Implementation of a nation-wide automated auditory brainstem response hearing screening programme in neonatal intensive care units

AIM: As part of a future national neonatal hearing screening programme in The Netherlands, automated auditory brainstem response (AABR) hearing screening was implemented in seven neonatal intensive care units (NICUs). The objective was to evaluate key outcomes of this programme: participation rate, first stage success rate, pass/referral rates, rescreening compliance, diagnostic referral rates, age of first diagnostic evaluation and prevalence of congenital hearing loss (CHL). METHODS: This prospective cohort study collected data on 2513 survivors. NICU graduates with one or more risk factors according to the Joint Committee on Infant Hearing were included in a two-stage AABR hearing screening programme. Conventional ABR was used to establish a diagnosis of CHL. RESULTS: A total of 2513 newborns enrolled in the programme with a median gestational age of 31.6 (range 24-43) wk and a median birthweight of 1450 (range 510-4820) g. In 25 (1%) cases parents refused screening. Four out of 2513 newborns were initially lost; 2484 newborns have been tested initially. A final 98% participation rate (2465/2513) was obtained for the whole programme. After a median postmenstrual age at the first test of 33.7 (range 27-54) wk, a pass rate of 2284/2484 (92%) resulted at the first stage. The rescreening compliance after the first test was 92% (184/200). A referral rate for diagnostic ABR of 3.1% (77/2484) resulted. Of the 77 referrals 14 (18.2%) had normal screening thresholds, 15 (19.5%) had unilateral CHL and 48 (62.3%) had bilateral CHL. The prevalence of unilateral CHL was 0.6% (15/2484) and of bilateral CHL 1.9% (48/2484). CONCLUSION: A financially supported two-stage AABR hearing screening programme can be successfully incorporated in NICU centres and detects a high prevalence of CHL in NICU graduates. Neonatal hearing screening should be part of standard clinical practice in all NICU infants.     

Interdisciplinary approach to design, performance, and quality management in a multicenter newborn hearing screening project

Previously presented results of the newborn hearing screening in Hamburg and the perspectives are subsequently discussed. Minimum standards referring a participation of 95% of the neonates and a fail rate of less than 4% hearing-impaired children at the primary screening are fulfilled in Hamburg. Systematic screening of newborn hearing by an interdisciplinary approach provides early identification and intervention for children with permanent unilateral and bilateral hearing loss. But a newborn hearing screening on a voluntary basis alone cannot be maintained in the long run. Further, an anonymous data collection is not sufficient in regard to an uninterrupted tracking of conspicuous and unscreened neonates. A lost-to-follow-up rate of 31.3% at primary screening in Hamburg is much too high and emphasizes the need for a public health approach to a population-based newborn hearing screening with an elaborate and name-based tracking system. The legislation and implementation of a nationwide newborn hearing screening program in Germany and the association of German newborn hearing screening centers are highlighting long efforts of hearing professionals. But the implementation of a newborn hearing screening only makes sense if there exists an efficient tracking system. Sad to say, we are still a long way from the implementation of such a tracking system.     

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.     

Low prevalence of hearing impairment among very low birthweight infants as detected by universal neonatal hearing screening

OBJECTIVES: To (a) study the prevalence of hearing impairment in a cohort of very low birthweight (VLBW) infants and (b) evaluate the effectiveness of transient evoked otoacoustic emissions (TEOAE) as a first stage in-hospital hearing screening tool in this population. STUDY DESIGN: The study group was a cohort of 346 VLBW infants born in 1998-2000 at The Sheba Medical Center. The prevalence of hearing impairment in the study group was compared with that of all other newborn infants participating in a universal newborn hearing screening programme during the same period. To evaluate the effectiveness of TEOAE, a control group of 1205 healthy newborns who had no known risk factors for hearing impairment was selected. The results and follow up of hearing screening for these infants were examined retrospectively. RESULTS: Only one VLBW infant (0.3%) was diagnosed with bilateral sensory-neural hearing loss. In addition, nine infants (2.7%) were diagnosed with conductive hearing loss. Bronchopulmonary dysplasia and low Apgar score were the most significant factors for predicting the occurrence of conductive hearing loss. The percentage of VLBW infants who successfully passed the in-hospital TEOAE screening was 87.2, compared with 92.2% in the full term control group. No false negative cases were detected on follow up. CONCLUSIONS: The study shows a low incidence of sensory-neural hearing loss in a cohort of VLBW infants and a relatively high incidence of conductive hearing loss. TEOAE screening was found to be an effective first stage in-hospital hearing screening tool in this population.     

