June 16, 2024

By Dr Suneela Garg, Dr K Madan Gopal & Dr Arvind Garg

To our valued readers, this article continues and expands our ongoing series dedicated to exploring the critical issues surrounding auditory health. In our previous instalments, we delved into noise-induced hearing loss, its impact on early childhood development, and the significant strides made in diagnostic and intervention strategies. Building on that foundation, we now turn our attention to the pressing matter of Universal Newborn Hearing Screening (UNHS), a crucial step towards ensuring that every child has the opportunity to achieve their full potential. This piece aims to deepen the conversation, highlighting the paramount importance of UNHS as a healthcare imperative and fundamental right, ensuring that no child is left behind due to undetected hearing loss.

Children’s rights to the “highest attainable standard of health” and to be supported in developing their “talents and mental and physical abilities to their fullest potential” are enshrined in the 1989 United Nations Convention on the Rights of the Child.

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Recent global estimates indicate that approximately 466 million people worldwide have disabling hearing loss, with 34 million of these being children. Early detection and intervention could significantly alter their developmental trajectories in many cases. Despite the high prevalence, the implementation of Universal Newborn Hearing Screening (UNHS) programmes varies widely, with significant gaps, particularly in low- and middle-income countries.

Developing speech, language, communication, and psychosocial skills is central to these entitlements. Recognising the importance of hearing, the WHO (2009) recommended implementing universal newborn hearing screening (UNHS) to detect hearing loss among infants so that appropriate care can be provided to reduce its negative consequences. WHO further highlighted the importance and imperative of addressing hearing loss at all ages and presented a call to action in the World Report on Hearing.WHO recommendation 27 calls for the global implementation of UNHS, emphasising the need to integrate ear and hearing services into health systems and undertake service development based on evidence-based principles. The purpose of UNHS is to enable the detection of hearing loss in infants so that timely health and educational/therapeutic interventions can be provided as early as possible to improve outcomes.

Children need to be exposed to quality and frequent communication in their daily lives to develop language and communication skills optimally. These skills underpin socio-emotional well-being and improve children’s long-term life chances with hearing loss. In addition, medical diagnostics, counselling, and interventions can help identify the aetiology of hearing loss, other medical conditions, and intervention strategies. Another major emphasis of the integrated care system is the engagement of parents, families, DHH leaders, and diverse cultural communities. These services aim to support the families of children with hearing loss and provide the children with role models for success.

While many developed countries have successfully implemented UNHS programmes, leading to early detection and intervention of hearing loss in newborns, adoption in developing countries still needs consistency. Barriers such as limited infrastructure, a lack of trained professionals, and socio-economic challenges hinder the widespread adoption of these life-changing screenings. Unfortunately, many hearing care programmes established in many countries have focused predominantly or solely on screening and diagnosis. All countries, even those with advanced and long-term programmes, still need some components. For example, few countries/systems have well-established data management systems to track quality indicators for screening, diagnosis, amplification fit, or early intervention services. While having the desire, commitment, and passion, many countries may need more resources for a thorough pathway following UNHS, such as medical, diagnostic, and audiology facilities for follow-up services. These difficulties and barriers are real. One of the solutions may be to form partnerships and international connections with established programmes to move forward, even in a very fundamental/limited way.

In India, hearing screening facilities are mostly available to newborns brought into tertiary hospitals. Some key issues in implementing the programme identified are a need for more human resources, inadequate infrastructure, equipment-related shortcomings, and low priority for hearing impairment (HI) prevention. The Government of India initiated efforts to prevent and control HI, i.e., the National Programme for Prevention and Control of Deafness and Rashtriya Bal Swasthya Karyakram. These are significant milestones in implementing systematic nationwide hearing screening programmes.

Early Detection and Identification Required? Auditory stimuli during the first six months of life are critical for developing speech and language skills. The crucial period for language learning is within the first 36 months of life. The factors predicted to be influential in the normal development of speech and language skills, which ultimately also will be predictors for cognitive development in children, including hearing ability, degree of HI (mild to profound), age of identification of hearing loss, age of intervention, aided audibility, duration, consistency of hearing aid use, and characteristics of the child’s language environment. Early identification of HI followed by a timely and effective intervention is necessary to minimise its negative effects on cognition, psychological, and verbal communication skills development. Several studies have shown that infants who receive intervention before six months have better school outcomes and improved language and communication skills by ages 2–5 years.

However, the disturbing fact is that the average age at which a child who has a profound, bilateral sensorineural hearing loss is identified at around 24 months, while HI of lesser degrees is often determined at an average age of 48 months of age, especially in rural areas, due to poor awareness about HI and its relation to speech and language development as well as scarcity of infrastructure. Thus, unnoticed or late detection of significant HI in infants and young children results in permanent disability. The prime needs are early detection, identification, and the earliest appropriate intervention. Enhancing infrastructure, training healthcare professionals, and raising public awareness about the importance of early hearing detection are critical steps. For example, mobile health technologies and tele-audiology could offer cost-effective solutions for remote and underserved areas. Policy advocacy and international cooperation are essential to allocating resources to UNHS programmes.

Ideal time for hearing screening: The core goals of the early detection and intervention programme under the Universal Newborn Hearing Screening (NHS) program are described as “1-3-6” goals, which implies that newborns should be screened before one month of age, confirm the diagnosis of hearing loss, fit hearing aid before three months, and enrol the child for early intervention before six months of age. The Joint Committee on Infant Hearing 2007 recommends that all infants be screened by one month. This recommendation is extensively recognised and has been institutionalised as a standard of care by hospitals nationwide.

A uniform, structured NHS program needs to be designed in India and implemented effectively by ensuring human resources, infrastructure, and resources for screening and management. The accomplishment of NHS programs lies in the timely identification, diagnosis, and management of children with hearing loss accomplished via a multidisciplinary NHS team who act as decision-makers and facilitators for different stages in the screening process. Primary healthcare providers such as ENTs, audiologists, family medicine practitioners, paediatricians, gynaecologists, and nursing staff are in a key position to educate families about the importance of early diagnosis and follow-up if they are well informed. Newborns and parents are observed regularly by the primary healthcare providers, and parents often seek their input on the infants’ medical and developmental needs, which provides an ideal opportunity to promote follow-up and make appropriate referrals. However, for this to happen, primary healthcare providers should be educated about the importance of early NHS. These implications will result in best practices in the medical and educational treatment of infants with permanent hearing loss. This information concerns what primary care providers know about this topic and what needs to be explored more.

In conclusion, universal newborn hearing screening is a medical necessity and a fundamental right supporting every child’s holistic development. The compelling evidence for UNHS’s benefits and the tragic consequences of inaction calls for a concerted global effort to make hearing screening accessible to all newborns. Together, we can ensure that every child has the opportunity to reach their full potential, unhindered by preventable hearing loss.

(Dr Suneela Garg is Chair, Progam Advisory Committee NIHFW, MoHFW GOI. Dr K Madan Gopal currently works as Advisor PHA NHSRC, MoHFW and Dr Arvind Garg works as Director of the Child Care Clinic and Head of Apollo Hospitals Delhi. Views expressed are personal and do not reflect the official position or policy of the FinancialExpress.com.)


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