Hearing Impairment in Congenitally Hypothyroid Patients

Objective

Thyroid hormone is necessary for normal development of the auditory system. The aim of this study was to investigate the rate of hearing impairment in congenitally hypothyroid (CH) patients, and its relation with factors such as CH severity and age at starting treatment, during CH screening program in Isfahan.

Methods

Hearing acuity was assessed in two groups of children with (94 patients aged 4 months – 3 years) and without CH (450), between 2000-2006. Otoacostic emission (OAE) was performed by a two step method. After two tests without OAE signals bilaterally, they were referred for auditory brainstem response (ABR) test. Subjects with both OAE and ABR abnormal test results were considered to have hearing problem. Obtained data was compared in case and control group and also CH patients with and without hearing impairment.

Findings

Three (3.2%) of patients and 1 of control group (0.2%) were diagnosed with sensorineural hearing loss. The rate of hearing loss was not different significantly in two studied groups (P>0.05). There was no difference between age of starting treatment and first T4 and TSH level in CH patients with and without hearing loss (P>0.05). CH neonates with hearing impairment had thyroid dyshormonogenesis according to the follow up results.

Conclusion

The rate of hearing loss was low among our studied CH patients. It may be due to proper management of CH patients. In view of the fact that all CH neonates were dyshormonogentic and considering the relation between certain gene mutations and hearing impairment in CH patients, further studies with larger sample size, with regard to different etiologies of CH should be investigated to indicate the possible gene mutations related to hearing loss in CH.     

听觉脑干反应和耳声发射在高危儿听力筛查中的应用

目的：耳声发射(OAE)和听觉脑干反应(ABR) 是新生儿听力筛查的常用方法。该研究旨在探讨畸变产物耳声发射(DPOAE) 和ABR应用于重症监护病房(NICU)高危新生儿听力筛查的差异和意义。方法：分别应用Smart-EP型听觉脑干诱发电位仪和Smart-OAE畸变产物耳声发射检查仪对600例(1 200耳)不同病因所致的高危儿同时进行DPOAE和ABR检查,将两种方法取得的检测结果进行比较。结果：在600例(1 200耳)高危新生儿中,ABR的异常率(78.6%,943/1 200耳)远高于DPOAE的未通过率(22.3%,268/1 200耳);二种检查的共同阴/阳性率分别为20.8%(241/1 200耳)和21%(252/1 200耳)。1 200耳中有493耳DPOAE和ABR的测试结果一致,占41.1%;707耳的测试结果不一致,占58.9%。DPOAE测试的假阳性率为6.0%(16/268耳),假阴性率为74.1%(691/932耳)。结论： DPOAE仅反映耳蜗功能,单独用于高危新生儿听功能筛查的价值有限。ABR检查果相对可靠,NICU高危新生儿听力筛查应先做ABR检查,ABR异常者再做OAE检查。ABR和OAE二种检测方法相互结合,方能提高高危新生儿听力筛查的准确性。     

Feasibility of neonatal hearing screening program with two-stage transient otoacoustic emissions in Turkey

BACKGROUND: The objective of this study was to investigate the incidence of hearing loss in neonates and evaluate the feasibility of a two-stage Transient Evoked Otoacoustic Emission (TEOAE) screening test. Maternal concerns about hearing screening were also studied. METHODS: Neonatal intensive care patients and well babies were screened using a two-stage TEOAE test, which was followed by an Auditory Brainstem Response (ABR) test for those babies who failed the first test twice. RESULTS: In total, 711 neonates were screened. At the end of the two TEOAE tests, the cumulative pass rate was 99.3% and false-positive rate was 0.3%. Five neonates (0.7%) were referred for the ABR test. Sensorineural hearing loss was found in three of them (0.4%). Of these three neonates, one was from the well baby nursery and two were from the NICU population. Families generally welcomed the screening program, with no refusals. Positive test results have not caused important maternal concerns. CONCLUSIONS: Congenital hearing impairment is a prevalent disease in Turkey. The two-stage TEOAE program is suitable for the neonatal hearing screening program. In general, hearing screening tests do not cause notable maternal concerns.     

