Loading

Research Article Open Access
Volume 5 | Issue 1 | DOI: https://doi.org/10.33696/pathology.5.046

Retesting of Neonatal Hearing Screening Before and During the COVID-19 Pandemic: A Longitudinal Study

  • 1Speech Therapy Course at the Federal University of Santa Catarina (UFSC), Florianópolis - SC, Brazil
  • 2Pharmacy Course at the Federal University of Santa Catarina (UFSC), Florianópolis-SC, Brazil
  • 3Medicine Course at the Federal University of Fronteira Sul (UFFS), Chapecó-SC, Brazil
+ Affiliations - Affiliations

*Corresponding Author

Patricia Haas; haaspatricia37@gmail.com

Received Date: February 01, 2024

Accepted Date: March 08, 2024

Abstract

Introduction: Universal Newborn Hearing Screening (UNHS) plays an essential role in the early identification of hearing loss in neonates. Risk factors for hearing impairment may include family history, prematurity, and exposure to ototoxic substances. Coronavirus Disease 2019 (COVID-19) might be a significant contributing factor affecting the structures of the inner ear. Objective: To assess the auditory follow-up process of retesting for UNHS before and during the COVID-19 pandemic among neonates from an Outpatient Auditory Health Service (SASA) in the state of Santa Catarina with SUS (Unified Health System) assistance. Methods: A retrospective longitudinal study analyzed data from neonates attended at a SUS Auditory Health Service (SASA) from January 2018 to December 2022. Information related to UNHS and retest outcomes was assessed. Data were analyzed using Microsoft Excel® and MedCalc® Statistical Software version 22.006, utilizing statistical measures and regression analyses to identify factors associated with UNHS failures and retesting. Results: A failure to retest rate of 2.6% in the right ear and 2.2% in the left ear was observed among evaluated neonates. The average age of mothers of neonates who did not pass the test was 33 years, while the overall average was 27 years. Failure to pass the retest and a longer interval between UNHS and retesting were associated with UNHS Initial Retest Default (IRD). There was an increase in dropout rates for UNHS retesting, and the time interval between UNHS and retesting was extended during the pandemic. Conclusion: Several factors, including the interval between tests, mothers' age, and medical conditions, influenced the retest outcomes. The pandemic led to a significant increase in dropout rates and extended time for retesting.

Keywords

Neonatal screening, Newborn, Hearing, Auditory health, National Policy for Hearing Health Care

Background

COVID-19 occurred globally in late 2019, a period during which the World Health Organization and government agencies declared a global health emergency [1]. In Brazil, each region implemented measures to contain the spread of the virus, aligning with the established guidelines. According to information from the Ministry of Health, pregnant women undergo physiological changes that make them more susceptible to respiratory complications and other conditions. Clinical manifestations in pregnant women diagnosed with COVID-19 ranged from symptomatic to asymptomatic, similar to the general population, and in some cases, required hospitalization in intensive care units (ICU) [2].

Considering that congenital infections represent risk factors dependent on the relationship between the placenta and the fetus, any placental injury can result in the transmission of congenital infections such as syphilis, toxoplasmosis, human immunodeficiency virus (HIV), chickenpox, rubella, herpes, and cytomegalovirus [3]. These infections can cause direct damage to the structures of the fetal inner ear or trigger immune-mediated damage in the host. Therefore, COVID-19, being a viral disease, can also impact the structures of the inner ear, and considering that the examinations conducted to assess the functioning of the auditory structures are primarily located in the inner ear, it is understood that COVID-19 infection can lead to failures both in the initial screening and in the retesting [4].

The first sense to be awakened in intrauterine life is hearing. Sounds produced by the pregnant woman and external sounds are auditory stimuli that lead the fetus to experience sensations that increase interest in sound immediately after birth. The lack of stimulation in the auditory system may lead to the development of speech and language disorders, learning disorders, and social issues in newborns. Early auditory intervention is suggested for these cases [5-7].