Hearing loss in children with congenital cytomegalovirus infection born to mothers with preexisting immunity

OBJECTIVE: To define hearing outcomes in children with congenital cytomegalovirus (CMV) infection born to mothers with non-primary CMV infection. STUDY DESIGN: A cohort of 300 children with congenital CMV infection identified by newborn virologic screening at the University of Alabama Hospital and a private community hospital in which the type of maternal infection could be classified constituted the study population. Maternal infections were categorized by analyzing serum samples. Children were followed prospectively and underwent serial audiologic evaluations. RESULTS: The frequency of hearing loss was not different between children born to mothers with non-primary infection (10%) and those with primary infection (11%). Significantly more children in the primary infection group had progressive and severe/profound hearing loss compared with children in the non-primary group. The frequency of bilateral, delayed onset, high-frequency, and fluctuating hearing loss was not different between the 2 groups. The mean age of diagnosis of hearing loss was 39 +/- 53 months for children born to mothers with non-primary infection and 13 +/- 21 months for the primary infection group (P = .16). CONCLUSIONS: Maternal preexisting seroimmunity to CMV does not provide complete protection against hearing loss in infants with congenital CMV infection.     

Infant,Maternal, and Hospital Factors' Role in Loss to Follow-up After Failed Newborn Hearing Screening

Objective

Completion of newborn hearing screening (NBHS) is recommended by 1 month old. Delays and loss to follow-up and documentation (LTF/LTD) after failed NBHS are common. Committees of experts have established hospital guidelines to reduce LTF/LTD. We aimed to identify maternal and infant factors associated with LTF/LTD and determine if adherence to hospital guidelines is associated with timely completion of follow-up screening.

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.     

NICU‐only versus universal screening for newborn hearing loss: Population audit

Aim: Targeted newborn hearing screening for infants in neonatal intensive care units (NICUs) may be considered when resources preclude universal newborn hearing screening (UNHS). However, process outcomes have not been compared between stand‐alone NICU hearing screening programs and NICU screening within a full UNHS program. Methods: Comparison of two consecutive hearing screening programs delivered under similar conditions in the four NICUs in Victoria, Australia. All NICU infants were eligible for pre‐discharge automated auditory brainstem response (AABR) hearing screening. Capture, referral and diagnostic data were collected for all NICU infants during the NICU‐only (April 2003–February 2005) and subsequent UNHS (April 2005–June 2006) programs. Results: 4704 eligible infants were admitted during the 23‐month NICU‐only period, and 3160 during the 15‐month UNHS period. Double AABR using ALGO 3i equipment was planned for both programs but, due to clinician concern about this high‐risk clinical population, the NICU‐only protocol was amended to single AABR using AccuScreen equipment. Capture rates were 71.1% (NICU‐only) vs. 95.4% (UNHS) (P < 0.001), successful follow‐up rates were 85.8% vs. 96% (P= 0.004), and mean corrected age at the first audiology appointment was 51.5 vs. 40.2 days (P= 0.05). Conclusions: NICU screening offered within a larger UNHS program outperformed the stand‐alone NICU hearing screening program on all measured parameters. Greater resourcing might address shortcomings of the stand‐alone program but would also reduce its potential savings. The high loss to follow‐up also argues against the often‐advocated approach of referring all NICU infants for diagnostic audiologic testing, bypassing hearing screening altogether.     

