The American Academy of Pediatrics has updated its recommendations on risk assessment, terminology, and other care components for children who are deaf or hard of hearing. The update is the first since 2009.
The AAP's clinical report was published online in Pediatrics.
Charles Bower, MD, with the department of otolaryngology at Arkansas Children's Hospital in Little Rock, led the research team representing AAP's Committee on Practice and Ambulatory Medicine, section on otolaryngology and head and neck surgery.
The report details how primary care clinicians can detect changes in hearing status by age.
Eliminating terms such as "failed" or "impairment"
A key change in this report is that it no longer uses terms such as "loss," "failed," or "impairment," "to reflect that children who are deaf or hard of hearing (D/HH) are equal, healthy, and whole," the authors wrote.
The report's recommendations are based on the literature and engagement with deaf and hard of hearing professionals and partner organizations, such as the National Association of the Deaf, working with the AAP Early Hearing Detection and Intervention program.
Birth to 5 a critical time
The authors noted that early medical support for hearing is especially important between birth and 5 years of age. That span is a critical time for brain and language development.
Parents and caregivers are often the first to notice a child's inattention or erratic responses to sound, they wrote, and it's important to address these concerns with a pediatrician even if the child has passed a newborn hearing test after birth.
Among recommendations in the update:
All children should have an objective, evidence-based risk assessment for changes in hearing.
Children at all ages should have prompt screening if there is clinical or caregiver concern about hearing.
A child who screens positive for atypical hearing in one or both ears should be referred to an audiologist for diagnostic consultation and testing.
Because standard testing for children with developmental or behavioral health conditions may be impossible or inaccurate, referral may be more appropriate to audiology for electrophysiological hearing testing using auditory brainstem response (ABR) with sedation.
To prevent false negatives and to avoid delays in identification, access to language, and support, screening tests should not be repeated more than once before referral to audiology.
Additional recommendations
The report authors pointed out that genetic causes may affect hearing and may show up beyond the newborn period.
They wrote that congenital cytomegalovirus (cCMV) infection is the most common infectious cause of childhood sensorineural hearing change and accounts for 25% of deaf and hard of hearing children at age 4.
Meningitis and otitis media also are leading causes of a change in hearing.
Judith E.C. Lieu, MD, MSPH, professor, program director and vice-chair for education in the department of otolaryngology and head and neck surgery at Washington University in St. Louis, who was not part of the research team, said screening recommendations have not changed much in the update, but she highlighted some points.
She noted that tympanometry is not listed as a method of hearing screening in primary care.
"I agree that tympanogram is not a hearing screening. It is an adjunct to look at middle ear function, but that doesn't necessarily mean it looks for hearing," she said.
Dr. Lieu says she does take issue with the stated length of one of the tests in the paper. She said she is concerned that the pure-tone audiometry test for ages 4 through adolescence is listed as taking 30 minutes in a primary care setting. She said she worries that pediatricians will be put off by reading that it is a 30-minute test.
"Honestly, in my experience, it doesn't take 30 minutes. Maybe 10 minutes," she said. "I don't know any pediatrician who could devote 30 minutes to one screening test."
Development milestones have been adjusted
Also different in these recommendations are the developmental and speech milestones updated according to the most recent AAP information, Dr. Lieu said. Though the new milestones don't change by much, they are important to note, she said, such as updated guidance on when to be concerned about speech delay.
She said she wished the guidance included more about hearing loss in older children.
The report authors stated that about 1 to 3 per 1,000 children have atypical hearing at birth and similar numbers become deaf or hard of hearing later in childhood.
But Dr. Lieu says that statistic may give the wrong impression about frequency of atypical hearing.
"Hearing loss increases during childhood," she pointed out. "By the time they hit about age 18, about 15% of kids have some kind of hearing loss."
"I don't think it's made clear to pediatricians that this is not 1 or 2 in a thousand children — this happens much more frequently," she said.
The report authors and Dr. Lieu report no relevant financial relationships.
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