Evaluation of an automated auditory brainstem response infant hearing screening method in at risk neonates

An automated auditory brainstem response (ABR) methodthe ALGO-1 Plus-has been developed for hearing screening in healthy neonates. The aim of this study was to test the validity of this automated ABR screening method in at-risk neonates in a neonatal intensive care unit. Two hundred and fifty at-risk neonates were selected for screening according to the criteria of the American Joint Committee on Infant Hearing. All 250 neonates were screened with the ALGO-1 Plus for bilateral hearing loss. When two consecutive screenings pointed to bilateral hearing loss (refer) further audiological investigations were performed and where necessary therapeutic measures were taken. All children who passed the screening unilateral or bilateral enrolled in a nationwide behavioural screening programme at the age of 9 months as well as in a 6-monthly follow up programme documenting speech and language development. A total of 245 (98%) neonates passed the ALGO-1 screening, 230 (92%) at the first attempt and 15 (6%) at the second attempt. Five (2%) were referred with bilateral hearing loss. One of these died of congenital rubella shortly after screening and bilateral congenital hearing loss of >35 dB was confirmed in the other 4. None of the infants who passed the screening were discovered to have moderate to severe bilateral hearing loss (> 40 dB) with behavioural screening (n=183/233) or at follow up (n=233/233). In this study, all at-risk neonates with bilateral congenital hearing loss were detected with ALGO-1 Plus screening. No falsenegatives were discovered.     

不同日龄新生儿诱发性耳声发射测试

对20例正常新生儿在出生后第1～5天逐日行瞬态诱发性耳声发射(TEOAE)和畸变产物耳声发射(I)POAE)的测试。了解不同日龄新生儿畸变产物耳声发射(DPOAE)和瞬态诱发性耳声发射(TEOAE)的特征，探讨应用OAE作新生儿听力筛查的最佳时机。随新生儿日龄的增加，其TEOAE和DPOAE检出率和反应幅值逐步提高，新生儿生后第1～2天的检出率和反应幅值显著低于第3～5天，至生后第3～5天．TEOAE和DPOAE检出率接近或达到100％，反应幅值也趋于稳定。结论：应用TEOAE和DPOAE进行新生儿听力筛查时，其日龄至少应在3天或3天以上，测试TEOAE和DPOAE快速、方便，不失为普遍性新生儿听力筛查首选方法。     

Bubble–CPAP vs. Ventilatory–CPAP in Preterm Infants with Respiratory Distress

Objective

Application of Continuous Positive Airway Pressure (CPAP) in neonate with respiratory distress is associated with reduction of respiratory failure, reduced complications and mortality. Bubble CPAP (B-CPAP) and ventilator-derived CPAP (V-CPAP) are two most popular CPAP modes. We aimed to determine whether B-CPAP and V-CPAP would have different survival rate and possible complications.

Methods

This prospective clinical trial was performed on 50 preterm neonates weighing 1000-2000 gr who were admitted to the neonatal intensive care unit of Afzalipoor Hospital because of respiratory distress between June 2009 and May 2010. Patients were randomly allocated into treatment groups using minimization technique. Survival analysis was applied to estimate and compare survival rates. Duration of oxygen therapy, hospital stay as well as hospitalization costs were compared using independent sample t-test.

Findings

Estimated survival rates at 24 hours in B-CPAP and V-CPAP groups were 100% and 77% respectively. Corresponding figures at 48 hours were 100% and 71%. In addition the hospitalization cost in V-CPAP group was significantly higher than in B-CPAP group.

Conclusion

According to our results, B-CPAP was effective in the treatment of neonates who were suffering from respiratory distress and reduced the duration of hospital stay. In addition to mentioned benefits, its low cost may be the reason to use B-CPAP broadly compared with V-CPAP.     

Confirmation of deafness in infancy.

