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TYPE
Original Research
PAGE NO.
07-15
10.37547/tajmspr/Volume07Issue04-02
OPEN ACCESS
SUBMITED
25 February 2025
ACCEPTED
20 March 2025
PUBLISHED
09 April 2025
VOLUME
Vol.07 Issue 04 2025
CITATION
Iqra Adrees, Nadeem Mukhtar, Nauman M Shah, & Anum Nasrullah. (2025).
Comparison of Hearing loss in Children 3 months to 3 years Old with and
without Risk Factors. The American Journal of Medical Sciences and
Pharmaceutical
Research,
7(04),
07
–
15.
https://doi.org/10.37547/tajmspr/Volume07Issue04-02
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Comparison of Hearing
loss in Children 3 months
to 3 years Old with and
without Risk Factors
Iqra Adrees
Clinical Audiologist, Audiology Centre, Lahore, Pakistan.
Nadeem Mukhtar
Consultant Audiologist, Hearing Aid and CI specialist Coordinator
Pakistan, Cochlear implant program, Pakistan.
Nauman M Shah
Consultant Audiologist, Hearing Aid & vestibular Specialist, Audiology
Centre, Lahore, Pakistan.
Anum Nasrullah
Clinical Audiologist, Audiology Centre, Lahore, Pakistan.
Corresponding author
*
Iqra Adrees
, Clinical Audiologist, Audiology Centre, Lahore,
Pakistan.
Abstract:
Background: Babies in newborn intensive
care units (NICU) are more expected to experience
hearing loss due to a wide range of risk factors, such as
prematurity, low birth weight, and hyperbilirubinemia.
Effects of hearing impairment among children include
poor consequences in speech, linguistics, social
interaction, education, intelligence abilities, and overall
well-being of life. Aims & Objective: The purpose of our
research was to find out the comparison of hearing loss
in children 3 months to 3 years old, with and without
risk factors. Methodology: Our study was conducted at
the Audiology Centre, Lahore. Children age range from
3 months to 3 years; both male and female genders
were included in our study. Detailed history-taking of
patients was done. We did an audiological evaluation
through TEOAEs, Immittance Audiometry, and Auditory
Brainstem Response Audiometry in 98 children (49 in
each group) with risk factors indicated by the Joint
Committee on Infant Hearings (JCIH) (2007) and
without risk factors. Every parent gave their consent to
participate in the study. Results & Findings: The total
number of children was 98; 59.6% were male and 39.4%
were female. The mean age of the children was
1.86±0.73. In the risk factor group, 77.6% of children
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had referred TEOAEs, while in the children without risk
factor group, 34.7% of children had TEOAEs referred. In
the risk factor group, 77.6% of children had hearing
loss, while in the without risk factor group, 36.7% of
children had hearing loss. The Wilcoxon Signed Ranks
test reveals a statistically significant difference (P <
0.05) between the hearing impaired with and without
risk factor groups. Conclusion: Our study reveals
significant at-risk factors for childhood hearing
impairment, including consanguinity, prematurity,
NICU stays for more than 5 days, family history of
hearing loss, meningitis, and low birth weight. This
current study recommends mandatory neonatal
hearing screening for early identification and
management. Advances in technology and evidence-
based public health approaches can help recognize,
treat, and cure hearing loss.
Keywords:
Hearing loss, Children, JCIH Risk factors,
OAEs, ABR, Tympanometry, NICU.
INTRODUCTION:
Based on studies on global data, 1-3 infants out of every
1000 are born with hearing loss (1). According to the
World Health Organization (WHO), between 0.5 and 5
newborns and infants out of every 1000 have severe-
to-profound hearing problems, or genetic or early
childhood
start
sensorineural
hearing
loss
(2).Worldwide, hearing loss counts as the fourth most
common cause of years spent disabled. According to
the most current data, there are half a billion people
globally who have a significant hearing loss (3). 9% of
individuals with hearing loss live globally (4).One of the
most prominent hereditary impairments in children is
hearing loss. Hearing is mandatory for communication
and helps children learn to identify objects, events and
awareness of sounds. Hearing is very essential for
educational purposes, life event experiences, group
activities, and social development. In children, hearing
loss is common and can lead to harmful outcomes in
schooling and social development. Effects of hearing
impairment
among
children
include
poor
consequences in speech, social interaction, education,
intelligence abilities, and overall well-being of life (5).
