Keywords
deafness - disease - newborn
Palavras-chave
surdez - doença - recém-nascido
Introduction
The process of acquisition and development of speech and language has a strict relationship
with hearing. The identification of the auditory changes right in the first months
of life of the baby allows the occurrence of intervention still in the critical period
ideal for stimulation of language and hearing, which enables the development of the
capacity to receive, recognize, identify and discriminate the sounds around them[1]
[2] .
Therefore, the concern and the recommendations on the phonoaudiological intervention,
as a way to prevent and/or mitigate the consequences of the lack of sound stimulation
due to the hearing loss have given rise do many researches[3] indicating that in Brazil 65% of the cases of deafness in childhood result from
problems acquired in the prenatal and/or postnatal period, while 4% are a consequence
of hereditary causes[4].
It is known that 2-4:100 newborns admitted in the Intensive Care Unit (ICU) have bilateral
hearing loss[5], which may be caused by congenital infections for mother to infant transmission.
These have deserved attention for some decades due to the concern with the sequels
and damages they cause to hearing[6].
In 1974, the infectionist Nahmias
[7], already concerned with the sequels of infecto-contagious diseases for mother to
infant transmission and aiming to draw attention from the physicians for the existence
of this group of congenital infections with similar characteristics, created the acronym
TORCH (Toxoplasmosis, Congenital Rubella, Cytomegalovirus and Herpes). In 1982, JCIH
added to the acronym TORCH the letter S, indicating Congenital Syphilis and currently
it is known as TORSCH-A, for it received another addition of letter A, from AIDS.
Nevertheless, even with the concern of some researchers, we still notice the risk
indicators present upon birth have not been deemed to be indicators of hearing alteration[8], even after establishment of the relationship between some congenital infections
and the hearing loss, as shown by a study on the most frequent infectious agents related
to hypacusis, including Cytomegalovirus, Rubella virus, gondii Toxoplasma and Herpes virus[9]
[10]
[11]
[12]
[13].
Faced with the data presented we consider the need of epidemiological studies on the
occurrence of risk indicators, especially of TORSCH-A group diseases in the population
of newborns, because a survey of this nature will allow that actions and programs
for promotion of woman's health may be implemented[14]
[15].
As well as recommendations with guidance on how to prevent infecto-contagious diseases
by mother to infant transmission, by changing in a safe and effective manner the risks
to the hearing to their children, in addition to keep close attention to Toxoplasmosis,
Herpes and the Cytomegalovirus in the recommended notification category, once these
are part of the risk indicators for deafness presented by the JCIH.
Therefore, the objective of this study is to verify and compare the occurrence of
risk indicators for hearing loss during the interval of 10 years (1995 and 2005) at
a hospital of the city of São Paulo - SP.
Method
This research was approved by the Ethics Committee in research of the Hospital Municipal
e Maternidade Escola Dr. Mário de Moraes Altenfelder Silva - SP, under the number
39/08, and was qualified as quantitative, retrospective. A secondary data survey and
analysis were carried out from the records of books supplied by the Baby Ward of Hospital
Municipal e Maternidade Mário de Moraes Altenfelder Silva - SP, popularly known as
Maternidade Vila Nova Cachoeirinha.
The sample was composed by secondary available records of the babies born in the maternity,
in the period from January through December of the years between 1995 and 2005.
The choice of the 10 years interval of 1995 and 2005 resulted from analysis of the
history of actions of the Ministry of Health that were taken in the country for the
TORSCH-A group diseases considered to be risk indicators for deafness.
With the loss of some data of the year 1995 it was possible to survey the number of
2077 newborns and for the year of 2005 the value of 5129. After this first survey
the analysis of Diagnosis Books analysis was started regarding the years defined,
which were submitted to a process of triage. The inclusion criteria adopted were:
-
Having risk indicators for Hearing Loss: Prematurity, Low Weight and Asphyxia;
-
Having cases confirmed, suspected or exposed of one of the infecto-contagious diseases
of TORSCH-A group, appointed by JCIH in 2007.