AIM: To assess delay in confirming hearing impairment in infants identified by universal neonatal screening and to investigate the causes. PATIENTS: Infants identified from 25 199 babies screened from January 1992 to December 1997. METHODS: A two stage transient evoked oto-acoustic emission test (TEOAE), with a threshold auditory brainstem response (ABR) recording undertaken on those who failed. The screen identified infants with a permanent congenital hearing impairment (PCHI) averaging 40 dBnHL or worse in the best ear. Those with less impairment were also ascertained. The positive predictive value (PPV) of the ABR test and measures of delay between identification and eventual diagnosis were analysed. RESULTS: A targeted PCHI was found in 1.18/1000 neonates. The PPV of the ABR for confirming a targeted PCHI was 100% when the ABR threshold was >/= 80 dBnHL. Nine of 11 infants with this threshold had severe or profound permanent deafness. The delay from ABR to audiological certainty was about 1 month-diagnosis was confirmed around 3 months. There was uncertainty when the ABR was 40-80 dBnHL. The PPV was 60% and 8% when the ABR thresholds were 70 dBnHL and 50 dBnHL, respectively. 85 of 111 infants with ABR thresholds in this range had a temporary conductive impairment. Their early diagnosis depended upon the type and degree of hearing impairment and diagnosis was delayed to about 8 months in these infants. CONCLUSIONS: Hearing impairments identified by universal screening are delayed in all but those with severe or profound bilateral PCHI. This delay can be reduced by applying in early infancy a battery of audiological tests and requires further exploration.     

Low Birth Weight and Its Related Risk Factors in Northeast Iran

Objective

This study was conducted to determine the prevalence of low birth weight (LBW) and its related risk factors in an appropriate sample of neonates in Shahroud, northeast Iran.

Methods

At this study, a random sample of 1000 neonates were selected of which 72 neonates were LBWs. We used univariate and multivariate logistic regression methods to evaluate the LBW risk factors in LBWs compared to normal weight infants.

Findings

7.2% of neonates were LBWs and 6.1% born before 37 weeks of gestation. Prematurity, high-risk pregnancy and maternal age have significant statistical association with LBW. Odds Ratio (OR) for prematurity was 42.82 (95%CI; 21.93-83.57), for high risk pregnancy 2.76 (95%CI; 1.47-5.19) and for maternal age group more than 35 years in comparison to 19-35 years age group 0.2 (95%CI; 0.05-0.71).

Conclusion

Based on this study; prematurity and high risk pregnancy were the most important risk factors for LBW. There was also a reverse association between maternal age and LBW.     

A meta-analysis and systematic review of the prevalence of mitochondrially encoded 12S RNA in the general population: Is there a role for screening neonates requiring aminoglycosides?

Background:

This was a meta-analysis and systematic review to determine the global prevalence of the mitochondrially encoded 12S RNA (MT-RNR1) genetic mutation in order to assess the need for neonatal screening prior to aminoglycoside therapy.

Materials and Methods:

A comprehensive search of MEDLINE, EMBASE, Ovid, Database of Abstracts of Reviews of Effect, Cochrane Library, Clinical Evidence and Cochrane Central Register of Trials was performed including cross-referencing independently by 2 assessors. Selections were restricted to human studies in English. Meta-analysis was done with MetaXL 2013.

Results:

Forty-five papers out of 295 met the criteria. Pooled prevalence in the general population for MT-RNR1 gene mutations (A1555G, C1494T, A7445G) was 2% (1–4%) at 99%.

Conclusion:

Routine screening for MT-RNR1 mutations in the general population prior to treatment with aminoglycosides appear desirable but poorly supported by the weak level of evidence available in the literature. Routine screening in high-risk (Chinese and Spanish) populations appear justified.Key words: Aminoglycoside, mitochondrial genetics, mutation, ribosomal ribonucleic acid, sensorineural hearing loss     

Short-Term Outcomes of Very Low Birth Weight Infants Born at a Tertiary Care Hospital,Istanbul, Turkey

Objective

To evaluate mortality and short-term outcomes in very low birth weight infants admitted to the tertiary neonatal intensive care unit, Istanbul, Turkey.

Methods

Study data were recorded prospectively from January 1, 2010, to December 31, 2010. The clinical findings in neonates with birth weights <1000g were compared with infants with birth weights of between 1000g and 1499g.

Findings

In the present study, survival rates were 40% and 86.2% for infants weighing <1000g and 1000g to 1499g, respectively. There was no difference between males and females with respect to mortality (P>0.05). The mean (±standard deviation) birth weight was 985.6±150.15 g and mean gestational age was 27.5±2.04 weeks. The antenatal steroid rate was 37.2%, and the Cesarean section rate was 73%. Respiratory distress syndrome was diagnosed in 89% of the infants, with a 69% surfactant administration rate. Severe intracranial hemorrhage (IVH) (grade >II) was 14%. Grade 4 periventricular leukomalacia was 10%. Twelve (24%) infants had evidence of bronchopulmonary dysplasia (BPD). Retinopathy of prematurity (stage >II) was 4%. The correlation between ROP rate and need for ventilation therapy was present (r=0.52). Proven necrotizing enterocolitis (stage >2) was not observed. Patent ductus arteriosus (PDA) was diagnosed in 67% of the neonates. BPD, IVH, and PDA were statistically higher in neonates with a birth weight <1000g.

