Guidance

6. Patient journey from screen to referral

Updated 25 February 2026

Applies to England

There are 2 newborn hearing screening protocols.

• the NICU  SCBU protocol – for babies who have been in a neonatal intensive care unit (NICU) or special care baby unit (SCBU) for more than 48 hours continuously.

• the well baby protocol – for all other babies.

The clinical care pathways for both well babies and babies cared for in a neonatal intensive care unit (NICU) describes the route that a parent and their baby will take from their first contact with an NHSP team member to the completion of the screening process. 

Operational guidance describes aspects of the NHSP patient journey for both pathways to help local programmes provide services which meet programme standards and commissioning expectations. At the end of each section is a call to action box that will help  identify gaps that may need to be addressed. Useful resources and supporting documents have been hyperlinked throughout to support local services in their working practices.

Information in the antenatal period

During pregnancy all parents should be provided with written information on hearing screening. Screening tests for you and your baby, brings together all antenatal and newborn screening information and is available in other languages. This information, which should be supported by verbal advice, is usually given out by the midwife during the antenatal period.

The following questions should be considered:

• do local audits show that the written screening information is being given out?

• do the midwives providing the verbal information have regular training to enable them to answer questions appropriately?

• are NHS screening programme videos and other resources being used?

•  is the method for accessing the information in different languages and formats known?

• are there opportunities for parents to ask questions?

• do postcodes map appropriately on NHS.UK for finding local newborn hearing services?

Further guidance on management of hearing screening services is available in local programme management tasks.

Accuracy of screening

No screen is 100% specific or sensitive (identifies all target cases and never refers those without). The screen is designed to pick up moderate or worse hearing loss. It will not necessarily pick up mild hearing losses and that is why it is important that parents continue to monitor their child’s reactions and making sounds. This is why parents are provided with a checklist after a baby has had clear responses following the hearing screen. This identifies sounds a baby should be making and their reaction to sound at different stages of their development. Parents are advised that hearing can change and children can acquire a hearing loss, such as glue ear, and if they are concerned about their child’s hearing or speech in the future they should speak to their GP or health visitor (HV). A child’s hearing can be assessed at any age and parental concerns should always be treated seriously.

Birth registration notification to the NHSP national IT system

Standard 1 – Identify the population and coverage

Local maternity services, or child health information services (CHIS), are responsible for entering high quality, timely data into the NHS number registration patient demographics service (PDS) . This enables electronic identification of babies eligible for screening within the NHSP national IT system. This should ideally be completed as soon as possible after birth and prior to any newborn screening being performed.

NHS numbers

The NHS number is used to match test results, monitor quality of care, improve neonatal research and help provide clinicians with the information they need to implement best practice. A newborn baby’s NHS number is vital for newborn hearing screening to ensure that all babies are offered the screen.

The national NHSP IT system has an interface with PDS  to receive electronic birth notifications for all live births within seconds of an NHS number being generated. Any change made to the demographic information in the PDS after the NHS number has been generated will not be transferred to the NHSP national IT system. However, changes made to the demographic information in the NHSP national IT system will be duplicated in the other screening programmes national IT systems that use this common data and care should be taken when editing demographic data. 

Non-live births should automatically be excluded from the NHSP national IT system. A local mechanism to identify deceased babies must be in place to ensure the NHSP national IT system is up to date and NHSP services do not offer hearing screening for a deceased baby. Any offer of screening to the family of a deceased baby should be reported as an incident.

If live births are registered as a stillbirth or neonatal death in error, these records will not reach the NHSP national IT system and the NHSP National IT system helpdesk should be informed where these records are missing. If following investigation, the birth was incorrectly marked as a stillbirth or deceased, an incident should be reported and appropriate action taken to add the record manually.

 The following questions should be considered:

• is the midwifery team aware of how important the PDS  interface is with newborn screening programme national IT systems and how they interface with each other?

• are NHS number and demographics data for each baby generated quickly and accurately?

• what happens if a birth notification record does not reach the NHSP national IT system?

• is there a clear escalation route when there is a problem identified such as a lead midwife who deals with PDS issues?

• are there failsafe systems in place when the NHSP national IT system is unavailable?

• is there a process in place to check that every baby born in your site appears on the NHSP national IT system?

Further guidance on management of NHSP services and their data can be found in the operational guidance on the NHSP national IT system.

NHSP: checks and audits to improve quality and reduce risks describes how NHSP providers can ensure incidents are avoided where possible.

NHSP programme standards advise NHSP services of key performance indicators and programme standard expectations.

Offering the newborn hearing screen

Eligibility

Standard 1 –coverage

All babies under 3 months of age, born or resident in England, should be offered a newborn hearing screen. All babies are eligible for screening.

Babies are excluded if they are less than 34 weeks gestational age, or over 3 months (12 weeks) of corrected age.

Child health information services (CHIS) can assist local services to make sure any baby who is eligible for hearing screening is offered it. Local services should establish a good working relationship with CHIS to facilitate this. This includes notification of independent births, movers in (up to 12 weeks old) and deceased babies throughout the screening and referral pathway, both within acute trusts and CHIS.

It is important to note that some babies less than 3 months (12 weeks) of age are not registered as ‘new births’ by maternity but as ‘new registrations’ by the local CHIS system, for example ‘free’ births and babies born abroad. These records will not appear in the NHSP national IT system and should be added.

CHIS or other local arrangements are responsible for identifying the baby and notifying the newborn hearing screening service for any babies who move into the area/country under three months (12 weeks) of age who have not been screened. The local screening service must be informed of these babies by CHIS, health visitor or primary care teams. The local screening service is responsible for adding the baby’s details to the NHSP national IT system, arranging an appointment and offering the screen.

If a baby moves in under 3 months of age (12 weeks), but has been screened outside of England, hearing screening should still be offered under England’s NHSP protocols.

Babies who move into England after the age of 3 months (12 weeks) are not eligible for newborn screening and do not need to be routinely added to the NHSP national IT system. There should be local protocols in place to ensure that the need for audiological referral is identified and appropriate referrals are made. The GP, HV, CHIS or other local arrangements are responsible for identifying the child and making the referral. However, if the child is then identified with a PCHI and under 5 years they need to be added onto the NHSP national IT system, by the local screening service.

