A Survey of the Knowledge, Attitudes and Practices of Pediatricians in relation to Newborn
Hearing Screening
A Research Proposal
Presented to
The Department of Preventive Medicine
University of the East Ramon Magsaysay Memorial Medical Center
Aurora Blvd., Quezon City
In Partial Fulfilment
Of the Requirements for the
Degree in Doctor of Medicine
By
Alonzo, Cyndi B.
Aldaba, Christine Victoria C.
Almenario, Mark Jester A.
Bato, Charmagne Ross E.
Batoon, Cecille Marie Julienne G.
Bautista, Leila Marie R.
Benito, Jelyn Rose F.
Boncoc, Paul Reginald M.
Borela, Jopet Esther L
Buenaventura, Lee Roi F.
Buenaventura, Nicolo F.
ABSTRACT
OBJECTIVE. Universal newborn hearing screening focuses on providing the earliest
possible diagnosis for infants with permanent hearing loss. The goal is to prevent or
minimize the consequences of sensorineural hearing loss on speech and language
development through timely and effective diagnosis and interventions, thereby
improving their academic and vocational achievements. Pediatricians are in a key
position to educate families about the importance of follow-up care and ensure
appropriate surveillance, if they are well informed. The objective of this study was to
survey the attitudes, practices, and knowledge of pediatric consultants in relation to
newborn hearing screening.
METHODS. A survey was created on the basis of input from focus groups with primary
care physicians. Surveys (n=126) were distributed to all pediatric consultants affiliated
to 17 training hospitals in Quezon City regarding their practices, knowledge, and
attitudes related to universal newborn hearing screening. The response rate was
47.62% (n=60).
RESULTS. Physicians reported a high level of support for universal newborn hearing
screening; 90% of the clinicians deemed it very important to screen all newborns for
hearing loss at birth, while the remaining 10% viewed it as somewhat important.
Although pediatricians reported confidence in talking with parents about screening
results, they indicated a need for further training in order to counsel parents better
after making a diagnosis. Several important discrepancies in the knowledge of the
pediatricians about the seriousness and consequences of hearing loss were identified,
and these represent priorities for education, as based on their relevance to medical
management and parent support.
CONCLUSION. Pediatricians support the efforts of Newborn Hearing Screening and its
procedure. However, a more in-depth awareness about Newborn Hearing Screening
among pediatricians is highly recommended to bridge the knowledge gaps through
primary sources of information and provision of action-oriented resources that aid in
the familiarity not only about Newborn Hearing Screening but also hearing loss itself
in order to put the pediatricians in a better position to support families on
identification of infants with hearing loss and prevention of its consequences.
Keywords: newborn hearing screening, physician knowledge, childhood hearing loss,
sensorineural hearing loss
Abbreviations:
NBHS- Newborn Hearing Screening
SNHL—sensorineural hearing loss
EOAE – evoked otoacoustic emissions
AAP—American Academy of Pediatrics
Introduction
Hearing loss affects approximately 2-4 per
1000 live births infants and has been
estimated to be one of the most common
congenital
anomalies
leading
to
impediment of speech, language and
development if undetected. Its prevalence
has been shown to be greater than that of
most other diseases and syndromes (eg,
phenylketonuria, sickle cell disease)
screened at birth. Furthermore, the
occurrence of hearing loss has been
estimated to be more than twice that of
other screenable newborn disorders
combined.
Universal newborn hearing screening has
become the standard of care throughout
the United States in an effort to provide
early detection and intervention for
infants with permanent hearing loss. In
1993, <5% of newborns were screened for
hearing loss. Today, 93% of newborns are
screened for hearing loss before hospital
discharge, and 39 states in the United
States have universal newborn hearing
screening legislation. (Erenberg et al.,
1999) The expansion of newborn hearing
screening in the past decade has helped
reduce the average age of identification of
infants with permanent childhood hearing
loss, allowing families and professionals to
prevent or minimize the negative impact
of sensorineural hearing loss (SNHL) on
speech and language learning (Vohr et al.,
1998). The overall success of these
efforts, however, depends on the
provision of timely and effective
diagnostic and intervention services.
The Newborn screening program was first
introduced to the Philippines in 1996
which was developed by a group of 24
pediatricians and obstetricians from
around the metropolitan area, which
aimed to establish the incidence of
metabolic conditions and to make
recommendations for the adoption of
newborn screening nationwide.
Currently, the Newborn Screening
Program in the Philippines includes
routine
screening
for
congenital
hypothyroidism,
congenital
adrenal
hyperplasia,
galactosemia,
phenylyketonuria
and
glucose-6phosphate dehydrogenase deficiency
(R.A. 9288) and is available in practicing
health
institutions
which
include
hospitals, lying in clinics and health
centers.
A study conducted by Olusanya et. Al
investigated the initiation and progress of
early detection of infants with hearing
loss in developing countries. The study
showed that in the East Asia Pacific
Region, the Philippines had no
government support for infant hearing
screening, and that it was the only
country in the region which had no
support program for cases of found
hearing loss.