Conclusion

Survival rate of VLBW infants increased with increasing BW. Sex was not a risk factor for mortality. The need for ventilatory therapy may be an important risk factor for ROP in infants <1500g.     

Assessment of Febrile Neonates According to Low Risk Criteria for Serious Bacterial Infection

Objective

It is propounded that febrile neonates with low risk criteria (LRC) can be carefully observed without parenteral antimicrobial therapy; but yet, reliability of LRC to exclude serious bacterial infection (SBI) is uncertain.

Methods

The records of all febrile term neonates, seen in the emergency room and admitted in neonatal ward of 17 Shahrivar children''s hospital of Rasht, Iran from January 2004 to January 2009 were reviewed. All of them underwent full sepsis workup. The prevalence of SBI in total population and LRC positive and negative neonates were calculated

Findings

A total of 202 records of previously healthy febrile neonates were evaluated. SBI was shown in 38 (18.8%). The most common type of SBI was urinary tract infection (UTI). Sixty-two (31%) neonates had LRC, and only one (1.6%) had SBI (UTI with E. coli). SBI was significantly more common in neonates without LRC (26.6% versus 1.6%, P<0.001). The negative predictive value (NPV) of LRC to exclude SBI was 98.4% (^95%confidence interval: 96.7% to 100%).

Conclusion

These findings suggest that LRC may be relied upon to exclude SBI in febrile neonates. We propose that all febrile neonates be admitted, ill or LRC negative neonates should undergo a full sepsis work up and be administered systemic antibiotics immediately. LRC positive neonates should be under close observation.     

The Effect of Endotracheal Tube Suctioning Education of Nurses on Decreasing Pain in Premature Neonates

Objective

Endotracheal tube suctioning (ETS) is a painful and invasive procedure. Studies have shown that the performance of nurses in this procedure is weak, so we conducted a study to evaluate the effect of ETS education for nurses on neonates’ pain in neonatal intensive care units (NICUs).

Methods

In a quasi-experimental study, performance of 25 nurses working in NICU was assessed before and after ETS education by a checklist. In addition pain score of 50 neonates was measured using pain assessment tool (PIPP) one minute before, during and 5 minutes after ETS. The neonates had a gestational age of less than 37 weeks and were intubated (at least for 8 hours and up to 24 hours). A P. value of less than 0.05 was considered as statistically significant.

Findings

Mean scores of nurses’ performance were significantly different before and after education (P≤0.001) by Wilcoxon test. Friedman test revealed that PIPPs before, during and after ETS were significantly different before and after education (P≤0.05). Mann-Whitney test showed no significant differences between PIPPs before ETS, before and after education (P=0.2), but PIPPs during and after ETS were significantly different (P≤0.01).

Conclusion

ETS causes moderate to severe pain in neonates. Education improved performance of nurses and decreased pain in neonates during and after ETS. Despite education, neonates will experience mild pain during ETS, so other interventions need to be considerate.     

Predictors of Mortality in Out Born Neonates with Acute Renal Failure; an Experience of a Single Center

Objective

To evaluate the incidence, etiology, outcome, and predictors of mortality in neonates with Acute Renal Failure (ARF) in an out born Neonatal Intensive Care Unit (NICU) of India.

Methods

A retrospective analysis of case records of out born neonates, who had ARF at admission or developed ARF during NICU stay, from January to December 2011 (one year) was done.

Findings

Out of the total 456 neonates admitted during the study period, 44 (9.6%) neonates with ARF (32 males, 12 females) were studied. Their mean gestational age, weight, and age at admission was 34.7±3.9 weeks, 2100±630 grams, and 2.1±6.3 respectively. Causes of ARF were pre-renal in 22 (50%), intrinsic renal failure in 16 (36.3%), and post-renal in six (13.6%). Oliguria was present in 29 neonates. Neonatal sepsis was the commonest cause of ARF, followed by perinatal asphyxia, respiratory distress syndrome, and genitourinary anomalies. ARF was present at admission in 37 neonates. The mortality rate was 15.9% (7/44). Thirty-seven (84%) were discharged with complete recovery of renal functions and followed for six months. Shock, oliguria, need for mechanical ventilation, and presence of disseminated intravascular coagulopathy (DIC) emerged as predictors of mortality in neonates with ARF.

