Hearing Screening

For optimal development, children and youth need to have excellent hearing. Auditory deprivation in early infancy can cause irreversible deficits in language development, communication and psychosocial skills, cognition and literacy.⁴ A hearing impairment can delay the newcomer child’s acquisition of English or French and affect the process of adaptation and acculturation.

Screening and intervention for hearing loss in youngsters is important for a number of reasons:

• Half of all cases of deafness and hearing impairment are avoidable through primary prevention.²
• The impact on a child’s speech and language is directly proportional to the severity of hearing loss and delay in diagnosis and intervention.⁴
• The earlier children with a hearing loss start intervention services, the more likely they are to reach full potential.

Causes of hearing impairment and deafness

Young newcomers to Canada – particularly those from developing countries – may be more likely to experience hearing impairment than the general population. World Health Organization (WHO) data indicate that 80% of people with hearing impairment worldwide are from low- and middle-income countries, which is where many young newcomers to Canada originate.^2,3

Half of children with hearing loss have no identifiable risk factors.

Causes of hearing impairment and deafness can include: ^2,4-6

• Genetics (in 50% of cases, there is a family history of permanent hearing loss).
• Craniofacial abnormalities, including those involving the external ear (in neonates).
• Congenital infections (e.g., bacterial meningitis, cytomegalovirus, toxoplasmosis, rubella, herpes, syphilis).
• Problems during pregnancy or in the perinatal period (e.g., traumatic birth, severe jaundice).
• A neonatal intensive care unit stay (> 2 days) or any of the following (irrespective of duration of stay): assisted ventilation, ototoxic drug use, hyperbilirubinemia requiring exchange transfusion, extracorporeal membrane oxygenation.
• Infectious diseases (e.g., meningitis, measles, mumps, rubella, tuberculosis).
• Chronic ear infections.
• Iron deficiency anemia.
• Exposure to ototoxic drugs.
• Excessive noise (e.g., personal listening devices, machinery, gunfire, explosions).

The WHO reports that 80% of hearing impairment worldwide is due to chronic suppurative otitis media (CSOM), and 90% of such cases are in the developing world.⁷  The results of a recent Australian study indicate a much higher rate of suppurative otitis media among the Australian refugee population than among the general population.⁸

Signs of hearing loss in infants and children

Chronic suppurative otitis media (CSOM) may be seen as ‘normal’ by newcomers from developing countries and they may not seek medical care.  CSOM is often misdiagnosed as otitis externa.⁸

Signs of hearing loss are summarized below.^9,10 Clinicians should not attribute a delay in language and speech development to a different mother tongue or different culture until hearing testing and other appropriate evaluations are performed.

An infant or toddler with a hearing loss may:

• Stop babbling (a parent usually doesn’t notice this until about 12 months of age).
• Not pay attention or react to loud noises around the house (e.g., the doorbell, telephone or a dog barking).
• Not turn toward sound by 3 to 4 months of age, or do not turn toward spoken words by 9 months.
• Have frequent colds or ear infections with or without fluid draining from the ears.
• Not say single words by 12 months.
• Not understand simple phrases unless the speaker is facing them (e.g., “Go get your shoes”).
• Start speaking later than usual or be difficult to understand.
• Speak loudly or turn up the volume on a television or radio so much so that it disturbs others.

A pre-schooler or school-aged child with a hearing loss may:

Do not attribute a delay in language and speech development to a different mother tongue or different culture until hearing testing and other appropriate evaluations are performed.

• Start speaking later than usual or be difficult to understand.
• Need things to be repeated.
• Speak loudly or turn up the volume on the television or radio.
• Have difficulty following simple instructions.
• Seem like they are not paying attention, especially in a group or a noisy setting, like child care or schoolyard.
• Have trouble learning in school (vision should also be checked).
• Be easily frustrated, more so than other children of the same age.

More information for parents on their child's hearing is available on the Canadian Paediatric Society’s Caring for Kids website.

Screening recommendations

Newborns

Because half of children with hearing loss have no identifiable risk factors, universal hearing screening of newborns is recommended by a number of organizations, including the CPS.^{1, 4,11,12}

Such screening programs generally aim to:⁴

• Screen newborns by 1 month of age,
• Confirm diagnosis by 3 months, and
• Implement intervention, if required, by 6 months.

Screening of newborns is recommended to help ensure early detection and management, whether treatment is medical, surgical or involves devices such as hearing aids, cochlear implants, bone-anchored hearing aids or other assistive devices.⁴

Newcomer children may not have undergone screening for hearing loss in their country of origin.  A 2010 report by the WHO highlights that:¹²

• The implementation of government-funded national hearing screening programs for youngsters is inconsistent worldwide.
• In almost all countries in Southeast Asia, there are no newborn and infant hearing screening programs.
• Although early hearing detection and intervention programs are mandatory in about half of European countries, the degree of implementation and coverage varies greatly from country to country, as well as regionally.

