International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 211-214
http://dx.doi.org/10.4236/ijohns.2013.25044 Published Online September 2013 (http://www.scirp.org/journal/ijohns)
Newborn Hearing Screening—Experience at
a Tertiary Hospital in Northwest India
John Jewel1, P. V. Varghese1, Tejinder Singh1, Ashish Varghese2
1Department of Paediatrics, Christian Medical College, Ludhiana, India
2Department of EN T — H e ad a n d Neck Surger y , Christian Medical College, Ludhiana, India
Received June 29, 2013; revised July 30, 2013; accepted August 9, 2013
Copyright © 2013 John Jewel et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective: To determine the in cidence of hearing impairmen t in a standardized population of neonates seeking care in a
tertiary hospital in Northwest India. Universal hearing screening is implemented in many developed countries. However,
neither universal screening, nor high risk screening, exists in India. The incidence of hearing loss in India is found to be
1 to 6 per 1000 newborns screened [1-3]. Screening only the high risk neonates misses 50% of babies with hearing loss
[4,5], hence a cost effective universal screening is the viable option to sustain such a program. In our study, the pos-
sible burden of hearing disability was ev aluated in babies born at a tertiary care hospital in Northwest India. One thou-
sand newborns were screened using Transient Evoked OtoAcoustic Emissions (TEOAE) and 28.6% of them had risk
factors. Four out of One Thousand were detected with hearing loss. Brain Stem Evoked Response (BERA) was used to
confirm and determine the extent and the type of deafness in the n eonates who were screened positive.
Keywords: Hearing Loss; Newborns; Transient Evoked OtoAcoustic Emissions; Universal Screening; Brainstem
Evoked Response Audiometry (BERA)
Hearing is a vital part of a newborn’s contact with his
environment. The ability to communicate, acquire skills,
and perform academically is all greatly dependent on the
ability to hear; especially in the present era which is quite
dependent on audio-video based on technology. The less
privileged youth of our country depends largely on busi-
ness outsourced from other countries for economic sta-
bility. In this scenario, hearing and language sk ills are of
prime importance, even to the poor urban slum dweller.
As hearing impairment is a hidden disability, it is usu-
ally detected after 2 years, by which time there is irre-
versible stunting of the language development potential
. Many developed countries have well established uni-
versal neonatal hearing screening programs. Considering
the infrastructure limitations in India, it is crucial to
adopt a cost effective way of detecting hearing loss to
make this program viable. This study was undertaken to
evaluate the possible burden of hearing loss among the
neonates born in a tertiary care center in northern India
and to justify the implementation of a universal hearing
screening program in India, using cost effective and ap-
propriate technology. Screening of neonates was done
using Transient Evoked OtoAcoustic Emissions (TEOAE)
and Automated Auditory Brainstem Response (ABR).
This study was undertaken in order to detect the fre-
quency of congenital hearing loss among neonates in a
tertiary care center in North India. The study also identi-
fies the challenges in implementing a universal screening
programme in normal neonates in North India and is
among the few similar articles from North India.
2. Material and Methods
The study was conducted prospectively on all neonates
born in Christian Medical College and Hospital, Ludhi-
ana from 1st August, 2007 to 31st January, 2009.
Parents or the grandparents of the neonates were in-
formed about the study and motivated to undergo the
screening program. An informed consent was taken from
the parent/guardian and approval of research and ethics
committee was obtained.
Using a pretested questionnaire , potential risk fac-
tors were identified. Both the normal and high-risk neo-
nates underwent hearing assessment after 48 hours of
birth using TOAE as the first level of screening. Neo-
nates who failed the initial screening were subjected to
opyright © 2013 SciRes. IJOHNS
J. JEWEL ET AL.
repeat testing with TOAE after one month (Screening
Algorithm, Table 1). This was done in the Department of
Otolaryngology at Christian Medical College and Hos-
pital, Ludhiana using a GSI Audio Screener SN20008P™,
which is a completely automated analysis system that
gives a “PASS” or “REFER” result. Absence of emis-
sions for 2 out of the 3 frequencies tested (2 kHz, 3 kHz
and 4 kHz) was given a “REFER” result. Infants who
failed the screening twice were referred to the Audiolo-
gist (Table 1).
Data from the questionnaire and the results of the test-
ing were tabulated in Microsoft EXCEL™ and subjected
to analysis using student t-test and coefficient of correla-
Among the 1000 neonates that were screened initially, 60
babies failed the first screening (6%).
Forty two out of the failed neonates came for follow
up, out of which 4 babies failed in the second screening
as well. Hearing loss in these 4 babies was confirmed
Three neonates out of the 4 who failed to have identi-
fiable risk factors, which were low birth weight < 1.5 kg
(1 baby), severe birth asphyxia (1), NNH requiring ex-
change blood transfusion (1), and meningitis (1). 1 baby
had no risk factor for hea ring loss.