Conclusion

The incidence and mortality rate of neonatal ARF were 9.6% and 15.9% respectively in our out born NICU. Neonatal sepsis was the commonest cause of ARF followed by perinatal asphyxia. Shock, oliguria, need for mechanical ventilation, and presence of DIC were associated with poor outcome.     

The Clinical and Bacteriogical Spectrum of Neonatal Sepsis in a Tertiary Hospital in Yaounde,Cameroon

Objective

Sepsis is an important cause of morbidity and mortality in neonates especially in developing countries where identification of the germs and treatment is often unsatisfactory. The aim of the study was to assess the clinical presentation, and bacteriological profile of neonatal infections, and the sensitivity of the causative germs to antibiotics.

Methods

We carried out a prospective analytic study in the Yaounde Gynaeco-Obstetric and Pediatric Hospital in Cameroon over a 6 months period from 18^th November 2008 to 18^th May 2009. On the basis of history and/or clinical findings and paraclinical investigations, 218 neonates out of a total of 628 admissions were investigated and managed for neonatal infection.

Findings

The most frequent symptoms were fever (44.95%), refusal to feed/irritability (32.11%), and respiratory distress/cough (28.90%). Premature birth and prolonged rupture of membranes were the most frequent risk factors. Klebsiella spp, Escherichia coli and Enterobacter spp were the most frequent germs identified in respectively 28.6%, 21.4% and 14.3% of the positive samples. Overall sensitivity of the cultures to ampicillin, netilmicin and gentamycin was poor at 29.4%, 31.4% and 18.9% respectively, whereas imipenem, ofloxacin, ciprofloxacin and ceftazidime had the best sensitivities in 91.7%, 90%, 85.3% and 69.4% of the cultures respectively. The mortality rate was 22%, and low birth weight, premature birth and septicemia were significant risk factors for death.

Conclusion

Mortality from neonatal sepsis in this context is still high and there is an upsurge of multi-resistant germs to currently used antibiotics, calling for the need for rational use of antibiotics in the management of these infections.     

The Evaluation of Red Reflex Sensitivity and Specificity Test among Neonates in Different Conditions

Objective:

Red reflex test is an effective screening tool in the early diagnosis of neonatal eye abnormalities. The aim of this study was to detect the sensitivity and specificity of red reflex assessment in neonates, performed by pediatricians (or other care providers) in comparison with ophthalmologists. Also association between red reflex findings and neonatal variables is evaluated.

Methods:

By a prospective study all neonates born from July 2011 until March 2012 in Mustafa Hospital, a general teaching hospital in Ilam city, Iran, were evaluated. Neonates were firstly investigated by pediatrician in substandard conditions at the first day of birth and several days later by ophthalmologist in standard conditions.

Findings:

Totally 255 neonates including 141 boys and 114 girls were investigated, 144 of whom were born by cesarean section. There was a significant relationship between method of childbirth (72.9% disorders in CS vs 56.8% in vaginal delivery (P<0.007)), duration of delivery (disorders in prolonged: 100% and 11.8% vs no prolonged: 56.8% and 6.3% in standard and non standard conditions respectively (P<0.0001)), difficult delivery (98.6% disorders vs 6.5% in standard and non standard conditions respectively (P<0.01)) and increase or decrease of red reflex sensitivity test. A significant difference (identification of ophthalmic problems) was seen among neonates’ inspections in primary hours and substandard conditions compared to further inspections in standard conditions particularly from 3^rd day of birth.

Conclusion:

Due to a considerable difference between the results of ophthalmic examination of neonates in different conditions, red reflex examination by pediatricians is suggested for all neonates to early identification of ophthalmic problems at the first step. It is also suggested a red reflex screening for all neonates before being discharged from hospital as well as 6 weeks later and in case of any problem to be referred to ophthalmologist.     

Neonatal Resuscitation in the Delivery Room from a Tertiary Level Hospital: Risk Factors and Outcome

Objective

Timely identification and prompt resuscitation of newborns in the delivery room may cause a decline in neonatal morbidity and mortality. We try to identify risk factors in mother and fetus that result in birth of newborns needing resuscitation at birth.