Babies are also excluded from NHSP if they are diagnosed with:

• confirmed congenital cytomegalovirus (cCMV)

• microtia or external ear canal atresia

• neonatal bacterial meningitis or meningococcal septicaemia

• programmable ventriculo-peritoneal (PVP) shunts in place

A referral, for these exclusions, is the responsibility of the medical team caring for the baby. Further guidance on these exclusions is available in the Contraindications section below.

Screening teams should treat these babies as screen referrals and continue to manage them as such on the NHSP national IT system using the screening outcome of ‘Incomplete-Screening contraindicated’.

Screening teams should then expedite and monitor their referral to audiology, in conjunction with the medical team as described in the NHSP Surveillance and audiological referral guidelines.

Where and when does screening take place?

Well babies

Screening may be offered in hospital, outpatient clinics, community locations or in the patients home. All screening is undertaken by NHSP trained staff.

Where hearing screening is offered in hospital, ideally, the screen should be completed prior to discharge from hospital. If the initial screening process cannot be completed as an inpatient, an outpatient/home visit appointment will need to be arranged by the responsible NHSP service provider so that the screen can be completed within four weeks.

Every effort should be made to ensure the screen is offered and completed prior to discharge if that is appropriate for the family or there is concern that they may not return for an outpatient appointment. However, if they have been screened with a first automated otoacoustic emission (AOAE) and a no clear response has been recorded, it is important to discuss the options of an outpatient appointment to complete a second AOAE screen rather than attempting an automated auditory brain response (AABR) on a baby who is less than 12 hours old for example.

If the family opt to complete all the screening tests, AOAE1, AOAE2 and AABR, in hospital and a no clear response is obtained on completion of the screen, the baby must be referred to diagnostic services provided by audiology. It is important that this possible outcome is included in the conversation with the family to support informed choice.

Where screening is carried out by NHSP trained staff in the community or outpatient clinics any screening required should be completed by four weeks of age. If no clear response is obtained on completion of the screen, the baby is referred to diagnostic services provided by audiology.

NICU babies

The term NICU includes SCBU, paediatric intensive care (PICU) or children’s intensive care unit (ICU). It does not include transitional care.

For babies spending 48 hours or more in a NICU it is advisable to defer screening until babies are no longer receiving treatment and are ready for discharge. The baby should be recovered and be considered well, but not less than 34 weeks gestational age.

Screening is carried out by NHSP trained screeners. NICU equipment may cause electrical interference which could affect the screening equipment, and it is important the hearing screener eliminates this as much as possible before starting the screen.

The entire screening process should be completed while the baby is still in hospital and as close to discharge as possible. If the screening process is not completed, an outpatient or home visit appointment should be arranged to complete the screen.

Regardless of the screening protocol, all babies with a screen positive outcome should be offered an appointment and seen for audiological assessment in less than 4 weeks (28 days) or less than 4 weeks (28 days) corrected age if born less than 40 weeks gestation.

 The following questions should be considered:

• are all babies appearing in the NHSP national IT system?

• are other babies listed on ward lists or birth registers?

• are staff undertaking screening notified of births in a timely manner?

• does the CHIS system have other babies listed?

• are all transfers/movers in and independent births notified to screening teams?

• is baby on NICU?

• do midwives know the importance of offering the screen before discharge and how to contact your service if needed?

• are community staff undertaking the screen made aware of which babies have been screened in NICU?

• are procedures in place to ensure a mother of a deceased baby is not approached or contacted regarding the screen?

• is the mother being discharged to a temporary address from maternity?

• is there a mechanism to be notified of a change of address?

• is there an understanding of families that might have difficulties attending appointments?

Further guidance on management of NHSP services and their data is available from guidance notes on non-availability of NHSP national IT system and missing birth notifications and operational guidance on the NHSP national IT system.

NHSP: checks and audits to improve quality and reduce risks describes how NHSP providers can ensure incidents are avoided where possible.

NHSP programme standards advise NHSP services of key performance indicators and programme standard expectations.

Contraindications for newborn hearing screening

Although rare, there are some circumstances where babies eligible for screening are not screened. Guidance on the management of these babies records is available in the generic user guide on the Resources page of the NHSP national IT system.

Babies too poorly to screen

Screening should normally be completed by 3 months (12 weeks) corrected age. However, there is room for flexibility, and screening can be carried out at up to 6 months of age if the baby becomes well enough.

If the screen cannot be completed by 6 months of age, a letter is sent to the medical consultant (including a copy to the GP and HV), discharging the baby from the screening programme to their care, suggesting they refer to audiology should this be appropriate in the future.

 This course of action is suggested rather than scheduling the baby for routine targeted follow up to avoid any possibility of contacting a family of a deceased baby and enable audiology services to offer the most appropriate test based on the age of the child.

Urgent audiological assessment

There are 4 groups of babies that require immediate audiological assessment.

Group 1. Microtia or external ear canal atresia

These babies will always have a degree of hearing loss, this contraindication ensures a more timely referral to Audiology services.

Group 2. Neonatal bacterial meningitis or meningococcal septicaemia

In cases where it is confirmed, or strongly suspected, in the judgement of the paediatrician, or the neonatologist in bacterial meningitis, any organism, or meningococcal septicaemia.

This exclusion is made because the risk of sensorineural hearing loss (SNHL) is very high. The urgency for post-meningitis babies is related to the risk of ossification of the cochlea, and that urgent cochlear implant referral may be required.

Viral meningitis is not considered to be a specific risk to hearing, and where this is confirmed, the screen can proceed as normal with no need for extra follow-up.

Group 3. Programmable ventriculo-peritoneal shunts in place

This exclusion is due to the risk of magnetic fields arising from audiological stimulus transducers affecting the shunt.

Programmable ventriculo-peritoneal shunts are implantable devices that can be fitted to young babies, as a treatment for hydrocephalus to drain excess cerebrospinal fluid (CSF) from the brain to another part of the body.

