Early Hearing Detection and Intervention (EHDI)

Office of Children with Special Health Care Needs

The Early Hearing Detection and Intervention (EHDI) Program provides oversight to healthcare practitioners to ensure all newborns receive early screening, diagnosis and intervention for hearing loss.

Hearing loss is one of the most common birth conditions, occurring in 1 in every 500 newborns. The first months and years of life are a critical period for brain development needed for communication, social and emotional development, and even academic success. Early identification of hearing loss and appropriate intervention ensures a child will have the opportunity to reach their maximum potential.

Utah Early Hearing Detection and Intervention (EHDI) Program Goals:

All newborns receive hearing screening before discharge or before 10 days of age if born out of hospital.
For infants who fail the screening, a repeat screening should be conducted before 10 days of age.
If an infant fails the 2nd hearing screening:
1. Test for congenital Cytomegalovirus (CMV) infection before 21 days of age.
2. Complete a diagnostic hearing evaluation by a pediatric audiologist with expertise in testing infants before 3 months of age.
If an infant is diagnosed as deaf or hard of hearing (DHH)
1. Enroll infant into Early Intervention services before 6 months of age.
2. Refer family to EHDI parent to parent support services

Parents

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Physicians

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Hospitals

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Midwives

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Audiologists

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Parents

Many babies with hearing loss will react to loud sounds, cry, and babble. The only way to know if your baby has typical hearing is to have a screening done with special equipment.

Initial Newborn Hearing Screening
All babies born in Utah will have a hearing screening before they leave the hospital. If your baby was born out of hospital, your baby should have their hearing screened before 10 days of age.

Be sure to know the results of your baby’s hearing screening. The results will be a “pass” or a “fail”.

There are two tests which may be used to screen a baby’s hearing. Both tests are safe and do not hurt.

Otoacoustic Emissions (OAE)
Soft sounds are directed into the ear through a tiny earphone. When a normal inner ear (hearing organ) receives a sound, it sends a "sound" (emission) back out. A special microphone measures these responses. If a baby has hearing loss, little to no "sound" or emission may be measured. This means further testing is necessary.

Automated Auditory Brainstem Response (AABR)
Soft clicking sounds are played through earphones into the baby’s ears. Band-aid like sensors placed on the baby’s head measure the brain’s response to these soft sounds. The machine compares the response from the baby being tested to a normal hearing response for babies. If there is a good match, the baby passes the screening. If the match is not close enough, the baby will fail the screening.

These tests may be used alone or in combination. Both tests are accurate and reliable. Some hospitals use a 2-step process. Babies are first screened with OAE, and those who do fail the OAE are then screened by the AABR.

PLEASE NOTE:
The OAE and AABR are screening tests designed to capture most babies who have hearing loss but slight or mild hearing losses or those in a narrow range of pitches could be missed. It is very important to have a complete diagnostic hearing test if your child has any risk factors or if you ever have concerns about their hearing.

Babies who pass a newborn hearing screening can still develop hearing loss at a later time. In cases of mild hearing loss, your baby may pass the hearing screening. If your child has any of the following risk factors, they should receive a full hearing test with a pediatric audiologist using the following timelines. This chart is a general best practice guideline. Monitor your baby’s speech and hearing development and follow-up with your pediatrician if any concerns arise. If your child’s hearing care is already managed by a pediatric audiologist, follow their recommendations.

If your baby failed their second hearing screening, they need to be tested for a congenital Cytomegalovirus (CMV) infection before 21 days of age as CMV testing is very time-sensitive. CMV is a common virus that infects people of all ages; however, when it occurs during pregnancy, the baby can become infected, potentially causing damage to the brain, eyes, and/or inner ears. CMV causes 1/3 of all childhood hearing loss.

Congenital CMV testing is simple and painless, and is accomplished using a urine or saliva sample (the inside of your baby’s cheek is swabbed). Your baby will also be referred for a diagnostic hearing evaluation with a pediatric audiologist.

A diagnostic hearing evaluation should be completed before 3 months of age by a pediatric audiologist. A pediatric audiologist has expertise in developmentally appropriate test techniques, general child development, and parent counseling regarding infants and children with hearing loss.

