• Minnesota Newborn Hearing Screening (NHS) Program

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Guidelines for Organization and Administration of
Special Care Nursery and Neonatal Intensive Care Unit
(NICU) Universal Newborn Hearing Screening
Revised, May, 2008
The goal of an Early Hearing Detection and Intervention (EHDI) Program is to identify
and provide effective intervention for newborns and infants with permanent childhood
hearing loss and those at risk for hearing loss that may affect health, communication,
learning and development. To achieve this goal, Minnesota law (Minnesota Statutes
144.966) requires that a hearing screen must be performed on all newborns prior to
hospital discharge, or as soon as medically feasible for infants with a prolonged stay in
Special Care Nursery and the NICU. National standards hold that screening should be
complete by one month of age; hearing loss should be clinically diagnosed by 3 months
of age and intervention initiated by 6 months of age or as soon as medically feasible for
infants with a prolonged stay in the NICU. Corrected gestational age needs to be
considered for the significantly premature infant. With prompt referral and follow-up,
Minnesota children have an opportunity to receive appropriate care and services even
Because of the importance of early identification of hearing loss, all screening, follow-up,
and tracking procedures must be consistent with current Minnesota statutory
requirements. This document provides recommended guidelines for newborn hearing
screening programs in the Special Care Nursery and the NICU. Please see separate
document regarding hearing screening guidelines for infants in the Well Baby Nursery.
Additional resources are available from the Minnesota Department of Health (MDH) to
assist hospitals and hearing screeners with specific issues of program development and
management such as training, supervision, equipment options, and quality assurance
issues (www.health.state.mn.us/newbornscreening).
Child and Family-Centered Communication
Minnesota statute requires hospitals to present information to parents that covers the
following topics:
• Potential risks and effects of hearing loss
• Benefits of early detection and intervention
• Nature of the screening procedure
• Applicable costs of screening procedure
• Parental option to have screening performed but to request that test results be
destroyed by the MDH
• Parental option to refuse screening
Best practice would also include providing the following to parents:
• Prevalence of and risk factors for permanent childhood hearing loss (Appendix A)
• Possibility of late or progressive onset of hearing loss, including otitis media
• Developmental milestones for speech, language, and hearing (Appendix B)
Screening may be performed by trained personnel including the following:
• Audiologists, audiological technicians/assistants
• Nurses
• Nursing assistants
• Other trained medical personnel
Although licensed audiologists do not need to conduct the actual hearing screening,
audiologists are uniquely qualified to develop and implement all aspects of an EHDI
program. Hospital screening programs benefit from direct access to audiological
consultation to address screening criteria, quality assurance, follow-up assessment and
intervention services.
Training qualified screeners is an ongoing process. Training typically includes three
phases: initial training and demonstration of skills, ongoing quality assurance, and
refresher training. Resources for training may include experienced screening program
managers and local licensed audiologists.
Initial training content is based on current best practice procedures as reported in
professional literature. Assuring competent screeners is a critical component for every
screening program. Training components include the following:
• Competency-based demonstration of trainees’ performance in the nursery
• Periodic observation of each screener in the nursery environment by a skilled
professional such as an audiologist and/or program manager;
• Annual staff refresher training, with individual training available as needed.
Screening programs must use objective physiological screening methods such as
Automated Auditory Brainstem Response (AABR) or otoacoustic emissions (DPOAEs or
TOAEs) that do not require a behavioral response from the infant. OAE and AABR have
proven to be effective screening measures. All equipment must meet technical
specifications, calibration standards, and hospital safety standards. If only one test
technology is to be utilized in the NICU, recent JCIH guidelines (2007) recommend that
it be the AABR.
Hearing Screen Stimulus Parameters
TOAEs should be measured in response to a click at approximately 80dBSPL (78-
82dBSPL). DPOAEs should be measured in response to a series of paired tones (f1 and
f2), with a ratio of 1.22 at a moderate level, where L1/L2= 65/55dBSPL.
Newborn screening AABRs typically are evoked using click stimuli at 30 to 35dBnHL at
a moderate rate. Non-automated ABR testing is NOT recommended for newborn hearing
screening programs in hospital nurseries due to issues of potential operator error and
significant time/cost effectiveness issues.
Default stimulus parameters of either OAE or AABR equipment should be reviewed by
the screening program’s consulting audiologist or MDH audiologists to assure they are
appropriate or to adjust them to be in accordance with clinically accepted national
Pass/Refer Criteria
Manufacturer’s pass/fail criteria should be reviewed by the consulting audiologist or
MDH audiologist and should be in accordance with clinically accepted national practices.