The cost-effectiveness of universal newborn screening for bilateral permanent congenital hearing impairment: systematic review

ObjectiveUniversal newborn hearing screening for bilateral permanent congenital hearing impairment is standard practice in many developed economies, but until there is clear evidence of cost-effectiveness, it remains a controversial use of limited health care resources. We conducted a formal systematic review of studies of newborn hearing screening that considered both costs and outcomes to produce a summary of the available evidence and to determine whether there was a need for further research.MethodsA search was conducted of medical and nursing databases and gray literature websites by the use of multiple keywords. The titles and abstracts of studies were examined for preliminary inclusion if reference was made to newborn hearing screening, and to both costs and outcomes. Studies of potential relevance were independently assessed by 2 health economists for final inclusion in the review. Studies that met inclusion criteria were appraised by the use of existing guidelines for observational studies, economic evaluations and decision analytic models, and reported in a narrative literature review.ResultsThere were 22 distinct observational or modeled evaluations of which only 2 clearly compared universal newborn hearing screening to risk factor screening for bilateral permanent congenital hearing impairment. Of these, the single evaluation that examined long-term costs and outcomes found that universal newborn hearing screening could be cost-saving if early intervention led to a substantial reduction in future treatment costs and productivity losses.ConclusionsThere are only a small number of economic evaluations that have examined the long-term cost-effectiveness of universal newborn hearing screening. This is partly attributable to ongoing uncertainty about the benefits gained from the early detection and treatment of bilateral permanent congenital hearing impairment. There is a clear need for further research on long-term costs and outcomes to establish the cost-effectiveness of universal newborn hearing screening in relation to other approaches to screening, and to establish whether it is a good long term investment.     

Newborn hearing screening: will children with hearing loss caused by congenital cytomegalovirus infection be missed?

OBJECTIVE: To predict whether universal newborn auditory screening will identify most infants with sensorineural hearing loss (SNHL) caused by congenital cytomegalovirus (CMV) infection. STUDY DESIGN: A cohort of 388 children born between 1980 and 1996 at one hospital and identified during the newborn period as having congenital CMV infection received repeated hearing evaluations to assess whether hearing loss had occurred. RESULTS: SNHL was detected in 5.2% of all infants at birth. Late-onset SNHL occurred among the children throughout the first 6 years of life. By the age of 72 months, the cumulative incidence of SNHL was 15.4% in the cohort. Children with clinically apparent disease at birth had significantly more SNHL than children without any apparent disease (22.8% vs 4.0% at 3 months and 36.4% vs 11.3% at 72 months of age). CONCLUSIONS: Universal screening of hearing in neonates will detect less than half of all SNHL caused by congenital CMV infection. Because most infants with congenital CMV infection are without symptoms at birth, these children are unlikely to be recognized as being at risk for SNHL and will not receive further hearing evaluations to detect late-onset hearing loss. A combined approach of universal screening of neonates for hearing, as well as for detection of congenital CMV infection, needs to be considered.     

The Milan Project: a newborn hearing screening programme

Aim: Since 1997 a newborn hearing screening programme has been implemented by the U.O. Neurologia-Neurofisiopatologia and Dipartimento di Neonatologia of the Istituti Clinici di Perfezionamento ICP in Milan for both babies with no risk and those at risk of hearing impairment. This programme was named the Milan Project. Methods: The protocol for no-risk babies consisted of three stages: in the first two stages, newborns were tested with transient click-evoked otoacoustic emissions (TEOAE), in the third one with conventional auditory brainstem responses (ABR). The first TEOAE test was performed by 36 h of age, before discharge, the second one after 15-30 d in case of referral, and the third one, by ABR, for those babies who failed the second TEOAE stage. Newborns at audiological risk were submitted to conventional ABR before the third month of corrected age. Some of this latter population was also submitted to the TEOAE test. The entire tested population (no-risk babies and newborns at audiological risk) consisted of 19 777 babies: 19 290 without risk (“no risk”) and 487 at risk (“at risk”). Results: During the course of the Milan Project, hearing impairment (ABR threshold equal to or greater than 40 dB nHL) was identified in 63 newborns (19 from the no-risk and 44 from the at-risk population), with a prevalence of 0.32%. Bilateral hearing impairment (BHI) was found in 33 newborns (10 from the no-risk and 23 from the at-risk population), corresponding to 0.17%. Among infants with bilateral hearing impairment, 30.3% had no risk factors. The prevalence of hearing impairment was determined on days 15-30 after birth.