In a study done in 2003 in the Philippine
General Hospital, neonates were screened
for hearing loss using the evoked
otoacoustic emissions ( EOAE), which is a
universally well known and accepted
procedure. During a period of one year,
from March 2000 to March 2001, 301
high-risk neonates and 105 non high-risk
neonates were identified to be at
risk(Quintos, et al. 2003). Although there
are disorders screened in the Newborn
Screening Program implemented by the
government, the screening for the hearing
loss of infants should also be included in
the program.
Thus, it is the aim of this study to
determine the knowledge, attitude and
practices amongst pediatricians from
training hospitals located in Quezon City
in relation to the Newborn hearing
screening.
This has been done by utilizing a
questionnaire determining the proportion
of pediatricians well informed about
NBHS, those with a positive attitude
towards NBHS, and those who routinely
subject their newborn patients to NBHS,
either through referrals or direct
implementation.
Universal newborn hearing screening
focuses on providing the earliest possible
diagnosis for infants with permanent
hearing loss. The main goal of early
identification and intervention programs
is to improve the speech and language
development of infants and children who
are deaf or hard of hearing, thereby
improving their academic and vocational
achievements. Although the need for
successful universal newborn hearing
screening programs cannot be denied, the
legislative support, technology, and
expertise needed to implement such
programs on a national level has only
recently been realized.
Physicians are in a key position to educate
families after hearing screening and to
ensure appropriate follow-up care and
surveillance, particularly for those infants
who fail the newborn hearing screening.
Newborns and parents are seen regularly
by their primary care physicians, and
parents often seek input from their
physician on the infant’s medical and
developmental needs. This provides an
ideal opportunity to promote follow-up,
make appropriate referrals, and support
families. However, this requires that
physicians be knowledgeable about the
implications of hearing screening results
as well as current best practices in the
medical and educational treatment of
infants with permanent hearing loss. This
study will reflect the degree of knowledge
of our pediatricians today regarding
NBHS, provide leverage on what they still
need to know and how they prefer to
learn this new information to further
improve their practice. Such findings is
essential
for
creating
effective
partnerships with the medical home to
meet the needs of families of infants with
newly diagnosed permanent hearing loss.
The survey was limited to a total
of 60 pediatrician respondents, although
we sampled and recruited 126 number of
participants from 9 training hospitals
overall return rate was 47.62% (n=60).
Data analysis was limited to the
descriptive assessment of the knowledge,
attitudes and practices of pediatricians.
The hospitals to which pediatricians are
surveyed, were from training hospitals
located in Quezon City. This study did not
attempt to compare pediatricians coming
from private and government training
hospital. Future studies may cover on
this, as well as to cover more samples
involving other hospitals of Quezon City.
Methodology
Study design and sample size
The research made use of a descriptive
study design which aims to describe the
current
status
of
pediatricians’
knowledge, attitudes and practices with
regards to Newborn Hearing Screening by
having
them
answer
survey
questionnaires. Subjects were acquired
from the training hospitals in Quezon City.
Training hospitals were chosen because
they are the institutions who will produce
the next generation of pediatric
consultants, thus, it would be best to
assess their pediatricians with regards to
their knowledge, attitude and practices in
relation to the aspect of Newborn Hearing
Screening. The minimum sample size for
this study to be relevant was 96.
Description of population
There are a total of 17 training hospitals in
Quezon City (Appendix C). From the 17
hospitals, 9 hospitals were willing to
participate in the study. These include
National Children’s Hospital, United
Doctor’s Medical Hospital, St. Luke’s
Medical Center, De Los Santos Medical
Center, Capitol Medical Center, Dr. Fe del
Mundo Medical Center, UERMMMC I,
World Citi Medical Center and Philippine
Children’s Medical Center.
The survey questionnaires were given to
all the available pediatric consultants
listed to be practicing in the participating
training hospitals in Quezon City as
provided by the Medical Directors, with
no further exclusion and inclusion criteria
such as their sub specialization or number
of years in practice. As long as the
pediatric consultant is affiliated with the
selected hospital, he/she was deemed
eligible to participate in the study.
Description of the survey tool
The survey tool, which is the
questionnaire, was a modified survey
form from the study by Moeller, et al. of
the American Academy of Pediatrics who
conducted a study to gather the
knowledge, attitude and practices of
primary care physicians in relation to
NBHS in Puerto Rico in 2006. Their
questionnaire, which was composed of 22
questions, was reduced to 19. Question
18 (How helpful would the following types
of materials be to you in your practice?)
and 19 (How frequent do you use the
internet to access information about
medical topics?) of the original
questionnaire were removed because of
their similarity to question 15, which asks
about the respondent’s primary source of
information about newborn hearing
screening. Question 20 (Please list any
professional medical organizations that
have published policy statements about
newborn hearing screening) was also
taken out because NBHS has not been
mandated by the government or any
professional medical organization in the
Philippines.