It is estimated that by 2050, approximately 2.5 billion people will have hearing impairments, with 1 in 4 individuals experiencing some degree of hearing loss, and at least 700 million will require access to healthcare and auditory rehabilitation services. Moreover, 60% of hearing losses in newborns can be prevented by expanding and improving screening for neonates with risk factors for auditory diseases during UNHS conducted in maternity hospitals after birth [8]. UNHS is the initial step for identifying childhood hearing impairments. From its screening program, if a newborn fails the test or presents any Indicators of Risk for Hearing Impairment (IRHI), they are referred for retesting and/or monitoring and appropriate referrals to other necessary levels of healthcare [9].

It is crucial that the diagnosis of hearing impairment be conducted within the first month of life. Therefore, it is relevant to identify IRHI as early as possible. Some IRHI can be identified during pregnancy, highlighting the importance of providing guidance during prenatal consultations. This guidance is of great importance for early auditory diagnosis, as families need to be informed about the significance of UNHS and the auditory development of the newborn. However, some research indicates a high rate of families' lack of awareness regarding the importance of UNHS [11-14].

According to research, the most common IRHI include a family history of permanent deafness, stay in the Neonatal Intensive Care Unit (NICU), ototoxic medications, mechanical ventilation, low birth weight, prematurity, congenital infections, genetic syndromes associated with hearing impairment, Apgar score of 0 to 4 at 1 minute or 0 to 6 at 5 minutes, as well as alcoholism or drug use during pregnancy [11,15]. According to national and international guidelines, the flowchart of UNHS dictates that newborns without IRHI who failed the initial screening should undergo retesting, as well as newborns who passed or failed UNHS and have IRHI [16]. The attendance rate for retesting is one of the quality indicators of a UNHS program, with an expected attendance rate of 90% for newborns referred for retesting [17].

From the aforementioned information, it emphasizes the importance of preventive measures and early childhood auditory diagnostic assistance, as they are crucial in primary health care to remain updated and standardized in collecting data. This allows for the analysis of care, detected results, and leads to potential new public health policies for childhood auditory health. Following this guidance, this research aimed to verify the auditory follow-up process of retesting for UNHS before and during the COVID-19 pandemic among neonates from an Outpatient Auditory Health Service (OHS) in the state of Santa Catarina, Brazil, with SUS assistance.

Materials and Methods

Study design and location

This study constitutes retrospective longitudinal research involving the secondary analysis of data recorded in the database of neonates attended at a reference center in Auditory Health within the scope of the SUS from January 2018 to December 2022. The inclusion criteria encompassed neonates who underwent UNHS and were properly registered in the mentioned database, regardless of the presence or absence of risk indicators for hearing impairment, as long as they were referred to the OHS. Exclusion criteria were established to remove neonates who had satisfactory results in UNHS and did not present risk factors for hearing loss from the study. Neonates with incomplete information that was essential for the research were also excluded.

Data collection

The data collection was conducted by analyzing the available information in the database of the Auditory Health Service, a reference center in Santa Catarina. This service plays a crucial role in performing UNHS in a referenced Auditory Health Service that serves two large public maternity hospitals. It oversees retests and follows the protocol established by the Care Network for Persons with Disabilities in Santa Catarina [18].

Information was gathered encompassing prenatal, childbirth, and postpartum data, sociodemographic characteristics of the mother and newborn (including sex and age), results of Transient Evoked Otoacoustic Emissions (TEOAE) and/or Auditory Brainstem Response (ABR) tests classified as "PASS" or "FAIL," as well as the identification of IRHI. For newborns who did not pass the UNHS, information regarding attendance or non-attendance for retesting and the related care procedures involved in this process were also collected.

Data analysis

The data were organized into spreadsheets using Microsoft Excel® and subsequently exported for analysis using the MedCalc® Statistical Software version 22.006. For the analysis of quantitative (numeric) data, descriptive statistics were employed, providing summary measures (position and variability), such as mean, median, minimum, maximum, and standard deviation. Relevant statistical graphs were utilized to ensure adequate visualization of the obtained results. Descriptive statistics with single and double entry tabulations were used to describe categorical variables, showing absolute and relative frequencies relevant to the study's objectives.

