Evidence to Practice:
Improving Care for Children with Hearing Loss
Shannon Sullivan, MD
University of Iowa Children’s Hospital

Newborn hearing screening has become successful over the last decade. Currently, more than 95% of newborns are screened for hearing loss.

However, diagnosis and intervention rates are lower: Fewer than 60% of newborns who do not pass their screening have a documented diagnosis, and only 77% of those diagnosed with hearing loss receive intervention services by 6 months of age.

Of infants who do NOT pass their newborn hearing screening:

• Fewer than 60% receive a diagnosis

• Only 77% of those with a diagnosis are treated by the age of 6 months

EHDI: Improving the Effectiveness of Newborn Hearing Screening, Diagnosis,
and Intervention

In 2001, the American Academy of Pediatrics (AAP) implemented a program, Improving the Effectiveness of Newborn Hearing Screening, Diagnosis, and Intervention (EDHI) through the Medical Home, focused on increasing the involvement of primary care pediatricians and other child health care providers by linking follow-up services more closely to the newborn’s medical home.

The Iowa EHDI program works with primary care providers to ensure Iowa children are screened, rescreened, and receive an audiological assessment. In addition, the EHDI program follows up with primary care providers and parents of the 10% of infants identified with risk factors associated with late onset or progressive hearing loss to ensure children receive a follow-up hearing screen or assessment as recommended by the Joint Committee on Infant Hearing Screening.

Iowa’s EHDI program is successfully screening 99% of newborns for early hearing loss. Of those screened, 91.6% in 2009 and 93.7% in 2010 passed. Additionally, of the newborns that missed or did not pass their initial birth screen, 70% went on to pass their outpatient screen in 2009.

In 2009, 661 children were lost to follow-up or documentation. Sixty- five children were diagnosed with a permanent hearing loss. Another 291 children were shown to have a conductive hearing loss; however, identifying the number of children who had a permanent conductive loss or normal hearing is impossible because there is no evidence of the child being rescreened following medical intervention.

To rule out the possibility of a permanent loss, it is imperative that children return to a pediatric audiologist for a hearing screen and/or diagnostic evaluation if they do not pass their birth screen, and require medical intervention to treat fluid or ear infections. In 2008, experts reviewed and prioritized existing newborn hearing screening and diagnosis and intervention recommendations, to identify the most effective of these recommendations, and to create a plan for incorporating evidence-based recommendations into practice.

Conclusions and recommendations from the workshop, Accelerating Evidence into Practice for the Benefit of Children with Early Hearing Loss, are summarized in an article of the same name in the supplement, “Improving the System of Care for Infants and Children with Early Hearing Loss” (Pediatrics 2010; 126:S1-S69).

Workshop participants used a modified Delphi process to identify the top five recommendations for each of the following key areas:

1. Diagnosis

2. Treatment

3. Parental awareness

4. Public awareness

5. Continuous quality improvement

For example, participants indicated:

Participants also made choices for organizing a stewardship group, with public-private oversight, funded and organized by the federal government, as the top priority. The  conclusion of the Pediatrics article states,

More infants are being screened early for hearing loss, but the extent of essential diagnostic follow-up and treatment is variable, and there is concern that not all children are receiving the best possible evidence-based care. The outcomes of infants identified with early hearing loss and their families can be improved by efforts to accelerate evidence into practice and to continuously monitor access, quality, and outcomes of services.

With continued support from Iowa’s primary care providers, it is possible to reduce the number of children who become lost to follow-up, and to increase the number of children who are identified with a hearing loss and enrolled in appropriate early intervention services in a timely manner.

For more information, visit:

Iowa's Early Hearing Detection and Intervention Program

Early Hearing Detection at the National Center for Medical Home Implementation

For information about follow-up efforts specific to Iowa, please contact: