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Clinical Report—Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening

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Clinical Report—Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening Guidance for the Clinician in Rendering Pediatric Care Clinical Report—Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening Allen D. “Buz” Harlor, Jr, MD, Charles Bower, MD, THE abstract COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, THE SECTION ON OTOLARYNGOLOGY–HEAD AND NECK Congenital or acquired hearing loss in infants and children has been SURGERY linked with lifelong deficits in speech and language acquisition, poor KEY WORD academic performance, personal-social maladjustments, and emo- hearing screening, hearing loss, audiology tional difficulties. Identification of hearing loss through neonatal hear- ABBREVIATIONS ing screening, regular surveillance of developmental milestones, audi- AAP—American Academy of Pediatrics tory skills, parental concerns, and middle-ear status and objective OAE—otoacoustic emission ABR—auditory brainstem response hearing screening of all infants and children at critical developmental VRA—visual reinforced audiometry stages can prevent or reduce many of these adverse consequences. The guidance in this report does not indicate an exclusive This report promotes a proactive, consistent, and explicit process for course of treatment or serve as a standard of medical care. the early identification of children with hearing loss in the medical Variations, taking into account, individual circumstances may be appropriate. home. An algorithm of the recommended approach has been devel- This document is copyrighted and is property of the American oped to assist in the detection and documentation of, and intervention Academy of Pediatrics and its Board of Directors. All authors for, hearing loss. Pediatrics 2009;124:1252–1263 have filed conflict-of-interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any KEY POINTS commercial involvement in the development of the content of 1. Every child with 1 or more risk factors on the hearing risk assess- this publication. ment should have ongoing developmentally appropriate hearing screening and at least 1 diagnostic audiology assessment by 24 to 30 months of age. 2. Periodic objective hearing screening of all children should be per- formed according to the recommendations for preventive periodic health care.1 3. Any parental concern about hearing loss should be taken seriously and requires objective hearing screening of the patient. 4. All providers of pediatric health care should be proficient with pneu- www.pediatrics.org/cgi/doi/10.1542/peds.2009-1997 matic otoscopy and tympanometry. However, it is important to re- doi:10.1542/peds.2009-1997 member that these methods do not assess hearing. All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, 5. Developmental abnormalities, level of functioning, and behavioral revised, or retired at or before that time. problems (ie, autism/developmental delay) may preclude accurate PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). results on routine audiometric screening and testing. In this situa- Copyright © 2009 by the American Academy of Pediatrics tion, referral to an otorhinolaryngologist and a pediatric audiologist who has the necessary equipment and expertise to test infants and young children should be made. 6. The results of abnormal screening should be explained carefully to parents, and the child’s medical record should be flagged to facili- tate tracking and follow-up. 1252 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 29, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS 7. Any abnormal objective screening TABLE 1 Recommendations for Preventive explicit process for the early identifi- result requires audiology referral Pediatric Health Care1 cation of children with hearing loss in and definitive testing. Stage Age Sensory the medical home. To assist in the de- Screening: 8. A failed infant hearing screening or 6. Hearing tection and documentation of and in- a failed screening in an older child Infancy Prenatal tervention for hearing loss, an algo- should always be confirmed by fur- Newborn a rithm of the recommended approach 3–5 d1 b with key points has been developed ther testing. By1mo b (Fig 1), as have several tables. 9. Abnormal hearing test results re- 2mo b 4mo b quire intervention and clinically 6mo b RISK INDICATORS FOR HEARING appropriate referral, including oto- 9mo b LOSS laryngology, audiology, speech- Early childhood 12 mo b b Some degree of hearing loss (Table 2) language pathology, genetics, and 15 mo 18 mo b is present in 1 to 6 per 1000 newborn early intervention. b 24 mo infants.5 Most children with congenital 30 mo b b hearing loss are potentially identifi- INTRODUCTION 3y 4y a able by newborn and infant hearing Failure to detect congenital or ac- Middle childhood 5 y a screening. However, some congenital quired hearing loss in children may re- 6y a 7y b hearing loss may not become evident sult in lifelong deficits in speech and 8y a until later in childhood. Hearing loss language acquisition, poor academic 9y b also can be acquired during infancy or a performance, personal-social malad- 10 y childhood for various reasons. Infec- Adolescence 11 y b justments, and emotional difficulties. 