PVP shunts have a magnetic valve, placed just under the skin behind the ear, for adjustment by an external control magnet. This implanted magnetic valve can unintentionally be reprogrammed by other magnetic devices if they are placed near the ear, which can then lead to a change in CSF pressure, thereby putting the baby at risk.

Some audiological equipment, including some screening devices, generate magnetic fields which can cause a potential risk. 

To reduce this risk from hearing screening devices all babies with PVP shunts should be referred directly to audiology for assessment instead of being offered the newborn hearing screen.

Audiology services can use insert earphones when testing the baby’s hearing, which pose less risk as the magnetic field is further away from the PVP shunt.

The British Society of Audiology (BSA) has guidance for audiology services on assessment for patients with PVP shunts. 

Group 4. Confirmed congenital cytomegalovirus (cCMV)

This exclusion is because the risk of hearing loss is very high, and the window of opportunity for treatment is short. These babies should be referred by the Paediatrician to Audiology for an early hearing assessment. The urgency is related to the short window of opportunity for anti-viral treatment.

Congenital cytomegalovirus is a common virus, which can be associated with hearing loss if contracted in utero (congenital CMV or cCMV). It is the only cause of SNHL that can be treated, but the treatment is time dependent. Identification and treatment within 4 weeks of birth can help stop hearing loss deterioration. 

To speed the identification of hearing loss associated with cCMV, it is recommended babies identified with confirmed cCMV before hearing screening has taken place, should be referred immediately to audiology for hearing assessment instead of being offered the newborn hearing screen. Advice for audiology services who see babies with cCMV is available from the BSA or by emailing bsa@thebsa.org.uk.   

Audiology and paediatric teams will need to agree referral mechanisms, time scales and implications for audiological testing of babies that have not reached term. The regional lead for paediatric infectious diseases and/or local paediatric audio-vestibular physician should be contacted by the paediatrician for further advice if required.

Referral timeframes

Babies in groups 1 to 3 should be seen either within 4 weeks of the decision that screening is not appropriate for recovery from the acute episode, or in less than 4 weeks (28 days) corrected age if born less than 40 weeks gestation.

Babies in group 4, may need to be seen sooner, within a timescale that is agreed with the paediatrician that permits early anti-viral treatment to start if needed.

Referral, for babies contraindicated for the hearing screen, is the responsibility of the medical team caring for the baby. When making the referral, audiology colleagues must be made aware of the reason.

Screening teams should treat these babies as screen referrals and continue to log them as such on the NHSP national IT system using the screening outcome of ‘incomplete - screening contraindicated’, expedite and monitor their referral to audiology in conjunction with the medical team. The NHSP national IT system can be used to monitor that the baby has been appointed in audiology.

Guidance for audiology teams for the assessment and management of these groups of babies is available from the BSA within its Guidelines for the early audiological assessment and management of babies referred from the newborn hearing screening programme Contact the BSA for details.

If babies have already had an auditory brainstem response (ABR), audiological assessment following an urgent referral by the medical team, before screening has been undertaken, then the screen should not be offered.

Skin conditions

If an AABR screen is required, but baby has epidermolysis bullosa or a similar skin condition where it is not possible to attach sensors. These babies must be referred to audiology for assessment.

It is the responsibility of the audiologist to liaise with the parents and agree a suitable timeframe for the assessment. Audiology may decide to defer testing until a behavioural assessment can be undertaken.

Very early screening

The screen can be carried out as soon as baby is born and over 34 weeks gestational age, but if screening is offered too soon after the baby is born there may be fluid or debris in the ear canal which will affect the ability to record an AOAE so it is better to wait until as close to discharge from hospital as possible, or consider with the family if an outpatient appointment to complete screening would be more suitable for them.

Responsibility

NHSP providers are responsible for ensuring screen completion and audiological follow-up of all the babies registered with a GP that maps to them as the responsible provider.

Where screening is offered in hospital, providers should try to complete screening for all babies (well and NICU) born in their maternity units, regardless of where they live. Where screening is not completed before discharge, outpatient appointments should be offered. If the parents live outside the providers area, then they may prefer to complete the screen where it was started, or if they live a further away, it may be easier for them to have the screen completed by their local NHSP provider. In the latter case, the birth provider should liaise with the responsible provider to ensure timely screen completion, family friendliness and parental choice.

In areas where babies are not offered screening in hospital, providers are responsible for screening all the NICU babies resident in their units, and those well babies whose GP maps to them as the responsible provider. This applies, regardless of whether the patient’s postcode is geographically outside their Local Authority area, however liaison with neighbouring NHSP providers is vital to ensure no babies miss their hearing screen.

Informed consent

Prior to screening, informed consent must be gained from an individual with parental responsibility for the baby. To make an informed decision and therefore give valid consent parents (including those with parental responsibility where they are not the biological parent) should:

• be provided with information that gives the risks and benefits of screening

• have been provided with information on hearing loss within the Screening tests for you and your baby booklet, during the mother’s antenatal care

• be provided with verbal information about the screen, at an appropriate time by an NHSP trained screener, before being offered the screen

• understand their verbal consent to screen covers the entire screening process including the audiological assessment if it is required immediately or as a targeted follow up

• understand their consent may be withdrawn at any time

• understand how the data is stored and used, as without the data being stored the screen cannot be carried out

• be given the information sheet for parents to ensure that the consent giver has been informed about and understands the facts listed there.  The information sheet may be provided to the parents as part of the consent discussion.

• if the consent giver declines the offer of screening, they should be directed to the 2 checklists ‘making sounds’ and ‘reacting to sounds’ in the personal child health record PCHR (Red Book) together with an explanation about why these lists are important.

The child’s GP and HV should be notified of any decline, withdrawal of consent, or non-attendance at appointments.

 The following questions should be considered:

• are all mothers provided with written and verbal information in a format/language they understand, enabling them to make an informed decision?

• how do the primary care team (GPs/HVs) receive notification of screens declined or not completed due to non-attendance to outpatient or withdrawal of consent?

• is there a mechanism for parents that decline, withdraw consent or do not bring their child for screening to access hearing screening or referral to audiology later?