Additionally, regression analyses were conducted to identify factors associated with retesting failures and to analyze the non-attendance rate for retesting, as well as the time taken for retesting. These analyses were crucial to guide proposals for improving auditory health promotion in Santa Catarina.

Ethical aspects

This research was approved by the Research Ethics Committee (REC) of the Federal University of Santa Catarina, under protocol number CAAE: 39562720.8.0000.0121.

Results

Table 1 presents a comprehensive summary of the distribution of retest examinations conducted. Two types of examinations, OAE (Otoacoustic Emissions) and ABR (Auditory Brainstem Response), were offered to the evaluated 1,206 neonates (100%). Among these, 118 (9.79%) underwent OAE, while 725 (60.14%) underwent ABR, and 363 (30.07%) did not attend the retest. The table also displays the results of the examinations by ear, combining the data from both types of examinations. Accordingly, 811 neonates (67.30%) obtained satisfactory results in the right ear, whereas 816 (67.7%) achieved satisfactory results in the left ear. Regarding cases of failure, 32 neonates (2.6%) presented failures in the right ear, while 27 (2.2%) showed failures in the left ear.

Table 1. Results of Retesting UNHS Examinations and Distribution of Results by Retested Ear (2018-2022).

Variables

Distribution Total for Retesting UNHS

Exams

n (Total)

(%)

 

 

P*

P**

OAE

118

9.79%

 

 

< 0.0001

< 0.0001

ABR

725

60.14%

 

 

No show

363

30.07%

 

 

Total

1206

100.0%

 

 

Results

Right ear

Left ear

P*

P**

n (Total)

(%)

n (Total)

(%)

 

 

Pass

811

67.30%

816

67.70%

< 0.0001

< 0.0001

Fail

32

2.60%

27

2.20%

Not done

363

30.10%

363

30.10%

Total

1206

100.0%

1206

100.0%

P*: P-value (Chi-square test); P**: P-value (Fisher's exact test); OAE: Evoked Otoacoustic Emissions; ABR: Auditory Brainstem Response

Based on the data presented in Table 2, several factors showed significant associations with the likelihood of failure in the UNHS retesting. Notably, the use of mechanical ventilation emerged, revealing a substantially increased likelihood of failure for neonates undergoing this intervention. Additionally, the presence of congenital malformations and the manifestation of neurological disorders were also strongly associated with retesting failure. NICU admission and the occurrence of neonatal jaundice also demonstrated statistically significant associations with retesting failure.

Table 2. Neonatal Health Factors and Probability of Failure in UNHS Retesting (2018-2022).

Variable

Gross OR*

CI95%

P-value

Adjusted OR

CI95%

P-value

Use of mechanical ventilation

No

1

 

 

1

 

 

Yes

3.66

1.3399 - 9.9975

0.0114

5.1903

1.6487-16.3397

0.0049

No prenatal follow-up

No

1

 

 

1

 

 

Yes

 

10.8514

0.9620 - 122.4015

0.0538

59.6179

3.2588-1090.6650

0.0058

Malformation

No

1

 

 

1

 

 

Yes

 

24.9688

7.6303 - 81.7052

<0.0001

30.4692

8.1816-113.4704

<0.0001

Neurological disturbances

No

1

 

 

1

 

 

Yes

 

14.8519

2.4061 - 91.6745

0.0037

12.2323

1.6792-89.1082

0.0135

Trisomy 21

No

1

 

 

1

 

 

Yes

 

5.4122

0.5902 - 49.6323

0.1353

9.937

0.9796-100.8028

0.0521

Admission to NICU

No

1

 

 

1

 

 

Yes

 

1.6533

0.7854 - 3.4803

0.1855

2.0713

0.8063-5.3208

0.1303

Jaundice

No

1

 

 

1

 

 

Yes

 

4.0101

0.8569 - 18.7662

0.0778

4.1374

0.6816-25.1132

0.1227

Family History of Hearing Loss

No

1

 

 

1

 