Methods

Case notes of all deliveries and neonates born from April 2010 to March 2011 in Mahdieh Medical Center (Tehran, Iran), a Level III Neonatal Intensive Care Unit, were reviewed; relevant maternal, fetal and perinatal data was extracted and analyzed.

Findings

During the study period, 4692 neonates were delivered; 4522 (97.7%) did not require respiratory assistance. One-hundred seven (2.3%) newborns needed resuscitation with bag and mask ventilation in the delivery unit, of whom 77 (1.6%) babies responded to bag and mask ventilation while 30 (0.65%) neonates needed endotracheal intubation and 15 (0.3%) were given chest compressions. Epinephrine/volume expander was administered to 10 (0.2%) newborns. In 17 patients resuscitation was continued for >10 mins. There was a positive correlation between the need for resuscitation and following risk factors: low birth weight, preterm labor, chorioamnionitis, pre-eclampsia, prolonged rupture of membranes, abruptio placentae, prolonged labor, meconium staining of amniotic fluid, multiple pregnancy and fetal distress. On multiple regression; low birth weight, meconium stained liquor and chorioamnionitis revealed as independent risk factors that made endotracheal intubation necessary.

Conclusion

Accurate identification of risk factors and anticipation at the birth of a high-risk neonate would result in adequate preparation and prompt resuscitation of neonates who need some level of intervention and thus, reducing neonatal morbidity and mortality.     

Confirmation of deafness in infancy

AIM—To assess delay in confirming hearing impairment in infants identified by universal neonatal screening and to investigate the causes.
PATIENTS—Infants identified from 25 199 babies screened from January 1992 to December 1997.
METHODS—A two stage transient evoked oto-acoustic emission test (TEOAE), with a threshold auditory brainstem response (ABR) recording undertaken on those who failed. The screen identified infants with a permanent congenital hearing impairment (PCHI) averaging 40 dBnHL or worse in the best ear. Those with less impairment were also ascertained. The positive predictive value (PPV) of the ABR test and measures of delay between identification and eventual diagnosis were analysed.
RESULTS—A targeted PCHI was found in 1.18/1000 neonates. The PPV of the ABR for confirming a targeted PCHI was 100% when the ABR threshold was ⩾ 80 dBnHL. Nine of 11 infants with this threshold had severe or profound permanent deafness. The delay from ABR to audiological certainty was about 1 month—diagnosis was confirmed around 3 months. There was uncertainty when the ABR was 40-80 dBnHL. The PPV was 60% and 8% when the ABR thresholds were 70 dBnHL and 50 dBnHL, respectively. 85 of 111 infants with ABR thresholds in this range had a temporary conductive impairment. Their early diagnosis depended upon the type and degree of hearing impairment and diagnosis was delayed to about 8 months in these infants.
CONCLUSIONS—Hearing impairments identified by universal screening are delayed in all but those with severe or profound bilateral PCHI. This delay can be reduced by applying in early infancy a battery of audiological tests and requires further exploration.
     

Consensus statement of the Indian Academy of Pediatrics on newborn hearing screening

Justification

Hearing impairment is one of the most critical sensory impairments with significant social and psychological consequences. Evidence-based, standardized national guidelines are needed for professionals to screen for hearing impairment during the neonatal period.

Process

The meeting on formulation of national consensus guidelines on developmental disorders was organized by Indian Academy of Pediatrics in Mumbai, on 18^th and 19^th December, 2015. The invited experts included Pediatricians, Developmental Pediatricians, Pediatric Neurologists and Clinical Psychologists. The participants framed guidelines after extensive discussions.

Objective

To provide guidelines on newborn hearing screening in India.

Recommendations

The first screening should be conducted before the neonate’s discharge from the hospital–if it ‘fails’, then it should be repeated after four weeks, or at first immunization visit. If it ‘fails’ again, then Auditory Brainstem Response (ABR) audiometry should be conducted. All babies admitted to intensive care unit should be screened via ABR. All babies with abnormal ABR should undergo detailed evaluation, hearing aid fitting and auditory rehabilitation, before six months of age. The goal is to screen newborn babies before one month of age, diagnose hearing loss before three months of age and start intervention before six months of age.