When the verbal explanation is compromised, for example there is no opportunity to discuss the screen prior to attending an outpatient appointment, the Screening tests for you and your baby information should be available or NHS UK should be suggested in the appointment letter.

Screening coverage can be improved and incomplete screening outcomes, caused by missed appointments, withdrawn consent or decline, may be avoided by making every effort to maximise coverage by 3 months of age, including:

• telephone, text or email reminders

• outreach clinics or home visits

• liaison with trust antenatal and newborn screening coordinators, midwifery and health visiting teams

• contact with paediatric wards and intensive care units to identify readmitted unscreened babies

If an incomplete outcome, caused by missed appointments, withdrawn consent or decline, is not avoidable:

• referral for targeted follow-up is not required

• screening teams need to ensure parents are provided with information about how to seek assessment in the event of future concern

• HVs and GPs must be informed of babies that have not completed screening and are responsible for ongoing surveillance

Further guidance on management of hearing screening services is available in guidance on local programme management tasks.

Who can give consent?

Consent must be given by a person with parental rights and responsibilities for the child.

If there is any doubt relating to parental responsibility at the point of screening, the screen should be postponed and advice sort locally. Maternity staff and HV’s should be able to advise about parental responsibility and how they have obtained consent for other tests and screening programmes. Safeguarding teams, local social care services and medical records teams may also be able to help. 

 The following should be considered:

• are contact details for local social care services available for guardian/parental consent?

Adopted babies

When managing health records for adopted children, services must take particular care to ensure confidentiality, continuity of care, and sensitive handling of personal information. NHS England’s ‘Key Principles for ensuring continuous records of adopted babies’ should be followed in conjunction with local information governance procedures. NHS England’s guidance emphasises the importance of maintaining a single, continuous health record, even when a child’s NHS number or identity changes following adoption.

These principles highlight that:

• Relevant pre‑adoption health information should be integrated into the child’s ongoing record so that clinicians have access to a complete clinical history.

• Information governance and data principles must be enhanced to prevent unnecessary exposure of birth family details and to protect the child’s privacy.

• Access to sensitive information should be restricted to appropriate staff only.

• System flags or alerts should prompt careful handling to safeguard the child’s identity and wellbeing.

The following process must be followed within the NHSP national IT system.

1.) Create a new record for the child using the new NHS number and updated demographic details (adoptive or foster parent information).

2.) In the first line of the address field, add: CONFIDENTIAL & SENSITIVE.

3.) Add the new parent/carers’ contact details and mark them as the primary contact using the checkbox. The system defaults the relationship to Mother; once the record is saved, update this to the correct relationship (e.g., Foster Parent, Adoptive Parent).

4.) Merge the old and new records, selecting:

• New record as Record 1

• Original record as Record 2

5.) If the primary contact checkbox was selected in the new record, the merge process will ask which contact details to retain.

• Select the new adoptive/foster parent details.

6.) After merging, create a case note titled: CONFIDENTIAL & SENSITIVE – Adoption Record Management.

During the merge, all demographic details from the original record — including the birth mother’s name and any previous case notes (e.g. manual address changes) — will be carried into the merged record. The CONFIDENTIAL & SENSITIVE case note is essential to alert staff to the presence of sensitive historical information and ensures careful handling.

Recording consent status

The person who takes verbal consent must ensure that the information is recorded on the screening equipment if the screening offer is accepted then set consent to “full”.

Where the hearing screen is contraindicated the consent status will remain “not asked”

Where the screener obtaining consent does not have access to the NHSP national IT system to add details of the consent giver it may be acceptable to your Caldicott Guardian to record the details of the person who gives consent in the patient notes rather than in the NHSP national IT system.

Consent need only be obtained once; however, any screener carrying out a screening test has a responsibility to assure themselves that appropriate consent has been obtained, particularly where the screener was not the one who initially gained consent.  This additional check provides the parents an opportunity to ask any further questions about the screen or withdraw.  When there is a time lag between taking consent and carrying out the screen (as sometimes occurs in NICU) there will need to be a local process to ensure that the consent is recorded in the NHSP national IT system.

Further guidance on management of NHSP services and their data is available in the NHSP national IT system chapter.

Use of interpreters

The hearing screening team is responsible for determining if an interpreter is required.

The Screening tests for you and your baby booklet is available in  other languages.

The availability of interpreting services is the responsibility of the provider organisation.

 The following questions should be considered:

• is use of interpreters recorded on the NHSP national IT system?

• do local audits show that interpreters are always available when required?

• is there a written local policy on the use of interpreters or language line?

• does the team have an awareness of the ethnic and cultural diversity of your local population?

• locally, is the need for interpretation shared amongst health professionals and NHSP stakeholders such as medical teams, paediatrics, maternity, audiology or early intervention?

Further guidance on management of hearing screening services is available in guidance on local programme management tasks and operational guidance on the NHSP national IT system.

Starting the screen

Before starting the screen, the correct screening protocol needs to be determined and any risk factors identified.

Risk factors

It is important to obtain risk factors prior to screening because this can influence the pathway a baby may need to follow from a screening, audiological and ongoing surveillance perspective. Some conditions or factors can mean babies have a higher risk of hearing loss. These children may need to be referred immediately or for targeted follow up and parents need to understand the implications of these risk factors.

There are 3 ways to categorise risk factors within NHSP.

They are conditions or treatments:

• which are known to have a risk of hearing loss

• that mean a baby can develop a hearing loss that needs targeted follow up

• where screening is contraindicated and baby should be referred immediately and continue to be monitored through targeted follow up

The presence or absence of these risk factors must be recorded for all babies in the NHSP national IT system.