 

Yes

 

1.9509

0.2453 - 15.5148

0.5276

3.2307

0.3832-27.2351

0.2809

Prematurity

No

1

 

 

1

 

 

Yes

0.704

0.3550 - 1.3960

0.3149

0.5332

0.2263-1.2563

0.1504

Age of the mother

x

1

 

 

1

 

 

x + 1 year

nd

nd

nd

0.9919

0.9421-1.0444

0.7577

*= OR, unadjusted Odds Ratio; P value Z-test to unadjusted Odds Ratio;

aOR, odds ratio adjusted for the independent variables included in the models (Maternal age, Mechanical ventilation use, Did not undergo prenatal testing, malformation, neurological disorders, trisomy 21, ICU admission, family history of hearing loss, prematurity).

Model – Dependent Variable = falha na UNHS; *Method Enter, Overall Model Fit, Significance level  P<0,00001 Constant -3,17538; Hosmer & Lemeshow test, Significance level P = 0,5015; Area under the ROC curve (AUC) = 0,751 (95%CI 0,719-0,782);

The results below refer to Table 3, which demonstrates the quantity of IRHI present in 824 neonates who attended the UNHS Retest. Most neonates (45.63%) showed one IRHI, while 17.96% did not have any related IRHI. Additionally, 20.00% exhibited two IRHI, 11.77% had three IRHI, 3.16% recorded four IRHI, 1.09% presented five IRHI, and only 0.36% had six IRHI.

Table 3. Quantity of IRHI present in the neonates who attended the UNHS Retest, Florianópolis, SC (2018-2022).

Variable

Number of IRHI present in neonates.

P*

n

%

IQR

None

148

17.96%

18.5-38.5

0.001437

One

376

45.63%

19.0-67.0

Two

165

20.00%

21.8-103.5

Three

97

11.77%

16.5-84.3

Four

26

03.16%

81.0-206.0

Five

9

01.09%

31.5-97.75

Six

3

0.36%

25.25-111.50

Total

824

100%

 

IRHI: Indicators of Risk for Hearing Loss. P*: P value to Kruskal-Wallis test.

1,2,3,4,5,6 P <0.05 compared to row number (Post-hoc analysis for pairwise comparison of subgroups If the Kruskal-Wallis test is positive -P<0.05).

Table 4 shows the analysis of the maternal age variables in years and the retest results of the UNHS. Among the n=718 neonates who attended the retest, the median age of mothers whose neonates passed the retest was 28 years. In contrast, the 36 mothers who took their children to the retest and whose children failed the exam had a higher median age of 33 years.

Table 4. Analysis of the Influence of Maternal Age on the Results of the UNHS Retest, Florianópolis, SC (2018-2022).

Variable

Passes in the Retest

Fails the Retest

P**

n

Median

IQR

n

Median

IQR

 

Mother’s Age (years)

718

28

23 -34

36

33

18-71

0.9556

P**: P values obtained to comparison of medians UNHS (Mann-Whithney test); UNHS: Universal Newborn Hearing Screening

Table 5 describes a total of 1,206 neonates who were scheduled for the UNHS retest. In the years before the pandemic, 2018 and 2019, 4.40% of the neonates were referred for the retest, with 0.70% not attending in 2018. In 2019, 35.10% of the babies were referred for the retest, with a non-attendance rate of 9.80%. However, during the pandemic years, in 2020, 24.90% were referred for the retest, with a non-attendance rate of 9.80%. In 2021, 17.00% of the babies were referred, and 6.40% did not attend. In the post-pandemic period, in 2022, 18.70% were referred, with a non-attendance rate of 4.60%. From the total sample of 1,206 neonates, there was an evasion rate of 30.10%, with the pandemic period registering the highest evasion rate.

Table 5. Distribution of Neonates by Year and Attendance at the UNHS Retest Before and During the Pandemic, Florianópolis, SC (2018-2022).