Conclusions: The results show that the implementation of a hospital-based, universal neonatal hearing screening programme for babies with and without audiological risk is feasible and effective. The effectiveness of the programme has increased as a function of the years since its inception, with a strong decrease in the referral rate. Further improvement is obtained if the TEOAE measurements are repeated in cases of referral scoring before discharge.     

Implementation and results of bedside hearing screening with automated auditory brainstem response in the neonatal intensive care unit

Aim: To evaluate implementation and results of neonatal hearing screening with automated auditory brainstem response (AABR) by bedside nurses in a single‐centre neonatal intensive care unit (NICU). Methods: Retrospective review of charts of 2074 newborns admitted over a 4‐year period. Results: One thousand eight hundred and 24 newborns (88%) were screened. A ‘pass’ result was obtained in 1761 patients (96.5%). From 63 infants with ‘refer’, 40 were tested with auditory brainstem response: in 28 hearing loss was confirmed. Three hundred and nine neonates were screened before postmenstrual age (PMA) of 34 weeks: 78% successfully passed the first test. Sixty‐seven infants with ‘refer’ at the first test before PMA of 34 weeks were re‐evaluated: 48 had normal hearing tests, 24 of whom still younger than 34 weeks. For 12 of 19 infants with ‘refer’ before 34 weeks, follow‐up was available: in 7 hearing loss was confirmed. Conclusion: Neonatal hearing screening with AABR can be easily performed by the bedside nurse in the NICU even in premature babies before 34 weeks PMA. A ‘pass’ result can be obtained in almost 80% of them; a ‘refer’ result at that age, however, must be interpreted cautiously, as false ‘refer’ occurred in 5/12 of these infants.     

Hearing improvement in patients with Fabry disease treated with agalsidase alfa

Aim : To describe the nature and prevalence of hearing loss in Fabry disease, and its response to enzyme replacement therapy (ERT) with agalsidase alfa. Methods : Fifteen male patients with Fabry disease were enrolled in a randomized, double-blind study and received placebo ( n = 8) or ERT ( n = 7) with agalsidase alfa for 6 months. This was followed by an open-label extension of 36 months thus far. Alongside this trial, an additional eight men and two women have so far received open-label ERT for between 6 and 30 months. Pure-tone audiometry, impedance audio-metry and otoacoustic emission testing were performed at 0 (baseline), 6, 18, 30 and 42 months. Results : Nine patients (36%) had bilateral and ten (40%) had unilateral high-frequency sensorineural hearing loss (SNHL). Three (12%) had unilateral middle ear effusions with conductive losses persisting beyond 6 months. Only five patients (20%) had normal hearing. The high-frequency SNHL deteriorated over the first 6 months in both placebo and active treatment groups by a median 6.3 dB ( p < 0.0001, Wilcoxon matched-pairs). This hearing loss subsequently improved above baseline by 1.5 dB at 18 months (p = 0.07), by 5.0 dB at 30 months ( p = 0.006) and by 4.0 dB at 42 months ( p = 0.01).
Conclusion : Significant hearing loss, usually high-frequency SNHL, is a common manifestation of Fabry disease in adults. α-Galactosidase A replacement therapy with agalsidase alfa appears to reverse the hearing deterioration in these patients. This improvement, however, is gradual, suggesting the need for long-term ERT.     