At the end of this selection 565 newborns were found with risk indicators for Hearing
Loss (HL) in 1995, and 1047 newborns with some risk indicator of HL for the year 2005,
and such values were taken as the composition of the sample for each year.
Consequently, the study kept on involving the sample analysis of reports of 565 children
born in 1995, and 1047 children born in 2005. The following variables were noticed:
-
Gender: female or male;
-
Weight: in kg;
-
Gestational Age: in weeks;
-
Prematurity: yes or no;
-
Low weight: yes or no;
-
Asphyxia: yes or no;
-
Consanguinity: yes or no;
-
Toxoplasmosis: confirmed, suspect or not;
-
Rubella: confirmed, suspect or not;
-
Syphilis: confirmed, suspect or not;
-
Cytomegalovirus: confirmed, suspect or not;
-
Herpes: confirmed, suspect or not;
-
HIV: exposed or not.
The other risk indicators described by the JCIH in 1994 and 2007 were disregarded
for lack of information in the description of the Hospital Discharge of the individuals.
Besides having been verified whether having low weight or not, the variable Weight
was used in the creation of a weight range category: < 1500g, 1500 to 2500g e >2500g,
from the numbers referred to in the record book. The data obtained in each year was
described in a worksheet of program Microsoft Excel 2003.
In order to compare the distributions of Sex, Weight range and Risk indicators in
the years 1995 and 2005 the Chi-Square test (Bussab and Morettin, 2002) was applied. In the hypothesis tests the significance level was set at p < 0.05,
and the analysis was carried out with the help of the applications Statistical Package
for Social Sciences (SPSS) version 11.0 and Minitab version 15.
Results
When comparing each risk indicator between the two years we noticed the Prematurity
had a significant difference between the distribution of the percentages in both years,
and the percentage of premature children was higher in 1995 (p < 0.001). The risk
indicator of Low Weight did not present a significant difference between the percentages
of occurrence (p = 0.209); the Asphyxia had a significant difference in the percents
of both years (p = 0.027), and the percent of occurrence in 1995 was higher than that
of 2005 ([Table 1]).
Table 1.
Distributions of frequencies and percentages of prematurity, low weight and asphyxia
in 1995 and 2005.
|
Risk indicators
|
1995 (n= 565)
|
2005 (n= 1047)
|
|
|
No
|
Yes
|
Total
|
No
|
Yes
|
Total
|
P
|
|
Prematurity
|
253 (44,8%)
|
312 (55,2%)
|
565 (100%)
|
621 (60,4%)
|
407 (39,6%)
|
1028 (100%)
|
0,001
|
|
Low weight
|
210 (37,2%)
|
354 (62,8%)
|
564 (100%)
|
423 (40,4%)
|
623 (59,6%)
|
1046 (100%)
|
0,209
|
|
Asphyxia
|
397 (70,3%)
|
168 (29,7%)
|
565 (100%)
|
771 (75,4%)
|
252 (24,6%)
|
1023 (100%)
|
0,027
|
[Table 2] describes the distributions of frequencies and percentages of the diseases found
in the books analyzed (Toxoplasmosis, Syphilis and HIV) in both years. The children
who were not classified in the worksheet as not having confirmed, suspect or exposed
cases were considered not to have the disease. In 2005, there were 17 cases (1.6%)
confirmed or suspect of Toxoplasmosis and there was a significant difference between
the percents of absence of this disease in both years, with a higher occurrence (confirmed
or suspect) in 2005 (p = 0.008). As regards to syphilis, there was only 1 case confirmed
in 1995 (0.2% of all children in this year). In 2005 there were 14 confirmed and 21
suspect cases that correspond to 3.3% of the children born in this year. There was
a significant difference between the percents of occurrence of Syphilis in both years
(p < 0.001) and the higher percent of occurrence was in 2005. For HIV there was a
difference between the percents of children exposed to the disease in both years (p < 0.001),
with the percent of exposed children in 2005 higher than in 1995.
Table 2.
