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Accuracy and Use of the Reflexive Behavioral
(“Baah”) Test and Risk Factor Questionnaire
for Hearing Screening in Infants
Six Months Old and Below
Gienah F. Evangelista, MD,1 Patrick John P. Labra, MD,1 Charloe M. Chiong, MD, PhD,1,2
Alessandra Nadine E. Chiong, MD1 and Precious Eunice R. Grullo, MD, MPH1
1Philippine National Ear Institute, National Institutes of Health, University of the Philippines Manila
2Department of Otorhinolaryngology – Head and Neck Surgery, College of Medicine and Philippine General Hospital, University of the Philippines Manila
ABSTRACT
Objecve. To determine the accuracy, sensivity, specicity, posive predicve values, and use of the Reexive
Behavioral “Baah” Test and NHSRC Level 1 and Level 2 Quesonnaires in detecng hearing impairment in rural
health communies.
Methods. This was a prospecve cross-seconal study conducted at the rural health unit of ve municipalies.
Infants less than six months old were screened for hearing impairments using the OAE device (standard), the Reexive
Behavioral “Baah” test, and the NHSRC Level 1 and Level 2 Quesonnaires. The “Baah” test and the lling out of the
NHSRC Level 1 and 2 Quesonnaires were done by trained health workers while OAE was done by an audiologist.
Results. A total of 103 babies, with a mean age of 41.9 days at the me of tesng and a male to female rao of 1.02:1
(52 males and 51 females) were tested. A hearing impairment prevalence of 4.9% (5 out of 103) was noted. The
“Baah” test showed to have a sensivity of 60%, specicity of 97.96% and an accuracy rate of 96.12%. The NHSRC
Level 1 and Level 2 Quesonnaires showed sensivity, specicity, and accuracy rate of 40%, 67.35% and 66.02%,
respecvely for the former and 40%, 85.71% and 83.50%, respecvely for the laer. Analysis of the complimentary
use of the NHSRC Level 1 and Level 2 Quesonnaires with the “Baah” test also showed no signicant improvement
to using the “Baah” test as a stand-alone screening tool with sensivity, specicity, and accuracy of 60%, 67.35%
and 66.99%, respecvely for the “Baah” test and Level 1 Quesonnaire, and 60%, 83.67% and 82.52%, respecvely
for the “Baah” test and Level 2 Quesonnaire.
Conclusion. The Reexive Behavioral “Baah” test is a potenally accurate, sensive, specic, and acceptable stand-
alone hearing screening test to idenfy infants with higher risk of hearing impairment in the rural health community
seng. On the other hand, the use of the NHSRC Quesonnaires as a stand-alone or complementary tool for
“Baah” is unnecessary as it results to more false posive and false negave results.
Keywords: newborn hearing screening, community hearing
screening, “Baah” test, NHSRC Quesonnaire, reexive
behavioral test, otoacousc emission test
INTRODUCTION
In developing countries, approximately 6 out of 1000 live
births are noted to have permanent bilateral congenital or early
onset hearing loss.1 Late detection leads to severe lifelong
impairments on speech, language, academic performance,
emotional, and personal-social development. Neonatal
hearing screening policies coupled with regular surveillance
was found to prevent or lessen such impairments.2
eISSN 2094-9278 (Online)
Published: September 28, 2023
hps://doi.org/10.47895/amp.v57i9.4378
Corresponding author: Gienah F. Evangelista, MD
Philippine Naonal Ear Instute
Naonal Instutes of Health
University of the Philippines Manila
623 Pedro Gil St., Ermita, Manila 1000, Philippines
Email: gfevangelista@up.edu.ph
ORCiD: hps://orcid.org/0009-0002-8060-4914
VOL. 57 NO. 9 2023 21
ORIGINAL ARTICLE
e World Health Organization (WHO), as well as the
Joint Committee on Infant Hearing ( JCIH), recommended
two methodologies for hearing screening: the Otoacoustic
Emissions (OAE) test and the Automated Auditory
Brainstem Response (AABR).3,4 On the other hand, protocols
using the said methodologies have been varied depending on
institution standards: a two-stage OAE then AABR for initial
screen or one-stage AABR in Germany; one-stage OAE
initial screen then one-stage AABR re-screen in Nigeria and
United Kingdom; and both initial and re-screen using OAE
in the Philippines; to cite a few.4,5
In the Philippines, 1.38 for every 1,000 live births are
noted to have bilateral profound congenital hearing loss. is
estimate increases to 22 per 1,000 live births when cases of
unilateral and milder forms of hearing loss are also included.6
In order to address the burden of untreated hearing loss,
Republic Act No. 9709 also known as the Universal Newborn
Hearing Screening and Intervention Act of 2009 was passed
into law mandating access to hearing screening to all newborns
prior to discharge or before three months old. In accordance
to its manual of operations, two tests are currently accepted
as screening methods: Otoacoustic Emissions (OAE) test
and the Automatic Auditory Brainstem Response (AABR).5
Currently, primary utilization of OAE is being observed
for its advantages on cost, test duration, and availability.