Risk factor or contraindication	Definition	Immediate or targeted referral to audiology?
Bacterial meningitis	Confirmed or strongly suspected bacterial meningitis (any organism) or meningococcal septicaemia	Immediate
Confirmed congenital cytomegalovirus	Confirmed congenital infection	Immediate
Microtia / external ear canal atresia	Malformation of the external part of the ear / Absence of an ear canal in one or both ears	Immediate
Programmabale ventriculo-peritoneal shunt	A baby with a surgically implanted programmable ventriculo-peritoneal shunt used as a treatment for hydrocephalus	Immediate
Congenital infection	Confirmed congenital infection such as toxoplasmosis or rubella	Targeted
Craniofacial anomalies	A (noticeable) cranio-facial anomaly such as cleft palate (excludes cleft lip only, minor pits or minor ear tags)	Targeted
NICU baby protocol without CR in one or both ears on AOAE and CR/CR on AABR	Resident on NICU over 48 hours with no clear response (NCR) on AOAE both ears but clear response (CR) on AABR both ears	Targeted
Syndrome (please add syndrome name)	Confirmed syndrome related to hearing loss	Targeted
Family History of hearing loss (broad family)	Hearing loss (unilateral or bilateral) in baby’s parents, grandparents, uncles and aunts (if blood relatives), cousins and siblings. Should be permanent (not glue ear) and present from childhood, irrespective of degree of loss	Not required
Family history of hearing loss (parents/siblings only)	Permanent, unilateral or bi-lateral hearing loss of any degree, from childhood, in baby’s immediate blood relative (not glue ear)	Not required
IPPV > 5 days or ECMO	SCBU/NICU baby who had IPPV > 5 days or who underwent Extra-Corporeal Membrane Oxygenation (ECMO)	Not required
Jaundice at exchange transfusion level	Jaundice where bilirubin (normally unconjugated) reached a level indicating the need for exchange transfusion, taking into consideration other factors such as hypoxia, acidaemia and prematurity	Not required
Neurodegenerative or neurodevelopmental disorder	Developmental delay associated with a neurological disorder	Not required
NICU > 48 hours	Baby resident in a SCBU or NICU for a continuous period of 2 days (48 hours) or more	Not required

Obtaining information about risk factors

A risk factor recording sheet can be used to assist screeners in ascertaining risk factors before screening.

Family history for both well and NICU protocol babies should be ascertained by screeners questioning of the birth mother and father. An ascertaining family history questionnaire and family history flow diagram should be used to assist screeners.

Well baby protocol with risk factors

Generally these babies are nursed on wards and therefore:

• hospital based screeners should seek confirmation from the medical or paediatric team looking after baby or appropriate maternity staff

• community based screeners would ascertain this from the discharge summary

An example would be craniofacial anomalies such as cleft palate.

NICU baby protocol with risk factors

A member of the medical or paediatric team looking after baby, NICU or SCBU team should supply this information and a mechanism for obtaining this must be established locally. It is not appropriate for screeners to try and ascertain this information from medical notes. The risk factor recording sheet should be used to identify known risks.

Ototoxic drugs

Administration of ototoxic drugs is not an indication for targeted follow up. Where a baby is receiving ototoxic drugs and the levels have risen outside the therapeutic range it is the responsibility of the medical or paediatric team looking after the baby to make decisions about referral for audiological assessment based on the information in the NHSP Surveillance and audiological referral guidelines.

Unknown congenital infection status

Unless a blood test has been performed to confirm if the baby has or has not got/had a congenital infection this risk factor is unknown.

 The following questions should be considered:

• do screeners screen without knowing whether risk factors are present?

• are there locally agreed procedures for ascertaining risk factors?

• do screeners understand the importance of recording all risk factors on NHSP national IT system, regardless of need for follow up?

• are their opportunities for liaison with or access to the medical, paediatric or neonatal teams looking after baby to ascertain risk factor information?

Further guidance on management of NHSP services is available in local programme management tasks.

Infection control

Agreed local infection control policies must be followed at all times, ensuring:

• screening equipment is cleaned following the procedures defined in the manufacturer’s equipment protocols

• local hand hygiene procedures must be followed before and after every baby screened

• consumables such as ear tips, muffs and sensors are disposed of in an appropriate manner after each screen has been completed

• consumables, which are single use items, are never reused

 The following questions should be considered:

• is there a local infection control policy?

• are screeners assessed for their compliance?

Screening test

Well baby protocol

Automated Otoacoustic Emission (AOAE)

The first stage of the screening protocol. A soft clicking sound is played into the baby’s outer ear. When the cochlea in the inner ear receives sound, it responds, and this is collected by the microphone in the screening equipment. (For a more in depth explanation screeners can refer back to the NHSP eLearning module, unit 4 – The Screening test).

AOAE 1 – both ears are tested. If the result is a clear response in both ears the screen is complete. If the result is a no clear response in one or both ears the next protocol stage of the screen is AOAE 2.

 Occasionally AOAE 2 may be considered inappropriate due to:

• lack of suitable time interval (minimum of 5 hours) between AOAE 1 and AOAE 2 due to the discharge of the baby

• technical difficulty with the test, such as persistent noisy breathing causing high artefact (noise) levels, or the presence of excess debris in one or both ears

In these circumstances the AABR would be the next protocol stage of the screen, however it would be sensible to discuss the options of an outpatient appointment with the family unless it is thought that there is a chance the family would not return to complete the screen. This would allow time to elapse and to offer the AOAE2, and AABR if needed, at the appointment.

AOAE 2 –  it is only required to retest the ear(s) that did not show a ‘clear response’ result at AOAE1 If only screening one ear, the screener must make sure the correct ear is selected and tested. An interval as long as possible and greater than 5 hours must be left between AOAE 1 and AOAE 2 to give any birth fluid or debris chance to disperse. If there is any doubt about which ear showed a ‘clear response’ at AOAE 1 then AOAE 2 should be carried out on both ears.

If the result of the AOAE 2 is a clear response in the ear(s) that required re-testing the screen is complete.

If the result is a no clear response or not complete in one or both ears the next protocol stage of the screen is the AABR.

Automated Auditory Brainstem Response (AABR)

This is the final stage of the screening protocol. Soft clicking sounds played into the baby’s outer ear via baby earmuffs, the sound triggers electrical impulses, which are collected into the screening equipment by 3 small sensors placed on the baby’s high forehead, back of shoulder and nape of the neck. (For a more in-depth explanation screeners can refer to the NHSP eLearning module, unit 4 – The Screening test).

