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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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6Hearing

An estimated 1% to 2% of infants and children in the United States suffer from hearing impairment. Approximately half of these cases are congenital or are acquired during infancy. Severe or profound hearing loss affects one of every 750 live births. Approximately 5% of infants in neonatal intensive care units have evidence of significant hearing loss. Some 8 million school-aged children experience temporary hearing loss, which usually occurs as a complication of otitis media with middle ear effusion.

Hearing is necessary for normal development of speech and language and is also important for acquiring psychosocial skills during infancy and childhood. Because most speech and language development occurs between birth and 3 years of age, early detection of hearing impairment in infants and children and initiation of medical and educational interventions are critical.

Refer to chapter 35 for information on hearing screening in adults.

Recommendations of Major Authorities

Normal-Risk Children

  • American Academy of Pediatrics and Bright Futures
  • endorse the recommendation by the Joint Committee on Infant Hearing and alsorecommend that pure-tone audiometry be performed at 3, 4, 5, 10, 12, 15, and 18 years of age. Subjective assessment of hearing should be performed at other ages.
  • American Speech-Language-Hearing Association --
  • Annual pure-tone audiometry should be performed for children functioning at a developmental level of age 3 years to grade 3 and for any high-risk children, including those above grade 3.
  • Canadian Task Force on the Periodic Health Examination --
  • Repeated examination of hearing is recommended for young children, especially during the first year of life. Suggested guidelines for this examination include checking the startle or turning response to a novel noise produced outside the infant's field of vision at birth and 6 months of age and checking for the absence of babbling at 6 months of age. Screening using auditory brainstem responses or evoked otoacoustic emission by 3 months of age is not recommended pending further evaluation. Routine hearing assessment of asymptomatic preschoolers using history-taking, audiometry, tympanometry, or acoustic reflexometry is not recommended.
  • Joint Committee on Infant Hearing (American Speech-Language Hearing Association, American Academy of Pediatrics, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Audiology, American Academy of Pediatrics and the Directors of Speech and Hearing Programs in State Health and Welfare Agencies) and Bright Futures --
  • endorse the goal of universal detection of infants with hearing loss as early as possible using auditory brainstem response or otoacoustic emissions. All infants should be screened before 3 months of age.
  • US Preventive Services Task Force --
  • There is insufficient evidence to recommend for or against routine screening of asymptomatic neonates for congenital hearing loss using evoked otoacoustic emission (EOE) testing or auditory brainstem response (ABR). Routine hearing screening of asymptomatic children beyond age 3 years is not recommended. There is insufficient evidence to recommend for or against routinely screening asymptomatic adolescents for hearing impairment. However, screening of workers for noise-induced hearing loss should be performed in the context of existing worksite programs and occupational medicine guidelines.

High-Risk Children

  • American Academy of Pediatrics and American Speech-Language-Hearing Association (ASHA) --
  • Children with frequently recurring otitis media or middle ear effusion, or both, should have audiology screening and monitoring of communication skills development. ASHA recommends annual pure-tone audiometry testing for all children at high risk for hearing impairment.
  • Joint Committee on Infant Hearing (American Speech-Language Hearing Association, American Academy of Pediatrics, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Audiology, American Academy of Pediatrics and the Directors of Speech and Hearing Programs in State Health and Welfare Agencies) --
  • Neonates (birth to 28 days of age) with one or more of the neonatal risk criteria should have audiology screening, preferably before hospital discharge but no later than 3 months of age.

Neonatal Risk Criteria

Family history of hereditary sensorineural hearing loss; in utero infection (eg, cytomegalovirus, rubella, syphilis, herpes, or toxoplasmosis); craniofacial anomalies, including those with morphological abnormalities of the pinna and ear canal; birth weight less than 1500 grams (3.3 lbs); hyperbilirubinemia at a serum level requiring exchange transfusion; ototoxic medications, including but not limited to aminoglycosides, used in multiple courses or in combination with loop diuretics; bacterial meningitis; Apgar scores of 0 to 4 at 1 minute or 0 to 6 at 5 minutes; mechanical ventilation lasting 5 days or longer; and stigmata or other findings associated with a syndrome known to include a sensorineural and/or conductive hearing loss.

