Ear Care for the Most Vulnerable Infants Hearing screening and intervention prove particularly challenging with NICU babies. Extra vigilance and parent support are required. All Ears on Audiology
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All Ears on Audiology  |   August 01, 2017
Ear Care for the Most Vulnerable Infants
Author Notes
  • Andrew P. McGrath, AuD, CCC-A, is director of audiology at Women & Infants Hospital in Providence, Rhode Island, and a clinical instructor of pediatrics at the Brown University Medical School. amcgrath@wihri.org
    Andrew P. McGrath, AuD, CCC-A, is director of audiology at Women & Infants Hospital in Providence, Rhode Island, and a clinical instructor of pediatrics at the Brown University Medical School. amcgrath@wihri.org×
  • Betty R. Vohr, MD, is medical director of the Neonatal Follow-up Clinic at Women & Infants Hospital in Providence, Rhode Island, medical director of the Rhode Island Hearing Assessment Program, and a professor of pediatrics at the Brown University Medical School. bvohr@wihri.org
    Betty R. Vohr, MD, is medical director of the Neonatal Follow-up Clinic at Women & Infants Hospital in Providence, Rhode Island, medical director of the Rhode Island Hearing Assessment Program, and a professor of pediatrics at the Brown University Medical School. bvohr@wihri.org×
Article Information
Hearing Disorders / Special Populations / Early Identification & Intervention / Healthcare Settings / All Ears on Audiology
All Ears on Audiology   |   August 01, 2017
Ear Care for the Most Vulnerable Infants
The ASHA Leader, August 2017, Vol. 22, 20-22. doi:10.1044/leader.AEA.22082017.20
The ASHA Leader, August 2017, Vol. 22, 20-22. doi:10.1044/leader.AEA.22082017.20
Infants’ experiences in the neonatal intensive care unit (NICU) are highly variable, depending on the complexity of their cases and degree of prematurity. Those with more severe or chronic medical and neurodevelopmental conditions present particular challenges to the audiology team.
Complications of their conditions can delay hearing screening, and the medical equipment helping to support them may interfere with the screening itself. The NICU environment can also be noisy for this vulnerable population. Yet another challenge is the emotional fragility of these infants’ parents.
Although audiology isn’t part of the primary NICU care team, every infant receives a hearing screen, and any infant with a failed screen receives diagnostic audiological testing. This means the hearing-screening staff and audiology team play an important role, particularly after a baby does not pass the hearing screening. Audiologists can also play a key role in the development, implementation and oversight of the newborn hearing program (see more on newborn hearing screening on the ASHA Practice Portal). In these cases, the audiologist serves as the primary source of hearing-related information for the parents and the medical team.
To address the particular challenges of the NICU population, audiologists need to communicate and work closely with the NICU staff as soon as it’s appropriate, consider the effects of medical equipment, communicate with parents with a great deal of sensitivity, and work at coordinating discharge planning and follow-up care with the infant’s parents and other providers.

Complications of infants’ conditions can delay hearing screening, and the medical equipment helping to support them may interfere with the screening itself.

NICU population
Infants admitted to the NICU can be as small as 500 to 750 grams and born as early as 23 to 25 weeks’ gestation. Their medical conditions can be relatively mild, such as feeding and growth problems, or comparatively severe, such as extreme prematurity, perinatal asphyxia, congenital malformations or syndromes, and severe infections. The primary NICU care team includes neonatology, nursing, respiratory therapy, social work and case management.
In addition to newborn hearing screening, audiology services in the NICU may include a comprehensive diagnostic audiologic evaluation prior to discharge. Hearing loss is one of the most common congenital health conditions in the United States. Each year, approximately 6,000 newborns—of the nearly 4 million births in the U.S.—are diagnosed with permanent hearing loss, and premature infants are 50 percent more likely than full-term infants to develop hearing loss, according to the Centers for Disease Control and Prevention (bit.ly/CDC-infantHL). NICU graduates frequently require audiology follow-up in the outpatient setting, either for management of diagnosed hearing loss or for monitoring due to risk factors associated with late-onset hearing loss.
Early Hearing Detection and Intervention (EHDI) program guidelines for newborn hearing screening (from the American Academy of Pediatrics, AAP) recommend newborn hearing screening in the first month of life, diagnostic testing (when indicated) by age 3 months, and hearing loss management and entry into early intervention services (when necessary) by age 6 months. Also, the Joint Committee on Infant Hearing (JCIH) recommends screening NICU infants using automated auditory brainstem response to ensure assessment of the entire auditory system.
We typically don’t conduct newborn hearing screening before the infant is 34 weeks gestational age because of immaturity within the auditory nervous system. In fact, screening is complicated even at this age by continued immaturity or by chronic medical conditions. In response to a failed hearing screen with automated auditory brainstem response (AABR), diagnostic procedures include the auditory brainstem response, otoacoustic emissions and middle-ear immittance tests, as appropriate.

If a permanent hearing loss is diagnosed, it is almost always unexpected and likely devastating news for parents. Proper support and concern for these parents is vital.

Unique NICU challenges
The infant’s medical condition may complicate hearing screening and diagnostic evaluation. This is often due to medical equipment, such as an incubator, mechanical ventilator, nasogastric feeding pump, and various monitors and bioelectric leads. Such equipment emits a strong electromagnetic field, which may interfere with elecrophysiological measurements.
The equipment also contributes significant levels of noise. Noise is frequently a problem in the NICU, with noise levels regularly reaching 120 dB (see sources). The AAP recommends that NICU noise levels not exceed 45 dB. However, this recommendation is achieved only 5.5 percent of the time (see sources).
The audiologist should be aware of noise levels in the room and control this as much as possible during hearing screening and diagnostic testing. If possible, an isolated room away from the bulk of the noise should be considered, and any noise that can be eliminated, even temporarily, should be. Audiologic intervention, when necessary, may also be complicated by initial delays in the screening/diagnostic process, prolonged stay in the NICU, and by more pressing medical challenges.
One important consideration when working with NICU babies is the emotional fragility of the parents. Parents of NICU babies often endure an emotional roller coaster that can last weeks and sometimes many months, losing sleep while watching as their new baby is whisked from the delivery room into intensive care. Add to this the fact that we often conduct hearing screening and diagnostic audiological testing late in an infant’s NICU stay, after initial health issues have stabilized.
If, at this point, a permanent hearing loss is diagnosed, it is almost always unexpected and likely devastating news for parents (see sources). The emotional toll can be overwhelming, and the proper support and concern for these parents is vital. The audiologist is central in ensuring proper delivery of the diagnosis, prognosis and expected management of the hearing loss. The information is best presented by a team of providers, and the audiologist should be cautious not to overwhelm the parents with information at this first discussion. Remember that many parents are completely unfamiliar with hearing loss terminology, so it helps to be available for follow-up a day or two after the initial conversation.
Treatment essentials
As with all cases of pediatric hearing loss, early and accurate diagnosis and rapid, appropriate management and intervention are key (find related resources at EHDI-PALS.org). This is perhaps even more crucial in cases of NICU infants facing other, often severe, physical or developmental issues, and a possibly delayed hearing loss diagnosis. In these cases, it may be necessary to consult with otolaryngology, genetics and developmental pediatrics.
Also key in these cases is ongoing emotional support of parents, who are responsible for coordinating a slew of medical appointments related to their child’s fragile health. Communicating diagnostic information with the primary care pediatrician upon discharge is also critical. With coordinated patient-centered care, NICU infants with all degrees of hearing loss will receive the services needed to address unique challenges and optimize their outcomes.
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August 2017
Volume 22, Issue 8