Incidence of peri- and intraventricular hemorrhages in a premature population at the Central Hospital of Yaounde (Cameroon)]

In Cameroon, prematurity is common but few studies have been carried out on periventricular and intraventricular hemorrhage in premature neonates. Seventy neonates born between 28 and 34 weeks gestational age were studied by cerebral ultrasonography. Thirty infants (42.8%) showed evidence of periventricular or intraventricular bleeding. This proportion was 58.3% in infants born between 28 and 31 weeks gestational age. All stage III (3 cases) and stage IV (2 cases) hemorrhages were bilateral. Bilateral bleeding was less common among patients with stage I (2 cases) or stage II (2 cases) hemorrhages. Among patients born between 32 and 34 weeks gestational age, only 34.8% had ventricular hemorrhage which was always stage I or II and usually unilateral (two stage I and one stage II bilateral bleeds). The incidence of periventricular and intraventricular hemorrhage is high in Yaoundé. Ultrasonographic evaluation should be routinely performed in infants born before 35 weeks gestational age.     

Hearing impaired neonate: role of the paediatrician

Electrophysiological screening of the hearing of newborn infants has demonstrated that hearing impaired infants can be successfully detected soon after birth.(1) There is much evidence to support the belief that the early fitting of hearing aids when needed (at less than 6 months of age) and guided early language stimulation can result in good outcomes in the language of deaf children.(2,3) The paediatrician and family doctor play key roles in ensuring these outcomes.     

Various aspects of hearing loss in newborns: A narrative review

Hearing loss is considered the most common birth defect. The estimated prevalence of moderate and severe hearing loss in a normal newborn is 0.1%-0.3%, while the prevalence is 2%-4% in newborns admitted to the newborn intensive care unit. Neonatal hearing loss can be congenital (syndromic or non-syndromic) or acquired such as ototoxicity. In addition, the types of hearing loss can be conductive, sensorineural, or mixed. Hearing is vital for the acquisition of language and learning. Therefore, early detection and prompt treatment are of utmost importance in preventing the unwanted sequel of hearing loss. The hearing screening program is mandatory in many nations, especially for high-risk newborns. An automated auditory brainstem response test is used as a screening tool in newborns admitted to the newborn intensive care unit. Moreover, genetic testing and screening for cytomegalovirus in newborns are essential in identifying the cause of hearing loss, particularly, mild and delayed onset types of hearing loss. We aimed to update the knowledge on the various aspects of hearing loss in newborns with regard to the epidemiology, risk factors, causes, screening program, investigations, and different modalities of treatment.     

Auditory profile in children recovering from bacterial meningitis

In the present study BERA profile of 30 post-meningitic children was compared with 15 normal children of the same age and it was observed that 36.6% children in the age range of 6 months to 36 months were found to have varying degree of sensorineural deafness. Severe bilateral sensorineural hearing loss (>80 dB) was observed in 6.6% children and moderate (40–80 dB) hearing loss in 30% of children. Abnormalities were bilateral in both the samples of children with severe hearing loss (>80 dB) whereas among 9 children who had moderate hearing loss abnormalities were bilateral in one patient and unilateral in the remaining 8 children. A relationship between higher incidence of sensorineural deafness and younger age of children, and occurence of seizures during meningitis were noted. But no relationship was observed with either sex, hydrocephalus, subdural effusion or with low CSF sugar and high CSF proteins.     

