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CU-Boulder research demonstrated that early identification and treatment were key to helping children remain in the normal cognitive range, helped launch nationwide adoption of universal newborn screening

Three decades ago, children born deaf or hard-of-hearing faced especially high hurdles—often marginalized as problem children who lacked normal cognitive ability, not seen as regular kids who just couldn’t hear.

The children’s hearing problems went undetected sometimes for years, when treatment was less effective than it would have been if begun during infancy. Key proof that early detection and treatment were critical came from the University of Colorado Boulder.

Today, all 4 million American newborns annually are screened for hearing loss, and those with hearing loss—about one in 300—start treatment by six months of age.

Early diagnosis and treatment have helped a new generation of hearing-impaired children study alongside children who hear, keep up with their peers in school, and enjoy a range of careers many previously could not attain.

When properly implemented, early detection and treatment—meaning by six months—can help hearing-impaired children keep up with their peers rather than lag far behind. Those were among key findings from researchers at CU-Boulder in the 1990s.

In fact, the language ability of children who have normal cognition and who were diagnosed and began treatment before six months is about 20 percent better than kids with normal cognition but diagnosed and treated after six months. That was one key finding Professor Christine Yoshinaga-Itano, professor of speech, hearing and language sciences, and her colleagues reported in 1998.

Also, the language abilities of children with “low cognition” but who were identified and treated early were almost identical to later-identified kids with normal cognition.

Those “dramatic” results prompted the American Academy of Pediatrics to endorse universal-newborn-hearing screening in 1999—a move that helped persuade all 50 states to adopt newborn-hearing-screen laws by 2009.

In fact, universal-newborn-hearing screening is listed among Ten Great Public Health Achievements between 2000 and 2010 by the U.S. Centers for Disease Control and Prevention.

“In my doctoral program, I did nothing related to public policy, and yet almost everything that has happened since has been related to implementation of public policy,” Yoshinaga-Itano observes.

CU’s research showing the critical importance of early detection and treatment “has basically touched every family in the state of Colorado,” she says.

It has improved lives. Before the adoption of universal-newborn-hearing screening, “People would just label these children as bad children” and often referred to treatment for attention-deficit and hyperactivity.

The tide begins turning

[video:https://youtu.be/IVdrAQfuSB4]

In the early 1990s, many experts endorsed universal-newborn-hearing screening. Some but not all research buttressed that view. Nonetheless, Colorado was one of the first three states that strove to implement universal screening.

In 1992, the Colorado State Department of Health launched a five-year plan to implement universal-newborn-hearing screening in the state. The health department’s move lacked the force of law, but within two years, 17 hospitals, which handled 40 percent of Colorado births, were on board.

Two then-new technologies made newborn-hearing screening much more accurate, efficient and economical than it had been previously. One device tested the cochlea, the organ of hearing, and the other checked to see if sound signals reached the brain stem.

While Colorado pursued universal-newborn-hearing screening, Yoshinaga-Itano simultaneously landed a seven-year grant from the National Institutes of Health to study the long-term health outcomes of children who were deaf or hard-of-hearing.

As universal-newborn-hearing screening spread and Yoshinaga-Itano’s team collected more data, clear trends emerged. Infants tested and treated early had better language skills, translating to better performance in school.

Colorado was the logical place to conduct this research in Colorado, because it had a large sample of early tested newborns. Rhode Island and Hawaii were also testing most newborns then, but Colorado’s newborn stream (and data pool) was six times larger than the other states’.

Additionally, neither Rhode Island nor Hawaii then assessed diagnostic or treatment outcomes of deaf or hard-of-hearing children.

Believing that Yosinaga-Itano and her colleagues had the only data that could persuasive evidence of the efficacy of early screening and treatment, the NIH asked her to further analyze Colorado’s data.

In a 1995 paper published in the journal Pediatrics, Yoshinaga-Itano and her colleagues reported that kids screened early were remained at near-normal levels in their language development, while among later-screened children, language skills lagged significantly.

Other researchers viewed CU’s results with suspicion. As Yoshinaga-Itano observes: “People didn’t believe it, because they said it couldn’t be possible that there’s that much difference between a child identified at birth and a child identified after six months.”

Landmark paper, new legislation

Two years later, armed with more data, the CU researchers analyzed the larger sample of data. Of 150 children studied, half had been identified as hearing-impaired at birth, and half had been identified after six months.

The researchers found the same effect: screening and treating before six months can significantly help children develop alongside their normally hearing peers. This was true regardless of socio-economic status, cognitive ability, race and gender.

Six months was the clear dividing line, the team found. Children identified and treated at several intervals after six months “all had the same (poor) development.”

“The early identified (kids) had great language development, the late-identified had poor language development,” she notes.

The effect was “astoundingly powerful.” It was so striking that the researchers themselves worried that they’d erred. “We checked the data like 50 times.”

It’s a dramatic result, but identification only opens the door for opportunity. You can squander that opportunity.” 

This research helped persuade the Colorado Legislature to pass one of the nation’s first laws mandating universal-newborn-hearing screening. That was 1997, when Colorado became the third state (after Rhode Island and Hawaii) to pass a law mandating newborn hearing screening.

The bill’s cosponsors spanned the political spectrum and included Marilyn Musgrave and Ed Perlmutter, who went on to serve Colorado in Congress as Republican and Democratic representatives, respectively.

“Fortunately for us, maternal child health is a nonpartisan issue,” Yoshinaga-Itano observes. She testified for the bill along with doctors, health-department officials, audiologists and parents.