Hearing impairment can be acquired or congenital, with
possible causes including hereditary infections,
inherited disorders, non-syndromic causes, injury, and
other things. Assessment of hearing deafness must be
based on suspected diagnosis, degree and type of
hearing loss, age of onset, and including additional
variables. Hearing therapy for children with hearing loss
may involve the use of cochlear implants, auditory
devices, assistive listening devices, and bone-anchored
devices. Early screening and assessment of hearing loss,
as well as understanding its cause, may help with
prediction and guidance for families (2).
Hearing problems must be diagnosed within three
months after birth in order to get appropriate therapy.
Early intervention should begin before six months of
life, using the 1-3-6 early hearing diagnosis and
treatment (EHDI) (6). As suggested by the Joint
Committee on Infant Hearing (JCIH), hearing
evaluations of all infants should be done within one
month of age, and for infants whose referral
assessment is required, a detailed audiological
assessment must take place within three months of
age, and infants with hearing impairments must get
proper intervention at six months of age (7). The aim of
preliminary hearing assessment and treatment is to
help infants who are deaf develop their ability to read,
write, and speak (8).The World Health Organization
(WHO) estimates that primary, secondary, or tertiary
intervention may avoid 50% of hearing loss (3). Children
with Hearing impairment often show quiet disabilities,
demanding active investigation for it (9). The JCIH
recommendations include the following high-risk
factors: A family history of sensorineural hearing
impairment, birth weight under 1500 grams,
hyperbilirubinemia over 15 mg/dL requiring blood
transfusion, meningitis, NICU admission for more than
five days, consanguinity, and premature birth (5).
According to JCIH, babies in newborn intensive care
units (NICU) are more probably to develop hearing loss
due to a wide range of risk variables, such as
prematurity, low birth weight, and hyperbilirubinemia
(10). Hearing loss was independently associated with
the presence of at least one JCIH risk factor, admission
to the NICU for longer than five days, birth weight, and
age (11). The goal of our investigation was to find out
the comparison of hearing loss in children 3 months to
3 years old, with and without risk factors. There are
several significant benefits to studying the comparison
of hearing loss in children between the ages of three
months and three years, both with and without risk
factors. Some of these advantages include early
detection, at-risk population identification, prevalence
estimation, assessment of impacts, and long-standing
outcome evaluation. The results of these investigations
will ultimately enhance the quality of life and chances
for future achievement of young children with hearing
impairments by improving the diagnosis, treatment,
and outcomes of this condition.
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METHODOLOGY
This study employed a cross-sectional observational
design and was conducted at the Audiology Centre in
Lahore over a three-month period, from December
2023 to February 2024. The sample size was calculated
to be 98 participants, with 49 individuals in each group,
based on a 95% confidence level, 10% absolute
precision, and expected proportions of hearing loss risk
factors in the population 10% for those with risk factors
and 96.3% for those without. The sampling method
used was convenience sampling.
N=
𝑍
1−𝛼
2
⁄
2
[𝑃
1
(1−𝑃
1
)+𝑃
2
(1−𝑃
2
)]
𝑑
2
𝑍
1−𝛼
2
⁄
= 𝐶𝑜𝑛𝑓𝑖𝑑𝑒𝑛𝑐𝑒 𝑙𝑒𝑣𝑒𝑙 = 95% = 1.96
𝑃
1
= 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑝𝑟𝑜𝑝𝑜𝑟𝑡𝑖𝑜𝑛 𝐼 = 10%
𝑃
2
= 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑝𝑟𝑜𝑝𝑜𝑟𝑡𝑖𝑜𝑛 𝐼𝐼 = 96.3%
d= Absolute precision=10%
Participants included in the study were children aged 3
months to 3 years, of both genders, and were
categorized into two groups based on the presence or
absence of hearing loss risk factors, as outlined by the
Joint Committee on Infant Hearing (2007). Inclusion
criteria encompassed children with specific risk factors
such as premature birth, low birth weight (<1500 g),
hyperbilirubinemia requiring exchange transfusion,
NICU admission for more than 5 days, consanguinity,
meningitis, delayed cry at birth, or a family history of
hearing impairment. Children who met any of the
following exclusion criteria were not included:
presence of occlusive earwax, ear discharge, lack of
parental consent for OAE/ABR testing, or congenital
conditions like microtia, canal atresia, craniofacial
anomalies, and syndromic illnesses.