After the modifications, the survey was
pre-tested for length and clarity among 6
pediatric residents in UERMMMC I. After
completion, they were asked for
comments regarding the questionnaire’s
structure and contents. Comments
regarding the length of the survey form,
which at that time consisted of three
pages, were made. Data collection for the
pre-test was done approximately 20
minutes after distribution. In response to
pre-testing, the number of spaces
between questions and the font sizes
were reduced in order to make it appear
shorter. The survey form was thus
reduced to a two- page, one paper form.
The estimated time to fill up the
questionnaire, which was 15 minutes, was
also noted on the first part of the survey
form so as to give the respondents an idea
on how much time it will take to fill up the
survey form.
Data Distribution and Collection
In each hospital, a letter of consent
addressed to the Medical Director was
given before handing out the survey
forms to every available pediatrician
affiliated to their institution. A total of
126 questionnaires were distributed,
surpassing the minimum sample size. A
copy of the approved letter from the
Medical Director was attached to each
questionnaire
distributed
to
the
pediatricians of each hospital. For
consultants who weren’t available to
answer the survey at the time of
distribution, survey forms were left with
their secretary and their contact numbers
were noted. They were followed-up every
once in a while as to when the survey
forms can be collected. The number of
collected questionnaires was recorded for
each hospital.
Statistical Analysis
The responses of the pediatricians for
each question were tabulated and
expressed in proportional percentages.
Data and Results
Demographics
Of the 126 questionnaires distributed to
all pediatricians, 60 (47.62%) surveys were
returned; these responses form the basis
for analysis. Demographic results are
shown in Table 1. The samples were well
distributed by gender, years of practice
and year of birth.
On average, respondents reported that
68.48% of their practice was composed of
children less than 5 years of age. The
same respondents were asked to
approximate the number of children with
hearing loss that they had seen in the past
3 years. 58.33% reported seeing an
average of 6.62 children with hearing loss
while 23.33% (n=13) had no known
patients with hearing loss. The remaining
18.33% had no answer. Of those who
have seen a patient with a hearing loss,
the respondents’ average years of
practice was 9.48 years while those who
did not receive patients with hearing loss
had an average of 13.14 years of practice.
Attitudes about Newborn Hearing
Screening
Newborn Hearing Screening has raised
concerns about its cost, the impact on
parental anxiety and accuracy of such
program. This section reports the current
attitudes of pediatricians about Newborn
Hearing Screening.
When the pediatricians were asked about
the importance of newborn hearing
screening, 90% of the clinicians deemed it
very important, while the remaining 10%
viewed it as somewhat important (Figure
1, see appendix).
When they were asked whether NBHS
causes anxiety to the parents, 57% states
that it does not while 40% say that this is
so. The remaining 3% were unsure.
The respondents were also asked about
their confidence in explaining the
newborn hearing screening process to
parents who have questions about the
infant’s results. 58% of the respondents
were very confident while 35% are
somewhat confident. The remaining 7%
said they are not confident.
Current Practices Related to Newborn
Hearing Screening
The respondents were asked to whom
they routinely refer a child with confirmed
permanent hearing loss (Figure 2, see
appendix). Notably, 92% of respondents
answered that they would refer the family
to an otolaryngologist, and 8% said that
they would refer to both otolaryngologist
and neurologist. Furthermore, none
responded that they will refer to
geneticist. The Joint Committee on Infant
Hearing Screening for children with
congenital hearing loss (Moeller, et al.,
2006) recommends referals to geneticists
for genetic evaluation which could have
avoided unecessary and costly clinical
tests, allowing one to anticipate potential
health problems and therapeutic options.
When they were asked for how many
Newborn Hearing Screening results they
receive for the past year, 62% indicated
that they receive <50%. While 27%,
receive > 50%, and 12% have no answer.
Percieved Knowledge Needs
Newborn Hearing Screening has not been
implemented in all hospitals by the
government. When the pediatricians
were asked whether their hospital have
an Early Hearing Detection and
Intervention Program, 59% (35/60) of the
respondents replied that their hospitals
do practice the program, while 23%
(14/60) replied that their hospital do not
have such program, 10% (6/60) were
unsure, and the remaining 8% (5/60) had
no answer. Of the 59% (35/60) who said
that their hospital has a newborn hearing
screening program, 63% (22/35) does not
really have NBHS in their hospital, while
37% (13/35) of the respondents do have
NBHS in their hospital. Of those who
answered that their hospital has no
newborn hearing screening program, 64%
(9/14) has an NBHS program in their
hospital, while the remaining 36% (5/14)
does not. In summary, only 30% (18/60)
correctly answered the question whether
or not their hospital has a newborn
hearing screening program. 52% (31/60)
answered the question incorrectly, and
the remaining 18% (11/60) either did not
answer the question or was unsure about
it. The information of whether or not the
hospital has a newborn hearing screening
program was confirmed through the
Department
of
Health
Advisory
Committee on Newborn Screening of
2009.
Our Pediatricians do not frequently
encounter children with congenital
hearing loss in their practice. However,
they have expressed strong interest in
guidelines and information that would
provide to be helpful to the families of
this children (Moeller, et al., 2006). As
such when they are asked whether their
training in medical school meets the
needs of infants with permanent hearing
loss (Figure 3, see appendix), 28% of the
respondents consider their training as
adequate. On the other hand 55% judge
their training as inadequate regarding this
matter while 14% were unsure and 3%
had no response.