The babies who were screened positive for hearing
loss were confirmed using ABR. Two of them had severe
Sensorineural hearing losses and the other two were di-
agnosed with moderate to severe hearing loss. All the
babies were referred to an Audiologist for further inter-
ventions (Table 2).
It is well recognized that unidentified hearing loss can
adversely affect optimal speech and language develop-
ment, acquisition of literacy skills, academic, social and
emotional develop ment. There is robust evidence that the
identification and remediation o f hearing loss, wh en don e
before six months of age for newborn infants who are
hard of hearing, enable them to perform significantly
higher on vocabulary, communication, intelligence, so-
cial skills and behavior necessary for success in later life
. In 1994, the Joint Committee on Infant Hearing
(JCIH) established in the United States recommended
screening of high risk babies for hearing loss using High
Risk Registry . Several studies thereafter suggested
that up to 50% of all the children with congenital h earing
loss have no risk factors and would be missed by screen-
ing only th ose at high risk [8-11]. American Academy of
Pediatrics (AAP) in 1999 advocated universal newborn
hearing screening programme (UNHSP) and remedial
Table 1. Screening algorithm.
Total Neonates Test Passed Failed Test
Initial screening 1000 940 60
(18 lost to follow up) 42 38 4
Confirmation with ABR: Moderate to profound sensorineural hearing loss—
4; At risk infants—3; Neonate with no ide nti fiable risk factor—1.
Table 2. Distribution of cases according to risk factors for
Birth weight less than 1.5 kg 35 1 36
Asphyxia 4 1 5
Family history o f hearing impairment 5 0 5
NNH Requiring Exchange Transfusion 52 1 53
Meningitis 1 1 2
At risk neonates 260 3 263
Neonates with no risk factors 736 1 737
intervention, which is being practiced in most of the de-
veloped countries. The AAP Task Force on newborn and
infant hearing recommends UNHS by three months of
age with intervention by six months of age. The Joint
Committee on Infant Hearing (JCIH) position statement
provides guidelines that include Newborn Hearing Screen-
ing (NHS) soon after birth, before discharge from hospi-
tal, or before one month of age, diagnosis of hearing loss
through audiological and medical evaluation before three
months, and intervention through interdisciplinary pro-
grams for infants with confirmed hearing loss before six
months of age .
4.1. Rationale for Universal Hearing Screening
Universal screening for hearing loss is based on the fol-
1) It is seen that 42% - 70% of children will be missed
using only risk-base d s c r e ening [5,12].
2) A critical period exists for optimal language devel-
opment and earlier interventions may produce better re-
3) Treatment of hearing defects has been shown to
improve communication, better self-confidence and alle-
viate parental frustration and guilt.
Over the study period from 1st August, 2007 till 31st
January 2009, we screen ed a total of 1000 babies and the
incidence of hearing loss as per our observation is 4 per
1000 babies tested, out of which 3 babies had high risk
factors for hearing loss and 1 baby was a well baby (Ta-
Copyright © 2013 SciRes. IJOHNS
J. JEWEL ET AL. 213
4.2. TEOAE vs BERA as Initial Screening
Otoacoustic emissions are the most sensitive tests for
screening although it may have to be combined with o t h er
tests for complete diagnosis . However it may give
false results in the presence of debris or vernix in the ex-
ternal audi tory canal o f n ewborn b ab ies. Brainstem Evoked
Response Audiometry (BERA), though highly reliable,
requires high technical expertise, which is more expen-
sive as opposed to TEOAE. Also BERA makes use of a
cumbersome machine whilst the TEOAE screener is a
portable machine. It also requires sedating the infant be-
cause of the lengthy procedure. TEOAE, on the other
hand does not assess the cortical pathway for hearing. It
may also give false results in ne onates with auditory neu-
ropathy. However, it is an excellent tool as an initial
The relative advantages and disadvantages of a two-
stage (OAE/BERA) protocol for newborn hearing screen-
ing need to be considered carefully for individual cir-
cumstances. Transient Evoked OtoAcoustic Emissions
(TEOAE) are a non-invasive and inexpensive test that
can be done in the nursery setting with little expertise
and a shorter time as compared to BERA. Different stud-
ies have revealed TEOAE sensitivity as high as 95% -
98% and a specificity of 80% - 85% [14,15]. Therefore,
TEOAE cannot completely replace BERA as a screening
modality, but can on ly complement it. In location s where
getting infants to return for outpatient screening and test-
ing is very difficult, and the substantially lower failure
rate that will likely be achieved by using both OAE and
BERA at the same sitting has significan t advantages. In a
setting like ours, this may not be very practical, but has
to be considered wherever possible.