Despite the enactment of this law, coverage and
implementation remains relatively low with only about 10%
of babies born each year being appropriately screened. is
challenge has been consistent with other developing countries
where the lack of an economical, reliable, and simple-to-
use methodology that can be deployed in geographically-
challenging areas remain as a primary barrier. In addition,
investment in these instruments is often not seen as a
government priority.1 In fact, the WHO has acknowledged
these barriers and has proposed two interim approaches aside
from using the aforementioned physiological measures: (1)
guided Family Questionnaires asking the parents/ caregivers
on the neonate’s response to loud sounds and language use and
(2) use of behavioral measuring devices.7 In the Philippines,
these two have also been adapted as seen in the utilization of
the UNHS High Risk Questionnaire for Community-Based
Facilities Questionnaire Level 1 and 2 and the Reexive
Behavioral “Baah” Test.5,8,9
To address the unavailability of objective hearing
screening tests in areas that are geographically-challenging
or isolated, low-income, and with inadequate health care
facilities, Gloria-Cruz et al. explored the possibility of using
generic Filipino words commonly used to call attention,
namely: “Psst” and “Baah”. In this study which included adult
participants, it was found out that the “Baah” sound when
done after two deep breaths with sudden and maximal eort
can be reproducible, hits a wide variety of frequencies, and
can be vocalized at a higher intensity than 90dB SPL, which
is the cut o for profound deafness in newborns. Building on
this, the researchers introduced the possibility of using the
“Baah” sound as a cost-eective, valid, and feasible hearing
screening test.8
is was further substantiated by the study of Garcia et
al., where the reexive behavioral “Baah” test was compared to
the standard OAE as a hearing screening test in infants less
than six months old in a tertiary hospital. In this study, 101
infants were blindly tested using both techniques yielding a
sensitivity of 71.4%, specicity of 95.7%, positive predictive
value of 55.6%, and negative predictive value of 97.8% for
the “Baah” test (P value <0.0001). In addition, an accuracy
of 94% was also noted, with the “Baah” test giving 95 out
of the 101 infants the correct diagnosis. In conclusion, the
“Baah” test was noted to have potential as an acceptable,
accurate, and cost-eective screening tool, especially for areas
without available OAE or AABR. For this purpose and as
recommended by Garcia et al., the reexive behavioral “Baah”
test is suggested to be administered in a community setting
to test its utility as part of a community-based newborn
hearing screening program.9 is study aims to compare the
use of the Reexive Behavioral “Baah” Test and the NHSRC
High Risk Questionnaire for Community-Based Facilities
Level 1 and Level 2 against the Otoacoustic Emission (OAE)
test in a community-based setting.
MATERIALS AND METHODS
Study Design
is was a prospective, cross-sectional study.
