What is the next step for a 2-year-old with a history of normal hearing at birth, six ear infections in the past year, and concerns about expressive language delay?

Immediate Comprehensive Audiologic Evaluation Required

This 2-year-old with recurrent otitis media and expressive language delay requires immediate referral for comprehensive audiologic evaluation by a pediatric audiologist, regardless of the normal newborn hearing screen. 1, 2

Why Urgent Hearing Assessment is Critical

The combination of six ear infections in one year and expressive language concerns creates multiple high-risk indicators that mandate formal hearing evaluation:

• Recurrent otitis media for at least 3 months is a recognized risk indicator for delayed-onset hearing loss that requires audiologic assessment regardless of newborn screening results 1
• Parental concern about language delay must be taken seriously and requires objective hearing screening - parents often identify hearing problems 12 months before physicians 1, 2
• Hearing testing is specifically recommended when language delay or learning problems are suspected at any time in a child with history of ear infections 1, 2

The Testing Protocol

Primary Care Cannot Substitute for Comprehensive Evaluation

• This child is only 2 years old, so primary care office screening is inadequate - comprehensive audiologic evaluation by a pediatric audiologist is required for children younger than 4 years 1, 2
• At least one auditory brainstem response (ABR) test should be included as part of complete diagnostic evaluation for children under 3 years to confirm any hearing loss 1
• The comprehensive evaluation must include air-conduction and bone-conduction thresholds, speech detection thresholds, and assessment of speech understanding 2

Critical Pitfall to Avoid

Never assume normal newborn hearing screening rules out current hearing loss - this child has multiple acquired risk factors (recurrent otitis media) that can cause delayed-onset or progressive hearing loss that develops after birth 1, 3

Simultaneous Referrals Required

Speech-Language Evaluation

• Immediate referral to a speech-language pathologist for formal language testing with validated tools is required alongside the audiologic evaluation 1, 2
• Language testing is specifically recommended for all children with suspected hearing loss 1, 2

Otolaryngology Evaluation

• Referral to pediatric ENT is warranted given the history of six ear infections in one year to assess for chronic otitis media with effusion and determine if tympanostomy tubes or other intervention is needed 2
• Middle-ear effusion persisting for 3 months or longer requires otologic evaluation 1

Timeline for Action

• Hearing evaluation should occur within days, not weeks - federal guidelines specify referral within 2 days of suspected hearing loss 1
• If hearing loss is confirmed, intervention (hearing aids if needed) must begin by 6 months from diagnosis, and early intervention services should start immediately 1, 2
• Children identified and treated within the first 6 months of life have significantly better language outcomes, achieving language development within normal range by age 5 1

What Not to Do

• Do not wait for "watchful waiting" - the 3-month observation period for otitis media with effusion does not apply when language delay is already present 1
• Do not use office-based screening methods (tuning forks, behavioral observation, tympanometry alone) as substitutes for comprehensive audiologic testing 1
• Do not delay evaluation to treat current ear infections first - hearing assessment should proceed concurrently with medical management 1

Documentation for Referrals

When referring to specialists, document: 1

• Duration of ear infection history (6 episodes over 12 months)
• Specific concern about expressive language delay
• Normal newborn hearing screen result
• Request for urgent evaluation given language concerns