AABR is carried out on both ears, irrespective of the results obtained at AOAE 1 and/or AOAE 2. Once a result has been obtained in both ears the AABR is complete. If the result is clear response in both ears the screen is complete. If the result is a no clear response in one or both ears an immediate referral for audiological assessment is required. An AABR should never be repeated on an ear where a no clear response result has already been recorded.

It is not appropriate to return to an AOAE2 if an AABR was attempted but the baby became unsettled.

NICU baby protocol

The AOAE and AABR are performed on both ears – the tests can be completed in any order, but both must be completed.

Only one AOAE test is required under the NICU protocol, and once a result is obtained from both ears, regardless of the outcome, the AOAE is complete. It is important to complete the AOAE in both ears for a NICU screen as bilateral NCR may indicate the presence of a mild or progressive hearing loss and requires targeted follow up. 

The AABR is carried out on both ears irrespective of the results obtained at AOAE. If the AABR result shows no clear response in one or both ears, then a referral for audiological assessment is required.

A targeted follow up must be offered for babies following the NICU screening protocol who have a no clear response AOAE in both ears and clear response on AABR in both ears as explained in NHSP Surveillance and audiological referral guidelines.

Change from well baby to NICU protocol

There are 3 scenarios for babies moving from ‘well baby’ to NICU baby protocol.

Transfer to NICU before discharge

If a baby completes the screen with a clear response (at AOAE or AABR) under the well baby protocol, but before discharge is transferred to an intensive care unit for more than 48 hours, then they should be rescreened under the NICU protocol.

This is the only circumstance in which repeat screening - after a screening outcome has already been set - can be permitted.  However, if a baby was referred to Audiology because of their well baby screen, in this instance, the screening tests should not be repeated under NICU protocol.

Admission to NICU after discharge

If a baby has not started or not completed screening, is discharged from hospital to community, and is then readmitted to an intensive care unit for more than 48 hours, then screening should be completed under the NICU protocol.

If screening was started, any screening outcome will need to be unset on the NHSP national IT system and change the baby’s screening protocol to NICU.

Any screening test results obtained under the well baby protocol will be removed from the grid on the demographics section, will not be used to suggest a screening outcome, but will be retained in the list of screening test results.

The following points should also be completed:

• carry out AOAE and AABR as close to discharge as possible

• upload the new results to the NHSP national IT system - and set the screening outcome accordingly

• enter a case note to explain the circumstances

Re-admission to hospital

If a baby completes the screen, discharges home, but is subsequently admitted to hospital, and the medical staff feel the baby’s condition or treatment may affect the baby’s hearing, the baby should not be rescreened.

The medical team caring for the baby should refer the baby to the audiology department for a hearing assessment.

Optimising screening test conditions

Establishing good test conditions before starting a screen is important, and will avoid the need to pause or stop during a screen and restart. Guidance on how to use NHSP screening equipment is provided in equipment supplier manuals, and other supporting documents. For an in depth explanation screeners can refer back to their NHSP eLearning module, Unit 7 – NHSP knowledge update - The Screening test plus Unit 4 – The screening tests).

Screeners should receive training and competency assessment for clinical skills, including how to manage equipment and difficult screening test conditions.

AOAE

Fitting the earpiece

Good earpiece fit is crucial for a successful AOAE test, because it keeps noise out of the ear and maximises the microphone’s ability to record a response from the ear if one is present. 

The information provided by the screening equipment supplier should be used to assess the fit of the earpiece.   Time should be allowed to enable the baby to settle and wait for good test conditions before the screen is started.

Test conditions and monitoring the test

The equipment will provide information that enables the screener to monitor the progress of the test and the test conditions. The screener should monitor the earpiece fit and the state of the baby visually throughout the test as well as monitoring the information provided by the equipment during the test. The test should be paused or stopped as necessary, for example, if the baby becomes restless, the earpiece falls out or the environmental noise becomes high.

AABR

Sensor positions

Sensors should be placed high forehead, nape of the baby’s neck and on the back of the shoulder. Equipment specific information is provided by each screening equipment supplier.

Skin preparation

Good preparation is essential to ensure low and balanced impedances. This optimises the chance of recording a response, if one is present, and minimises test time. Prep pad or substance in use should be approved for use locally.

Earphone placement

Ensure the earphones are sealed and making good contact with the skin around the whole circumference of the ear and that the loudspeaker is not blocked by the pinna.

Test conditions and monitoring the test

Do not start a test until the baby is sleeping or well settled and test conditions are good. Testing unsettled or crying babies is counterproductive.

It is preferable, and easiest, to screen the baby in a cot. If this is not possible and baby is in parent’s arms, for example, ensure there is no contact between their arm and the nape sensor.

Reduce sources of external acoustic noise by switching off TVs, closing doors, tactfully asking other people present to keep noise to a minimum.

Reduce electrical noise by turning off electrical equipment that can be, keeping the screening equipment at least one metre away from other electrical equipment, large metal objects or power outlets. Use the length of the screening equipment leads to keep as great a distance as possible between the baby and the screening equipment.

Monitor the state of the baby, and the attachment of the sensors and earphones visually, and using the information on the screening equipment before the test is started and during the test.

If test conditions deteriorate, pause the test and resettle the baby. Machines allow different pause times. Use the pause function only when necessary and try not to- prolong a test, especially if the parent is becoming anxious.

Errors and issues

Repeating tests

Babies whose newborn hearing screen shows clear responses in both ears should not be subject to repeated screens. Screening tests with a result of no clear response must not be repeated. Repeating tests may compromise the ability of the screen to detect hearing loss.

A test may be repeated if the result was incomplete because poor test conditions developed during the screen. In this circumstance the screener must take steps to improve the test conditions before repeating the test or may need to return to screen at another time if test conditions cannot be improved.

For AOAE tests a maximum of 3 test attempts per ear per protocol stage AOAE1 and AOAE2 is permitted.

For AABR tests, if conditions are acceptable, the screen should not be stopped unless it is unavoidable. Only one further attempt is permitted following an incomplete result in one or both ears where the incomplete result was due to poor test conditions. However, if the AABR outcome is a no clear response in one ear with an incomplete result in the other a referral to audiology is required, as the baby should not be brought back to repeat the incomplete test.

