DISCUSSION
This study is one of the many steps towards evaluating the need and applicability of universal
hearing screening in a developing country like India. We‘ve tried to look into the incidence of
hearing impairment in at risk newborns using two staged TEOAE or DPOAE . TEOAE or
DPOAE was preferred as screening tool due its numerous advantages over BERA as
discussed before.
Screening the hearing loss at birth with TEOAEs or DPOAE and later confirming it at three
to sixth months was taken as the standard. Deka et al(102) studied the maturation of central
auditory connections. They have proposed that though cochlea is fully developed at birth, the
myelination of vestibulocochlear nerve and maturation of brainstem takes nearly six months.
This forms the basis of screening and re-screening protocols where final confirmation of
hearing loss is made only at around three to six months of age. This accounts for the possible
false-positive results that may result from an immature central connection of cochlea.
The incidence of hearing impairment in this cohort is 12.0% . There are few surveys showing
incidence of hearing impairment in India. In one such study, by P.Nagapoornima et al in
2006, an incidence of hearing impairment of 5.6/1000 was demonstrated.(94) The incidence
of hearing impairment in our study 12.0%( 18/150) is much higher than the national average
of 4/1000. (12) This may be because our hospital being a tertiary care centre has large
number of high-risk deliveries leading to larger case load of at risk group. The incidence of
hearing impaired 12.0% is very high in relation to other studies in risk infants for which early
intervention can be taken ,(15) advocating for an early implementation of hearing screening
in our nation.
In this study a high incidence of hearing impairment of 12.0% is seen in at risk group. This
finding is in par with the literature reports of incidence in at risk infants being approximately
10 times greater than the incidence in normal population if one or more risk factors included
in ―High-risk Registry (HRR)‖ of Joint committee for infant hearing are present.(9)
Along with the well known risk factors of HRR in the infants with hearing loss. But a strong
association between these other risk factors and hearing impairment could not be established
due to small sample size, warranting a detailed study of these other possible risk factor for
congenital hearing impairment. The identification of local risk factors and addition of them
into high-risk registry can improve the outcome and efficiency of target screening in resource
poor nation like ours.
It is necessary and high time to implement and incorporate universal neonatal screening in
our country to secure normal, social and holistic development of the child by detecting
hearing loss at birth and providing remedial services at the earliest. National policies in these
lines have to be made for neonatal hearing screening in all national health care facilities in
India.
Universal newborn hearing screening can yield high returns, and the 2-staged hearing
screening programme is cost effective and feasible . A child who receives early interventions
for hearing loss requires less expensive special education in later part of life and has a better
chance to have a normal social life and improved quality of life.
Considering the infrastructure limitations and financial hindrances in developing country like
ours, cost-effective measures like high-risk screening and behavioural observational methods
using calibrated noise making toys can be used to screen and follow-up all the newborns, till
the time universal screening policies are made into practice.
Anganawadi workers can be trained to administer these tests of behavioral observation
and reorganization of hearing impaired at earliest so that these neonates can further be
referred for proper audiologic assessment and early intervention or rehabilitation.
Till the national policies are made, private health institutions and pediatricians can screen the
newborns for hearing impairment using hand-held TEOAE / DPOAE instruments, as these
instruments are less technical, hardly cost around 1.5 to 2 lack rupees and give automated
results as pass or fail.
A two-staged screening can be planned and the screening timing can be incorporated along
with timing of discharge from hospital and timing of 1st dose of triple antigen vaccination (6
weeks) without extra burden on follow-up. Those who fail this 2-staged screening and all of
those who are having risk factors for hearing loss should undergo a confirmatory BERA and
referred for detailed audiological evaluation if necessary. Creating awareness among the
parents regarding the importance of hearing screening and available technology and benefits
of detecting this hidden defect can itself decrease the burden of the disease.