Typical passing criteria for TOAEs include overall reproducibility greater than 50%, at
least 50 low noise samples collected, stimulus stability of 75% or greater, and responses
present at least 6dB above noise floor for at least three of the five test frequencies, with
4000Hz a mandatory passing frequency. Typical passing criteria for DPOAEs requires
absolute response amplitude of at least –6dB and responses at least 6dB above the noise
floor at three or more of the test frequency bands, with the 4000Hz region a mandatory
passing frequency.
• Screening AABR pass criteria for newborns typically require repeatable Wave V
evoked responses to clicks at ≤35 dB nHL for each ear, within specific latency
parameters. Once again the consulting audiologist or MDH audiologist should
review the default pass/fail criteria for the specific AABR equipment used to
ensure compliance with accepted national practices.
A quality screening program benefits from incorporating new and improved evidence-
based technologies and procedures as they become available.
Hearing Screening Protocol
The prevalence of hearing loss has been reported to be 10 times greater among infants in
the neonatal intensive care unit than in the well baby nursery (Norton et. al., 2000). The
purpose of a screening test is to identify those infants at risk for hearing loss who need
further testing. A screening test is not a diagnosis. Because of the higher risk of hearing
loss in the NICU population, typical referral rates in the NICU are 7 to 10%.
Hearing loss may be related to conductive involvement, sensory deficit, neural
dysfunction or to some combination of the above. In addition NICU infants are at risk for
late onset hearing loss (see JCIH risk factors, Appendix A). While the additional risk for
neural hearing loss, specifically auditory neuropathy/dysynchrony, is not well
established, it has been reported more frequently in the NICU population than among
healthy newborns.
If the newborn is expected to remain in the hospital for a prolonged period, screening
needs to be performed prior to three months corrected age or when medically feasible. If
the infant’s status changes after the initial hearing screen then a re-screen may be
Choice of the equipment used in hearing screening in the NICU needs to be made
carefully. Hearing screening using otoacoustic emissions effectively identifies cochlear or
conductive hearing loss but will miss hearing loss of neural origin. Therefore, infants in
the NICU for more than five days and therefore presumed to be at highest risk for neural
hearing loss (JCIH, 2007) must have AABR included as part of their hearing screening
prior to discharge in order to be effectively screened
If nurseries have both AABR and OAE equipment available, use of a dual screening
method is recommended as it may be most effective in identifying hearing loss in these
infants at risk for later learning issues. Infants need to be referred for audiological
assessment to include diagnostic ABR if either screening is not passed. If an infant fails
both OAE and AABR screening, diagnostic ABR prior to discharge would be optimal. If
scheduling is not possible, or if the infant’s status or family situation does not allow for
testing prior to discharge, audiological assessment with diagnostic ABR needs to be
completed on an outpatient basis as soon as medically feasible. If only one hearing
screening technology is to be utilized in the NICU, recent JCIH guidelines (2007)
recommend that it be the AABR.
Passing newborn hearing screening does not guarantee that hearing will remain normal
nor does it eliminate the need to monitor the infant’s or child’s speech and language
skills. Audiological re-evaluation during early childhood is recommended when
parents/caregivers are concerned about hearing and/or speech/language development as
well as for those infants with risk factors for emergent hearing loss.
Minnesota Statute 144.966 requires the following documentation
• Screening results need to be recorded in the infant’s medical record.
• Screening results need to be communicated to the parents of the infant so that they
are well-understood.
• Screening results must be communicated to the infant’s primary care physician in
• Screening results must be reported to the MDH.
In order to improve follow-up for infants with failed hearing screens
• Families of infants who refer on the hearing screening should be provided with
information about why their baby may not have passed the hearing screening, the
importance of follow-up. In addition, a follow-up appointment for a pediatric
audiological evaluation should be scheduled.
• For infants who refer, the primary care physician and MDH should be promptly
notified of the follow-up audiology appointment to facilitate timely follow-up and
If an infant is transferred, the hospital that discharges the infant home is responsible for
According to MN statute 144.966, a physician, nurse, midwife, or other health
professional attending a birth outside a hospital or institution shall provide information,
orally and in writing, as established by the Department of Health, to parents regarding
places where the parents may have their infant’s hearing screened and the importance of
the screening.
Infants re-admitted to the hospital during the first month of life who have conditions
associated with potential hearing loss (e.g., hyperbilirubinemia, meningitis, sepsis) need
to have the hearing screen repeated prior to discharge. Because of the high incidence of
neural hearing loss associated with significantly elevated bilirubin, these infants should
be referred for audiological assessment to include ABR measures.
