The entire premise of newborn screening is to detect disorders quickly so babies can be treated early, averting death and preventing or limiting brain damage, disability and a lifetime of costly medical care.
Arizona was one of the poorest performing states in the Journal Sentinel analysis, yet has become a model thanks to its transparency and to a top health official's willingness to solve the problem, said Scott Becker, executive director of the Association of Public Health Laboratories, a group that includes directors of state labs throughout the country.
"The health official and the state can lead by communicating — saying, 'This is an important issue and I expect, in our state, that we are going to take this seriously,'" Becker said.
Humble's target in his state is based on federally backed guidelines recommending that blood samples take no more than three days to arrive at labs for newborn screening. Children with many of the disorders screened for can die or become extremely ill just a few days after birth. But states often use varying thresholds to track samples — if they track them at all.
In Texas, the percentage of blood samples received at the state lab within four days rose to 95.6% in March — a big improvement from about 85% last year.
Since the state's poor performance was reported, Texas health department officials have been examining the processes of both top- and bottom-performing hospitals to figure out what's going right and what is going wrong, and communicating what they learn to hospital staffs.
Washington state has passed comprehensive legislation in response to the Milwaukee Journal Sentinel's investigation, although it was one of the better-performing states in the analysis of hospital-by-hospital data.
In mid-March, Gov. Jay Inslee signed a bill that requires hospitals to collect blood samples for screening within 48 hours of a baby's birth, and then deliver the sample to the state public health lab within 72 hours of collection. Days when the lab is closed, such as Sundays, are not counted against the 72-hour requirement.
The law also requires the health department to publicly post each hospital's performance on the agency's website each year.
The bill had personal significance for sponsor state Rep.

Through its robust quality assurance programme, NHSP ensured that every member of the multidisciplinary team was trained and involved in providing optimal care. Implementation of NHSP was like a military campaign, well thought out and, although not without its problems, successful. This success has ensured that many other countries have followed suite, and screening is offered across the UK as well as in other parts of the world.
There were two other important changes at the same time as the inception of NHSP. The start in 2000 coincided with MCHAS—modernising children's hearing aids—a project which introduced digital hearing aids into the UK for all children, with consistently high standards of fitting and maintenance of hearing aid care. At about the same time, there was an increasing confidence in, and acceptance of, cochlear implants for children. Early diagnosis following NHSP has reduced the age of implantation, affording the child the earliest possible access to good speech signals, with excellent results in speech and language development.
NHSP has also facilitated aetiological investigation by making this a part of the whole process and ensuring that medics have had the training to take this forward. In addition, part of NHSP has been the collection of robust and invaluable epidemiological data, but, unfortunately, the outcomes of screening have not yet been published. Although Public Health England, which has taken over hearing screening in England, now only covers screening, the pattern for subsequent care has been established and continues.
The children are the true beneficiaries of this exciting project. The effect of NHSP has been to significantly lower the age of confirmation of deafness. Figures show that the vast majority of congenitally deaf children have their hearing loss confirmed by 6 months of age with many identified within the first 4 weeks of life. Identification is the first step and ensures that habilitation is started within the first 6 months, with hearing aids being a part of that for many children. We are seeing the impact of early diagnosis in better speech and language skills and educational attainment. Pimperton et al's paper has shown exciting results with relatively early diagnosis (by 9 months). Hopefully, based on evidence from the USA, with lower ages of diagnosis, we may see even better reading competences for all deaf children in the future.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.

