Managing Children with“Little” Hearing Losses

The impact of unilateral and mild hearing loss on the development of infants, preschoolers and school-aged children has been largely unrecognized or ignored by audiologists, educators, and physicians (1, 3). In the last two decades research findings have emphasized the subtle and long term effects even “little” hearing losses can have on the development of academic, social, and behavior skills (2-7). Recognition of the deleterious effects associated with mild and unilateral degrees of hearing loss in children has resulted in increasing attention toward the need to consider use of amplification in classrooms and to develop 504 accommodation plans to support the success of these children (8).

The spread of universal newborn hearing screening becomes across the United States has resulted in an increase in the early identification of mild and unilateral hearing impairment including the identification of mild hearing loss in the mid and high frequency ranges that previously would not have been identified prior to school age. With early identification of these hearing deficits, a variety of management questions arise, such as: What is a reasonable management plan for a baby with mild or unilateral hearing loss? Is amplification appropriate? If so, when should it be fit? What services could the parents expect to receive from the early intervention program when their child has one of these hearing problems?

USHL - Unilateral hearing loss: a sensorineural hearing loss in excess of 40 dB HL in the worse hearing ear; hearing thresholds not to exceed 15 dB HL in the better hearing ear for the frequencies of 1000, 2000, and 4000 Hz. Air-bone gap not to exceed 10 dB HL.

BSHL - Mild bilateral sensorineural hearing loss of flat configuration: an average sensorineural hearing loss in both ears in the range of 20 dB HL to 40 dB HL for the frequencies of 1000, 2000, and 4000 Hz. Air-bone gap not to exceed 10 dB HL.

HFSHL - Minimal sensorineural hearing loss in the high frequency range: air-conduction thresholds greater than 25 dB HL at two or more frequencies including or above 2000 Hz (3000, 4000, 6000, 8000 Hz) in both ears with air-bone gaps at 3000 and 4000 Hz no greater than 10 dB.

With the implementation of universal newborn hearing screening, the audiologist and early intervention system may be encountering the need to appropriately manage “little” hearing losses in infants and toddlers for the first time. Parents and the medical community may have questions regarding the extent that seemingly minor hearing problems can be expected to impact child development and how this relates to needed audiological management and early intervention services.

Prevalence

Prevalence studies have long indicated that 1 baby per 1000 will be born deaf (4). Recent studies have indicated that a total of 5.4%-5.6% of the childhood population will have some degree of hearing impairment (9,10). Even mild and unilateral sensorineural hearing loss will cause children to be at risk for the following problems:

1. difficulty understanding speech under adverse listening conditions (background noise, reverberation, distance greater than one meter, etc.), especially if the hearing loss is not identical in both ears (5, 11-14, 37)

  1. increased family tension, family disruption, breakdowns in family communication, greater fatigue of listener’s with hearing loss, and social isolation (16-17 )
  2. diminished self-esteem, social-emotional health at risk, increased incidence of behavior problems (2, 7, 18-20)
  3. delayed development of verbal skills and reduced academic achievement (21-25)

As with other disability conditions there are fewer children with severe and profound degrees of impairment and a much higher number of children with lesser degrees of hearing loss. Of 2995 the 8 – 12 months old infants that were tested, 168 had identifiable hearing loss (5.6% of infants tested). Of this number, 18 infants had permanent bilateral mild hearing loss (0.6% of total infants tested) and 51 infants (1.7% of total) had unilateral permanent hearing loss from mild to profound degree9. Of 1218 children in grades 3, 6, and 92, the prevalence of bilateral hearing loss in children was 2.2% and the prevalence of unilateral hearing loss in children was 3.4%.

Table 1. Of 2995 8-12 month-old infants tested, 168 had identifiable hearing impairment (5.6% of infants tested) in 234 ears (4% ears tested had hearing impairment)9

Hearing Loss / 27-39 dB HL / 40-59 dB HL / 60-90 dB HL / 100+ dB HL
Both unilateral and bilateral / 152 ears
(65% of ears with hearing loss) / 42 ears
(18% of ears with hearing loss) / 19 ears
(8% or ears with hearing loss) / 21 ears
(9% of ears with hearing loss)
Bilateral only: conductive + permanent / 60 ears
(30 infants) / 16 ears
(8 infants) / 8 ears
(4 infants) / 8 ears
(4 infants)
Unilateral only: conductive + permanent / 92 ears/ infants / 26 ears /infants / 11 ears /infants / 13 ears/ infants)
Bilateral: permanent / 18 infants
(1.33% total) / 4 infants
(0.13% total) / 3 infants
(0.1% total) / 4 infants
(0.13% total
Unilateral: permanent / 57 infants
(1.9% total) / 14 infants
(0.47% total) / 8 infants
(0.27% total) / 11 infants
(0.37% total)

