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Year : 2015  |  Volume : 21  |  Issue : 3  |  Page : 179-182

Universal hearing screening vs targetted hearing screening: Make a choice

1 Shabda Brahma Speech and Hearing Centre, Ahmedabad, India
2 Department of ENT, B.J. Medical College, Ahmedabad, India
3 Department of ENT, M.P. Shah Medical College, Jamnagar, Gujarat, India

Date of Web Publication17-Jul-2015

Correspondence Address:
Vikas Sinha
Department of ENT, M.P. Shah Government Medical College, Jamnagar, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-7749.161023

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Introduction: Universal newborn hearing screening (UNHS) is mandatory in all developed country and is setting the trend in developing country too. Due to a large population, lack of education, less professionals, and limited access to such facilities in India few places targeted hearing screening (THS) is coming up. However, the comparison between UNHS and THS is less investigated till date. Aim of the Study: This study aimed to investigate the comparison between two hearing screening program that is UNHS and THS in the Indian context. Methods: In UNHS all the infants were screened at Tertiary Centre and for THS only infant with high-risk factors were screened at Advanced Audiological Centre. Further, all referral, screening, and diagnostic data were included in data analysis of both hearing screening program. Result: UNHS was difficult due to some system failure and a lot of time was wasted doing the different procedure. However, THS was much easier and false-positive and negative were lesser. Conclusion: In a vast population country with lack of manpower for the fi eld, it is important to have an alternative approach to the system for better outcome of the program.

Keywords: High risk factors, Newborn, Otoacoustic emissions, Targetted hearing screening, Universal hearing screening

How to cite this article:
Vishwakarma C, Mathur R, Vishwakarma R, Jindal S, Sharma P, Sinha V. Universal hearing screening vs targetted hearing screening: Make a choice. Indian J Otol 2015;21:179-82

How to cite this URL:
Vishwakarma C, Mathur R, Vishwakarma R, Jindal S, Sharma P, Sinha V. Universal hearing screening vs targetted hearing screening: Make a choice. Indian J Otol [serial online] 2015 [cited 2023 Feb 6];21:179-82. Available from: https://www.indianjotol.org/text.asp?2015/21/3/179/161023

  Introduction Top

Hearing loss is an invisible disability, and is considered to be the most prevalent congenital abnormality in newborns. It is twice as prevalent as other conditions that are screened for at birth, such as sickle cell disease, hypothyroidism, etc. [1] Early period from birth to 3 years is the "critical period" for the development of normal speech and language. India being the 2 nd largest populated country, where the birth rate is 20.22/1000, it is important that we identify and intervene at the right time for the hearing disability. [2],[3],[4] In developed countries with a high standard of health care, primary services include the early detection of congenital hearing loss and the initiation of auditory habilitation before 6 months of age.

Early identification of hearing loss in infants can be traced back to the work of Dr. Marion Downs in the 1960s. [5] Newborn hearing screening plays integral role in early identification of hearing loss and this is being done in all the developed countries (US, UK, European countries, etc.). We do not have such practice yet developed wherein we compulsorily test the newborns for the hearing. The reasons are very obvious such as manpower shortage, lack of awareness among the population about the test/means to know the hearing status, and lack of guidance factor too.

Present study tries to find out the efficacy of universal newborn hearing screening (UNHS) and targeted hearing screening (THS) for the Indian scenario, which can be opted as the model in large population size. It is obvious that we would be missing some babies with hearing loss if THS comes out as a viable solution. No prospective studies have compared outcomes of children who received screening through a UNHS program and those who were managed using a risk factor-based approach. [6] Recently there was a study done in Egypt, and the authors tried to compare the two programs. [7]

Transient evoked otoacoustic emissions (TEOAEs) is the most adequate hearing screening tests because they are accurate, economic, and of simple execution. In recent years, automated auditory brain stem response (ABR) instruments have been developed for screening neonates in hospital setting in order to identify patients with auditory neuropathy, and it is important to reduce the number of false-positives. [8] In the present study, we have used TEOAEs and ABR.