If your child is deaf or hard of hearing, it is important you give your child access to language as soon as possible. You can choose verbal or visual communication - or both! There are no right or wrong answers. Communication decisions should be based on your family's needs. As you learn about your baby, you may adjust along the way. That is okay! If hearing aids are recommended, your baby should be fit as soon as possible. If your child is not using hearing aids, it is recommended to give your child access to a visual language such as American Sign Language (ASL). Regardless of the choice you make, your child should be enrolled in Early Intervention or 'EI' as soon as possible, but no later than 6 months of age. EI providers will help your family learn about, and maximize, language development tailored to your family's needs.

Here are 8 reasons to say YES to Early intervention. opens in a new tab

After hearing loss has been identified, your child will likely be followed closely the first several years in order to monitor for changes in hearing or progressive/worsening hearing loss. Your audiologist will recommend your child’s hearing evaluation schedule based on their case history, but it could be as often as every 3 to 6 months. If you notice any changes in your child’s hearing, an evaluation should be conducted as soon as possible (do not wait until your next regularly scheduled appointment).

An audiologist is the only professional qualified to select and fit all forms of amplification for children (hearing aids, FM systems, cochlear implants, and other assistive listening devices). It is important to select a pediatric audiologist with experience managing infants and children with hearing loss.

Utah Family Support and Resources

EHDI Parent Notebook (Engl opens in a new tab | Span opens in a new tab)
Find a Utah Pediatric Audiologist
Important Steps for Your Baby's Hearing Health
Medical Home Portal | Hearing Loss & Deafness
Utah DHHS Children’s Hearing Aid Program (CHAP)
Utah DHHS Congenital Cytomegalovirus (CMV) Public Education & Testing
Utah Family Voices
Utah Parent Center
Utah EHDI Parent Consultant | Talk with a parent who has been in your shoes
Utah Services for the Deaf and Hard of Hearing (Sanderson Center)

Getting Services for Your Child

National Family Support and Resources:

A.G. Bell Association for the Deaf & Hard of Hearing
American Society for Deaf Children
Baby Hearing
CDC's Developmental Milestones | Indicadores del desarrollo | CDC
EHDI-PALS | A national link to pediatric audiologists and family resources
Family Leadership in Language & Learning Center (FL3)
Hands and Voices
Hearing First
National Center for Hearing Assessment and Management (NCHAM)
Sign It! | Access to free sign language classes for newly diagnosed young children

Physicians

All newborns should be screened before discharge or if born out of the hospital before 10 days of age. If the baby does not pass, a rescreen should be completed before 14 days of age. If the baby does not pass a second hearing screening, please confirm the CMV testing has been completed (birth facility typically facilitates this process) and your patient has been referred to a Pediatric Audiologist opens in a new tab for diagnostic hearing testing.

Utah is a two-stage hearing screening state. This means that a baby may be tested twice (stage 1= inpatient and stage 2 = outpatient) before further diagnostic hearing testing is required. 90% of infants who fail the inpatient screening will go on to pass the outpatient screening. The other 10% are at a higher risk for permanent hearing loss.

Do not minimize the importance of hearing screening by saying that it is likely just fluid. Any child that does not pass a hearing screening is at higher risk for a hearing loss; there is a possibility of hearing loss even in the presence of fluid and further testing is needed.

There are two technologies which may be used to screen a baby’s hearing. These tests are automated, giving a ‘pass’ or ‘fail’ result. The automated tests allow for anyone trained on the equipment to complete the testing, including nurses, medical assistants, midwives, etc.

Otoacoustic Emissions (OAE)
OAEs assess the outer hair cell structures of the cochlea. Soft sounds are directed into the ear canal through a small earphone. When a normal functioning cochlea receives a sound, it sends an emission (from the outer hair cells) back out. A microphone records the response and interprets the emissions. If a baby has hearing loss (sensorineural or conductive), OAEs are significantly reduced or absent. This means further testing is necessary.

Automated Auditory Brainstem Response (AABR)
The AABR assesses the auditory pathway up through the brainstem. Click stimuli are played through earphones into the baby’s ears. Electrodes are placed on the baby’s head to measure the brain’s response to these soft sounds. The AABR compares the response from the baby to responses of infants with normal hearing levels. If there is a good match, the baby passes the screening. If the match is not close enough, the baby fails the screening and further testing is needed to determine the cause.