The pediatricians were asked to cite their
primary source of information with
regards to NBHS. Majority of their sources
are from educational meetings like
lectures, seminars, and conventions.
(Figure 4.)
The Department of Health (DOH) has set a
maximum rate of P550 for the newborn
hearing screening. Aproximate cost of
Newborn Hearing Screening in Philippine
hospitals like in St. Luke’s Medical Center
is P400.00. When the respondents were
asked regarding how much will it cost for
a NBHS, 37% of the pediatricians
responded with an estimated cost beyond
P550 while 43% (26/60) estimated the
cost to be below P550.00, and the
remaining 20% did not have an answer.
With regards to the cost of the Newborn
Hearing Screening, 88% of the
pediatricians claim that NBHS is worth its
cost, while 5% says that it is not. On the
other hand, the remaining 7% are unsure.
Of the 43% (26/60) who had a correct
estimate of the NBHS screening, 76.92%
(20/26) said that it was worth it, 11.53%
(3/26) said they were unsure about it
while another 11.53% (3/26) said it was
not worth it.
In testing the knowledge of these
pediatricians, specific questions were
asked regarding specific ages when tests,
follow-ups and interventions should be
done. Table 2 summarizes the responses
of the pediatricians regarding these
questions and the entries marked with “ *
”indicates the percentage of responses
consistent with the guidelines.
The
Guidelines for Pediatric Medical Home
Providers
(American Academy of
Pediatrics, 2002). The 1-3-6 Guidelines
recommends, (1) completed newborn
hearing screening before 1 month of age,
(2) diagnosis of hearing loss and hearing
aid fitting before 3 months, and (3)
enrollment in early intervention before 6
months. 32% were able to respond
correctly that those newborn who did not
pass the hearing screening should recieve
additional testing at ≤ 1 month age, 50%
of the respondents answered > 1 month,
3% said as soon as possible, 2% at < 1 year
of age, and the remaining 13 % were
unknown. Regarding the question on the
definite diagnosis of newborn hearing
loss, 22 % had the correct response that
the diagnosis should be done before 3
months, while 62 % answered > 3 months,
1% said before 1 year old, 3% said as soon
as possible, and 12 % were unknown. The
earliest age at which a child can begin
wearing hearing aids should be done
before 3 months, only 7% of the
respondents were able to answer
correctlty, while 72% answered > 3
months, 3% answered as soon as possible,
and the remaining 18% were unknown.
The respondesnts were also asked to
estimate the appropriate age on when to
enroll a child with permanent hearing loss
to early intervention services, 17 % were
able to respond correctly that it should be
done before 6 months, 38% said its > 6
months, 1 % answered before 1 year of
age, 12% had no answer and 32% said it
should be done ASAP (Table 4).
The knowledge of the pediatricians
regarding the causative conditions was
assessed with multiple-choice question,
“Which of the following conditions put a
child at risk for permanent late-onset
hearing loss?” Correct response in this
question would be meningitis, > 48 hours
NICU stay, history of CMV, congenital
syphilis and family history of childhood
hearing loss. 3% of the respondents were
able to respond correctly, 92% have an
incorrect response, and 5% had no
answer. Table 5 summarizes the
frequency of their responses.
When the pediatricians were asked about
the determining audiologic characteristics
that qualify an infant for cochlear
implantation, among the total number of
respondents,
7%
(4/60)
correctly
answered profound bilateral hearing loss,
70% (42/60) had incorrect answers, 17%
(10/60) had no answer and 6% (4/60)
were unsure. Thus, when the physicians
were asked wether they believe there is a
need for the each of the following
components related to hearing loss (Table
9).
Finally, the pediatricians were asked to
rate their confidence in talking with
parents regarding 5 specific topics (Table
4); 45% of the respondents are very
confident, 53% are somewhat confident,
and 2% are not confident. 18% are very
confident in talking about the use of sign
language versus auditory or oral
communication. 52% and 30% are
somewhat confident and not confident,
respectively, with this aspect. With
regards to talking to parents about
consequences of unilateral or mild
hearing loss, 29% are very confident, 63%
are somewhat confident, and 8% are not
confident. Moreover, with talking to
parents about bilateral hearing loss of
moderate to profound degrees, 27% are
confident, 62% are somewhat confident,
10% are not confident, and 1% answered
they are unsure of their confidence
regarding this matter. In relating which
infants may be candidates for cochlear
implants, 15% are very confident, 43% are
somewhat confident, 40% are not
confident, and 2% are unsure of their
confidence regarding this matter (Table
7).
Discussion
Our study shows that most pediatricians
support the efforts for Newborn Hearing
Screening – 90% deemed this very
important. The 10% think that it is
somewhat important and this may
suggest a need for clearer understanding
of the possible consequences of hearing
loss on language development and
learning.