  Methods Top

Subject selection

  • Data collection for the study was done from December 2012 to August 2014, at two centers: Tertiary Centre and Advanced Audiological Centre
  • Referral source for subjects (UNHS and THS subjects) were from Tertiary Centre where all live birth were tested, and other Neonatal Intensive Care Units (THS subjects) in the city who want to get hearing checked for their babies
  • All the subject's detailed medical, perinatal, family history, and clinical examination with assessment of Apgar score at 1 and 5 min were taken. Otoscopic examination was also done for patency and structure of ear canal, ear drum
  • Subjects were categorized into two different groups: UNHS group and THS group

    • Newborn should be within 5 months of age (neonates and infants) for UNHS
    • Targeted hearing screening group had babies having high risk factors including: Preterm delivery, low birth weight, Apgar score of 0-4 at 1 min or 0-6 at 5 min, mechanical ventilation lasting 5 days or longer, hyperbilirubinemia requiring transfusion, ototoxic medications, associated syndrome, recurrent otitis media, in utero infections (cytomegalovirus, rubella, syphilis, herpes or toxoplasmosis).
  • Exclusion was for those subjects whose admission was not more than 4 days and who died before the age of 5 months
  • In total, 2000 babies were tested in UNHS group and 1020 babies were tested in THS group. Testing was carried in stages as Stage 1: TEOAE testing, Stage 2: If refer call them for TEOAE again after 2 weeks and Stage 3: ABR to be done if refer again in Stage 2
  • In UNHS/THS, TEOAE was carried by nurse, resident doctor or by a certified audiologist. However, ABR was always done by a certified audiologist
  • UNHS was carried out at Tertiary Care Centre, whereas THS was done at Advanced Audiological Centre
  • All the tests were carried out in sound-treated conditions.


  • At Advanced Audiological Centre, intelligent hearing system (IHS) TEOAE and ABR were used [Figure 1]. In IHS instrument, 1024 sweeps, rate: 19/s, nonlinear modality and at 80 dB SPL testing was carried out. The software determined the amplitude of the TEOAEs in five frequency bands: 1, 1.5, 3, 4, and 5 kHz. Whereas RMS ABR Medulla, Emmissia RMS TEOAE [Figure 2] was used at Tertiary Centre
  • Testing was done in natural sleep/under sedation (Triclofos Sodium 500 mg as per body weight). Testing was aborted if subjects become active or starts crying. Retesting was advised if permitted on the same day or at next appointment. The results of TEOAEs were interpreted according to the Rhode Island criteria; [9] pass: Response is 3 dB or more in at least 4 frequency bands
  • ABR recordings were done at Advanced Audiological Centre and Tertiary Centre, using the IHS instrument and RMS Medulla, respectively. Testing was carried under sedation. Three electrode montage used where the active electrode on the forehead, reference, and ground electrode to the ipsilateral and contralateral mastoids, respectively placed. Acoustic rarefaction clicks of 0.1 ms duration were presented at a rate of 11.1 p/s at different intensities starting from 50 to 90 dB nHL till there is replicable V peak obtained.
Figure 1: Intelligent hearing systems

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Figure 2: RMS systems

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  Results Top

Universal newborn hearing screening group

Study was carried out in three stages, which is demonstrated in [Figure 3]. In Stage 1, 76% of the participants passed whereas 24% of the participants were referred out of 2000 babies. Referred group was further called for Stage 2 testing and 65% of the participants failed to report for this stage examination (drop out). Further remaining 35% were tested and 16% were referred. In Stage 3, 91% participants were passed, 6% had a bilateral hearing loss, and 3% had a unilateral hearing loss.
Figure 3: Pie chart showing subjects participation at different stages in universal newborn hearing screening group

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Targeted hearing screening group

1020 babies with high risk were tested for THS group in Stage 1. 83% were passed and 17% were referred in Stage 1. Further for Stage 2, only 24% were failed to come (drop out) while 76% babies were tested. 20% subjects who got refer were further tested. In Stage 3 testing, 80% of the participants were passed, 14% had a bilateral hearing loss and 6% had a unilateral hearing loss. Results are also depicted in [Figure 4].
Figure 4: Pie chart showing subjects participation at different stages in targeted hearing screening group

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  Discussion Top

Universal newborn hearing screening group

The [Figure 3] shows that for Stage 1 there was more number of pass subjects, in Stage 2 when refer group called, high number of drop outs noticed. Those who came for Stage 2 testing, a high number of subjects were labeled pass in Stage 3 where TEOAE and ABR were done. Almost double the number of bilateral hearing loss identified than a unilateral hearing loss.