Parcipants
Participants came from ve out of six municipalities who
participated in the 1st and 2nd Newborn Hearing Screening
and Teleaudiology Course held last June 25 to 27 in Iloilo
City, and August 9 to 11 in Manila City. All infants among
the ve municipalities who were considered as participants
in this study were able to satisfy the following criteria at the
time of data collection: (1) infants below six months old, of
both sexes; (2) consent from parents/legal guardian; (3) with
developed ear canal. Excluded participants from this study
were those: (1) above six months of age; (2) already screened;
(3) without consent from parents/legal guardian; (3) with
active ear infection; and (4) external ear deformities (i.e.,
atresia, agenesis) where the OAE probe cannot be inserted.
Seng
Hearing screening tests were done in two separate rooms.
To facilitate the patient ow during testing, the rst room was
assigned for the Reexive “Baah” test while the second room
was for the OAE test. Since layout of rural health units diered
for each municipality, this set-up was pre-planned during
the ocular of the testing site prior to the hearing screening
day. e screening environment for OAE must be consistent
with the National Hearing Screening Reference Center’s
(NHSRC) technical standards, including: (1) minimal noise
of ≤40 dB; (2) presence of curtains or dividers; (3) turned o
VOL. 57 NO. 9 202322
“Baah” Test and Risk Factor Quesonnaire for Hearing Screening
Table 2. Results of Behavioral “Baah” Test, WHO Level 1 and 2 Quesonnaires versus Distoron Product Otoacousc Emission
Tesng (N=103)
“Baah” Test NHSRC Level 2 Quesonnaire NHSRC Level 2 Quesonnaire
No response With response Posive ndings No ndings Posive ndings No ndings
DPOAE Bilateral pass 1.94% (2) 93.20% (96) 31.07% (32) 64.08% (66) 13.59% (14) 81.55% (84)
Unilateral refer 0% (0) 2.91% (3) 1% (1) 1.94% (2) 1% (1) 1.94% (2)
Bilateral refer 1.94% (2) 0% (0) 1% (1) 1% (1) 1% (1) 1% (1)
Table 1. Demographics of Infants Screened at Rural Health
Units
Variable Mean ± SD
Age at me of screening (in days) 41.90 ± 31.46
Male to Female Rao* 1.02:1
Birth Weight (in grams) 2,892 ± 508
Age of Gestaon at Birth (in weeks) 38.78 ± 1.42
*Results are reported as rao
cellphones, radio, TV, or any other audio devices; and (4) done
post-nursing and separate from other participants.
Tesng Procedure
After registration and collection of general data, the
baby was directed to the rst room where the trained
health personnel/ professional and partner observer will be
administering the Reexive “Baah” Test. e tester positioned
himself/herself at the vertex of the patient’s head with his/her
mouth about one foot away while the observer was positioned
at the side so as to easily observe behavioral responses. When
ready, the tester took two deep breaths and suddenly produced
the “Baah” sound. e sound level meter value was checked
and recorded (value must be in between 80 to 95 dB). Upon
production of the stimulus, the observer then waited and
recorded the response of the infant which may include:
blinking, sudden and forceful shutting of already closed lids,
and stirring and startling reex. If any of the mentioned
responses were observed, the observer recorded “present”,
otherwise “absent” if none were noted. After the rst test, the
patient was led to another quiet room designated for the OAE
test. e OAE test was administered by a designated blinded
audiologist. Once ambient noise and seal of the probe to the
ear canal was acceptable, testing automatically commenced.
e machine then indicated either a “pass” or “refer” result.
For the latter result, ear probe was removed, ear was massaged
to relax ear canal retraction and a review of the previously
employed techniques was done to determine confounding
factors. e test was then repeated following the stop criteria
for an outpatient OAE screening. Final recording was then
written down in the case report form.9
Focus Group Discussion
After all the patients were tested, a short focus group
discussion was done with the trained health personnel to
evaluate the conduct of the “Baah” test. A topic guide was
used to extract data on experiences and perceptions on the
tool’s utility, specically on the hindrances or challenges
encountered in doing the test.
Primary and Secondary Outcome Measures
e primary outcome measures for this study are the
presence or absence of the following: (1) response to the
OAE test, (2) response in the reexive behavioral “Baah” test,
and (3) risk classication based on the UNHS Level 1 and
2 Questionnaires.
Data analysis
Data was tabulated using a 3 x 6 table to quickly compare
the Reexive “Baah” Test and UNHS Questionnaires with
the OAE test result. Qualitative data from the focus group
discussion was analyzed by identifying common themes.
