extremely low gestation infants are at high risk for auditory neuropathy
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Extremely low gestation infants are at high risk for auditory neuropathy. Lynn M. Iwamoto, MD; Konstantine Xoinis, MD; Yusnita Weirather, MA, CCC-A; Hareesh Mavoori, PhD; Steven Shaha, PhD Kapiolani Medical Center for Women & Children, Hawaii Pacific Health Center for Health Outcomes - PowerPoint PPT PresentationTRANSCRIPT
Extremely low gestation Extremely low gestation infants are at high risk for infants are at high risk for
auditory neuropathyauditory neuropathy
Lynn M. Iwamoto, MD; Konstantine Xoinis, MD; Yusnita Lynn M. Iwamoto, MD; Konstantine Xoinis, MD; Yusnita Weirather, MA, CCC-A; Hareesh Mavoori, PhD; Steven Shaha, Weirather, MA, CCC-A; Hareesh Mavoori, PhD; Steven Shaha,
PhDPhD
Kapiolani Medical Center for Women & Children, Hawaii Pacific Kapiolani Medical Center for Women & Children, Hawaii Pacific Health Center for Health OutcomesHealth Center for Health Outcomes
Honolulu, HawaiiHonolulu, Hawaii
Faculty Disclosure InformationFaculty Disclosure Information
• In the past 12 months, I have not had a In the past 12 months, I have not had a significant financial interest or other significant financial interest or other relationship with the manufacturer(s) of the relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) product(s) or provider(s) of the service(s) that will be discussed in my presentation.that will be discussed in my presentation.
• This presentation will not include discussion This presentation will not include discussion of pharmaceuticals or devices that have not of pharmaceuticals or devices that have not been approved by the FDA.been approved by the FDA.
Auditory NeuropathyAuditory Neuropathy
Auditory dys-synchrony (AD)Auditory dys-synchrony (AD) Transmission of sound to the brain is Transmission of sound to the brain is
abnormalabnormal Abnormal brainstem evoked responses Abnormal brainstem evoked responses
(ABR)(ABR) Normal acoustic emissions (OAE)Normal acoustic emissions (OAE) Preserved cochlear microphonicsPreserved cochlear microphonics Acoustic reflex absentAcoustic reflex absent
May be missed with OAE screeningMay be missed with OAE screening
Auditory NeuropathyAuditory Neuropathy
PathophysiologyPathophysiology Cochlear inner hair cellsCochlear inner hair cells Neural pathways: CN VIIINeural pathways: CN VIII BrainstemBrainstem
Speech perception is impairedSpeech perception is impaired Fluctuating lossesFluctuating losses Difficulty in background noiseDifficulty in background noise
Prognosis is unpredictablePrognosis is unpredictable Optimum management is unclearOptimum management is unclear
High risk neonatesHigh risk neonates Sensorineural hearing loss is 10 Sensorineural hearing loss is 10
times more prevalenttimes more prevalent Auditory neuropathy (AN)Auditory neuropathy (AN)
Rance, et al 1999Rance, et al 1999 1991-1996 1991-1996 5199 infants screened (at risk population)5199 infants screened (at risk population) 2.3/1000 AN2.3/1000 AN 11% of 109 SNHL11% of 109 SNHL
Berg, et al 2005Berg, et al 2005 Mar 2002-Dec 2003Mar 2002-Dec 2003 24.1% of 432 NICU (regional perinatal 24.1% of 432 NICU (regional perinatal
center)center)
Risk FactorsRisk Factors
Family historyFamily history PrematurityPrematurity HyperbilirubinemiaHyperbilirubinemia Ototoxic medicationsOtotoxic medications HypoxiaHypoxia HydrocephalusHydrocephalus MeningitisMeningitis
ObjectivesObjectives
Establish prevalence rate for auditory Establish prevalence rate for auditory neuropathy in the high risk nurseryneuropathy in the high risk nursery
Differentiate infants with auditory Differentiate infants with auditory neuropathy from those with cochlear neuropathy from those with cochlear hearing losshearing loss
Patient PopulationPatient Population
Retrospective reviewRetrospective review 1999-20031999-2003 Kapiolani Medical Center for Women and Kapiolani Medical Center for Women and
Children Newborn Special Care UnitChildren Newborn Special Care Unit Sensorineural hearing lossSensorineural hearing loss