4.3. Problems and Limitations of Study
One problem we faced was getting a noiseless surround-
ing in the nursery setting. The babies had hence to be
transported to the audiology room for testing which in-
creased the discomfort for the relatives. Some babies
woke up during transit, increasing the time taken for the
To improve the follow-up rate, we coincided the im-
munization visit with that of screening. Performing a test
on that day was a little time consuming because one has
to wait for the baby to go to natural sleep.
A hearing screening equipment facility in every hos-
pital with a maternity unit today may not be an eco-
nomically viable proposition. In this backgrou nd, a prac-
tical interventional model was conceived in the city of
Cochin (which has 20 hospitals with maternity units) in
January 2003. A program with centralized screening fa-
cility, where a screener would operate out of one hospital,
to cater to the different hospitals of the city was success-
fully implemented with the co-operation of IAP .
This is a viable and cost effective model for the whole
 K. R. Bachmann and J. V. Arvedson, “Early Identifica-
tion and Intervention for Children Who Are Hearing Im-
paired,” Pediatrics in Review, Vol. 19, 1998, pp. 155-165.
 P. Nagapoornima, A. Ramesh, Srilakshmi, S. Rao, P. L.
Patricia, M. Gore, M. Dominic and Swarnarekha, “Uni-
versal Hearing Screening,” Indian Journal of Pediatrics,
Vol. 74, No. 6, 2007, pp. 545-549.
 Rehabilitation Council of India, “Status of Disability in
India-2000,” New Delhi, 2000, pp. 172-185.
 Yoshinaga, S. Itano, A. L. Sedey, D. K. Coulter and A. L.
Mehl, “Language of Early and Later Identified Children
with Hearing Loss,” Pediatrics, Vol. 102, No. 5, 1998, pp.
 J. Hadad Jr., “Hearing Lo ss,” In: R. E. Behrman, R. K lie g-
man and H. B. Jenson, Eds., Nelson Textbook of Pediat-
rics, 17th Edition, Saunders, Philadelphia, 2004, pp. 2129-
 Joint Committee on Infant Hearing, American Academy
of Audiology, American Academy of Pediatrics, Ameri-
can Speech-Language-Hearing Association, Directors of
Speech and Hearing Programmes in State Health and
Welfare Agencies, “Year 2000 Position Statement: Prin-
ciples and Guidelines for Early Hearing Detection and
Intervention Programmes,” Pediatrics, Vol. 106, 2000, pp.
 Joint Committee on Infant Hearing, “Joint Committee on
Infant Hearing (JICH) 1994 Position Statement,” Pediat-
rics, Vol. 95, 1994, pp. 152-156.
 M. A. M. De, “Newborn Hearing Screening,” eMedicine,
2004, pp. 1-14.
 K. R. White, B. R. Vohr and T. R. Behrens, “Universal
Newborn Hearing Screening Using Transient Evoked
Otoacoustic Emissions: Results of the Rhode Island Hear-
ing Assessment Project,” Seminars in Hearing, Vol. 14,
1993, pp. 18-29.
 G. Isaacson, “Universal Newborn Hearing Screening and
Intervention,” Ad vances in Otolaryngolo gy-Head a nd N e ck
Surgery, Vol. 15, 2001, pp. 1-19.
 K. White and A. Maxon, “Universal Screening for the
Hearing Impairment: Simple, Beneﬁcial and Presently
Justiﬁed,” International Journal of Pediatric Otorhinola-
ryngology, Vol. 32, No. 3, 1995, pp. 201-211.
 K. L. Stein, “Factors Influencing the Efficacy of Univer-
sal Newborn Hearing Screening,” Pediatric Clinics of
North America, Vol. 46, No. 1, 1996, pp. 95-102.
 S. J. Norton, M. P. Gorga, J. E. Widen, R. C. Folsom, Y.
Copyright © 2013 SciRes. IJOHNS
J. JEWEL ET AL.
Copyright © 2013 SciRes. IJOHNS
Sinnger, B. Cone-Wesson, et al., “Identification of Neo-
natal Hearing Impairment: Evaluation of Transient Ev oke d
Otoacoustic Emission, Distortion Product Otoacoustic Emis -
sion, and Auditory Brainstem Response Test Perform-
ance,” Ear and Hearing, Vol. 21, 2000, pp. 508-528.
 R. Keren, M. Helfand, C. Homer, H. McPhilips and T. A.
Lieu, “Projected Cost Effectiveness of Statewide Univer-
sal Newborn Hearing Screening,” Pediatrics, Vol. 110,
No. 5, 2002, pp. 855-864. doi:10.1542/peds.110.5.855
 K. P. Abraham, “Newborn Hearing Screening,” Indian
Pediatrics, Vol. 48, No. 5, 2011, pp. 355-359.