RESULTS AND DISCUSSION
A total of 103 babies, with a mean age of 41.9 days at
the time of testing and a male to female ratio of 1.02:1 (52
males and 51 females) were tested in the months of August
and September 2018. e average birthweight and age of
gestation are seen in Table 1.
Results for the 103 participant’s OAE compared to
the results from the “Baah” test and NHSRC Level 1 and
Level 2 Questionnaires are reected in Table 2. Two were
screened to have bilateral refer results in OAE, both of which
reected a positive result in the “Baah” test (no response).
On the other hand, only one of the OAE positive patients
were agged positive in both the Level 1 and Level 2
questionnaires. e same observation may be seen for the
three infants screened with unilateral refer results in OAE
where only one showed a positive nding for both Level 1
and Level 2 questionnaires. Using the questionnaires as stand-
alone screening tools may therefore miss 60% of potential
hearing-impaired infants in the community that would need
an objective hearing screening/ conrmatory test.
e observation is parallel to the calculated sensitivity
of the “Baah” test and NHSRC Level 1 and Level 2
Questionnaires of 60%, 40%, and 40%, respectively and
specicity of 96.12%, 67.35%, and 85.71%, respectively (Table
3). Among the three screening tools, the “Baah” test exhibited
the highest specicity which translates to a low false positive
rate for bilaterally impaired patients. is indicates that
patients who tested positive for “Baah” have a high probability
VOL. 57 NO. 9 2023 23
“Baah” Test and Risk Factor Quesonnaire for Hearing Screening
of having bilateral hearing impairment. Unfortunately,
the rather low sensitivity (60%) coupled with the positive
predictive value of 60% means that there may be “Baah”
negative infants who have hearing impairment. In this study,
it is exhibited by the false negative result for two patients who
have unilateral refer results in OAE, failing to identify such
patients is one of the limitations of the “Baah” test (Table 3).
us, counselling of parents to continue monitoring hearing
milestones or any indication of poor language development
is still needed. On the other hand, as indicated in the
likelihood ratio (Table 4), a positive “Baah” test is 29x more
likely to appear compared to someone without hearing loss.
In addition, the “Baah” test was able to identify 97.96% of
infants with normal hearing (negative predictive value). In
itself, the “Baah” test exhibited an accuracy rate of 96.12%.
e same cannot be observed for the NHSRC Level 1
and 2 Questionnaires as a stand-alone screening test (Table
4). Both have shown a relatively lower specicity of 67.35%
and 85.71%. is means that there is a higher possibility
that infants with hearing impairment will not be correctly
identied. With a relatively lower sensitivity of 40% for both
and a positive predictive value of 5.88% and 12.5%, it can
be noted that a signicant number of false positive results
were identied. is may lead to the unnecessary allocation
of resources and stress for conrmatory testing of normal
hearing infants. In detail, it was noted that 1.94% (n=3; 2
unilateral refer) or 40% of OAE positive infants (n=5) were
missed by both Questionnaires.
e results from the OAE test were also analyzed
against the Reexive “Baah” test coupled with each of the
NHSRC Questionnaire (Table 5). In using the “Baah” test
with the Level 1 Questionnaire, the number of infants
correctly screened was only 69 out of 103 infants. is was
a miniscule improvement from the results if the NHSRC
questionnaire was used alone and a decrease from the results
of the “Baah” test if used alone. When the “Baah” test with
the Level 2 Questionnaire was used, the number of infants
correctly screened decreased to 85 out of 103 infants. is
was also lower than the number of correctly screened infants
if each test was used independently. Moreover, for both
combinations, two infants with unilateral refer OAE results
were missed.
To further analyze the combinations, the accuracy of
the “Baah” test with the NHSRC Level 1, and “Baah” test
plus the NHSRC Level 2 Questionnaire (Table 6) were
determined. Although the sensitivity, specicity, positive and
negative predictive values, accuracy, and likelihood ratios
increased, such were still non-superior to the “Baah” test when
used alone.
e likelihood ratios for the positive and negative test
results for the “Baah” test and NHSRC Level 1 and Level 2
Questionnaires are in Table 7.