These tests may be used alone or in combination. Both tests are accurate and reliable. Some hospitals use a 2-step process. Babies are first screened with OAE, and those who fail the OAE are then tested with the AABR.

PLEASE NOTE:
The OAE and AABR are screening tests designed to capture most babies who have hearing loss but slight or mild hearing losses or those in a narrow range of pitches could be missed. It is very important for the infant to have a complete diagnostic hearing test if any risk factors are present or if parents ever have concerns about their hearing.

NICU Hearing Screening Guidelines
Newborns who have been in the NICU must have an Automated ABR to rule out a neural hearing loss. (JCIH, 2019)(Joint Committee on Infant Hearing (JCIH) Positions Statement)

If hearing screening was missed or the family has not returned for the rescreen, it is essential for the primary care provider (PCP) to educate the family on the importance of this testing.

If newborn hearing screening is performed in a physician’s office, state law requires that results be sent to the State EHDI Program (no parental release is required). Please fax to (801) 536-0492 or email ehdi@utah.gov.

If a baby fails two hearing screenings, they should:

Be referred to a Pediatric Audiologist opens in a new tab for diagnostic testing, and
complete congenital cytomegalovirus (CMV) testing.

If a baby is diagnosed with hearing loss, they should be referred to agencies capable of providing specialized early intervention services for children who are deaf or hard-of hearing and to appropriate medical specialists: ENT, genetics, ophthalmology, and other specialists as needed.

This testing is time-sensitive and must be completed before the infant is 21 days old (to rule out a congenital infection vs acquired). This test must be performed using either urine or saliva. Urine is preferred due to the risk of false positives with saliva. Blood should not be used. If testing has not been completed prior to 21 days of age please contact the Utah EHDI Program at (801) 273-6600 for guidance.

CMV testing results (both positive and negative) are required to be reported to the Utah EHDI Program. Please fax to (801) 536-0492 or email email ehdi@utah.gov.

If an infant has a positive CMV test, they should undergo a comprehensive diagnostic audiologic evaluation as soon as possible. Frequent audiologic re-assessment is also needed to promptly identify and treat progressive hearing loss. The frequency of this testing should be determined by the child's audiologist.

A general recommendation for all babies with congenital CMV (regardless of their newborn hearing screening results) is to have a hearing re-assessment every 3 months in the first three years of life, and then every six months through age six years; however, each child should be considered on an individual basis as timing of assessments may need to be more frequent or altered based on antiviral therapy, rehabilitation needs, pediatric audiologist guidance, or parent concerns.

Some infants may benefit from antiviral therapy. There is limited data on the use of antiviral medications in infants with congenital CMV infection in the absence of any known sequelae. Studies are ongoing to determine what types of therapy are of greatest benefit to CMV-infected infants. Infants with suspected congenital CMV infections should be evaluated by physicians who specialize in these infections.

More information on CMV is found here.

An infant (< 6 months adjusted age) diagnostic hearing assessment, at minimum, must include frequency-specific auditory brainstem response (ABR) testing and OAEs, bilaterally. Only completing OAEs and/or click ABR is not ‘diagnostic’ and may miss significant hearing loss. A diagnostic assessment may require more than one appointment and should be completed by a pediatric audiologist with expertise in testing infants.

Diagnostic ABR assessment is best completed as soon as possible in order to reduce the need for sedation.

Forms

EHDI Newborn Hearing Screening Results Forms: opens in a new tab
CMV and ABR Testing Order Form opens in a new tab
CMV Testing Information for Providers opens in a new tab
CMV Testing Declination form opens in a new tab
Parent Infant Program Referral form opens in a new tab **Note: Download and then open within Adobe

Resources

Hospitals

Guidelines for conducting well-baby hearing screenings

Test no sooner than 12 hours after birth or as close to discharge as possible.
Test when infant is quiet or sleeping.
Ensure a quiet environment for testing, away from background noise.

If a newborn does not pass the screening it is acceptable to repeat the screening no more than two times during the same session.