 

Variable

Forwarded to UNHS Retest

 

P*

 

P**

Total

Did not return

Returned

n (Total)

(%)

n (No)

(%)

n (Yes)

(%)

Year

2018

53

4.40%

8

0.70%

45

3.70%

0.0013

ND

2019

423

35.10%

118

9.80%

305

25.30%

2020

300

24.90%

104

8.60%

196

16.30%

2021

205

17.00%

77

6.40%

128

10.60%

2022

225

18.70%

56

4.60%

169

14.00%

Total

1 206

100.0%

363

30.10%

843

69.90%

P*: P-value (Chi-square test); P**: P-value (Fisher's exact test). MCD: Carmela Dutra Maternity, HRSJ: Regional Hospital of São José.

Table 6 shows the time interval between the initial UNHS and the retest before the pandemic, with an average of 25 days in 2018 and 35 days in 2019. During the pandemic period, this average increased, being 40 days in 2020 and 44 days in 2021. After the pandemic, there was a decrease in this average, recording 37 days in 2022.

Table 6. Time for UNHS Retesting per Year Before and After the Pandemic, Florianópolis, SC (2018-2022).

Variable

The time between initial UNHS and retest for neonates who attended (days).

P*

n

Median

IQR

Year

2018

148

252,3 e 4

18.5-38.5

0,001578

2019

376

35 1

19.0-67.0

2020

165

40 1

21.8-103.5

2021

97

44 1

16.5-84.3

2022

38

37

8.0-85.0

Total

824

 

 

IRHI: Indicators of Risk for Hearing Loss; P*: P value to Kruskal-Wallis test

Discussion

The rate of detection of hearing impairment in this research is relatively low, indicating that the majority of neonates have hearing within normal limits (2.6% failed in the right ear, and 2.2% failed in the left ear). These data are satisfactory and suggest that the initial screening conducted in neonates might be effective in early identification of hearing problems, noting that there were more failures in the right ear, but without statistical significance. According to Marinho et al. [19], there is no consensus on the predominance of ears in failures in neonatal hearing screening.

Furthermore, the statistically significant association (p <0.0001) between the OAE and ABR examination types, as described in Table 1, and the obtained results indicates that the screening procedures are effective. This statistical validity strengthens confidence in the study's results and suggests that the screening method is robust and reliable. Presenting a detailed analysis of the influence of maternal age on the retest result, the study reveals significant observations about the median age of mothers whose neonates passed the retest (28 years), while mothers whose neonates failed the retest had a higher median age (33 years). This difference in maternal age suggests that neonates from older maternal age groups may be more likely to fail the UNHS retest, as corroborated by Cheung et al.'s study [20]. The research does not contain data regarding whether mothers contracted COVID-19 postpartum, nor whether neonates were infected subsequent to the initial screening.

Different factors have shown significant associations with the likelihood of failure in the UNHS retest. Notably, the use of mechanical ventilation emerged as a critical factor associated with an increased probability of failure in neonates undergoing this intervention. Additionally, the presence of birth malformations and the manifestation of neurological disorders also showed strong associations with retest failure, corroborating the findings in Keihanidost et al.'s study [21]. Hospitalization in the NICU and the manifestation of neonatal jaundice also exhibited statistically relevant correlations with retest failure, as indicated by Werkineh et al. [22].

Highlights a significant concern related to neonatal evasion from the UNHS retest. It is observed that, in the pre-pandemic period (2018 and 2019), the referral rate for retesting considerably increased from 4.40% to 35.10%. However, simultaneously, the non-attendance rate also increased from 0.70% to 9.80%. This may indicate greater awareness about the importance of retesting but also emphasizes the need to address factors contributing to non-attendance.

During the pandemic period (2020 and 2021), although the referral rate for retesting was lower compared to the pre-pandemic period, the non-attendance rate remained notably high. The results suggest that even in a scenario of reduced referrals, evasion continues to be a relevant concern. In the post-pandemic period (2022), the referral rate increased while the non-attendance rate decreased. This might indicate a positive trend in awareness and neonatal attendance for retesting following the end of the pandemic period.