Table 3. 2x2 Table for the Reexive “Baah” test, Level 1 Quesonnaire and Level 2 Quesonnaire vs. OAE test
OAE (+) (n) OAE (-) (n)
“Baah” (+)
(n)
3
(a= true posive)
2
(b= false posive)
Posive Predicve Value
=True posive/ Test Outcome posive
=a/(a+b) = 60%
“Baah” (-)
(n)
2
(c= false negave)
96
(d=true negave)
Negave Predicve Value
=True negave/ Test Outcome negave
=d/(c+d) = 97.96%
Sensivity
=a/ (a+c)
= 60%
Specicity
=d/(d+b)
=97.96%
Accuracy
=a+d/(a+b+c+d)
=96.12%
NHSRC Level 1 (+)
(n)
2
(a= true posive)
32
(b= false posive)
Posive Predicve Value
=True posive/ Test Outcome posive
=a/(a+b) = 5.88%
NHSRC Level 1 (-)
(n)
3
(c= false negave)
66
(d=true negave)
Negave Predicve Value
=True negave/ Test Outcome negave
= d/(c+d) = 95.65%
Sensivity
=a/ (a+c)
= 40%
Specicity
=d/(d+b)
= 67.35%
Accuracy
=a+d/(a+b+c+d)
=66.02%
NHSRC Level 2 (+)
(n)
2
(a= true posive)
14
(b= false posive)
Posive Predicve Value
=True posive/ Test Outcome posive
=a/(a+b) = 12.5%
NHSRC Level 2 (-)
(n)
3
(c= false negave)
84
(d=true negave)
Negave Predicve Value
=True negave/ Test Outcome negave
= d/(c+d) = 96.55%
Sensivity
=a/ (a+c)
= 40%
Specicity
=d/(d+b)
= 85.71%
Accuracy
=a+d/(a+b+c+d)
=83.50%
OAE (+) includes both unilateral and bilateral refer results
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“Baah” Test and Risk Factor Quesonnaire for Hearing Screening
Table 6. 2x2 Table for the Reexive “Baah” test, Level 1 Quesonnaire and Level 2 Quesonnaire vs. OAE test
OAE (+) (n) OAE (-) (n)
“Baah” (+)
(n)
3
(a= true posive)
2
(b= false posive)
Posive Predicve Value
=True posive/ Test Outcome posive
=a/(a+b) = 60%
“Baah” (-)
(n)
2
(c= false negave)
96
(d=true negave)
Negave Predicve Value
=True negave/ Test Outcome negave
=d/(c+d) = 97.96%
Sensivity
=a/ (a+c)
= 60%
Specicity
=d/(d+b)
=97.96%
Accuracy
=a+d/(a+b+c+d)
=96.12%
“Baah” and
NHSRC Level 1 (+)
(n)
3
(a= true posive)
32
(b= false posive)
Posive Predicve Value
=True posive/ Test Outcome posive
=a/(a+b) = 8.57%
“Baah” and
NHSRC Level 1 (-)
(n)
2
(c= false negave)
66
(d=true negave)
Negave Predicve Value
=True negave/ Test Outcome negave
= d/(c+d) = 97.06%
Sensivity
=a/ (a+c)
= 60%
Specicity
=d/(d+b)
= 67.35%
Accuracy
=a+d/(a+b+c+d)
=66.99%
“Baah” and
NHSRC Level 2 (+)
(n)
3
(a= true posive)
16
(b= false posive)
Posive Predicve Value
=True posive/ Test Outcome posive
=a/(a+b) = 15.79%
“Baah” and
NHSRC Level 2 (-)
(n)
2
(c= false negave)
82
(d=true negave)
Negave Predicve Value
=True negave/ Test Outcome negave
= d/(c+d) = 97.62%
Sensivity
=a/ (a+c)
= 60%
Specicity
=d/(d+b)
= 83.67%
Accuracy
=a+d/(a+b+c+d)
=82.52%
OAE (+) includes both unilateral and bilateral refer results. “Baah” (+) includes only bilateral
Table 4. Likelihood Raos and Posest Probabilies for the
Reexive “Baah” Test and NHSRC Level 1 and Level 2
Quesonnaire
"Baah"
Test
NHSRC
Level 1
NHSRC
Level 2
Likelihood rao for a
posive test (LR +)
=29.41 =1.225 =2.8
Likelihood rao for a
negave test (LR -)
=0.2857 =0.8909 =0.7
Posest Probability for a
posive test (PosestProb+)
=60% =5.88% =12.5%
Posest Probability for a
negave test (PosestProb-)
=1.44% =4.45% =3.45%
Table 5. Combined Results of Behavioral “Baah” Test with WHO Quesonnaire-based Screening versus Distoron Product
Otoacousc Emission Tesng (N=103)
“Baah” Test “Baah” Test plus
NHSRC Level 1 Quesonnaire
“Baah” Test plus
NHSRC Level 2 Quesonnaire
Posive Findings No Findings Posive Findings No Findings Posive Findings No Findings