In Texas, newborn hearing screening was mandated in 1999 through the passage of House Bill 714. In 2011 the mandate was expanded through House Bill 411 and Senate Bill 229. The Texas Department of State Health Services (DSHS) is the oversight agency.
James T. (Jim) Walsh, US House Representative from 1989 – 2009, was active in the passage of the first nationwide act that guaranteed hearing screenings for newborns and infants. In 1991, Walsh sponsored and introduced the Hearing Loss Testing Act. The Newborn and Infant Screening and Intervention Program Act was authored and sponsored, mainly, by Walsh in 1999. On March 11, 2009, the act was renamed as the James T. Walsh Universal Newborn Hearing Screening Program, and was identified within 42 United States Code 280g-1. The Act is for “the early detection, diagnosis, and treatment regarding hearing loss in newborns and infants,” and included several provisions so that these endeavors would be accomplished.
Since that time, Congress has expanded and reauthorized the original Act. Current legislation, known as the Early Hearing Detection and Intervention Act 2010, was approved and signed by President Obama on December 22, 2010. In 2015, the US House of Representatives proposed amended legislation to reauthorize a program for early detection, diagnosis, and treatment regarding deaf and hard-of-hearing newborns, infants, and young children.

This curriculum has been tested to be used by teachers nation-wide in urban, rural and suburban, public, and private settings.
There will be continuing initiatives to reach Hispanic/Latino/Latina individuals through participation with various Spanish language and Hispanic interest-meetings, exhibit opportunities, and collaborative efforts with the NIH Hispanic Communications Work Group that includes the Radio Unica/Wal-Mart Hispanic Latino/Latina Health Fair series. Most NIDCD health information materials are available in Spanish. An initiative to reach the rural community with advice about hunting and farming equipment uses shooting instructors as the dissemination source. WISE EARS!® information is provided to these individuals through their classroom instructors.
188.8.131.52 Performance Measures
- Increase Public Awareness through education and mass media efforts.
- Expand the campaign on the national level by increasing the coalition membership.
184.108.40.206 Outcome Measures
- Track outreach efforts through data provided by North American Precis (NAPS) to increase the awareness of the importance of protection against noise-induced hearing loss amongst the under-represented groups. NAPS will target Spanish language populations specifically.
3.2 Area of Emphasis Two: Early Hearing Detection and Intervention
Each year, approximately two to three out of 1,000 babies born in the United States have a detectable hearing loss, which can affect their speech, language, social, and cognitive development. More lose their hearing later during childhood. Many of these children may need to learn speech and language differently, so it's important to detect deafness or hearing loss as early as possible.
3.2.1 Objective One: Increase Public Awareness on the Importance of Newborn Hearing Screening and Communication Options
220.127.116.11 Action Plan
NIDCD established the Early ID Ad Hoc Committee in January 2000. It now includes representatives from 14 organizations. The committee meets quarterly to create, share, and participate in collaborative efforts. These efforts focus on increasing the parents and families awareness of the importance in having a child's hearing screened, options for their child if he or she is diagnosed with hearing loss, and emphasizes initiatives to increase follow through for children who are believed to have hearing loss at birth.
NIDCD began a multi-year campaign called "Labor Day" in September of 2003 and will expand that initiative in 2004 with the support of work group members.

Infant Hearing Screening Advisory Committee Meeting
[33 Pa.B. 1421]
The Infant Hearing Screening Advisory Committee, established under the Infant Hearing Education, Assessment, Reporting and Referral Act (11 P. S. §§ 876-1-- 876-9) will hold a public meeting on Wednesday, March 26, 2003, in Conference Room 614, Department of Labor and Industry Building, 7th and Forster Streets, Harrisburg, PA, from 1 p.m. to 4 p.m.
The Department of Health reserves the right to cancel this meeting without prior notice.
For additional information or persons with a disability who wish to attend the meeting and require an auxiliary aid, service or other accommodation to do so, contact Karl Hoffman, Program Administrator, Hearing Program, Division of Newborn Disease Prevention and Identification, (717) 783-8143 or for speech and/or hearing impaired persons, V/TT (717) 783-6514 or the Pennsylvania AT&T Relay Services at (800) 654-5984.
ROBERT S. MUSCALUS, D.O.,
[Pa.B. Doc. No. 03-472. Filed for public inspection March 14, 2003, 9:00 a.m.]
No part of the information on this site may be reproduced for profit or sold for profit.
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