Vickie Thompson, principal investigator on the Early Hearing Detection & Intervention grant at CU-Denver and longtime proponent of universal screening, testified. Dr. Albert Mehl, a pediatrician who helped launch the newborn hearing screening program at Boulder Community Hospital, also testified.

So did Janet DesGorges, a mother of a daughter born hard-of-hearing and now the executive director of Hands & Voices, a nonprofit that supports families of children who are deaf or hard-of-hearing.

The bill’s “legislative declaration” (stating the law’s intent) cited Yoshinaga-Itano’s findings, noting that early detection and treatment of hearing loss in infants had been shown to be “highly effective in facilitating a child’s development in a manner consistent with the child’s age and cognitive ability.”

Further, lawmakers declared that children who do not receive early intervention and treatment “frequently require special-educational services,” which are publicly funded. In short, this legislation helped kids and reduced the need for some special-ed funding.

The bill passed in one legislative session—a relative rarity—and the Colorado strategy for passing such laws was quickly replicated in other states.

Securing pediatricians’ support

Helping to pass a law in Colorado was a milestone, but if newborn hearing screening were to become universal nationwide, the American Academy of Pediatrics (AAP) had to be on board.

If the AAP endorsed the practice, it would essentially become a standard of care, and states would be more inclined to pass legislation.

This graph from Christine Yoshinaga-Itano’s 1998 study published in the journal Pediatrics shows mean total language quotient scores at 31 to 36 months by age of identification of hearing loss and cognition. It shows that early identification and treatment makes a marked difference in children’s language abilities. 

The AAP’s Pediatrics’ Task Force on Newborn and Infant Hearing invited Yoshinaga-Itano to present her findings. The group told her that it would not endorse universal-newborn-hearing screening unless the data showed that deafness and hearing loss could be as devastating as phenylketonuria (or PKU, an inability to process an amino acid) and as easy to treat as PKU, for which all newborns were already being screened.

PKU, which can cause brain damage, is treated by withholding milk from newborns, which helps them remain cognitively normal.

Yoshinaga-Itano was discouraged. “That standard is really high.”

But the AAP weighed the data showing that early identified, normal-cognition children had significantly greater language skills than normal-cognition but later-identified children.

The AAP was convinced by this, because, “if you don’t identify early and treat early, you end up creating an impact that is as great as having a cognitive disorder.”

In early 1999, the AAP formally endorsed universal-newborn-hearing screening. In noting the need to screen and treat hearing-impaired children before six months, the AAP statement cited Yoshinaga-Itano’s 1998 Pediatrics article.

The endorsement also cited work by the late , another early advocate for universal-newborn-hearing screening. Downs, who passed away this year at the age of 100, was professor emerita at the CU Health Sciences Center and the namesake of the Marion Downs Hearing Center in Aurora.

She was a pioneer in the 1950s and 1960s for early screening of hearing in newborns when few believed it could be done.

The American Academy of Audiology quoted Downs this way: “In my opinion, Dr. Yoshinaga-Itano is responsible for the fact that nearly every child born in the United States is now being screened for hearing loss in the newborn nurseries of this country.”

“Her research on the advantages of early identification, accomplished with her usual meticulous control, and pediatric journal articles, finally convinced physicians to throw their support for newborn screening in the nation’s hospitals.”

Within 10 years of the AAP endorsement, all U.S. states had mandated universal-newborn-hearing screening.

“It was one of the fastest moving health initiatives I think anywhere,” Yoshinaga-Itano says.

Newborn hearing screening is now a standard of care. “But Colorado was the first state to be able to demonstrate that it could be done.”

The results here led to further positive developments. With the implementation of newborn infant hearing screening, infants with profound hearing loss are candidates for earlier cochlear implantation—at 12 months and sometimes even younger.

Earlier identification led to research that demonstrated that earlier cochlear implantation resulted in optimal outcomes for these infants.

Before the implementation of universal-newborn-hearing screening, most children with hearing loss or deafness were educated with other deaf or hard-of-hearing kids. Now, almost all of these children are educated in their neighborhood schools, “competing with their normally hearing peers and doing well,” Yoshinaga-Itano observes.

“It’s a dramatic result, but identification only opens the door for opportunity. You can squander that opportunity.” If the families don’t receive the support and education they need, simply identifying the children early doesn’t guarantee good results.

More recently, Yoshinaga-Itano has consulted other nations striving to implement universal-newborn-hearing screening. This list includes the United Kingdom, Canada, Australia, New Zealand, Japan, China, Korea, Belgium, Poland, Spain, Austria, Denmark, Sweden, Norway, Netherlands, Mexico, Chile, Argentina, Brazil, Thailand, Philippines and South Africa.

Worldwide, more than 10 million babies annually are screened for hearing loss at birth.

Some states and countries are more able than others to implement effective programs, but, Yoshinaga-Itano observes, they’re moving in the right direction. They recognize the critical window of opportunity between birth and six months.

“People used to believe that babies couldn’t do anything. But actually, their brains are pretty amazing.”

For more information on the CU Department of Speech, Language and Hearing Sciences, click . For the Center for Disease Control and Prevention’s synopsis of historical moments in newborn infant hearing screening, click . For more information on Colorado’s newborn hearing screening program, click . For more background on the late Marion P. Downs, click  for an NPR segment on All Things considered.

Clint Talbott is director of communications and external relations manager for the College of Arts and Sciences and editor of the College of Arts and Sciences Magazine.