12 y b tious diseases, especially meningitis, Early identification of hearing loss and 13 y b are a leading cause of acquired hear- appropriate intervention within the 14 y b b ing loss. Trauma to the nervous sys- first 6 months of life have been demon- 15 y 16 y b tem, damaging noise levels, and oto- strated to ameliorate many of these 17 y b toxic drugs can all place a child at risk adverse consequences and facilitate 18 y b of developing acquired hearing loss.6,7 b language acquisition.2 Supportive evi- 19 y 20 y b Otitis media is a common cause of usu- dence is outlined in the Joint Commit- 21 y b ally reversible hearing loss. Certain tee on Infant Hearing’s “Year 2007 a To be performed. physical findings, historical events, Position Statement: Principles and b Risk assessment, with appropriate action to follow if and developmental conditions may in- positive. Guidelines for Early Hearing Detection dicate a potential hearing problem. and Intervention Programs,” which These conditions include, but are not was endorsed by the American Acad- All providers of pediatric health care limited to, anomalies of the ear and emy of Pediatrics (AAP).3 This evidence need to recognize children who are at other craniofacial structures, signifi- also is part of the rationale for the AAP risk of or who suffer from congenital or cant perinatal events, and global devel- statement “Newborn and Infant Hear- acquired hearing loss, be prepared to opmental or speech-language delays. ing Loss: Detection and Intervention,”4 screen their hearing, and assist the fam- All older infants and children should be which endorses universal hearing ily and arrange for proper referral and screened for risk factors involving hear- screening and reviews the primary ob- treatment by identifying available hear- ing problems. A summary of high-risk in- jectives, important components, and ing resources within their communities. dicators for hearing loss and develop- recommended screening methods and In addition, the pediatric health care pro- mental milestones are included in parameters that characterize an ef- fessional can play an important role in Tables 3 and 4, respectively. All infants fective universal hearing screening communication with the child’s school- with a risk indicator for hearing loss, re- program. Furthermore, the AAP teacher and/or nurse and special educa- gardless of surveillance findings, should statement “Recommendations for tion professionals to facilitate proper ac- be referred for an audiologic assess- Preventive Pediatric Health Care”1 commodation and education once a ment at least once by 24 to 30 months of promotes objective newborn hearing hearing deficit has been confirmed. age, even if the child passed the newborn screening as well as periodic hear- This clinical report replaces the previ- hearing screening. Children with risk in- ing screening for every child through ous 2003 clinical report and seeks to dicators that are highly associated with adolescence (Table 1). promote a proactive, consistent, and delayed-onset hearing loss, such as hav- PEDIATRICS Volume 124, Number 4, October 2009 1253 Downloaded from www.aappublications.org/news by guest on September 29, 2021 FIGURE 1 Hearing-assessment algorithm within an office visit. CMV indicates cytomegalovirus; ENT, ear, nose, and throat. ing received extracorporeal membrane shown that only 50% of children with tal concern is of greater predictive oxygenation or having cytomegalovirus hearing loss are identified by the com- value than the informal behavioral ex- infection, should have more frequent au- prehensive use of such question- amination performed in the physi- diological assessments. Key point 1: Ev- naires.8,9 Key point 2: Periodic objective cian’s office.10 Parents often report ery child with 1 or more risk factors on hearing screening of all children suspicion of hearing loss, inattention, the hearing risk assessment should should be performed according to the or erratic response to sound before have ongoing developmentally appropri- recommendations for preventive peri- hearing loss is confirmed.11 One study ate hearing screening and at least 1 di- odic health care1 (Table 1). showed that parents were as much as agnostic audiology assessment by 24 to If a parent or caregiver is concerned 12 months ahead of physicians in iden- 30 months of age (Table 1). that a child might have hearing loss, tifying their child’s hearing loss.3 Key Although questionnaires and check- the pediatrician needs to assume that point 3: Any parental concern about lists are useful for identifying a child at such is true until the child’s hearing hearing loss should be taken seriously risk of hearing loss, studies have has been evaluated objectively.
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