Amplification for children with hearing loss in only one ear

A large proportion of children who are being identified by universal newborn hearing screening have unilateral hearing impairment. There are several compelling reasons to provide direct audiological management to children with this type of hearing impairment. First, it is recognized that there is a critical time period from birth to the first months and years of life during which neural development and important synaptic connections are being formed (26-30). Children with unilateral hearing loss in excess of 40 dB HL are at risk for sensory deprivation due to a lack of stimulation of the impaired ear’s cochlea and the auditory pathways. In the case of children with unilateral hearing loss who may later lose the hearing ability in their better hearing ear, the prevention of sensory deprivation in the poorer hearing ear can be highly important to their future auditory function. This is the strongest argument for early amplification of hearing loss in one ear. Second, when two ears work together the ability to hear in noise is better than for either ear alone. A loss of this binaural summation advantage results in significant negative effects on speech recognition for persons with unilateral hearing loss (31-34). For example, one study found that listening with two ears together can result in a word recognition score that is approximately 18-30% better than the score that is obtained when only one ear is used to listen (35). Third, two ears also work together to allow us to listen more effectively in noisy situations and to localize the direction of sound sources (36). That is, without auditory input into two ears, it is very difficult for a listener to attend to one conversation in the midst of competing conversations or noise (36). Taken together, research findings clearly support the need for early identification, amplification, and intervention for infants and toddlers with unilateral hearing loss.

Comment: The use of amplification does not “inoculate” a child with hearing loss from developing delays in language, cognitive, or social skills. The use of amplification in early childhood can be assumed to decrease a child’s risk for developing these delays. Development of competence of subtle social cues, fast-paced conversation, and understanding of humorous or idiomatic expressions requires consistent hearing of incidental language surrounding a child in infancy, toddlerhood and as a preschooler. The consistent use of amplification can allow a child to master these skills prior to school age. Once a child reaches school age, cosmetic and social concerns may arise that can cause the parent/child to choose to discontinue consistent hearing aid wear as the child enters school or shortly thereafter. In the classroom, hearing aid benefit for mild or unilateral hearing losses can be limited due to background noise in the classroom that also will be amplified and will interfere with listening, unless technology (e.g., FM system) is also used by the child in the classroom. Unless classroom hearing technology is used consistently in conjunction with personal amplification, the level of interference in communication due to amplified noise may be more disruptive to a child’s attention and learning than not wearing hearing aids. Although discontinuing use of personal amplification is not a preferred choice, early use of hearing aids can provide gains in language, listening, learning, and social skills that will provide continuing longterm benefit to the child.

Suggestions for Evaluation and Management of Infants Identified by Newborn Screening:

Mild and Unilateral Sensorineural Hearing Loss

AGE

/

AUDIOLOGICAL

/

FAMILY-CENTERED INTERVENTION

2 weeks to 3 months of age / Hearing loss indicated via universal newborn hearing screening, high-risk indicators, or referral. Confirm presence/degree of loss via OAE/ABR. Refer family to local early intervention program (Part C). Share written information with parent1. If unilateral loss, consider amplification.If hearing aids are recommended, seek medical clearance and begin the necessary funding approval process. / UNHS personnel inform parents of newborns that do not pass universal hearing screening about the results of screening in a culturally sensitive and language appropriate manner and the describe the need for evaluation to rule out the presence of a hearing problem.Initial contact with family by early intervention program (EIP). EIP to provide written information describing the schedule of communication and auditory development1. Provide parents with a list of pertinent websites, written materials.
3-6 months / Appropriate amplification fit to hearing loss by pediatric audiologist2. Fit loaner hearing aids as necessary while waiting for 3rd party payer approval. Specialconsideration given to instrument specifications such as noise reduction/suppression, locking battery drawer, FM capability.Communicate/consult on specific amplification considerations with early interventionist and parent to assure fit of amplification to natural environment needs. / Offer to connect the parents with other parents of children with unilateral ormild hearing loss. Early interventionist support to family during the amplification adjustment period. Opportunity to assist with establishing the amplification wear pattern, provide tips to keep hearing aid(s) on child, increase parent comfort with inserting earmolds, practice of hearing aid checks using Ling 6-sound test.
6-9 months / Behavioral testing to confirm degree of hearing loss and obtain frequency specific information. Compare to early OAE/ABR confirmation for indication of possible loss progression.Coordinate with early interventionist to collaborate with family for completion of Early Listening Function3(ELF) or other amplification validation measure. / Stress the importance of frequent, meaningful parent - child interactions at close proximity.Emphasize the concept of “Language is caught, not taught” and the importance of early auditory development. Coordinate with audiologist and family to complete the ELF or other amplification validation and auditory skill development measure such as Little Ears4.
9-15 months / Reevaluate hearing to check stability of hearing loss. Research indicates ¼ of children with hearing loss may have loss develop in the better ear. Remake earmolds as needed. Reverify output, gain, frequency response of amplification in relation to ear canal growth2. Cross-check appropriateness of amplification via feedback from parent and early interventionist. Now that child is mobile, consider appropriateness of use of FM in home or child care. / Discuss the possibility of hearing loss progression and need for monitoring of hearing ability. Check communication and cognitive milestones6. Now that child is mobile, discuss impact of listening from a distance and background noise as interfering with learning incidental language. Share information on child’s development with audiologist.
16-24 months / Reevaluate hearing to check stability of hearing loss. Remake earmolds as needed. Reverify amplification performance. Cross-check appropriateness of amplification via feedback from parent and early interventionist (i.e., via ELF). Communicate any changes in hearing status with early interventionist. Discuss lifelong need to avoid overexposure to noise and for regular hearing tests. / At 24 months obtain more comprehensive assessment of child development6. Delays in expressive language may begin to be apparent by 18 months. If concerns, address the need for communication intervention services. Emphasize the importance of reading aloud to the child on a daily basis.
25-36 months / Reevaluate hearing, including WIPI half-list at 40 dB HL. Remake earmolds as needed. Reverify amplification performance. Discuss the need to begin to train child to put on own hearing aids. Provide modeling on how to answer peer questions about wear of hearing aid(s). As child approaches entry into preschool, in conjunction with the early interventionist, pursue the purchase of a personal, classroom, or desk-top sound field amplification system. Consider FM need based on support from parent report (CHILD7 report form) or if WIPI test results for perception of low level speech in +5 S/N are < 88% correct. / Monitor communication development at 30 months. Discuss transition to community or public school preschool setting at age 3, especially if there are deficit areas present. Discuss need for child to develop independent skills with hearing aid(s)7 Final communication inventory and evaluation prior to age 3. Provide information to parent on the availability of establishing a 504 plan at school-age and potential need for FM technology in school classrooms. Exit from early intervention.

