Problem with baby’s hearing? An intervention checklist

Tell parents that, with their approval, the audiologist may fit the baby with hearing aids as early as this visit, as amplification can help even very young infants hear all sounds in the environment, particularly spoken language.

Ongoing monitoring
Family practices serving as medical homes should continue to monitor children who pass their newborn screening but have high-risk factors for delayed-onset hearing loss. Those factors are listed in the TABLE. Refer children at higher risk for an audiologic diagnostic evaluation by 24 to 30 months of age.⁶ Follow-up on parental concerns about infant hearing or speech and monitor infants’ developmental milestones, auditory skills, and middle ear status using the AAP’s pediatric periodicity schedule.⁶ Conduct global developmental screenings at 9, 18, and 24 to 30 months of age, and refer for speech-language-hearing evaluations when appropriate.⁶

The medical home as central referral point

The medical home is a central referral point for the complex needs of children with hearing loss. The physician and all other providers involved in the child’s care should report results of diagnostic evaluations to state EHDI coordinators. The medical home’s continued involvement includes medical clearance for hearing aids, additional consultations, and screenings as necessary to help children receive needed services and keep them from being lost to the system.^5,9

Referral for genetic consultation is important, because about half of all autosomal recessive sensorineural hearing losses that are not part of a syndrome are caused by mutations in the Connexin 26 GJB2 gene.^12,13 Referral to a pediatric ophthalmologist is similarly important, to identify deficits in visual acuity that frequently co-occur with hearing loss, especially in preterm infants.⁶ Results of these consultations can assist the physician in guiding families through the intervention process.

Coordination of care among multiple providers is essential. When a family physician’s practice serves as a medical home for a child with hearing loss, the physician should oversee and coordinate the efforts of all stakeholders in the EHDI process; make referrals to, and receive reports from, all providers involved in diagnosis and treatment; and ensure that relevant information is shared. During all phases of the process, the role of the family physician is to encourage families to comply with professionals’ recommendations and to stress the importance of making and keeping scheduled appointments.

Making plans for intervention
Families with children who have any degree of permanent hearing loss in one or both ears are entitled to early intervention services.⁶ In most states, these services are provided by a multidisciplinary team at no or low cost through a federal grant program. Services can be home- or center-based. They may include, as needed, education for the affected child and family; physical, speech/language, and occupational therapy; and social work and psychotherapy services. The team works with the family to develop an individualized family service plan to document and guide the early intervention process.¹⁴

Families with a hearing-impaired child have a range of options to choose from in their search for an approach that is best for the child and most acceptable to them. Communication options span a continuum from emphasis on sign language as used by the deaf community to a variety of oral-aural approaches designed to lead to spoken language. Parental choices are influenced most heavily by the child’s success with hearing aids. Parents need unbiased, culturally sensitive counseling about all available communication options and hearing technologies, so they can make informed choices for their children.⁶

Answering parents’ questions
To ensure that parents have appropriate expectations for what auditory technology can do for their child, they need to receive information about traditional digital signal processing hearing aids, osseointegrated hearing implant systems (also known as bone-anchored hearing aids), and cochlear implants. They need to know that a trial period will probably be necessary to determine whether hearing aids are appropriate or if cochlear implantation should be considered. Cost of hearing aids and cochlear implants is a serious concern for parents, and for many, it presents a major barrier to obtaining optimal care.²

Many insurance plans cover cochlear implants, but require that children be at least 12 months of age, have bilateral profound sensorineural hearing loss (or severe-to-profound sensorineural hearing loss for those ≥24 months of age), receive minimal benefit from hearing aids, be enrolled in auditory rehabilitative therapy, and possess no medical contraindications.¹⁵ Hearing aids and cochlear implants may also be covered for children enrolled in Medicaid or the State Children’s Health Insurance Program.¹⁶ However, according to a recent evaluation of hearing screening programs nationwide, public and private insurance policies almost never provide adequate coverage for hearing services.²