Before the pandemic, the average return time was 25 days in 2018 and 35 days in 2019. During the pandemic, there was a significant increase in this interval, with averages of 40 days in 2020 and 44 days in 2021. In the post-pandemic period (2022), the average return time decreased to 37 days. These data suggest that the pandemic directly impacted the delay in neonates returning for retesting, possibly due to health-related restrictions and safety measures, corroborating with Besen et al. [23]. However, it is encouraging to note that after the end of the pandemic, there was a decrease in the average time interval, which may indicate a gradual recovery towards the normalcy of screening processes, and this fact might be considered a limitation of the study.

Conclusion

The results of this research indicate that the statistically significant association between the types of exams and the obtained results validates the reliability of the screening procedures, strengthening confidence in the study's outcomes. However, the influence of maternal age and other factors such as the use of mechanical ventilation, birth malformations, neurological disorders, NICU hospitalization, and neonatal jaundice demonstrates the complexity of factors that can affect the auditory screening results. These findings highlight the need for a more comprehensive approach in neonatal auditory screening, considering various risk factors like maternal age, for more targeted intervention.

Regarding the time interval between the initial UNHS and retesting during the pandemic variations, there were significant delays in the return of neonates. However, after the end of the pandemic, there was a gradual recovery towards the normalization of screening processes. These findings underscore the importance of awareness, targeted strategies, and continuity of screening services to ensure healthy hearing development in newborns, especially in challenging situations like a pandemic.

Data Availability Statement

The authors declare the availability of Data Availability Statement.

Acknowledgments

The authors would like to thank Instituto Otovida for supporting this work.

References

1. Czeresnia RM, Trad ATA, Britto ISW, Negrini R, Nomura ML, Pires P, et al. SARS-CoV-2 and Pregnancy: A Review of the Facts. Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics. 2020 Sep;42(09):562-8.

2. MINISTÉRIO DA SAÚDE. SECRETARIA DE ATENÇÃO PRIMÁRIA À SAÚDE. NOTA TÉCNICA Nº 12/2020- COSMU/CGCIVI/DAPES/SAPS/M. INFECÇÃO COVID-19 E OS RISCOS ÀS MULHERES NO CICLO GRAVÍDICO-PUERPERAL. BRASIL, 2020. https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/nota-tecnica-no-12-2020-cosmucgcivi-dapes-saps-ms

3. Galvão MB, Fichino SN, Lewis DR. Processo do diagnóstico audiológico de bebês após a falha na triagem auditiva neonatal. Distúrbios da Comunicação. 2021 Sep 28;33(3):416-27.

4. Celik T, Simsek A, Koca CF, Aydin S, Yasar S. Evaluation of cochlear functions in infants exposed to SARS-CoV-2 intrauterine. American Journal of Otolaryngology. 2021 Jul;42(4):102982.

5. Bevilacqua M, Balen S, Martinez M, Pupo A, Reis A, Frota S. Tratado de Audiologia. 1st ed. Vol. 1. 2012.

6. Zumthor P. Performance, recepção, leitura. Ubu Editora LTDA - ME; 2018.

7. Oliveira L de FM de. Saúde auditiva: caracterização do serviço de referência em triagem auditiva neonatal de Uberlândia-MG. [Curso de Saúde Ambiental e Saúde do Trabalhador, Departamento de Geografia, Universidade Federal de Uberlândia]; 2021.

8. WHO: 1 in 4 people projected to have hearing problems by 2050 [Internet]. www.who.int. Available from: https://www.who.int/news/item/02-03-2021-who-1-in-4-people-projected-to-have-hearing-problems-by-2050

9. Marcella, Figueiredo N, Luíza M. Development and validation of the Logical Model of the Neonatal Hearing Screening Program. Revista CEFAC. 2020 Aug 19;22.

10. Lewis DR, Marone SAM, Mendes BCA, Cruz OLM, Nóbrega M de. Comitê multiprofissional em saúde auditiva: COMUSA. Brazilian Journal of Otorhinolaryngology. 2010 Feb;76(1):121-8.