1. Example: So Your Child Has A Hearing Loss,

2. ASHA Pediatric Working Group on Amplification Fitting

3. Early Listening Function (ELF), or

4. Little Ears Auditory Questionnaire

5. Suggested instruments: Communication and Symbolic Behavior Scales- Developmental Profile (CSBS-DP) The Mullen Scales of Early Learning; Ages and Stages Questionnaires (ASQ),

6. Examples: Minnesota Inventory of Early Child Development (24-40 months), ELM; Denver Developmental Screening Test

7. Children’s Home Inventory for Listening Difficulties (CHILD) or

Sequence of Development for Infants and Toddlers:

Auditory, Language, and Speech

Approx. Age /

Auditory Development

/

Language Development

/

Speech Development

0-28
days / Startle response; attends to music and voice, soothed by parent’s voice; some will synchronize body movements to speech patterns; enjoys time “enface” position; hears caregiver before being picked up
1-3 months / Looks for sound source; associates sound with movement; enjoys parent’s voice; attends to noise makers; imitates vowel sounds / Startles to loud sounds; smiles when spoken to; seems to recognize parent voice and quiets if crying; increases or decreases sucking behavior in response to sound. / Makes pleasure sounds (cooing, gooing); cries differently for different needs. Smiles when sees known caregiver
4-7 months / Uses toys/objects to make sounds; plays with noise makers; pays attention to music; enjoys rhythm games; responds to changes in tone of caregiver voice; notices toys that make sound; moves eyes in direction of sounds / Recognizes some words; responds to verbal commands (bye-bye); learning to recognize name; / Babbling sounds more speech-like with many different sounds, including p, b, and m. Vocalizes excitement and displeasure; makes gurgling sounds when left alone and when playing with caregiver.
8-12 months / Attends to TV; localizes to sounds/voices; enjoys rhymes and songs; enjoys hiding game; responds to vocal games (e.g., So Big!!,Peek-a-boo) / Recognizes words for common items like “cup,” “shoe,” “juice.” Begins to respond to requests. Understands NO. / Babbling has both long and short groups of sounds such as “tata upup bibibibi.” Uses speech or non-crying sounds to get and keep attention. Imitates different speech sounds. Has 1 or 2 words (no, dada, mama) although they may not be clear.
1-2
years / Dances to music; sees parent answer telephone/doorbell; answers to name call; listens to simple stories, songs, and rhymes / Points to pictures in a book when named; points to a few body parts when asked; follows simple commands and understands simple questions (“Roll the ball” “Where’s your shoe?”) / Says more words every month. Uses some 1-2 word questions (“Where kitty?”). Puts 2 words together (“More cookie”). Uses many different consonant sounds at the beginning of words.
2-3
years / Listens on telephone; dances to music; listens to story in a group; goes with parent to answer door; awakens to smoke detector. / Understands differences in meaning (“go/stop,” “up/down”). Follows two requests (“Get the book and put it on the table”). Attends to travel activities and communication. / Has a word for almost everything. Uses 2-3 word “sentences” to talk about and ask for things. Speech is understood by familiar listeners most of the time. Often asks for or directs attention to objects by naming them.

Adapted from: Ear Infections and Language Development, and Developmental Index of Auditory and Listening (DIAL),

References
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DEVELOPED BY KAREN L. ANDERSON, ED.S., AUDIOLOGY CONSULTANT, EARLY HEARING LOSS DETECTION AND INTERVENTION PROGRAM, FLORIDA DEPT OF HEALTH, CHILDREN’S MEDICAL SERVICES 2001.