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Hearing assessment update offers 7 recommendations, expands medical home guidance

August 28, 2023

Only half of children who are deaf or hard of hearing (D/HH) are identified through universal newborn hearing screens. Approximately one to three per 1,000 children become D/HH after the newborn period.

Surveillance of hearing thresholds after the neonatal period is important to identify infants, children and adolescents with delayed-onset hearing changes. Timely interventions are necessary to optimize language, cognitive and socioemotional development, and prevent additional disabilities.

An updated AAP clinical report from the Committee on Practice and Ambulatory Medicine and Section on Otolaryngology-Head and Neck Surgery provides recommendations for primary care pediatricians on assessing hearing throughout childhood and adolescence.

The report Hearing Assessment in Infants, Children, and Adolescents: Recommendations Beyond Neonatal Screening is available at and will be published in the September issue of Pediatrics.

What’s new?

The clinical report updates information on hearing assessment, aligns with Bright Futures recommendations and expands the considerations for providing a medical home for children who are D/HH.

The terminology reflects that children who are D/HH are equal, healthy and whole as they are, in keeping with AAP Words Matter guidance. Deficit-framing and pathologizing terminology such as “loss,” “failed” and “impairment” are not used.

Screening guidance

All children should undergo a risk assessment using objective and evidence-based risk factors associated with changes in hearing.

As a component of monitoring for hearing changes, scheduled hearing screening may take place in the primary care setting or via referral to an audiologist in accordance with the Bright Futures recommendations.

The clinical report includes a hearing assessment algorithm for primary care pediatricians, a table outlining risk factors for delayed-onset hearing changes and a chart comparing hearing screening technologies for use in a primary care setting.

The report discusses genetic causes, infectious etiologies such as congenital cytomegalovirus and meningitis, and physical findings associated with hearing levels.

Children of all ages should have prompt, objective hearing screening if there is either clinical or caregiver concern regarding their hearing. Hearing screening should not be repeated more than once before referral to audiology to avoid delays in identification and intervention.

Referral, support essential

It is important to refer children with a positive hearing screen to audiology for a comprehensive diagnostic evaluation. If children are unable to cooperate with the clinical evaluation due to behavioral and/or developmental conditions, a sedated auditory brainstem response may be necessary.

Hearing screening results should be reviewed with families and documented to facilitate tracking and follow-up.

The updated report discusses in detail the importance of follow-up, support and intervention for children who are identified as D/HH. Referrals to appropriate specialists, including audiology, otolaryngology, speech pathology, ophthalmology, genetics and development, also may be appropriate.

Intervention services are key to supporting the child's communication and language development and socioemotional needs within the family and school setting. Intervention services beginning at birth are guaranteed under the Individuals with Disabilities Education Act Part C. Children who are 36 months and older qualify for school-based Part B services or a 504 plan.

Access to language is the primary concern for a child newly identified as D/HH. Because the neurocritical period for language acquisition is birth to 5 years, children who become D/HH when they are younger than age 5 years are at risk for language deprivation. A variety of interventions can be implemented, alone or combined, including hearing aids, cochlear implants and a natural visual language of the Deaf such as American Sign Language (ASL).

The report contains links to resources for finding a pediatric audiologist, advocating for the legal rights of children who are D/HH, assessing ASL milestones and understanding the risks and benefits of cochlear implants. Recommendations and resources outline a path for primary care pediatricians to identify and care for patients who are D/HH and to support them and their caregivers in the medical home setting.

Drs. Bower and Hecht are lead authors of the clinical report.


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