The data collection involved a detailed history-taking
from the participants, followed by comprehensive
audiological evaluations. The audiological assessments
included Transient Evoked Otoacoustic Emissions
(TEOAEs), Immittance Audiometry, and Auditory
Brainstem Response (ABR) Audiometry. The ABR
testing, which serves as an objective assessment of
auditory pathway function, was conducted while the
children were either asleep or sedated. The ABR
procedure involved electrode placement as follows: a
positive electrode was positioned at the high forehead
(Cz), with negative electrodes placed on the right and
left mastoids or ear lobes (A1 and A2), and a ground
electrode was placed on the lower forehead. Key
measurements recorded during ABR testing included
the absolute latencies, amplitudes, and interwave
durations, particularly between waves I, III, and V, with
wave V being the most clinically significant for
detecting auditory thresholds. ABR Recording
Parameters: The ABR testing was performed using the
following parameters:
1.
Electrode Location:
Positive electrode at Cz (high
forehead), negative electrodes at the right and left
mastoids, and a ground electrode on the lower
forehead.
2.
Stimulus Type:
Alternating polarity
3.
Stimulus Rate:
44.1/s
4.
Amplifier Filters:
High frequency at 50 Hz and low
frequency at 1500 Hz
5.
Window Length:
15 ms
6.
Number of Sweeps:
4000 click or CE chirp sweeps,
with an artifact rejection level of ±5 µV
7.
Display:
Wave V response visualization
For statistical analysis, SPSS version 27.0 was employed.
The quantitative data were expressed as mean ±
standard deviation, and comparisons between groups
were made using the Wilcoxon Signed Ranks Test.
Statistical significance was considered at a p-value of
<0.05.
RESULTS & FINDINGS
Out of 98 children, 59.6% were male and 39.4% were
female. The mean age of the children was 1.86±0.73. In
the risk factor group, 77.6% of children had referred
TEOAEs, while in the children without risk factor group,
34.7% of children had TEOAEs referred. In the risk
factor group, 69.4% of children had normal
tympanograms, while in the children without risk factor
group, 85.7% of children had normal tympanograms.
Demographics, TEOAEs, and Immittance Audiometry
are shown in Table 1.
Table 1: Demographic and Audiological Characteristics of Children with and without Risk Factors for Hearing
Impairment
Children with Risk Factors
Children Without Risk
Factors
Total
Frequency
Percentage
(%)
Frequency
Percentage
(%)
Frequency
Percentage
(%)
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In the risk factor group, 18.4% of children had a history
of premature birth, 4.1% had a history of delayed cry at
birth, 6.1% had a history of hyperbilirubinemia
requiring blood transfusion, 12.2% had a history of
meningitis, 12.2% had a history of NICU stay for more
than 5 days, 16.3% had a history of low birth weight,
42.9% had a family history of hearing loss, 79.6% had a
history of consanguinity, and 24.5% had a history of
delayed developmental milestones. The details of the
risk factors are given in Table 2.