When asked whether training in medical
school meets the needs of infants with
permanent hearing loss, only 28% of the
respondents consider their training as
adequate. Majority of their sources of
information about newborn hearing
screening are educational meetings like
lectures, seminars, and conventions. This
is important in that recent lectures are
more updated and together with the
other resources such as journals, etc., are
more readily accessible. Accessibility of
such information is very valuable
especially when most of our pediatricians
do not frequently encounter or detect
children with congenital hearing loss in
their practice.
Better understanding of newborn hearing
screening and its advantages may improve
the confidence of physicians in explaining
the need and the process involved in the
screening to parents. Our results showed
that majority of pediatricians (62%)
receive <50% of Newborn Hearing
Screening results. This may suggest
parents’ lack of knowledge of the
importance of screening their babies for
hearing loss so as to avoid life-long
complications. The pediatricians also
reported the need for further training in
order to counsel parents better after
making a diagnosis. 7% of our
respondents answered that they were not
at all confident about this.
When asked if the screening causes added
anxiety to parents, majority (57%) stated
that it does not. However, a study by
Young and Tattersall (2005) showed that
it is more difficult to predict parents’
responses to failed or inconclusive
screening results, which requires further
screening. The study demonstrated the
importance of a reassuring screening
manner and this supports the need for
training mentioned above.
At least 50% of infants with congenital
hearing loss have a genetic cause,
according to Nance (2003). Therefore, our
results stating that none of the
respondents would refer to a geneticist
after a confirmed permanent hearing loss
suggest that there is a lack of
understanding of the genetic issues
associated with this. This understanding
may also help in identifying secondary
medical needs or disabilities. Also, a study
performed by Nikolopoulos and associates
(2006) indicated that approximately 4060% of deaf children also have ophthalmic
problems, pointing to the need for
immediate screening for ophthalmic
problems and specialized ophthalmic
examination once the diagnosis of
deafness is confirmed. Visual acuity
problems are also 2-3 times more
prevalent in children with SNHL than in
typically developing children. This
suggests
a
need
for
ongoing
developmental surveillance and regular
ophthalmologic evaluations.
Most of the pediatricians who responded
know the specific conditions that would
put a child at risk of late-onset NHL, which
includes meningitis, >48hr NICU stay,
history of CMV, congenital syphilis, and
family history of childhood hearing loss.
Because newborn hearing screening has
not been mandated by the government or
any professional medical organization in
the Philippines, it has not been
implemented in all hospitals in the
government. When asked whether their
hospital have an Early Hearing Detection
and Intervention Program, only 30%
answered the question correctly. It
suggests that only a few pediatricians
practice newborn hearing screening, and
only a few are aware as to where the
screening can be done. Hospitals which
has a newborn hearing screening program
should provide a more efficient and
aggressive promotion of their program.
Proper dissemination of information, with
regards to screening, is a must in order for
it to reach a wider population and
produce more NBHS-aware pediatricians
which in turn can help in informing the
public of its importance.
Price may be one of the major reasons
why parents hesitate on having their
babies undergo newborn hearing
screening. Because parents are not part of
our study, this speculation cannot be
confirmed. As mentioned in the Results,
the Department of Health has set a
maximum rate of P550 for the newborn
hearing screening, and the approximate
price among Philippine hospitals is P400.
However, some of the pediatricians were
also unsure of the pricing and 37% even
estimated the cost to be beyond P550.
This may cause parents to assume that
the screening is more expensive than it
really is and may contribute to the low
percentage of babies undergoing hearing
screening.
When asked to estimate the appropriate
age on when to enroll a child with
permanent hearing loss to early
intervention services, only 17% were able
to respond correctly, as seen in table 4.
Results revealed that more emphasis
should be placed on educating
pediatricians about when a child can
begin wearing hearing aids and also the
proper age for enrollment in early
intervention services.
When faced with a diagnosis of
permanent hearing loss, the pediatricians
perceived 2 areas which were particularly
challenging: (1) cochlear implants and (2)
communication methods. It is important
to know that not all children with hearing
loss are candidates for cochlear implants.
Also, pediatricians should be aware of the
complexity of the decision-making process
for the parents, as the technology in
pediatric cochlear implantation is
changing rapidly. A more informed and
updated pediatrician with regards to the
current practices in newborn hearing
screening is a must in order to provide
efficient screening.
In the topic of communication methods, it
is essential that families are well informed
about all types of options as soon as
possible after the diagnosis of permanent
hearing loss is made to avoid delay in the
child’s
development.
Information
regarding
the
advantages
and
disadvantages of each option as well as its
possible future complications should be
part of the early intervention program.
Limitations and Recommendations
The study population was limited to the
pediatric consultants practicing in the
training hospitals within Quezon City.
Thus, a larger and more randomized,
possibly nationwide, hospital sampling is
recommended to better reflect the
current status of our pediatricians’
knowledge, attidues and practices about
newborn hearing screening. Also, it is
notable that out of the 126 survey forms
distributed, only 60 were retrieved and
some still had incomplete data. This was a
result of not having a dedicated surveyor
who would really wait for each and every
pediatrician to answer the survey form
up-front. Leaving the survey forms to the
consultant’s secretary also negates the
possibility of properly orienting the
pediatric consultant about the importance
of the study before he/she answers the
survey.