Follow-up and Case Management
EHDI is part of a continuum of care that progresses from screening to assessment to
amplification (if elected) to educational intervention. Assessment referrals need to be
made to audiologists with expertise in pediatric physiological and behavioral assessment
and management. See the Minnesota Department of Health (MDH) website for
Audiology Regional Centers that provide pediatric diagnostic assessments and
habilitation services in Minnesota (www.health.state.mn.us/newbornscreening).
The National recommended time line for hearing screening and follow-up includes:
complete screening no later than one month corrected age or as soon as medically
feasible for screening, assessment no later than three months corrected age or as soon as
medically feasible for assessment/diagnosis, and amplification (if elected) and
intervention no later than six months corrected age or as soon as medically feasible for
intervention. With prompt referral and follow-up, Minnesota children will receive
appropriate care and services even earlier.
Middle Ear Effusion
Although persistent middle ear effusion necessitates medical referral, which might
delay the evaluation timeline several weeks, diagnostic audiological evaluation
must not be repeatedly postponed solely due to middle ear dysfunction and should
be completed before 3 months of age. The information from the diagnostic
audiological evaluation is valuable both in determining the extent of the effect of
the middle ear condition on the infant’s hearing, and identifying whether an
underlying sensorineural hearing loss exists, thereby impacting the course of both
medical and educational intervention.
Positive Risk Factor (JCIH 2007 clarification document)
The timing and number of hearing re-evaluations for children with risk factors
(Appendix A) should be customized and individualized depending on the relative
likelihood of a subsequent delayed-onset hearing loss. Infants who pass the neonatal
screening but have a risk factor should have at least 1 diagnostic audiology
assessment by 24 to 30 months of age. Early and more frequent assessment may be
indicated for children with cytomegalovirus (CMV) infection, syndromes associated
with progressive hearing loss, neurodegenerative disorders, trauma, or culture-
positive postnatal infections associated with sensorineural hearing loss; for children
who have received ECMO or chemotherapy; and when there is caregiver concern or a
family history of hearing loss.
Without an adequate follow-up plan, even the best EHDI program is ineffective. Refer to
the current Minnesota Department of Health (MDH) Infant Assessment and Pediatric
Amplification Guidelines.
Components of a quality assurance program include data management, screener
performance, site performance, outcome measures, and follow-up compliance. The goal
of quality assurance is information management and accountability to the following
• Family and the infant
• Screeners
• EHDI manager
• Clinical and educational audiologist
• Primary Care Provider (Medical Home)
• Hospital
• State of Minnesota
• Otolaryngologists
• Parents
• Medical and Educational Specialists
• Advocates
Appendix A
Risk indicators that are marked with a "*" are of greater concern for delayed-onset
hearing loss.
1. Caregiver concern* regarding hearing, speech, language, or developmental delay.
2. Family history* of permanent childhood hearing loss.
3. All infants with or without risk factors requiring neonatal intensive care for
greater than 5 days, including any of the following: ECMO*, assisted ventilation,
exposure to ototoxic medications (gentamicin and tobramycin) or loop diuretics
(furosemide/Lasix). In addition, regardless of length of stay: hyperbilirubinemia
requiring exchange transfusion.
4. In utero infections, such as CMV*, herpes, rubella, syphilis, and toxoplasmosis.
5. Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags,
ear pits, and temporal bone anomalies.
6. Physical findings, such as white forelock, that are associated with a syndrome
known to include a sensorineural or permanent conductive hearing loss.
7. Syndromes associated with hearing loss or progressive or late-onset hearing loss*,
such as neurofibromatosis, osteopetrosis, and Usher syndrome; other frequently
identified syndromes include Waardenburg, Alport, Pendred, and Jervell and
8. Neurodegenerative disorders*, such as Hunter syndrome, or sensory motor
neuropathies, such as Friedreich ataxia and Charcot-Marie-Tooth syndrome.
