How to approach chronic reduced hearing in children in primary care?

Approach to Chronic Reduced Hearing in Children in Primary Care

Primary care physicians should perform hearing testing when otitis media with effusion (OME) persists for 3 months or longer, or at any time language delay, learning problems, or significant hearing loss is suspected in a child. 1

Initial Assessment in Primary Care

• Identify risk factors for hearing loss including family history of childhood-onset hearing loss, NICU admission >5 days, ECMO therapy, CMV infection, and syndromic conditions 1
• Monitor for warning signs of hearing impairment:
  • Failure to localize sounds in horizontal plane 2
  • Limited or absent vocalization 2
  • Lack of response to name or familiar voices 2
  • Minimal startle response to loud sounds 2
• Assess for symptoms that may be attributable to hearing loss:
  • Balance (vestibular) problems 1
  • Poor school performance 1
  • Behavioral problems 1
  • Ear discomfort 1
  • Reduced quality of life 1

Primary Care Hearing Testing

• Initial hearing testing for children aged 4 years or older can be performed in the primary care setting 1
• Testing environment requirements:
  • Quiet environment, preferably in a separate closed or sound-proofed area 1
  • Use conventional audiometry with earphones 1
  • Fail criterion: >20 dB HL at 1 or more frequencies (500,1000,2000,4000 Hz) in either ear 1
• Methods NOT recommended as substitutes for primary care hearing testing:
  • Tympanometry and pneumatic otoscopy alone 1
  • Caregiver judgment regarding hearing loss 1
  • Auditory brain stem response and otoacoustic emission tests (these assess auditory pathway structural integrity, not hearing) 1

Referral Criteria for Comprehensive Audiologic Evaluation

• Children who fail primary care hearing testing 1, 3
• Children younger than 4 years 1
• Children who cannot be tested in the primary care setting 1
• OME persisting for 3 months or longer 1
• Suspected language delay, learning problems, or significant hearing loss 1
• Asymmetric hearing loss requiring further medical investigation 3

Comprehensive Audiologic Evaluation

• Comprehensive evaluation includes:
  • Air-conduction and bone-conduction thresholds for pure tones 1
  • Speech detection or speech recognition thresholds 1
  • Measuring speech understanding if possible 1
• Age-appropriate assessment methods:
  • Visual reinforcement or conditioned orienting response audiometry for infants aged 6-24 months 1
  • Play audiometry for children aged 24-48 months 1
  • Conventional screening audiometry for children aged 4 years and older 1

Language Testing

• Language testing should be conducted for children with hearing loss (pure tone average >20 dB HL on comprehensive audiometric evaluation) 1
• Denver Developmental Screening Test II can be used to screen general development, including speech and language, for older children 1
• Comprehensive speech and language evaluation is recommended for children who fail testing or whenever the parent/caregiver expresses concern 1

Medical Evaluation and Referral

• Every child with confirmed hearing loss and/or middle-ear dysfunction should be referred for otologic evaluation 1
• The primary care physician must partner with specialists, including otolaryngologists, to facilitate coordinated care 1
• Monitor middle-ear status, as middle-ear effusion can further compromise hearing 1
• Closely monitor developmental milestones and initiate referrals for suspected disabilities, as 30-40% of children with confirmed hearing loss will demonstrate developmental delays 1

Intervention Timeline

• For confirmed hearing loss, amplification devices should be fitted within 1 month of diagnosis 2
• Early intervention services should begin no later than 6 months of age 2
• Regular follow-up is essential to monitor progress and adjust interventions as needed 2

Common Pitfalls to Avoid

• Delaying referral while "waiting to see if it improves" - early intervention is crucial 2
• Overlooking the need for specialized assessment for asymmetric hearing loss 3
• Not considering patient preferences and sociodemographic factors that may influence access to hearing healthcare 3
• Focusing only on hearing aids without addressing comprehensive early intervention needs 2
• Using tympanometry and pneumatic otoscopy as substitutes for hearing testing 1

Impact of Untreated Hearing Loss

• Hearing loss can impair early language acquisition 1, 4
• Children experiencing the greatest conductive hearing loss for the longest periods may be more likely to exhibit developmental and academic sequelae 1
• Consequences include worse outcomes in speech, language, education, social functioning, cognitive abilities, and quality of life 4