As reported earlier [10] the good screening program has 1.5-5% refer rate compared to High refer rate in the present study (24%) which could be attributed to ambient sound level in the setup and also the human error as it was done by mix group of staff having nurse, audiometrist, audiologist or resident doctor, as per the availability. We could not find any previous study, which has said about the dropout rate this could be the first kind where we found more dropout rate (65%) when called for 2 nd stage testing. It was primarily due to parents thinking of nothing can go wrong when the delivery is been normal at full term, which parents said when contacted retrospectively after the study.

Targeted hearing screening group

Less refer noticed in Stage 1, and of them the majority of subjects came for Stage 2 testing. Those who got refer again Stage 2 were called for Stage 3 testing of which 14% were having a bilateral hearing loss and 6% detected having a unilateral hearing loss.

Less refer rate (17%) in the study compared to UNHS group noticed, as the test was carried by certified audiologist only with more care and tester tried to control the ambient noise by not allowing any activities in vicinity, switching of the fans, etc., as tester knew about the high-risk condition. Furthermore, we found less dropout rate (24%) as parents were anxious about the results so without wasting time they wanted to come for subsequent testing. More of refer subjects after Stage 2 were found which could be attributed to the fact that the group had high-risk babies.

  Conclusion Top

Present study was very simple in its methodology and statistics. The study tries to give emphasis on:

  • Importance on hearing screening program similar to previous studies
  • Furthermore, it motivates us to follow the guidelines of hearing screening. Staged testing protocol
  • Focus on training for the personnel carrying the test procedure to have less refer rate (THS group had less compared to UNHS group) due to human error and at times technical
  • Hospitals and doctors can spare some time in educating themselves and staffs regarding the importance of the program
  • Proper counseling protocols and good tracking system should can help in identifying and calling the babies who failed (dropouts) in the screening for 1 st and 2 nd stage testing. A small determined step forward can change lives of many children, families, society, and the country.

Limitations of the study

Following limitations of the study, which could have been control, were:

  • Same personnel testing both the groups
  • Same testing environment for both the groups each time
  • Same instrument to be used while conducting the study
  • Having a same referral source for all, the present study had UNHS and THS babies from Tertiary Centers and additional THS babies were tested from other referral sources as well.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

American Academy of Pediatrics, Joint Committee on Infant Hearing. Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics 2007;120:898-921.  Back to cited text no. 1
Birth Rate, Death Rate, Infant Mortality Rate and Total Fertility Rate: India and States. National Commission on Population, Govt. of India; 2010.  Back to cited text no. 2
Census India SRS Bulletins. Registrar General of India, Govt. of India; 2011.  Back to cited text no. 3
Census India SRS Bulletins. Registrar General of India, Govt. of India; 2013.  Back to cited text no. 4
Hall JW 3 rd . Handbook of Otoacoustic Emissions. San Diego: Singular Publishing Company; 2000.  Back to cited text no. 5
Wrightson AS. Universal newborn hearing screening. Am Fam Physician 2007;75:1349-52.  Back to cited text no. 6
Imam SS, El-Farrash RA, Taha HM, Bishoy HE. Targeted versus universal neonatal hearing screening in a single Egyptian center. ISRN Pediatr 2013;2013:574937.  Back to cited text no. 7
Korres S, Nikolopoulos TP, Komkotou V, Balatsouras D, Kandiloros D, Constantinou D, et al. Newborn hearing screening: Effectiveness, importance of high-risk factors, and characteristics of infants in the neonatal intensive care unit and well-baby nursery. Otol Neurotol 2005;26:1186-90.  Back to cited text no. 8
Maxon AB, White KR, Vohr BR, Behrens TR. Using transient evoked otoacoustic emissions for neonatal hearing screening. Br J Audiol 1993;27:149-53.  Back to cited text no. 9
Grimes RA. Update on Newborn Hearing Screening. Citing: Health.mo.gov. Available from: . [Last retrieved on 2014 Jun 10].  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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