Local managers must monitor the number of screener test attempts to ensure that tests are only stopped by the screener in appropriate circumstances; such as poor test conditions and not in an attempt to avoid a no clear response result. To review the stop reasons local managers will need to download the screening test results from the NHSP national IT system and review the results in the intermediate software. Guidance on how to download results can be found on the NHSP national IT system Resource tile in the Advanced user guide.

Saving results to the incorrect ear

Occasionally a screener will screen both ears but inadvertently save both results against the same ear.  This can be managed as follows:

• if possible, the ear that has not got a result recorded should be tested. In the NHSP national IT system, the unwanted duplicate result should be set to ‘not required’

• if rescreening is not possible, and the screener and local manager are confident both ears have been screened, manage this in the NHSP national IT system.  Guidance on how this can be amended can be found in the Advanced User guide found on the NHSP national IT system Resource tile.

• If there is any uncertainty regarding whether both ears were tested, the baby should be recalled for testing and a screening incident reported as described in managing safety incidents in NHS screening programmes.

Always write a case note to explain the circumstances.

Tests started in error

If an ear piece  is not placed in the baby’s ear or the sensor leads are not connected to a baby and a test is started in error and stopped, it is acceptable to set these results to ‘not required’ in the NHSP national IT system with a case note to explain the reason why.

Time lapse between AOAE 1 and AOAE 2

The NHSP national IT system allocates AOAE results to the AOAE 1 or AOAE 2 stage according to predefined rules. AOAE 1 is regarded as complete when a ‘clear response’ or ‘no clear response’ result is obtained or when 5 hours have elapsed from the first AOAE 1 test attempt.

Therefore, if a screener records a ‘not complete’ result in one ear and does not complete the screen because the baby becomes unsettled and completes the screen the next day, then these results will be classed as AOAE 2 because more than 5 hours has elapsed since the initial test attempt.

AOAE 3 in error

If on uploading screening results to the NHSP national IT system the screener realises they have completed a further AOAE when the protocol stage should have been AABR the following course of action is indicated.

1. The parent should be contacted and the mistake explained.
2. An AABR should be offered.
3. If the parents accept the AABR the test should be completed and the results uploaded on the NHSP national IT system.
4. The AOAE3 result should be set to Not Required
5. The screening outcome should be set and actions taken documented in a case note on the NHSP national IT system.
6. If the parents do not accept the AABR, the offer should be documented in the NHSP national IT system and set the screening outcome according to the results obtained.

AABR

Both ears are tested on AABR irrespective of the AOAE results. Where the screening equipment permits both ears should be tested simultaneously. Where it does not the screener must take great care to ensure that both ears are tested. This is best achieved by attaching the ear couplers to both ears initially and switching ears as soon as one is completed.  In the event that only one ear requires testing it is essential that the screener is absolutely certain which ear is still to be tested. If there is any doubt both ears should be tested. 

Uploading electronic screening results

The screening equipment data quality (SEDQ) interface is used to upload electronic results to the babies record in the NHSP national IT system.

SEDQ data should be uploaded in a timely way (within 3 working days of the test being carried out), where it is not automatically uploaded. If data does not reach the NHSP national IT system, providers can find SEDQ missing data guidance in the NHSP national IT System Advanced user guide.

Information about SEDQ and its interface can be found in Chapter 5 Equipment.

 The following questions should be considered:

• are screening protocols followed and audited?

• is equipment calibrated as required?

•  is there evidence that routine QA checks are undertaken?

• do screeners have their competency assessed as recommended?

• is screening data uploaded via SEDQ?

• is the appropriate action known when SEDQ data does not reach the NHSP national IT system?

• is manually entered data logged and checked?

Further guidance on management of babies within NHSP services and their data is available through NHS screening programmes care pathway (NHSP – Well and NICU baby), in guidance notes on local programme management tasks and operational guidance on NHSP national IT system, equipment and data and reports.

NHSP: checks and audits to improve quality and reduce risks describes how NHSP providers can ensure incidents are avoided where possible.

Screens completed

When the hearing screen is complete:

• the results should be shared with the parent as described in the NHSP e-learning screener dialogue

• written results are provided, by recording them on the hearing screening page within the PCHR (‘Red Book’)

If the completed screen outcome is a clear response in both ears the baby is discharged from the screening programme to be monitored by its parents as it gets older.

• the parents should be directed to the two checklists ‘making sounds’ and ‘reacting to sounds’ in the PCHR and explain why these are important for monitoring their babies hearing and speech development as they grow up

If the completed screen outcome is a clear response in both ears but baby requires a targeted follow-up due to risk factors:

• the parents should be informed of the likely appointment location for audiological follow up and ask for their preferred location if there is a choice

• the parent should be provided with the appropriate NHSP targeted follow up screen outcome letter

If the completed screen outcome is a no clear response in one or both ears:

• the baby is referred for an audiological assessment having negotiated the best time with the parents and following agreed local referral processes

• the parent is provided with the appropriate NHSP screen referral outcome letter which includes a link to the supporting video

• parents should be provided with local Audiology contact details, site maps and transport methods plus car parking facilities

• parents should be provided with the information ‘Your baby’s visit to the Audiology Clinic’

• the following advice should be provided to parents:  it may be helpful to take someone with them to the appointment for support, that it can take 2-4 hours and they will need to bring nappies feeds and so on to keep themselves and their baby comfortable

• the midwifery and HV teams should be made aware of the screen outcome

• letters should be sent from NHSP to the child’s GP and Health visitor to inform them of them screen outcome and referral

 The following questions should be considered:

• is the number of incomplete screens monitored?

• have outpatient clinic locations/times been selected to meet patient needs?

• are, was not brought (WNB) and declines or withdrew consent rates monitored and is a reduction strategy in place?

• has a clear, documented referral mechanism been agreed between the screening team and paediatric audiology team(s)?

• is the referral rate from each stage of the screen monitored?

• what is the process to inform midwifery when a hospital screened baby refers on the screen?