DPOAE Bilateral pass 1.94% (2) 93.20% (96) 31.07% (32) 64.08% (66) 15.53% (16) 79.61% (82)
Unilateral refer 0% (0) 2.91% (3) 1% (1) 1.94% (2) 1% (1) 1.94% (2)
Bilateral refer 1.94% (2) 0% (0) 1.94% (2) 0% (0) 1.94% (2) 0% (0)
In summary, if individually used, the “Baah” test was
able to correctly screen 101 out of 103 infants (accuracy of
96.12%) while the NHSRC level 1 and level 2 Questionnaires
were only able to do so in 68 (accuracy of 66.02%) and 86
(accuracy of 83.50%) infants out of 103, respectively. If the
“Baah” test was combined with either one of the NHSRC
Questionnaires, 40% potential unilaterally hearing-impaired
infants may be missed.
e frequency of observed responses to the “Baah” test
(Table 8) was also recorded with the auropalpebral reex being
exhibited 123 times, followed by the startle reex at 110, and
the generalized provoked arousal at 3. Since more than one
response may be seen in response to the “Baah” stimulus, a
discordance between the total number of observations and
the total number of infants tested may be noted.
VOL. 57 NO. 9 2023 25
“Baah” Test and Risk Factor Quesonnaire for Hearing Screening
In doing the “Baah” test, each examiner did an average
of 2.59 trials to get the desired result, reaching a maximum
intensity of 82 dB and consuming an average of 4.04 minutes
per baby (Table 9). ese were within the parameters of doing
the “Baah” test 2-4 times and producing a sound between
80 to 95 decibels. e consumed duration was notably
attributed to the preparation at the start and in between
trials. Nonetheless, with the average duration of 4 minutes
per baby, the “Baah” test exhibits a relatively fast screening
tool compared to the OAE and AABR.
As for the Level 1 Questionnaire (Table 10), determi-
nation of a positive assessment was noted to be detected most
in the presence of risk factors with 33 out of 34.
In using the Level 2 Questionnaire (Table 11), the most
common risk factor encountered was an APGAR score <5 in
ve minutes (7.07%, n=7) followed by any history of bacterial
meningitis or neonatal sepsis (4.9%, n=5), and family
history of permanent hearing loss in childhood (2.97%,
n=3). Some items like the history of NICU admission
≥ 48H, administration of ototoxic drugs, TORCH infection,
hyperbilirubinemia, and features or other ndings associated
with hearing loss all got 0 %. While such may be the case,
it should be noted that these items may sometimes be
unknown to the caregiver and/or to the healthcare personnel
conducting the interview.
e adaptability of the “Baah” test and the NHSRC
Level 1 and 2 Questionnaires are also evaluated through a
focus group discussion (Table 12) with the trained health
personnel. In the focus group discussion, identied strengths
of the “Baah” test centered on its ease-of-use, ease-of-
learning, applicability in the community setting, portability,
and economic impact. Disadvantages were centered mostly
on exhaustion secondary to vocal/ physical exertion and the
“Baah” test’s own limitation of only being able to identify
infants with bilateral hearing impairment. On the other
hand, such disadvantages can be easily addressed with
proper training, constant practice, and specic guidelines
on test administration. All members of the FGD expressed
a positive attitude in adapting the “Baah” test as a hearing
screening tool especially for areas without access to an OAE/
AABR device.