Auditory neuropathyAuditory neuropathy Gestational age-matched controlsGestational age-matched controls
Data CollectedData CollectedDemographicsDemographics
Gestational ageGestational age BirthweightBirthweight GenderGender EthnicityEthnicity Apgar scoresApgar scores Severity of illnessSeverity of illness
Length of hospitalizationLength of hospitalization Chronic lung diseaseChronic lung disease Intraventricular hemorrhageIntraventricular hemorrhage Necrotizing enterocolitisNecrotizing enterocolitis
Data CollectedData CollectedRisk FactorsRisk Factors
MedicationsMedications FurosemideFurosemide AminoglycosidesAminoglycosides VancomycinVancomycin DexamethasoneDexamethasone
InfectionsInfections CMVCMV ToxoplasmosisToxoplasmosis MeningitisMeningitis
Mechanical ventilationMechanical ventilation Conventional ventilationConventional ventilation High frequency ventilationHigh frequency ventilation
HyperbilirubinemiaHyperbilirubinemia Pulmonary hypertensionPulmonary hypertension
Nitric oxideNitric oxide
Data CollectedData CollectedRisk FactorsRisk Factors
AN vs SNHL vs ControlAN vs SNHL vs ControlAN/ADAN/AD
(24)(24)
SNHLSNHL(71)(71)
ControlControl(92)(92)
Gestational age Gestational age (wks)(wks)
28±528±5†† 33±533±5 32±532±5
Birthweight (g)Birthweight (g) 1318±8941318±894†† 1968±10061968±1006 1872±9961872±996
Male gender (%)Male gender (%) 5858 6161 5353
1 min apgar1 min apgar 4.8±2.54.8±2.5 6.1±2.26.1±2.2 5.6±2.35.6±2.3
5 min apgar5 min apgar 6.7±1.66.7±1.6 7.7±1.77.7±1.7 7.3±1.77.3±1.7
Length of Length of hospitalization (d)hospitalization (d)
117±76117±76**†† 73±8973±89** 40±6240±62
*p<0.05 vs. Control†p<0.05 vs. SNHL
Gestational Age DistributionHigh Risk Nursery 1999-2003
PREVALENCEBy Gestational Age Group
Exposure to MedicationsExposure to Medications
AN/ADAN/AD(%)(%)
SNHLSNHL(%)(%)
ControlControl(%)(%)
AminoglycosidAminoglycosideses
95.895.8** 80.380.3 70.770.7
FurosemideFurosemide 95.895.8††** 50.750.7** 32.632.6
VancomycinVancomycin 79.279.2††** 41.441.4 27.227.2
DexamethasoDexamethasonene
54.254.2** 32.432.4** 14.114.1
*p<0.05 vs control† † pp< 0.05 vs SNHL
Neonatal MorbiditiesNeonatal Morbidities
AN/ADAN/AD SNHLSNHL ControlControl
Peak Bilirubin Peak Bilirubin (mg/dl)(mg/dl)
12.7±4.212.7±4.2 13.1±6.313.1±6.3** 10.0±3.510.0±3.5
Ventilation (d)Ventilation (d) 45±4245±42** 28±3128±31 19±2919±29
HFOV (%)HFOV (%) 16.716.7 28.228.2** 8.78.7
CMV Infection CMV Infection (%)(%)
00 7.07.0** 00
*p<0.05 vs Control
Neonatal MorbiditiesNeonatal Morbidities
AN/ADAN/AD(%)(%)
SNHLSNHL(%)(%)
ControlControl(%)(%)
BPDBPD 66.766.7††** 30.030.0** 23.923.9
IVHIVH 16.716.7 9.99.9 3.33.3
HydrocephalHydrocephalusus
4.24.2 8.58.5 3.33.3
NECNEC 8.38.3 8.58.5 3.33.3
* p<0.05 vs. control† p < 0.05 vs. SNHL
SummarySummary
SNHL = 21/1000 in the NICUSNHL = 21/1000 in the NICU
AN/AD = 5.3/1000AN/AD = 5.3/1000 26% of hearing loss26% of hearing loss 2/3 were ≤ 28 wks gestation2/3 were ≤ 28 wks gestation 44% of hearing loss for those ≤ 28 wks44% of hearing loss for those ≤ 28 wks
SummarySummary
AN/AD vs. SNHLAN/AD vs. SNHL Younger gestationYounger gestation Lower birthweightLower birthweight Greater exposure to potential ototoxic Greater exposure to potential ototoxic
medicationsmedications FurosemideFurosemide VancomycinVancomycin
Higher incidence of BPDHigher incidence of BPD Longer hospitalizationLonger hospitalization
ConclusionsConclusions
Auditory neuropathy is a significant Auditory neuropathy is a significant problem in the high risk nursery problem in the high risk nursery population.population.
Extremely premature infants are at Extremely premature infants are at highest risk.highest risk.
PerspectivePerspective
Infants in the high risk nursery should Infants in the high risk nursery should be routinely screened by both ABR and be routinely screened by both ABR and OAE before hospital discharge.OAE before hospital discharge.
Early identification of AN/AD will lead to Early identification of AN/AD will lead to a better understanding of the a better understanding of the pathophysiology and the development pathophysiology and the development of appropriate intervention strategies.of appropriate intervention strategies.