Recommended guidelines for infant hearing screening: analysis

This paper has identified problems with the guidelines and the disadvantages of the ASHA protocol. Some of these are significant. Others are less important but represent issues that should be considered when designing an EID protocol. The problems and disadvantages are summarized below. 1. The guidelines should have estimated and cost and performance of the recommended protocol. 2. The guidelines should have identified the true advantage of ABR screening (lower cost) and the disadvantage (lower hit rate) as compared to other protocols. 3. The guidelines should have evaluated other possible protocols. 4. The guidelines recommended the same protocol for all facilities (with adequate resources) independent of local factors. 5. The guidelines recommended the same screening strategy for the ICN and the WBN when different protocols may be appropriate. 6. The guidelines reject ABR screening of all WBN infants as too expensive without estimates of cost. More importantly, this is a decision that should be made by local institutions or governments. 7. The screening protocol was developed without a detailed description of the diagnostic component of the EID protocol. 8. The guidelines should have provided more information to hospitals that do not have the resources necessary to implement the recommended protocol. 9. The recommended protocol requires significant in-patient testing that can cause problems with reimbursement. 10. Some infants at risk for progressive loss can be lost from follow-up. Apparently, the guidelines were developed using a subjective, experiential approach. Although clinical experience is important, subjective impressions can be subject to bias and error. Some type of quantitative analysis is essential when developing test protocols. Perhaps a more rigorous theoretical foundation is needed to focus research and guide the development of EID protocols. The ASHA protocol is reasonable, but there is little evidence indicating that it is superior to, or even as good as, other possible protocols. Like all protocols, it has advantages and disadvantages. That is not to say that all possible protocols are appropriate. For example, protocols that delay diagnostic testing beyond 6 months should be rejected if the goal is habilitation by 6 months. Protocols that use screening tests with extremely poor hit rates may be undesirable in most situations. There remains one fundamental question. Is it even appropriate to recommend a particular protocol when, by necessity, many important local factors must be ignored? Perhaps it would be better to provide the basic data and techniques that would permit audiologists to design EID protocols that are optimum for their own circumstances.