11. Freitas TV, Lewis DR, Nóbrega GB de. Processo de triagem auditiva neonatal e o impacto dos resultados. Distúrbios da Comunicação [Internet]. 2014 Dec 10 [cited 2023 Dec 5];26(4).

12. Luz I, Ribas A, Kozlowski L, Willig M, Berberian A. Newborn Hearing Screening in a Public Maternity Ward in Curitiba, Brazil: Determining Factors for Not Retesting. International Archives of Otorhinolaryngology. 2015 Nov 16;20(04):300-4.

13. Sabbag JC, Lacerda ABM de. Rastreamento e monitoramento da Triagem Auditiva Neonatal em Unidade de Estratégia de Saúde da Família: estudo-piloto. CoDAS. 2017 Aug 10;29(4).

14. Rezende AL de F, Resende LM de, Carvalho EA de A, Avan P, Carvalho SA da S. Avaliação de Crianças com Indicadores de Risco para Deficiência Auditiva Atendidas em um Serviço de Referência em Triagem Auditiva Neonatal. Distúrbios da Comunicação. 2020 Jan 20;31(4):630-40.‌

15. Nascimento GB, Kessler TM, Souza APR de, Costa I, Moraes AB de. Indicadores de risco para a deficiência auditiva e aquisição da linguagem e sua relação com variáveis socioeconômicas, demográficas e obstétricas em bebês pré-termo e a termo. CoDAS. 2020;32(1).

16. Ministério D, Saúde, Nacional P, Direitos Da Pessoa D, De. Diretrizes de Atenção da Triagem Auditiva Neonatal 1 da Triagem Auditiva Neonatal Diretrizes de Atenção [Internet]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_atencao_triagem_auditiva_neonatal.pdf

17. Pinto JD, Ferreira L, Temp DA, Dias V, Rohers DE, Biaggio EPV. Evasion of Newborn Hearing Screening retest: relation with risk factors for hearing impairment. Revista CEFAC. 2019;21(4).

18. ESTADO DE SANTA CATARINA SECRETARIA DE ESTADO DA SAÚDE ÁREA TÉCNICA DA SAÚDE DA PESSOA COM DEFICIÊNCIA SERVIÇO DE SAÚDE AUDITIVA ESTADO DE SANTA CATARINA SECRETARIA DE ESTADO DA SAÚDE ÁREA TÉCNICA DA SAÚDE DA PESSOA COM DEFICIÊNCIA SERVIÇO DE SAÚDE AUDITIVA [Internet]. Available from: https://www.saude.sc.gov.br/images/stories/SUR/DIRETRIZES_2021.pdf

19. Alves A, Cordeiro De Souza Pereira E, Kerlyne K, Torres C, Monforte A, Ii M, et al. Avaliação de um programa de triagem auditiva neonatal. Rev Saúde Pública 54:44.

20. Cheung A, Chen T, Rivero R, Hartman-Joshi K, Cohen MB, Levi JR. Assessing Loss to Follow-up After Newborn Hearing Screening in the Neonatal Intensive Care Unit. Ear and Hearing. 2022 Mar 1;43(2):577-81.

21. Keihani-Doust Z, Tabrizi A, Amini E, Sedaghat M, Ghahremani AA, Shariat M, Kavyani Z. Risk Factors for Hearing Loss and Its Prevalence in Neonates Older than 6 Months with History of Hospitalization in Intensive Care Unit. Iran J Child Neurol. Autumn 2018; 12(4):153-161

22. Werkineh HB, Gellaw WL, Untiso FL, Negash LG. Magnitude and Factors Associated with Refer Results of Newborn Hearing Screening at Academic Tertiary Level Hospital, Addis Ababa, Ethiopia. International Journal of Otolaryngology. 2022 Jul 7;2022:1-8.

23. Besen E, Mary K, Haas P, Alessandra Giannella Samelli, Marcos José Machado, Quialheiro A, et al. Universal neonatal hearing screening before and during the COVID-19 pandemic. International Journal of Pediatric Otorhinolaryngology. 2023 Sep 1;172:111689-9.

Author Information X