II. Health Supervision

Screening Services and Assessments: Hearing Screening

Hearing screening is a mandatory EPSDT service that must be provided at each HealthCheck preventive visit. Hearing loss is one of the most common conditions present at birth and, if undetected, will impede speech, language, cognitive, and socioemotional development. Early detection, prompt referral, and appropriate medical and educational interventions are critical in helping children develop optimal communication and social skills.

Newborn Hearing Screening

In the District of Columbia, all newborns must be screened with an objective method—either the auditory brainstem response (ABR) test or the evoked otoacoustic emissions (EOAE) test. Screening typically takes place in the hospital or birthing facility. Infants who fail the screening test should be referred promptly for formal audiologic assessment.

Periodicity and Guidelines for Hearing Screening

Hearing screening includes both subjective methods (health history, risk assessment, physical exam) and objective (pure-tone) hearing tests.

HealthCheck requires hearing screening as follows:

• Subjective screening at each preventive health visit from birth to 21 years
• Objective screening with pure-tone testing at key developmental ages:

Infancy:

• Screen at newborn visit and at 6 months

Childhood:

• Screen at 5, 6, 8, and 10 years

Adolescence:

• Screen at 12, 15, and 18 years

Comprehensive Hearing Screening

Comprehensive hearing screening includes these components:

• Health history and risk assessment
  • Child’s response to voices and other auditory stimuli
  • Delayed speech development
  • Chronic or recurrent otitis media with effusion (OME)
  • Other risk indicators (see below)
• Physical exam
  • Structural defects of the ear, head, and neck
  • Abnormalities of the ear (inflammation, cerumen impaction, tumors, foreign bodies)
  • Abnormalities of the eardrum (perforation, retraction, evidence of effusion)
• Objective, age-appropriate hearing testing
• Early detection and prompt referral to an approved speech and hearing center
• Documentation in the medical record of specific screening method(s) used, test results, and referral (if indicated)

Risk Indicators for Hearing Loss Screen infants, children, and teens who have one or more risk indicators as soon as possible, but no later than 3 months after risk is identified: Parent/caregiver concern about hearing, speech, language and/or developmental delay Family history of childhood or delayed-onset hearing loss Birthweight < 1500 grams Apgar scores of 0 to 4 at 1 minute or 0 to 6 at 5 minutes Neonatal events associated with hearing loss (in utero infection, cytomegalovirus, mechanical ventilation > 5 days) Recurrent or persistent otitis media with effusion (OME) > 3 months History of bacterial meningitis History of head trauma, especially with fracture of the temporal bone Craniofacial or temporal bone anomalies Physical findings associated with sensorineural or conductive hearing loss Recognizable syndromes associated with hearing loss History of ototoxic medications (e.g., aminoglycosides use > 5 days) Presence of neurodegenerative disorders History of childhood diseases associated with hearing loss (e.g., mumps, measles) Repeated exposure to potentially damaging noise levels Chemotherapy

Screening Methods

Infants and young children ages 6 months to 3 years

Screen young children with behavioral methods, using a conditioned response (visual reinforcement audiometry or conditioned play audiometry). ABR testing may also be used.

Children 3 years and older

Screen children and teens at specified ages using the pure-tone audiometer,¹ Welsh Allyn Audioscope, or other approved instruments. (Temporary hearing loss is common in school-age children, usually as a complication of OME.)

Testing Protocols

Test each ear separately. (Teach the desired motor response before screening, and conduct a pretest at higher threshold levels to be sure the child understands.)

Failure to respond to threshold levels of 20 decibels at 1000, 2000, and 4000 Hz tones indicates possible hearing impairment. If the child or teen fails to respond, teach the desired motor response again, then reposition earphones and rescreen. At least two presentations of each test stimulus may be required to ensure reliability. If the child or teen again fails to respond, refer for audiologic assessment.

References

¹ Perform pure-tone audiometry in a quiet environment using earphones, since ambient noise can significantly affect test performance, particularly at lower frequencies (500 and 1000 Hz).(Handheld audiometers have not been proven effective. Note: The audiometer must have double earphones and meet American National Standards Institute (ANSI) standards. The operator should listen to it each day of use to detect gross abnormalities, and should be sure it is calibrated annually.

Resources

Joint Committee on Infant Hearing. Year 2000 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Available online at www.infanthearing.org/jcih/

American Speech-Language-Hearing Association, Panel on Audiologic Assessment. 1997. Guidelines for Audiologic Screening. Rockville, MD: American Speech-Language-Hearing Association.

Green M, Palfrey JS, eds. Bright Futures: Guidelines for Infants, Children, and Adolescents (2nd ed., rev.). [Appendix D: Hearing Screening]. 2002. Arlington, VA: National Center for Education in Maternal and Child Health. Available online at www.brightfutures.org.