Ensuring a properly filled up survery form
can further increase the significance of
the study. Thus, improvement of the
methods at which data can be more
efficiently distributed and collected is
imperative in order to increase the yields
of the data collected and have a more
significant sample.
The researchers would also like to
recommend that questions regarding the
local guidelines for Newborn Hearing
screening tests in the survey forms to
further assess the knowledge of
practitioners for the newborn hearing
screening tests locally.
Questions
regarding the S.B. 2390 (AN ACT
ESTABLISHING A UNIVERSAL NEWBORN
HEARINGSCREENING PROGRAM FOR THE
PREVENTION, EARLY DIAGNOSIS AND
INTERVENTION OF HEARING LOSS
AMONG CHILDREN) would also give a
wider scope of area of knowledge to test.
Conclusion
On the basis of the results of this survey,
we have made the following conclusions.
There is evidence that Pediatricians
support the efforts of Newborn Hearing
Screening and its procedure. On the
other hand, the down side of this is that
there were still discrepancies in the
knowledge of the pediatricians about the
seriousness and consequences of hearing
loss on language development and
learning. These discrepancies on the facts
of hearing loss which includes the risk
factors for late-onset hearing loss, on
when one should be subjected to the
screening and on the issues of medical
management, such as knowing when
interventions should should take place,
and when and where to refer infants for
follow-up procedures, and for who are
candidates for cochlear implants.
We recommend for a more in depth
awareness about Newborn Hearing
Screening among Pediatricians. These
knowledge gaps should be addressed
through the primary sources of
information regarding NBHS. Majority of
the
pediatricians
resources
are
educational meetings which involves
lectures, seminars and conventions.
These may serve as venues for updates
and discussions about Newborn Hearing
Screening; altogether with the journals,
which are easily accessible for such
information to aid in the familiarity not
only about Newborn hearing screening,
but also hearing loss itself in order to put
the pediatricians in a better position to
support families on identification of
infants with hearing loss and prevention
of its consequences.
Literature Cited
Erenberg A, Lemons J, Sia C, Trunkel D,
Ziring P. Newborn and infant
hearing loss: detection and
intervention.American Academy
of Pediatrics. Task Force on
Newborn and Infant Hearing,
1998-
1999. Pediatrics. Feb 1999;103(2):
527-30.
Vohr BR, Carty LM, Moore PE, Letourneau
K. The Rhode Island Hearing
Assessment Program: experience
with statewide hearing screening
(1993-1996). J
Pediatr. Sep 1998;133(3):353-7.
Quintos, M.R., Isleta P.F., Chiong C.C.,
Abes G.T. 2003. Newborn hearing
screening using the evoked
otoacoustic
emission:
The
Philippine
General
Hospital
experience. Southeast Asian J
Trop Med Public Health. 34 Suppl
3:231-3.
Olusanya BO, Ruben RJ, Parving A:
Reducing
the
burden
of
communication disorders in the
developing world: an opportunity
for the millennium development
project. JAMA 2006, 296:441-444.
Yoshinaga-Itano C, Sedey AL, Coulter DK,
Mehl AL: Language of early and
later-identified children with
hearing loss. Pediatrics 1998,
102:1161-171.
Smith A, Mathers C: Epidemiology of
infection as a cause of hearing
loss. Infection and Hearing
Impairment 2006, 31-66.]
American Academy of Pediatrics (1999).
Newborn and Infant Hearing Loss:
Detection and Intervention. Task
Force on Newborn and Infant
Hearing. Pediatrics, 103, 527-530.
JCIH. Year 2000 position statement:
principles and guidelines for early
hearing
detection
and
intervention programs. Joint
Committee on Infant Hearing,
American Academy of Audiology,
American Academy of Pediatrics,
American
Speech-Language-
Hearing Association, and Directors
of Speech and Hearing Programs
in State Health and Welfare
Agencies.Pediatrics. Oct 2000;106
(4):798-817.
Moeller, M., White, K., Shisler, L. 2006.
Primary
Care
Physicians’
Knowledge, Attitude and Practices
related to Newborn Hearing
Screening. Pediatrics Official
Journal of the American Academy
of Pediatrics. 118;1357-1370.
http://www.pediatrics.org/cgi/co
ntent/full/118/4/1357 Retrieved
on: August 16, 2008.