Despite the benefits of screening, the implementation of universal hearing screening of newborns is unfortunately also inconsistent across Canada. Only some provinces or territories, such as Ontario and British Columbia, have fully funded screening programs.⁴

Children should have their hearing tested before they enter school or any time there is concern about a child’s hearing or language development.¹

Screening tests

Two tests can be used for hearing screening in newborns and children:⁴

1. Otoacoustic emission (OAE): Used to check the response of the inner ear to sound.
2. Automated auditory brainstem response (AABR): Used to check the brain’s response to sound.

According to best practice, OAE should be used first. If there is a ‘fail’, then AABR is used.¹³

Intervention

If the screening test is abnormal, a complete hearing test should be performed as soon as possible by a skilled audiologist.

The CPS position statement on hearing screening⁴ outlines a clinician’s next steps once a young patient has been diagnosed with hearing loss:

• Determine the etiology of hearing loss. Whether the child has associated comorbidities and/or syndromic or non-syndromic hearing loss can be learned through a detailed family history and medical evaluation.  Many newcomers to Canada lack the English or French language skills needed for giving a thorough history, so involving an interpreter can be a crucial aid to communication.  Read about using interpreters.
• Consult with a paediatric ear, nose and throat specialist, ophthalmologist and geneticist. Prompt vision assessment is important to determine whether there is an underlying genetic condition (e.g., Usher syndrome), as well as for optimizing sensory input.
• Help facilitate timely referral for medical, educational or surgical interventions. Newcomers face a variety of barriers to accessing care.  Be ready to provide extra assistance to newcomer families trying to navigate the health system.

Prevention

Clinicians should use periodic health visits to speak with young patients and families about preventing hearing loss, particularly when listening to music. The recommended upper limit of occupational noise exposure is 85 dB; noise exposure from rock concerts and personal music devices can reach 120 dB.¹⁴

Selected resources

• American Academy of Paediatrics, Joint Committee on Infant Hearing.  Position statement:  Principles and guidelines for early hearing detection and intervention programs. Pediatrics 2007;120(4): 898-921.
• Canadian Paediatric Society, Community Paediatrics Committee. Universal newborn hearing screening. Paediatr Child Health 2011;16(5):301-5.
• Centers for Disease Control and Prevention. Hearing loss in children: Screening and diagnosis.
• Harlor AD Jr., Bower C, Committee on Practice and Ambulatory Medicine; Section on Otolaryngology-Head and Neck Surgery. Hearing assessment in infants and children: Recommendations beyond neonatal screening. Pediatrics 2009;124(4):1252-63.

Useful Links

• Speech-Language and Audiology Canada  
• Canadian Association of the Deaf
• Canadian Hearing Society
• Centers for Disease Control and Prevention. Learn the Signs. Act Early.
• Centers for Disease Control and Prevention. Hearing loss fact sheet.
• First words/premier mots
• Ontario Ministry of Children and Youth Services. Can your baby hear?
• World Federation of the Deaf

References

1. Centers for Disease Control and Prevention. Hearing loss in children, 2012.
2. World Health Organization. Deafness and hearing loss. [Fact sheet, 2013]
3. Mathers C, Smith A, Concha M. Global burden of hearing loss in the year 2000. In: Global burden of disease, 2000. World Health Organization. Geneva, Switzerland: WHO, 2000.
4. Canadian Paediatric Society, Community Paediatrics Committee. Universal newborn hearing screening. Paediatr Child Health 2011;16(5):301-5.
5. Algarín C, Peirano P, Garrido M, Pizarro F, Lozoff B. Iron deficiency anemia in infancy: Long-lasting effects on auditory and visual system functioning. Pediatr Res 2003;53(2):217-23.
6. Nicolau Y, Northrop C, Eavey R.Tuberculous otitis in infants: Temporal bone histopathology and clinical extrapolation. Otol Neurotol 2006;27(5):667-71.
7. Acuin J. Chronic suppurative otitis media: Burden of illness and management options. Geneva, Switzerland: WHO, 2004.
8. Benson J, Mwanri L. Chronic supperative otitis media and cholesteatoma in Australia's refugee population. Aust Fam Physician 2012;41(12):978-80.
9. Canadian Paediatric Society, Community Paediatrics Committee. Your baby’s hearing. [Parent handout, 2008]
10. Ontario Ministry of Children and Youth Services. Can your baby hear?
11. U.S. Preventive Services Task Force, 2008. Universal screening for hearing loss in newborns.
12. World Health Organization. Newborn and infant hearing screening: Current issues and guiding principles for action. Geneva, Switzerland: WHO, 2010.
13. McLean M, Wolery M, Bailey DB Jr. Assessing Infants and Preschoolers with Special Needs, 3rd edn. Upper Saddle River, NJ: Pearson Education Corp., 2004.
14. Canadian Paediatric Society, Community Paediatrics Committee. Preventive health care visits for children and adolescents aged 6 to 17 years: The Greig Health Record – technical report. Paediatr Child Health 2010;15(3):157-9.