Cases found of group TORSCH-A and the prevalence in the years 1995 and 2005.
|
Diseases
|
Confirmed
|
1995 Suspect
|
No
|
Total
|
Confirmed
|
2005 Suspect
|
No
|
Total
|
|
Toxoplasmosis
|
1
|
0
|
564
|
565
|
1
|
16
|
1030
|
1047
|
|
(0,2%)
|
(0,0%)
|
(99,8%)
|
(100%)
|
(0,1%)
|
(1,5%)
|
(98,4%)
|
(100%)
|
|
Syphilis
|
1
|
0
|
564
|
565
|
14
|
21
|
1012
|
1047
|
|
(0,2%)
|
(0,0%)
|
(99,8%)
|
(100%)
|
(1,3%)
|
(2%)
|
(96,7%)
|
(100%)
|
|
Exposed
|
Non-Exposed
|
—
|
Total
|
Exposed
|
Non-Exposed
|
—
|
Total
|
|
HIV
|
I12
|
553
|
—
|
565
|
63
|
984
|
—
|
1047
|
|
(2,1%)
|
(97,9%)
|
—
|
(100%)
|
(6%)
|
(94%)
|
—
|
(100%)
|
The association between the 3 risk indicators analyzed showed that in the year 1995,
1.2% of the children had none of these, while in 2005 this percentage was of 9.1%.
In 1995, the higher percentage noticed between the indicators was of children with
Prematurity and Low Weight (28.9%), while in 2005 it was only of Low Weight (31.1%).
Still in 1995, there was a simultaneous occurrence of 3 indicators in 7.3% of the
children, while in 2005, the percentage was of 3.2%. There was a significant difference
between the joint percentage distributions of Prematurity, Low Weight and Asphyxia
in both years (p < 0.001) ([Table 3]).
Table 3.
Distributions of joint frequencies and percentages of prematurity, low weight and
asphyxia in 1995 and 2005.
|
Risk
|
1995
|
2005
|
|
None
|
7 (1,2%)
|
93 (9,1%)
|
|
Asphyxia
|
95 (16,8%)
|
192 (8,9%)
|
|
Low weight
|
135 (23,9%)
|
316 (31,1%)
|
|
Prematurity
|
92 (16,3%)
|
122 (12%)
|
|
Low weight and Asphyxia
|
15 (2,7%)
|
18 (1,8%)
|
|
Prematurity and Asphyxia
|
16 (2,8%)
|
9 (0,9%)
|
|
Prematurity and Low Weight
|
163 (8,9%)
|
234 (3%)
|
|
Prematurity, Low Weight and Asphyxia;
|
41 (7,3%)
|
33 (3,2%)
|
|
Total
|
564 (100%)
|
1017 (100%)
|
By taking into account the 3 risk indicators and the 3 diseases found, we computed
the number of indicators and diseases present in each children. The frequencies and
percentages of the numbers found in both years are described in [Table 4]. In both years the highest number of indicators and diseases noticed in the same
children was 3. Most children had a single risk indicator or disease (57.1% in 1995
and 69.4% in 2005). The children born in 1995 tended to have a higher number of risk
indicators and/or diseases than those born in 2005 (p < 0.001).
Table 4.
Number of risk identifiers per children in 1995 and 2005.
|
Number of risk indicators
|
|
|
YEAR
|
0
|
1
|
2
|
3
|
TOTAL
|
|
1995
|
6 (1,1%)
|
322 (57,1%)
|
195 (34,5%)
|
41 (7,3%)
|
564 (100%)
|
|
2005
|
1 (0,1%)
|
706 (69,4%)
|
272 (26,8%)
|
38 (3,7%)
|
1017 (100%)
|
From, the review of associations between Prematurity, Low Weight and Asphyxia with
Toxoplasmosis, in the years 1995 and 2005; for year 2005, out of 16 suspect cases,
14 (87.5%) did not present any of the risks analyzed and 2 (12.5%) were premature.