Appendix A
Tables and Figures
Tables
Characteristics
n(%) N=60
Physician Gender
Male
14 (23%)
Female
39 (65%)
Unknown
7 (12%)
Experience with Pediatric Population
0-5 years
15 (25%)
6-10 years
11 (18.33%)
11-15 years
8 (13.33%)
15 onwards
18 (30%)
Year of Birth
1950-1960
18 (30%)
1961-1970
12 (20%)
1971-1980
18 (30%)
1981-1990
3 (5%)
Unknown
9 (15%)
Table 1. Population
0-5 years
6-10 years
11-15 years
15 onwards
Unknown
With
hearing loss
11 (73.33%)
8 (72.72%)
5 (62.5%)
8 (44.44%)
4 (50%)
Without
hearing loss
2 (13.33%)
2 (18.18%)
2 (25%)
6 (33.33%)
1 (12.5%)
No
Response
2 (13.33%)
1 (9.1%)
1 (12.5%)
4 (22.22%)
3 (37.5%)
Table 2. Respondents’ number of years in practice and their
encounter with patients with hearing loss
0-5 years
6-10 years
11-15 years
15 onwards
Unknown
> 50%
Screening
Results
2
4
2
5
2
<50%
Screening
Results
12
6
6
10
4
No
Response
1
1
0
3
2
Table 3. Summary of the respondents years of practice with
their received NBHS results
a. NB who did not pass the hearing
screening should receive additional
testing
b. A child can receive a definite
diagnosis of NBHL
< 1 mo
*33
1-3 mos
15
4-6 mos
22
7-9 mos
2
10-11 mos
2
> 12 mos
7
> 24 mos
3
*17
*5
22
2
2
20
18
c. A child can begin wearing hearing aids
d. A child with permanent hearing loss
should be referred to early intervention
*3
*5
*3
*5
7
*7
0
2
0
2
38
17
53
18
* Responses that are consistent with the Guidelines for Pediatric Home Providers (www.medicalhomeinfo.org)
Table 4. Physician’s Estimates of Ages at which Follow-up Procedures should be Conducted (%)
Meningitis*
93%
>48hr NICU stay*
50%
History of Cytomegalovirus*
87%
Congenital Syphillis*
67%
Family Hx of Childhood hearing loss*
83%
Mother >40 at delivery
38%
Congenital heart defect
37%
Frequent Colds
48%
Hypotonia
33%
*Correct response;
Table 5. Percentage of pediatricians who indicated specific
conditions that would put a child at Risk of Late-Onset NHL
Infant with profound bilateral hearing loss*
Infant with bilateral mild-moderate hearing loss
Infant with unilateral mild-moderate hearing loss
Infant with unilateral profound hearing loss
Unsure
67% (40/60)
48% (29/60)
25% (15/60)
43% (26/60)
6% (4/60)
*the only correct response; percentage values reflect those who gave that answer over the total population
Table 6. Percentage from the total number of respondents who Indicated conditions of hearing loss that will
make an infant a candidate for cochlear implants
Very
Confident
(%)
45
Somewhat
Confident
(%)
53
Not
Confident
(%)
2
Unsure
(%)
b. use of sign language vs. auditory or communication
18
52
30
0
c. consequences of unilateral or mild hearing loss
29
63
8
0
d. consequences of bilateral hearing loss
27
62
10
1
e. which infants are candidates for cochlear implants
15
43
40
2
a. causes of hearing loss
Table 7. Physicians who are confident in talking to parents of child with permanent hearing loss
Adequate
Inadequate
Unsure
No answer
Number
17
33
8
2
Percentage
28%
55%
13%
3%
Table 8. Adequacy of Pediatric Training toward Infant Permanent Hearing Loss
0
Topic
Methods of screening
Protocol for follow-up screening
Methods of screening children 0-5 during well-child visits
Guidelines for informing families about screening results
Impact of different degrees of hearing loss on infant language
Early intervention options
Guidelines for screening late onset hearing loss
Useful contacts for more information
Patient education resources
Hearing aids and cochlear implants
Genetics and hearing loss
Great Need
50 (83%)
46 (77%)
50 (83%)
49 (82%)
51 (85%)
56 (93%)
53 (88%)
49 (82%)
49 (82%)
41 (68%)
42 (70%)
Somewhat of a Need
10 (17%)
14 (23%)
10 (17%)
9 (15%)
9 (15%)
4 (7%)
7 (12%)
11 (18%)
11 (18%)
19 (32%)
18 (30%)
Table 9. Pediatrician’s Perceptions About the Need for Training and/or Resources on Various Topics
Figures
Figure 1. Importance of NBHS (Question 5)
Not Needed
2 (3%)
1 (2%)
8%
ENT only
Both ENT
and
Neurologist
92%
Figure 2. Referals (Question 4)
Unsure
3%
Yes
40%
No
No
57%
Figure 3. NBHS causes anxiety to parents (Question 6)
Yes
Unsure
Figure 4. Primary sources for NBHS (Question 17)
7%
Very
confident
35%
58%
Somewhat
confident
Not
confident
Figure 5. Explain NBHS process (Question 9)
18%
30%
Correct
Incorrect
No answer
52%
Figure 6. Asked if their hospital has NBHS (Question 18)
Appendix B
Modified Questionnaire
Newborn and Infant Hearing Screening Program
We need your help to evaluate the present state of newborn hearing screening
programs in our country. Please take 15 minutes to tell us about your feelings and
experiences. Your response will be completely confidential and would possibly be
used to improve services for infants and young children with hearing loss. Your
participation is greatly appreciated.
Q1. Approximately what percentage of your practice is comprised of patients 0-5 years of
age?__________
Q2.Approximately how many children with permanent hearing loss have you had in your
practice during the past three years?__________
Q3.For newborns in your practice in year 2008, estimate the percentage for which you
received newborn hearing screening results.__________
Q4.To whom you would routinely refer the family of a child with a confirmed hearing loss?