Universal hearing screening

Objective To determine the weighted incidence of hearing impairment in a standardized population of at risk and not at risk neonates seeking care at a tertiary level hospital in India. Methods A prospective study of a nonrandomized cohort of 1769 neonates (1490: Not at risk; 279: At risk) from a total of 8192 neonates (6509: Not at risk; 1683: At risk) who sought care at St John’s medical College hospital from 1^st September 2002 to 31^st March 2006 were screened for hearing impairment using transient evoked otoacoustic emissions. Weighting was performed using the expected value of 10 % at risk and 90 % not at risk infants in a typical tertiary care level center in India derived from the National Neonatology and Perinatology database 2002–2003. Z test and 95 % confidence interval was used to determine the external validity of the results. P less than 0.05 was considered as statistically significant. The power of the study is 90 %. Results The incidence of hearing impairment in infants screened was 10 per 1769 infants screened (1490: Not at risk; 279: At risk) which is 5.65 per 1000 screened. 279 at risk infants were screened and 3 were detected to have hearing impairment which is an incidence of approximately 10.75 per 1000 screened. Of the 1490 not at risk infants screened 7 had hearing impairment that is 4.70 per 1000 screened. If this was extrapolated to a standardized population consisting of 10 % at risk and 90 % not at risk then the incidence would be 5.60 per 1000 screened with a 95 % confidence interval of 4.13–7.06. This narrow 95 % confidence interval with a p equal to 0.001 indicates that this value may be close to the caseload in a typical tertiary care center. Conclusion In this study the incidence of hearing impairment is 3 per 279 in at risk infants screened and 7 per 1490 in not at risk infants screened. The weighted incidence in a standardized population of neonates seeking care at tertiary level center in India is 5.60 per 1000 as per this study. This high incidence calls for all pediatricians to consider incorporating a basic hearing screen for all the neonates using cost effective and appropriate technology. Initial screening may be performed using behavioral observation techniques and confirmation by otoacoustic emissions.     

Hearing in newborn infants of opiate-addicted mothers

To investigate effects of maternal drug abuse on neonatal hearing, auditory brain-stem evoked potentials were recorded in 132 consecutive newborn infants of mothers who had taken heroin or methadone during pregnancy, alongside 1016 neonates with and 483 hospitalized neonates without risk factors, as defined by the Joint Committee on Infant Hearing. In infants antenatally exposed to opiates, the rate of severe bilateral hearing impairment (≥50 dB) did not differ from that of hospitalized neonates without risk factors (1.5% vs 2.5%). In contrast, intra-uterine toxoplasmosis, syphilis, or cytomegalovirus infection, bilirubin serum concentrations >25 mg/dl, craniofacial anomalies, and mechanical ventilation for 5 days or more were independently associated with increased rates of severe hearing impairment by analysis of all 1631 infants studied. Conclusion Newborns of opiate-addicted mothers are not at increased risk for early onset hearing loss. Received: 1 July 1998 / Accepted: 17 November 1998     

Ligurian experience on neonatal hearing screening: clinical and epidemiological aspects

AIM: Early identification and rehabilitation of newborns with congenital hearing impairment (HI) by Universal Neonatal Hearing Screening (UNHS). METHODS: The neonatal population was divided into two groups: babies with No Audiological Risk (NAR), and babies With Audiological Risk (WAR). NAR neonates underwent OAE testing, and in case of a doubtful (Refer) result, ABR testing was carried out. All WAR newborns underwent ABR testing within the third month of life. RESULTS: Between February 1, 2002 and December 31, 2004, UNHS was carried out on 32 502 newborns at the 13 regional birth centres, representing 98.7% of the whole regional neonatal population. The prevalence of HI in the population we tested was estimated at about 1 per thousand, while Bilateral Hearing Impairment (BHI) was estimated at 0.65 per thousand. A 3.7% prevalence of HI and a 2.8% prevalence of BHI was observed among the WAR population. Median age at the end of the diagnostic procedures was 6.7 months in the WAR population and 6.9 months in the NAR population. CONCLUSIONS: Our project is based on two levels of testing, which resulted in a 0.28% false-positive rate with 100% sensitivity and 99% specificity. Our screening is the first Italian experience that has been extended to a whole region and the results prove that regional neonatal hearing screening is feasible.