• how do the primary care team (GPs/HVs) receive notification that a baby has referred on the screen?

• is there a strategy in place for reducing the number of referrals to audiology if higher than expected?

• do the GPs/HVs locally want to know about the babies with clear responses and those requiring a targeted follow-up?

• how is follow-up ensured for unscreened or incomplete screens when a baby is transferring to another provider?

• how do the primary care team (GPs/HVs) receive notification of withdrawn consent after screening has started?

To assist providers further guidance on management of babies within NHSP local services and their data is available through NHS screening programmes care pathway, in guidance notes local programme management tasks and operational guidance on NHSP national IT system and data and reports.

NHSP: checks and audits to improve quality and reduce risks describes how NHSP providers can ensure incidents are avoided where possible.

Parental concerns

If a baby was screened at birth and had clear responses but parents have concerns about their baby’s hearing, they should be advised to contact their local GP or HV who will be able to arrange for a hearing assessment if necessary, and in line with NHSP surveillance and audiological referral guidelines.

Babies resident in Wales

If a baby born in the responsible hospital in England is resident in Wales, the ‘Wales’ NHSP provider should be selected in the NHSP national IT system which will permit the transfer of records between both programmes. The record should be transferred and the appropriate personnel in Wales informed if any further action is required. A list of Welsh contacts is available on the NHSP contacts database within the NHSP national IT system and NBHSW and NHSP interaction guidance advises providers how to manage records with Wales.

Screening outcome set

When all screening data has been uploaded, the screening outcome should be set on the NHSP national IT system as soon as possible.

Logic in the system suggests an outcome based on the baby’s protocol, their risk factors, the test protocol and result. There are a few occasions when a screener may need to override an outcome suggested by the system. Where there is a requirement to override the suggested outcome a reason must be provided.

Permitted overrides include:

• referral for targeted follow up for professional concern

• referral for targeted follow up for the presence of a local risk factor

• when recording a cranio-facial anomaly such as a cleft lip that does not require targeted follow-up

The local manager must monitor the use of status override to ensure this is not being used incorrectly.

If a follow up has been offered for a risk factor other than those recommended nationally it is the provider responsibility to offer targeted follow up in the event of transfer to a different provider that follows the national recommendations within NHSP surveillance and audiological referral guidelines.

 The following questions should be considered:

• are there robust systems in place to ensure screening results are uploaded and the outcome set in a timely manner?

• is there a system in place to check outcomes have been set correctly?

• is the use of ‘outcome override’ monitored closely?

• are transfers and shares between providers and services on national hearing screening IT system monitored regularly, actioned appropriately and dealt with in a timely way?

To assist providers further guidance on management of babies within NHSP local services and their data is available through NHS screening programmes care pathway (NHSP – Well and NICU baby), in guidance notes local programme management tasks and operational guidance on NHSP national IT system and data and reports.

NHSP: checks and audits to improve quality and reduce risks describes how NHSP providers can ensure incidents are avoided where possible.

Screening results from private hospitals

If a parent advises that their baby has already been screened privately and the outcome did not result in a referral to Audiology, an offer of NHSP can still be made; this is a matter for local policy. If screening takes place the result should be uploaded as usual. If the parents do not wish to accept the offer of screening the screening outcome should be set as ‘Incomplete - out of coverage’ making a note of the screen results the parents have advised in a case note.

Referral for immediate and targeted follow-up

Babies with a no clear response result in one or both ears or other result who require an immediate onward referral for audiological assessment, must be offered a diagnostic audiological assessment in a timely manner. The required timescale is less than 4 weeks (28 days) or less than 4 weeks (28 days) corrected age if born before 40 weeks.

All parents should be provided with details of where and when the appointment will be taking place and details of who to contact should they need to cancel and rearrange the appointment. The audiology appointment for an immediate referral should be agreed and arranged with the parent at the time of screen completion.

Referral or targeted follow up from screen would normally take place at the patients closest Audiology service, arrangements for offering timely referral to neighbouring services must be in place. All parties must be made aware of the referral and the family should be provided with details of who to contact about the referral and where their appointment will be.

To ensure attendance at audiology it is important to advise parents that there is a possibility that their baby has a hearing loss, and they realise the importance of the assessment, taking care not to over reassure that birth fluid or congestion is the reason for the hearing screening results. Families whose baby was diagnosed with permanent childhood hearing impairment (PCHI) have shared that they attended the appointment expecting a routine discharge, believing the lack of response was due to fluid rather than hearing loss—making the unexpected diagnosis even more distressing and difficult to process.

Attendance in Audiology and adherence to the attended assessment target should be monitored and  can be improved by reminder text or phone calls to families just prior to their appointment due date.  The following questions should be considered:

• is there a written policy or protocol for dealing with immediate and targeted referrals locally?

• are immediate referral appointments made at the bedside or at the family home in conjunction with the parents?

• do parents receive verbal and written confirmation of the referral appointment and additional information such as directions, car parking and so on?

• is there a failsafe in place that ensures audiology receive the referral?

• do parents receive reminders about attending the audiology appointment?

• are weekly audits carried out to ensure referred babies have been appointed and attend audiology?

• is the uptake of appointments and babies lost to follow-up being monitored closely?

Further guidance for providers and audiologists can be found within audiology operational guidance and from the BSA.

To assist providers further guidance on management of babies within NHSP local services and their data is available through NHS screening programmes care pathway (NHSP – Well and NICU baby), in guidance notes local programme management tasks and operational guidance on NHSP national IT system and data and reports.

NHSP: checks and audits to improve quality and reduce risks describes how NHSP providers can ensure incidents are avoided where possible.

Complete hearing satisfactory outcome following assessment

When Audiology discharge babies from the assessment pathway, they direct the parent to the two checklists ‘making sounds’ and ‘reacting to sounds’ in the PCHR and explain why these lists are important. If a follow up is required for risk factors audiology will target the record on the NHSP national IT system and arrange this appointment at an age appropriate time.

Providers and their associated audiology services must enter assessment data and complete follow up outcomes on the NHSP national IT system. There is further operational audiology guidance to support audiologists with this process.