___Otorhinolaryngologist ___Neurologist ___Other pediatricians
___Others (specify)
Q5. How important do you think it is to screen all newborns for permanent hearing loss?
__Very important
__Somewhat important
__Somewhat unimportant
__Very unimportant
__Unsure
Q6. Do you think hearing screening causes parents excessive anxiety and/or concern?
__Yes
__No
__Unsure
Q7. Estimate the approximate cost per baby for newborn hearing screening in the
Philippines.
_________(in pesos)
Q8. Do you believe that the universal newborn hearing screening is worth what it costs?
__Yes
__No
__Unsure
Q9. How confident are you that you could explain the newborn hearing screening process to
parents who have questions about the infant’s results?
__Very confident __Somewhat confident
__Not confident
Q10. How confident are you in talking to parents of a child with permanent hearing loss
about…
Very
Somewhat
Not
confident
confident
confident
a. Causes of hearing loss?-----------------------------------------------------b. Use of sign language vs. auditory/oral communication?-----------c. Consequences of unilateral or mild hearing loss?--------------------d. Consequences of bilateral hearing loss of moderate
to profound degrees?---------------------------------------------------------
e. Which infants may be candidates for cochlear implants?----------
Q11. Did your training prepare you adequately to meet the needs of infants with permanent
hearing loss?
__Yes
__No
__Unsure
Q12. For each item below, please indicate the level of need you believe physicians have for
that type of information related to permanent hearing loss in children.
Great need
Somewhat
Not needed
of a need
a. Methods for screening---------------------------------------------------------b. Protocol for follow-up screening--------------------------------------------c. Methods of screening children 0-5 during well-child visits-----------d. Guidelines for informing families about screening results-----------e. Impact of different degrees of hearing loss on infant language-----f. Early intervention options-----------------------------------------------------g. Guidelines for screening late onset hearing loss------------------------h. Useful contacts for more information-------------------------------------i. Patient education resources--------------------------------------------------j. Hearing aids and cochlear implants-----------------------------------------k. Genetics and hearing loss-----------------------------------------------------l. Other (describe)___________________________________
Q13. What is the best estimate of the earliest age at which: (Enter age estimate)
a. A newborn not passing the hearing screening should receive additional testing:__________
b. A child can be definitely diagnosed as having a permanent hearing loss:__________
c. A child can begin wearing hearing aids:__________
d. A child with permanent hearing loss should be referred to early intervention services:__________
Q14. Which of the following conditions put a child at risk for permanent late onset of
hearing loss? (check all that apply)
__meningitis
__mother over age 40
__frequent colds __congenital heart disease
__hypotonia
__history of cytomegalovirus (CMV)
__>48 hours in NICU
__congenital syphilis
__cleft palate
__family history of childhood hearing loss
Q15. Which of the following infants may be a candidate for cochlear implants? (check all
that apply)
__infant with bilateral mild-moderate hearing loss
__infant with profound bilateral hearing loss
__infant with unilateral mild-moderate hearing loss
__infant with unilateral profound hearing loss
__unsure
Q16. How informed do you think you are about issues related to permanent hearing loss?
Very
Somewhat
Somewhat
Uninformed
Informed
a. The incidence of hearing loss among newborns/infants----b. Procedures for newborn/infant hearing screening-----------c. Consequences of unilateral/mild hearing loss-----------------d. Consequences of bilateral severe or profound hearing losse. Medical interventions (e.g. cochlear implants)------------------
Informed
Uninformed
f. Audiological interventions (e.g. hearing aids)-------------------g. Educational interventions for hearing loss----------------------h. Genetics of hearing loss----------------------------------------------
Q17. What has been your primary source of information about newborn hearing screening?
___________________________________________________________________________________
_
Q18. Does your hospital have an Early Hearing Detection and Intervention Program?
__Yes
__No
__Unsure
Q19. Please list below any other concerns you have about newborn hearing screening,
diagnosis, and intervention.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_________________________________________________________
Please tell us about yourself:
Type of practice:
__Pediatrician
__OB/GYN
__Family Practice Physician
__Neonatologist
__Otolaryngologist
__Other (specify)__________
Practice setting: (where you spend most of your time)
__Hospital setting
__Medical school or parent university
__Other (specify)__________
Gender:
__Male __Female
Year of birth:________
Years of practice with pediatric population:__________
Thank
you!
Appendix C
Training Hospitals in Quezon City
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
AFP Medical Center
Capitol Medical Center
Dr. Fe del Mundo Medical Center
De Los Santos Medical Center
FEU – NRMF
East Avenue Medical Center
Jesus Delgado General Hospital
National Children’s Hospital
Philippine Children’s Medical Center
Philippine Heart Center
Quezon City General Hospital
Quirino Memorial Medical Center
St. Luke’s Medical Center
UERMMMC
United Doctor’s Hospital
Veteran’s Memorial Medical Center
World Citi Medical Center