As for the NHSRC’s Level 1 and Level 2 Questionnaires,
comments centered on the language barrier, presence of
jargons, and questions not readily answerable in RHU level.
Aside from answering the form itself, confusion was also noted
in terms of interpreting the results of the questionnaire. e
criteria of whether the questionnaire is positive or negative
was unclear and easily confusing for the healthcare workers.
us, among the three hearing screening tools evaluated
in this study, the “Baah” test exhibited the best sensitivity,
specicity, accuracy, and adaptability in the local community
setting. is opens an opportunity to its use as an accessible
screening tool to detect infants with potential hearing
impairment which facilitates early referral for further
assessment and conrmatory testing in higher centers.
Table 8. List of Observed Infant Responses to “Baah” Test
(N=103)
Observed Infant Behavior Frequency
Provoked Arousal 3
Startle Reex 110
Auropalpebral Reex 123
Table 10. Frequency of Posive Results of NHSRC Level 1
Quesonnaire among Screened Infants (N=103)
Observed Infant Behavior Frequency
Presence of Risk Factors 33
Maternal Concern 1
Healthcare Concern 0
Table 9. Variables Measured in the Conduct of “Baah” Test
Variable Mean ± SD
Number of Trials Done (per baby) 2.59 ± 1.18
Maximum Intensity Recorded (in dB SPL) 82 ± 3
Duraon of Tesng (in minutes) 4.04 ± 11.14
Table 11. Frequency of WHO-NHSRC Level 2 Quesonnaire
Risk Factors Present among Screened Infants
Observed Infant Behavior Percentage (N)
Birth weight <1500 grams 2% (2)
APGAR score <5 in ve minutes 7.07% (7)
History of NICU admission for ≥48 hours 0% (0)
History of mechanical venlaon use >5 days 0.97% (1)
History of bacterial meningis or neonatal
sepsis
4.95% (5)
Administraon of ototoxic drugs 0% (0)
Congenital Infecons (TORCH) 0% (0)
Hyperbilirubinemia requiring exchange
transfusion
0% (0)
Defects of the head and neck 1.01% (1)
Features and other ndings associated with
hearing loss
0% (0)
Family history of permanent hearing loss in
childhood
2.97% (3)
Table 7. Likelihood Raos and Posest Probabilies for the
Reexive “Baah” Test and NHSRC Level 1 and Level 2
Quesonnaire
“Baah” Test
“Baah” Test
and
NHSRC
Level 1
“Baah” Test
and
NHSRC
Level 2
Likelihood rao for a
posive test (LR +)
=29.41 =1.83 =3.67
Likelihood rao for a
negave test (LR -)
=0.2857 =0.5939 =0.4781
Posest Probability for a
posive test (PosestProb+)
=60% =8.54% =15.77%
Posest Probability for a
negave test (PosestProb-)
=1.44% =2.94% =2.38%
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unnecessarily increase the number of projected hearing-
impaired children and may thus lead to unnecessary use of
resources. In addition, both questionnaires fail to identify
all infants with possible unilateral and bilateral hearing
impairment. us, the use of such Questionnaires as a stand-
alone or as a complementary hearing screening tool to the
“Baah” test is not recommended.
Statement of Authorship
All authors certied fulllment of ICMJE authorship
criteria.
Author Disclosure
All authors declared no conicts of interest.
Funding Source
e study was funded by the Philippine California
Advanced Research Institutes.
REFERENCES
1. Olusanya BO. Neonatal hearing screening and intervention in resource-
limited settings: an overview.Arch Dis Child. 2012 Jul;97(7):654-9.
doi: 10.1136/archdischild-2012-301786.