The only case of Toxoplasmosis confirmed, in 1995, had only Prematurity. The case
of Syphilis confirmed in 1995 did not present with any indicator of Prematurity, Low
Weight or Asphyxia. In 2005, most cases confirmed or suspected did not present none
of such indicators either. Out of 12 cases exposed by HIV, in 1995, 41.7% had Prematurity
and 33.3% had no risks of Prematurity, Low Weight or Asphyxia. In 2005 most children
exposed (88.3%) had none of the 3 risks.
Discussion
The indicator Prematurity showed a significant difference in the comparison between
the years (p < 0.001), with a higher prevalence in the newborns of 1995, as well as
the indicator Asphyxia that had a higher prevalence in this year (p < 0.027), and
there was no significant difference only for the indicator Low Weight (p < 0.209).
Such findings may be justified according to the improvements along the years in the
maternity that helped and provided good resources and high qualify professionals to
women that seek assistance and follow up during the puerperal period, which decreased
the rate of premature newborns and those with Asphyxia along 10 years.
Only Toxoplasmosis, Syphilis and HIV were found and analyzed; this may be explained
by the fact that in 1995 the service and attention offered to pregnant women was poor
and most tests for identification of diseases transmitted by the mother were not performed.
Later on, after the 90's, with the introduction of programs aimed at the woman's health
it was possible to draw the attention of a larger group of women from the beginning
of the pregnancy to prenatal follow-up, and the triage was more faithful, which alerted
the suspicious and confirmed cases of such diseases[19]
[20]
[21].
When the risk indicators (Prematurity, Low Weight and Asphyxia) and the diseases (Toxoplasmosis,
Syphilis and HIV) were analyzed and compared between 1995 and 2005, there was an occurrence
of risk indicators higher than of diseases themselves, since the indicators are confirmed
right after the birth of these children, which did not rely on more objective and
invasive exams for their identification[8]
[12]
[22].
Upon association of the percentage of cases of Toxoplasmosis in both years (1995 and
2005), with the presence of risk indicators, only the year of 1995 had some relationship,
in this case, with Prematurity.
No studies were found that confirmed this finding, but other risk indicators, like
Weight at birth, had a better relationship in some studies[23] that found infections as the second most frequent disease in the pregnancy of mothers
of Low Weight, and the high number of mothers with Syphilis, Toxoplasmosis and HIV
was notorious.
When connected to risk indicators, syphilis did not present any relationship, different
from the research results[24] in Guinea-Bissau, which verified a strong association of positive serology for Syphilis
with premature birth and natimortality.
When connected to risk indicators, HIV presented cases only in 1995, in which 41%
of these related to Prematurity, which confirms some studies[25]
[26]
[27] that [sic] upon comparison with the occurrence of risk indicators and infecto-contagious
diseases for child hearing loss. The most frequent risk indicators were the permanence
at neonatal ICU with a longer period than 48 hours and the number of newborns that
remained was about 80%. This data was predicted, once most premature newborns need
intensive care upon birth.
From the analytic of the data surveyed we could show the importance of the research
carried out on risk indicators and the need to improve woman assistance programs for
public health and Phonoaudiology. Therefore, the identification of infecto-contagious
diseases and risk indicators for deafness from the very beginning of pregnancy and/or
the life of a baby may allow the suitable referral to programs of identification and
rehabilitation, by decreasing the extension of the sequels on the development of the
child. At the same time, with campaigns of adhesion to the programs that promote health,
it is possible to decrease such indicators and diseases causing hearing loss.
Conclusion
From the data analysis, it was possible to show the occurrence of risk indicators
for hearing loss and the importance for public health and Phonoaudiology of the need
to improve woman assistance programs. Once the data obtained revealed a higher number
of risk indicators in 1995, with improvement along the years, we confirmed programs
intended for the woman's health created along 10 years. Therefore, the identification
of infecto-contagious diseases and risk indicators for deafness from the very beginning
of pregnancy and/or the life of a baby may allow the suitable referral to programs
of identification and rehabilitation, by decreasing the extension of the sequels on
the development of the child. At the same time, with campaigns of adhesion to the
programs that promote health, it is possible to decrease such indicators and diseases
causing hearing loss.