Table 2: Distribution of Risk Factors Among Study Participants
RISK FACTORS
Frequency
Percentage %
Birth History
Normal
40
81.6
Premature
9
18.4
Delayed Cry at birth
No
47
95.5
Yes
2
4.1
Hyperbilirubinemia
requiring an exchange transfusion
No
46
93.9
Yes
3
6.1
Meningitis
No
43
87.8
Yes
6
12.2
NICU stay more than 5 days
No
43
87.8
Yes
6
12.2
Low birth weight
No
41
83.7
Yes
8
16.3
Family history of hearing loss
No
28
57.1
Yes
21
42.9
Consanguinity
No
10
20.4
Yes
39
79.6
Developmental Milestones
Normal
37
75.5
Delayed
12
24.5
In the risk factor group, 77.6% of children had hearing
loss, while in the without risk factor group, 36.7% of
children had hearing loss. In the risk factor, all children
had SNHL. 63.3% of children in the risk factor had a
profound degree of hearing loss, 6.1% had a severe
degree of hearing loss, and 8.2% of children had a
moderate degree of hearing loss. While in the children
without risk factors group, 26.5% of children had a
Age
1.69
±
0.73
2.02
±
0.70
1.86
±0.73
Gender
Male
26
53.1
33
67.3
59
59.6
Female
23
46.1
16
32.7
39
39.4
TEOAEs
Pass
11
22.4
32
65.3
43
43.9
Refer
38
77.6
17
34.7
55
56.1
Immittance
Audiometry
Type A
34
69.4
42
85.7
76
77.6
Type
As
2
4.1
1
2.0
3
3.1
Type B
12
24.5
5
10.2
17
17.3
Type C
1
2.0
1
2.0
2
2.0
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profound degree of hearing loss. The details of the type and degree of hearing loss are given in Table 3.
Table 3: Comparison of Hearing Loss Characteristics Between Children with and Without Risk Factors
Children with Risk Factors
Children Without Risk Factors
Frequency
Percentage (%)
Frequency
Percentage (%)
Hearing loss
No
11
22.4
31
63.3
Yes
38
77.6
18
36.7
Degree of hearing
loss
Moderate
4
8.2
4
8.2
Severe
3
6.1
1
2.0
Profound
31
63.3
13
26.5
Type of hearing loss
SNHL
38
77.6
14
28.6
CHL
0
0
3
6.1
MHL
0
0
1
2.0
BC ABR
No
38
77.6
44
89.8
Yes
11
22.4
5
10.2
The Wilcoxon Signed Ranks Test was applied, which
reveals a statistically significant relationship between
hearing loss with and without risk factors (P < 0.05), as
shown in Table 4.
Table 4: Wilcoxon Signed Ranks Test
Ranks
N
Mean Rank Sum of Ranks
withoutRiskHL -
Hearingloss
Negative Ranks
27
a
17.50
472.50
Positive Ranks
7
b
17.50
122.50
Ties
15
c
Total
49
a. withoutRiskHL < Hearingloss
b. withoutRiskHL > Hearingloss
c. withoutRiskHL = Hearingloss
Test Statistics
a
Without Risk HL – Hearing loss
Z
-3.430
b
Asymp. Sig. (2-tailed)
.001
a. Wilcoxon Signed Ranks Test
b. Based on positive ranks.
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Figure 1 shows a comparison of children with hearing loss with and without risk factors.
DISCUSSION
The goal of our investigation was to find the
comparison of hearing loss in children 3 months to 3
years old, with and without risk factors. According to
available research, impairment of hearing was more
reported among children with risk factors. A number of
researchers have suggested that genetic causes
contribute to approximately fifty percent of childhood
sensorineural hearing loss. Our study's findings are
similar and comparable to those of that study of
Abdulbari Bener, Amr A.M. Eihakeem et. al., which
shows that those with impaired hearing were more
inclined to have consanguineous parents (12). Another
study found that the inherited cause of hearing
disability provides information for clinical identification
of hearing-related cases using the latest generation of
sequencing in areas with a high number of
consanguineous partnerships (13).
Depending on the level of hearing loss, the hearing
needs of children may differ. The impact occurs more
strongly in children who are developing language skills
or getting educational experience (14). The study of
Giorgia Girotto,Massimo Mezzavilla et. al., matches our
study, which showed that hearing loss-affected
individuals had a higher rate of paternal consanguinity
than unaffected ones (15). According to the study of
Barbara Leal, Ana Cristina, et al., parental consanguinity
was linked to a greater risk of childhood deafness, and
our study correlated with it (16). The study of Hossam
Sanyelbhaa, Abdelmagied Kabel et al. also matches to
our study, which showed that, as compared to non-
consanguineous children, children of consanguineous
marriages had 76% higher chance to develop SNHL (17).