Infants and children less than 2 years of age with one or more of the following risk criteria should have audiology screening.

Risk Criteria for Ages 29 days to 2 Years

Parent/care-giver concern regarding hearing, speech, language, and/or developmental delay; bacterial meningitis or other infections associated with sensorineural hearing loss; head trauma associated with loss of consciousness or skull fracture; stigmata or other findings associated with a syndrome known to include a sensorineural and/or conductive hearing loss; ototoxic medications, including but not limited to aminoglycosides, used in multiple courses or in combination with loop diuretics; recurrent or persistent otitis media with effusion for at least 3 months associated with hearing loss; anatomic deformities and other disorders that affect eustachian tube function; neurofibromatosis type II and neurodegenerative disorders.

Infants and children with the following risk factors for delayed-onset hearing loss require hearing evaluation every 6 months until 3 years of age.

Risk Factors for Delayed-Onset Hearing Loss

Family history of hereditary childhood hearing loss; in utero infection, such as cytomegalovirus, rubella, syphilis, herpes, or toxoplasmosis; neurofibromatosis type II and neurodegenerative disorders; recurrent or persistent otitis media with effusion, anatomic deformities, and other disorders that affect eustachian tube function; neurodegenerative disorders.

  • US Preventive Services Task Force --
  • Screening for hearing impairment in high-risk infants can be recommended based on the relatively high prevalence of hearing impairment, parental anxiety, and the potential beneficial effect on language development from early treatment of infants with moderate or severe hearing loss. Refer to neonatal risk criteria listed above under Joint Committee on Infant Hearing. Clinicians examining any infant or young child should remain alert for symptoms or signs of hearing impairment, including parent/care-giver concern regarding hearing, speech, language, and/or developmental delay.

Basics of Hearing Screening

1. Assess the family and medical history of every child for risk factors for hearing impairment.

2. Ask parents about the auditory responsiveness and speech and language development of young children. Any parental reports of impairment should be seriously evaluated.

3. In infants, assessment of hearing by observational techniques is very imprecise. Consider referring all infants and young children with suspected hearing difficulties to an audiologist.

4. When performing physical examinations, remain alert for structural defects of the ear, head, and neck. Remain alert for abnormalities of the ear canal (inflammation, cerumen impaction, tumors, or foreign bodies) and the eardrum (perforation, retraction, or evidence of effusion).

5. Children as young as 6 months of age, depending on how cooperative they are, may be screened by pure-tone audiometry. Two screening methods are suggested as the most appropriate tools for children who are functioning at 6 months to 3 years developmental age: visual reinforcement audiometry (VRA) and conditioned play audiometry (CPA). For children from approximately 6 months through 2 years of age, VRA is the recognized method of choice. As children mature beyond their second birthday, CPA may be attempted. For those children who can be conditioned for VRA, screen using earphones (conventional or insert), with 1000, 2000, and 4000 Hz tones at 30 dB HL. For those children who can be conditioned for play audiometry, screen using earphones (conventional or insert), with 1000, 2000, and 4000 Hz tones at 20 dB HL. Hand-held audiometers are of unproven effectiveness in screening children.

After 6 months of age, any child may be screened for middle ear dysfunction using tympanometry. Perform tympanometry with a low frequency (220, 226 Hz) probe tone and a positive to negative air pressure sweep. Middle ear pressure peaks between -150 mmhos and +150 mmhos are considered normal. Patients with pressure peaks outside this range or lack of any identifiable pressure peak should be referred for otologic follow-up.

6. Repeat screening to substantiate audiometric evidence of hearing impairment. Remove and reposition the earphones and carefully repeat the instructions to the child to assure proper understanding and attention to the test. Referral to a qualified specialist (ie, audiologist, otolaryngologist) is recommended for confirmation and work-up of hearing impairment.