9. Culture-positive postnatal infections associated with sensorineural hearing loss*,
including confirmed bacterial and viral (especially herpes viruses and varicella)
10. Head trauma, especially basal skull/temporal bone fracture* that requires
11. Chemotherapy*.
Risk factor references available in JCIH 2007 Position Statement
Appendix B
Hearing & Speech Milestones
Birth to 3 months
• startles to loud sounds
• quiets or smiles when spoken to
• seems to recognize your voice and quiets if crying
• increases or decreases sucking behavior in response to sound
• makes pleasure sounds (cooing, gooing)
• cries differently for different needs
• smiles when sees you
3 to 6 months
• looks or turns toward a new sound
• responds to changes in tone of voice
• vocalizes excitement and displeasure
• enjoys rattles and other toys that make sounds
• babbling sounds more speech-like (such as ooh, aah, and ba-ba)
6 to 12 months
• enjoys games like peek-a-boo and pat-a-cake
• responds to his/her own name, telephone ringing, someone's voice,
even when not loud
• knows words for common things (cup, shoe) and sayings ("bye-
• imitates different speech sounds
• starts to respond to requests such as "come here"
• looks at things or pictures when someone talks about them
• has one or two words (bye-bye, dada, mama). although they may
not be clear
Appendix C
(a) Pass Both Ears, No Risk Indicators
Passes screen in both ears (AABR or both OAE and AABR).
Does not have any risk indicator for hearing loss (see risk indicators in
Appendix A).
Parents receive information (oral and written, culturally appropriate)
regarding developmental milestones for auditory, speech, and language skills.
In addition, parents should be encouraged to return for audiological evaluation
if their child is not meeting these milestones, or if they have concerns about
their child’s hearing at any point in the future.
(b) Pass Both Ears, Positive Risk
Passes screen in both ears (AABR or both OAE/AABR). However, infant has
one or more risk factors for hearing loss (see risk indicators in Appendix A).
Infant is referred and scheduled for repeat hearing screen at three months of
Parents receive information (oral and written) regarding developmental
milestones for auditory, speech, and language skills. In addition, parents
should be encouraged to return for audiological evaluation if their child is not
meeting these milestones, or if they have concerns about their child’s hearing
at any point in the future.
If the three month hearing re-screen is normal, a complete audiological
evaluation should occur at six months developmental age, using visual
reinforcement audiometry (VRA).
If follow-up testing is abnormal at three or six months, diagnostic ABR is
performed as soon as feasible.
(c) Does Not Pass in One or Both Ears, or Incomplete Test
Does not pass AABR hearing screen in one or both ears or does not pass
OAE or AABR (when dual technology is utilized) in one or both ears.
Testing cannot be completed in one or both ears.
Infant is referred and scheduled for diagnostic ABR as soon as medically
feasible. When possible, diagnostic ABR should be completed while an
inpatient or scheduled and completed prior to three months of age.
American Speech-Language-Hearing Association (2004). Guidelines for the Audiologic
assessment of children from birth to 5 years of age. Rockville, MD: ASHA.
CDC EHDI National Goals and Objectives, Final Version by the EHDI Data Committee,
July 13, 2006.
Gorga, M.P., Neely, T.S., Ohlrich, B., Hoover, B., Redner, J. & Peters, J. (1999). From
laboratory to clinic: A large scale study of distortion product otoacoustic emissions in
ears with normal hearing and ears with hearing. Ear and Hearing, 18, 440-455.
Hall, J.W., Smith, S.D., & Popelka, G.R. (2004). Newborn hearing screening with
combined otoacoustic emissions and auditory brainstem responses. Journal of the
American Academy of Audiology, 15, 414-425.
HRSA, Final Report. Evaluation of Universal Newborn Hearing Screening and
Intervention Program. Based on 2005 – 2006 Data.
Joint Committee on Infant Hearing Position Statement (2007), Year 2007 position
statement: Principles and guidelines for early hearing detection and intervention.
Pediatrics, 120, 898-921.
Joint Committee on Infant Hearing Position Statement (2007) Update. Clarification for
Year 2007 JCIH Position Statement. Retrieved May 2008, from
Minnesota Statute 144.966. Early Hearing Detection and Intervention Program. 2007.
Retrieved from www.leg.state.mn.us/leg/statutes
National Consortium for Newborn Hearing Screening. (Nov 16-18, 1995). TEOAE-based
universal newborn hearing screening. Georgetown University School of Medicine,
Washington DC.
Norton, S., Gorga, M., Widen, J., Folsom, R., Sininger, Y., Cone-Wesson, B., Vohr, B.,
& Fletcher, K. (2000). Identification of neonatal hearing impairment: A multicenter
investigation. Ear and Hearing, 21 (5), 348-356.
Ontario Health and Long-Term Care Ministry—Infant Hearing Program (2002).
Universal infant hearing screening assessment and communication development: Local
implementation support document.
Washington State Department of Health Protocol for Newborn Hearing Screening.
Retrieved June 24, 2007, from

Use: 0.1147