Another study also correlates to our study. This study
showed that 70% of the deaf children were from
parents who had cousin marriages (18). A study by
Yacouba Dia et al. also relates to our study: 93% of the
expected consanguinity rate tends to be correlated
with an exceptionally high consanguinity proportion
(19).
The study of Mercedes Valido Quintana et al. also
coordinated with our study, which proved that having a
family history of hearing loss was a risk factor (20).The
study of Talite le Roux (2014) is also parallel to our
study, which shows that the most common risks are
preterm, family history of infant hearing damage, and
NICU admission (21). Another study by Nermin Hrncic
(2018) is also similar to ours. In this investigation,
several major risk factors for hearing loss were
discovered, including a family history of persistent
childhood problems with hearing, being preterm, and
hyperbilirubinemia (22). Another study showed that
high sensorineural hearing loss rates were observed in
children with hyperbilirubinemia, while in our study,
only 6.1% of children had hyperbilirubinemia (23).
According to another study, being underweight at birth
raises the possibility of SNHL (24). Another study
correlates with ours, showing that the danger of loss of
hearing was significantly greater in infants admitted to
the NICU (25).The study of Carlos Fabian Martinez-Cruz,
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Adrian Poblano, et. al., is similar to our study, which
shows that as the primary risk factors for SNHL, low
birth weight, prolonged NICU stays, and meningitis in
high-risk infants require early management and hearing
screening (26). A study by Hassan Boskabadi et al.
showed that impairment of hearing was found to be
about 10
–
50 percent higher in infants with severe
jaundice. The bilirubin level provides the strongest
estimation for an infant's hearing condition, while in
our research, 6.1% of children had hyperbilirubinemia
(27). Another study found that admission to the
neonatal intensive care unit for longer than five days
was a crucial indication for diminished hearing in
infants (28). In our research, 16.3% of children had a
history of low birth weight, which is similar to another
study that showed that infant hearing impairment has
been linked to low birth weight (29).
The study of Silvia A. Borkoski-Barreiro et. al. also
correlates to our study. This study showed that,
unexpectedly, a greater number of VLBW babies are
receiving hearing loss diagnoses. Every infant with
SNHL had one or two hearing risk factors linked to
VLBW and had a quick diagnosis (30). A study by Xiadan
Zhu et al. showed that loss of hearing is highly prevalent
in infancy, especially in infants who are premature, and
hyperbilirubin is a major reason (31). A study by L. Pan
et al. showed that premature deliveries and very low
birth weight could raise the chance of developing
hearing loss (32). It has been discovered that children
with meningitis frequently suffer from sensorineural
hearing loss, which raises questions regarding the
importance of an appropriate and rapid audiological
diagnosis (33).
It is suggested that a hearing examination program
should be undertaken for all infants admitted. To
diagnose and treat hearing impairment quickly, a
newborn hearing screening protocol must be
established (34).Impairment of hearing inspection
should be part of the routine physical examination (35).
The chances that an infant may experience hearing
impairment rise with the number of risk factors to
which they are exposed. All newborns should have their
hearing tested because a significant portion of them
will have Sensorineural hearing impairment can occur
even when there are no known risk factors(36).Early
intervention is needed to enhance the social and
intellectual abilities of the child and minimize the
adverse effects of hearing impairment on interaction
(37).
CONCLUSION
The occurrence of hearing impairment among at-risk
factors was discovered to be quite significant in our
study. Consanguinity, prematurity, NICU stays for more
than 5 days, a family history of hearing loss, low birth
weight, and meningitis are important risk factors for
childhood hearing impairments. All children with risk
factors had bilateral profound sensorineural hearing
loss. However, we suggest a newborn hearing screening
program should be considered mandatory for the
better quality of life of children with hearing loss.
Hearing loss can be recognized and treated through the
use of current advances in technology along with
evidence-based public health approaches. The
following method involves affordable measures and
techniques, such as screening newborns and
preschoolers for hearing difficulties, as well as the
therapeutic treatment of ear challenges and the use of
listening innovations, such as cochlear implant devices
or hearing devices.
CONFLICT OF INTEREST
The authors declare no conflicts of interest regarding
this manuscript.
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