Patient Resources

  • Is My Baby's Hearing Normal? American Academy of Otolaryngology -- Head and Neck Surgery, Order Department, 1 Prince St, Alexandria, VA 22314; (703)836-4444.
  • Answers to Questions About Otitis Media, Hearing, and Language Development; How Does Your Child Hear and Talk?; Recognizing Communication Disorders. American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852. For general information, call: (800)638-8255. To order, call: (301)897-5700, ext 218; Internet address: http://www.asha.org
  • Middle Ear Fluid in Young Children: Parent Guide; Ear Infection in Children. The American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Provider Resources

  • Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

National Institute on Deafness and Other Communication Disorders. Internet address: http://www.nih.gov/nidcd

American Speech-Language-Hearing Association.
Internet address: http://www.asha.org

Selected References

  1. American Academy of Otolaryngology-Head and Neck Surgery, Joint Committee on Infant Hearing. 1990 position statement. American Academy of Otolaryngology-Headand Neck Surgery Bulletin. March 1991:15-18.
  2. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for pediatric preventive health care. Pediatrics. . 1995; 96:373–374. [PubMed: 7630705]
  3. American Academy of Pediatrics. Managing otitis media with effusion in young children. Pediatrics. . 1994; 94:766–773. [PubMed: 7936917]
  4. American Academy of Pediatrics. Joint Committee on Infant Hearing position statement 1982. In: Policy Reference Guide: A Comprehensive Guide to AAP Policy Statements through December 1991. Elk Grove Village, Ill: American Academy of Pediatrics;1991;333-334.
  5. American Academy of Pediatrics. Middle ear disease and language development. In: Policy Reference Guide: A Comprehensive Guide to AAP Policy Statements through December 1991. Elk Grove Village, Ill: American Academy of Pediatrics;1991;418.
  6. American Speech-Language-Hearing Association. Guidelines for the audiologic assessment of children from birth through 36 months of age. ASHA. . 1991; 33(suppl 5):37–43. [PubMed: 1673607]
  7. American Speech-Language-Hearing Association. Audiologic screening of newborn infants who are at risk for hearing impairment. ASHA. . 1989; 31(3):89–92.
  8. American Speech-Language-Hearing Association. Guidelines for identification audiometry ASHA.1985;May:49-53View this and related citations usingView this and related citations using .
  9. American Speech-Language-Hearing Association. Guidelines for screening for hearing impairment and middle-ear disorders. ASHA. . 1990; 32(suppl 2):17–24. [PubMed: 1970249]
  10. American Speech-Language-Hearing Association. Preferred practice patterns for the professions of speech-language pathology and audiology. Rockville, MD: ASHA. In press.
  11. American Speech-Language-Hearing Association. The prevention of communication disorders tutorial. ASHA. . 1991; 33(suppl 6):15–41. [PubMed: 1684110]
  12. Canadian Task Force on the Periodic Health Examination. Routine preschool screening for visual and hearing problems. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 27.
  13. Canadian Task Force on the Periodic Health Examination. Well-baby care in the first 2 years of life. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 24.
  14. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994.
  15. Joint Committee on Infant Hearing. Joint Committee on Infant Hearing 1994 position statement. Pediatrics. . 1995; 95:152–156. [PubMed: 7770297]
  16. National Institutes of Health. Early Identification of Hearing Impairment in Infants and Young Children. Bethesda, Md: National Institutes of Health. In press. [PubMed: 8401641]
  17. Thompson MD, Thompson G. Early identification of hearing loss: listen to parents. Clin Pediatr. . 1991; 30:77–80. [PubMed: 2007310]
  18. US Preventive Services Task Force. Screening for hearing impairment.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 35.
  19. Watkin PM, Baldwin M, Laoide S. Parental suspicion and identification of hearing impairment. ArchDis Child. . 1990; 65:846–850. [PMC free article: PMC1792472] [PubMed: 2400221]
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