Guidelines for conducting hearing screenings in the NICU

Newborns who have been in the NICU must have an Automated ABR to rule out a neural hearing loss. (Utah Newborn Hearing Screening Standards opens in a new tab and JCIH Recommendations)

Communicating hearing screening results to families

Provide results of the screening, whether the newborn passed or did not pass the hearing screening, and explain what the results mean. Follow EHDI Screener Guidelines and Scripts opens in a new tab.
Results should be conveyed verbally and in writing to the parents.
If the infant did not pass the initial screening, do not minimize the importance of the rescreen.
Schedule the repeat hearing screening appointment prior to discharge if an infant does not pass the initial screening.
If the initial screening was not completed (the baby was missed or results were incomplete) prior to discharge, it is the birth facility's responsibility to follow-up with the family and schedule outpatient screening.
Provide all parents with information on milestones opens in a new tab of normal auditory, speech and language development in children.

CMV Mandate Responsibility

It is the hospital screening program’s responsibility to report newborn hearing screening results to the primary care provider (PCP), the family and the State EHDI program.
If the baby does not pass inpatient screening, the PCP must be notified of the failed screening.
If the baby returns and does not pass their outpatient screening, complete the CMV and ABR Testing Order Form opens in a new tab and assist the family to the hospital lab for testing. Notify the PCP of failed screening and need for CMV testing. Notify the the EHDI Program at email ehdi@utah.gov.

Forms

CMV and ABR Testing Order Form opens in a new tab
Parent Infant Program Referral Form opens in a new tab **Note: Download and then open within Adobe,

Resources

Midwives

Birth attendants are required by law to assure initial hearing screening occurs no later than 7 days of age. If a newborn fails the hearing screening, a follow-up screening should be performed no later than 14 days of age.

If the newborn fails their initial hearing screen and the screen was performed more than 14 days after birth OR if the newborn fails their rescreen, the newborn should immediately be referred for congenital Cytomegalovirus (CMV) testing. **Note: The midwife can collect the speciment (urine or saliva only) and send directly to their preferred lab. Specimen kits are available to order direclty from labs.

A CMV and ABR Testing Order Form opens in a new tab should be completed and the family should be directed to a lab for CMV testing. Notify the primary care provider (PCP) (if known) and Utah EHDI at email ehdi@utah.gov or fax to (801) 536-0492.

CMV testing is time-sensitive and must be completed before 21 days of age in order to rule-out congenital vs. acquired CMV. CMV testing is simple and painless, and is accomplished using a urine or saliva sample (the inside of your baby’s cheek is swabbed).

Reporting newborn hearing screening results to the EHDI Program is mandated opens in a new tab and must be done within 7 days of the screening. Reporting can be done via email at email ehdi@utah.gov, fax to (801) 536-0492, direct entry into EHDI database (HiTrack), or other approved methods.

Forms

Resources

Audiologists

As an Audiologist, you play a key role in the EHDI Process:

Confirm CMV testing results and document them in your diagnostic report. If CMV testing has not been completed, please recommend to the family the importance of completing testing and assist them (if possible) to a hospital lab. .
Complete diagnostic audiologic evaluation prior to 3 months of age. (JCIH Recommendations opens in a new tab) This should Include:
- ABR (suprathreshold click AND frequency-specific stimuli)
- OAEs
- Tympanometry
- Bone-conduction (as indicated)
Report the results to the child's Primary Care Physician (PCP) and Fax to (801) 536-0492 (Utah EHDI Program)
Make a referral to USDB Parent Infant Program opens in a new tab.

Forms

Newborn Hearing & CCHD Screening Results Form opens in a new tab
Referral for Diagnostic Audiological Evaluation opens in a new tab
Utah EHDI Audiology PIP Referral Process. opens in a new tab **Note: Download and then open within Adobe.

Resources

Utah EHDI Well-baby Screening and Diagnostic Protocol
Utah EHDI NICU & High-Risk Protocol
Utah EHDI Infant Diagnostic & PIP Referral Process
8 Reasons to Say Yest to Early intervention
EHDI Parent Consultant Handout (English/Spanish)
EHDI Parent Notebook (English | Spanish) ** Note: Newer Version is availabe upon request, call 801-273-6600.
Newborn Hearing Parent Roadmap
Utah Newborn Hearing Screening Standards
JCIH Recommendations
NCHAM EHDI E-Book
Recommended Utah K-12 Hearing Screening Protocol

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