2. Buz Harlor Jr AD,Bower C;Committee on Practice and Ambulatory
Medicine; Section on Otolaryngology-Head and Neck Surgery.
Hearing assessment in infants and children: recommendations beyond
neonatal screening. Pediatrics. 2009 Oct;124(4):1252-63. doi: 10.1542/
peds.2009-1997.
3. American Academy of Pediatrics, Joint Committee on Infant
Hearing. Year 2007 Position statement: Principles and guidelines for
early hearing detection and intervention programs. Pediatrics. 2007
Oct;120(4):898-921. doi: 10.1542/peds.2007-2333.
4. World Health Organization. Newborn and infant hearing screening:
current issues and guiding principles for action [Internet]. 2017
[cited 2018 Aug]. Available from: https://www.who.int/blindness/
publications/Newborn_and_Infant_Hearing_Screening_Report.
pdf?ua=1.
5. Chiong CM, Abes GT, Reyes-Quintos MT, Ricalde RR, Llanes
EDV, Gonzalo E, et al. Universal Newborn Hearing Screening and
Intervention Act of 2009: Manual of Operations for Republic Act
9709. 2009.
6. Chiong C, Ostrea Jr E, Reyes A, Gonzalo-Llanes E, Uy ME, Chan
A. Correlation of hearing screening with developmental outcomes in
infants over a 2-year period. Acta Otolaryngol. 2007 Apr;127(4):384-8.
doi: 10.1080/00016480601075431.
7. Olusanya BO. Addressing the global neglect of childhood hearing
impairment in developing countries. PLoS Med. 2007 Apr;4(4):e74.
doi: 10.1371/journal.pmed.0040074.
8. Gloria-Cruz TLI, Abes GT, Abes FLLB. e voice test for newborn
hearing screening. Acta Med Philip. 2012;46(3):46-51. doi: 10.47895/
amp.v46i3.2086.
9. Garcia MCM, Chiong CM, Abes GT, Carrillo RJC. Accuracy
of reexive behavioral (“Baah”) test in the screening for hearing
impairment in infants six months old and below. Philipp J Otolaryngol
Head Neck Surg. 2012;27(1):6-11.
CONCLUSION
is study exhibited the potential of the Reexive
Behavioral “Baah” Test as an accurate and acceptable hearing
screening tool at the rural health unit’s level. e use of the
Reexive Behavioral “Baah” test as an alternate hearing
screening tool for areas without any available objective test
(i.e., OAE or AABR) may lead to an earlier detection of
potential hearing-impaired infants who will need referral
to a higher level facility for conrmation and intervention.
On the other hand, the use of the NHSRC Level 1 and
Level 2 Questionnaires, either as a stand-alone tool or as
a complimentary tool to the Behavioral “Baah” test may
Table 12. Focus Group Discussion Common Themes on the
Use of the “Baah” Test and the NHSRC’s Database
Responses
“Baah” test
Advantages
• Good posioning of paent, tester, and
observer
• Simple
• Comparably easy to do
• Free
• Can be done anywhere
• Results are known instantly
• Easy to learn
• Device-independent
• Low maintenance
“Baah” test
Disadvantages
• Needs observer to focus to be able to spot
the reacon
• Needs to reach certain decibel level
• Tiring since it requires physical and vocal
exeron
• Cannot test individual ears
• Dicult if baby is irritable
• Needs pracce
• Needs to do by pair
Recommendaons
for “Baah” test
• Set guidelines on healthy tesng number
and intervals
• Breaseed prior to tesng to calm the baby
• Pracce
• Do by pair
• Follow guidelines on how to properly do
it (i.e., Inhale two deep breaths before
vocalizing “Baah”)
NHSRC Level 1
Quesonnaire
• Appropriate for RHU level
• Translate to local language
• Unclear what Parts II and III are
• Unclear on how to interpret the responses
into posive or negave
NHSRC Level 2
Quesonnaire
• Some quesons are unknown: APGAR score,
some risk factors (TORCH, Mechanical
venlaon, NICU admission, features)
• Needs further training to be applicable to
RHU level
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