When to Refer a 2-Year-Old to Audiology
Any 2-year-old with parental concern about hearing, failed hearing screening, speech-language delay, or identified risk factors for hearing loss should be referred immediately to audiology for comprehensive evaluation. 1
Immediate Referral Indications
Parental Concern
- Take any parental concern about hearing loss seriously and refer promptly - parents often identify hearing problems 12 months before physicians recognize them 1
- Do not wait for "objective" confirmation if parents express worry about their child's hearing 1
Failed Hearing Screening
- Any child who fails objective hearing screening at the 18-month or 24-month well-child visit requires audiology referral 1
- Air-conduction hearing threshold levels greater than 20 dB at any frequency (500,1000,2000, or 4000 Hz) indicate possible hearing loss and warrant referral 1
Speech-Language Concerns
- All children who fail the speech-language portion of developmental screening must be referred for both audiology assessment and speech-language evaluation 1
- Children not meeting age-appropriate developmental milestones for hearing and language (Table 9 in guidelines) require immediate referral 1
Risk Factor-Based Referral (Even if Screening Passed)
All children with hearing loss risk factors require at least one diagnostic audiology assessment by 24-30 months of age, regardless of whether they passed newborn hearing screening. 1
High-Priority Risk Factors Requiring Earlier/More Frequent Assessment:
- Cytomegalovirus (CMV) infection 1
- Received extracorporeal membrane oxygenation (ECMO) 1
- Syndromes associated with progressive hearing loss 1
- Neurodegenerative disorders 1
- History of chemotherapy 1
- Culture-positive postnatal infections associated with sensorineural hearing loss 1
- Family history of hearing loss 1
- Craniofacial anomalies 1
- NICU stay greater than 5 days 1
Surveillance Schedule and Screening Protocol
Routine Surveillance at Every Well-Child Visit:
- Monitor auditory skills, developmental milestones, and parental concerns at each visit per AAP periodicity schedule 1
- Perform validated global developmental screening at 9,18, and 24-30 months 1
- Assess middle-ear status with pneumatic otoscopy and/or tympanometry 1
Middle Ear Disease:
- Children with persistent middle-ear effusion lasting 3 months or longer require referral for both otologic and audiologic evaluation 1
Type of Audiology Assessment Needed
For a 2-year-old, comprehensive audiologic evaluation by a pediatric audiologist should include: 1
- Visual response audiometry (typical for ages 6 months to 2.5 years) 1
- Play audiometry (for children approaching age 2.5-4 years) 1
- Ear-specific testing when possible using insert earphones 1
- Evaluation of air-conduction and bone-conduction thresholds 1
- Assessment to distinguish conductive from sensorineural hearing loss 1
Critical Pitfalls to Avoid
- Never assume hearing is normal based on office observation alone - formal audiologic testing is required even if the child seems to respond to sounds in the exam room 1, 2
- Do not delay referral for children with developmental delays, autism, or behavioral problems - these children require specialized audiologic assessment with appropriate equipment and expertise 1
- Pneumatic otoscopy and tympanometry assess middle-ear status but do not assess hearing - abnormal findings require audiology referral 1
- Do not overlook unilateral hearing loss, which can go undetected but still requires intervention 3
Outcomes of Early Identification
Early identification and intervention for hearing loss significantly improves: 4, 5
- Speech and language development 4, 5
- Academic achievement 4
- Social-emotional development 5
- Cognitive outcomes 4
- Overall quality of life 4, 5
The key principle: when in doubt, refer. Any abnormal objective screening result, parental concern, or identified risk factor warrants audiology referral - screening only benefits children if abnormal results lead to definitive testing and appropriate intervention. 1