Hearing Loss

Our baby-sitter thinks our 18-month-old can’t hear. We’ve started paying more attention and think she may be right. How do we check that out?

Hearing loss is the number one impairment in older adults. Almost always, its onset is gradual, frequently starting in the teenage and young adult years. It’s…

What?

I said hearing loss… Oh never mind. Just remember that much of our hearing loss is
“noise induced”—noise that’s too loud and for too long a time. The threshold for the amount of noise that causes damage is different for each of us, so we need to be careful early on. Those earbuds and head-sets delivering damaging decibels to your teenager’s eardrums will take their toll. It starts with knocking out their ability to hear high frequencies, and it doesn’t come back. Not only do you need to know what your children are listening to, you need to how loud it is.

But you were asking about your 18-month-old and whether they might have a hearing deficit. We’ll need to start by asking a bunch of questions, such as your family history, any problems during your pregnancy, any medical conditions your child has had…a bunch of stuff. But let’s tell you how this usually presents to our office.

Sally is a 2-year-old who has been in good health. Her mother brings her in because “she’s just not talking right.” There’s been no history of any medical problems and no family history of a hearing problem. When asked about the newborn hearing screen she had in the hospital, her mother answers that it wasn’t quite right and they were told to have it repeated at some time in the future. She thought her daughter seemed fine, and it “just slipped my mind.” After preliminary testing and an evaluation by an audiologist, Sally is now wearing hearing aids, due to her moderate bilateral hearing loss.

And then there’s this:

Billy, a 5-year-old boy, is brought into the clinic by his mother for his first-ever visit. She paces the room with arms folded across her chest, shaking her head. “Billy needs some medicine for ADHD. Everybody thinks so. He won’t pay attention and is all over the place. He’s starting to have trouble in pre-school and his teachers want us to do something.” A glance through the records she brings reveals that Billy has had multiple episodes of ear infections—not enough to warrant an ENT referral—but more than normal. An exam of his ears reveals scarring and retraction of his ear drums, with fluid in both middle ears. After the insertion of tubes by an ENT specialist, he’s no longer “all over the place” and is doing great in school. And he’s not taking any ADHD medication.

Hearing loss in young children can be subtle and difficult to pick up. In fact, that’s the rule rather than the exception. It’s common, affecting about 3-4 per 1,000 newborns. It’s important to catch this, since early identification and treatment of these infants can improve their chances of keeping up with their none-impaired peers. If not, it can lead to delayed language development, difficulty with behavior, and poor cognitive and academic performance. That’s going to be true for whenever the hearing loss develops, whether it’s congenital, or as in the case of Billy, it develops over the first few years of life. Those years—the first 36 months—are critical when it comes to language and cognitive development.

Sally’s mother mentioned that her daughter’s newborn hearing exam wasn’t quite right. How in the world do you check a newborn’s hearing? First, every state in the Union requires that this be done before the infant leaves the hospital. The procedure itself is quick and relatively easy. A newborn isn’t going to respond to your voice or other noise in a meaningful or predictable way, so the person doing the test inserts a small microphone into the ear canal and measures the sounds that come back from the inner ear. The newborn doesn’t have to do anything, just lie there. A normal test doesn’t mean everything is necessarily fine, only that you can wait a while before more formal testing. If it’s abnormal (like Sally), your child will need more testing sooner, preferably within 3 months.

We know there are some risk factors for hearing loss in the newborn—things that should be red flags.

• Specific in-utero infections (mainly viruses)
• Genetic disorders (there are only about 400 of theses)
• A family history of hearing deficits
• Ear and other facial abnormalities noted at birth
• A significantly elevated bilirubin level during the first few days of life
• Low birth weight
• A low APGAR score at birth – 3 or less at 5 minutes
• 5 or more days spent in the Neonatal Intensive Care Unit (NICU)
• Exposure to several specific antibiotics, known to damage the hearing mechanism

Beyond the newborn period, there’s a different set of red flags for hearing loss.

• Frequent middle ear infections (otitis media) – the most common cause
• Trauma
• Foreign bodies (a favorite repository for beans, beads, and anything that will fit in your child’s ear canal)
• Some of the genetic syndromes that were unknown and undiagnosed at birth, and that are only becoming manifest at one or two years of age

That’s a lot to think about! What are some simple things we should be looking for with our child?

Here’s a simple “hearing checklist” for your infant or toddler:

• Birth to 3 months
  • Your child becomes quiet around usual and everyday voices and noises.
  • They react to loud sounds by blinking, waking up, or startled movements.
  • They make soft baby gurgles while awake.
• 3 to 6 months
  • They will turn their head and eyes toward normal sounds, such as voices, a barking dog, or the beeping fire-truck that Uncle Robbie gave them.
  • They start to make simple sounds like “ba,” “ooh,” and “ga.”
  • You’ll notice a reaction when you change the tone in your voice.
• 6 to 9 months
  • They now respond to “soft” sounds, such as talking.
  • They begin to respond to their own name.
  • Your child understands simple words such as “bye-bye” and “no.”
• 9 to 12 months
  • They will repeat single words and begin to copy animal sounds.
  • When asked, they will point to favorite toys or food.
  • They consistently respond to soft and loud noises
• 12 to 18 months
  • They will follow simple spoken instructions, such as “pick up the spoon” or “get the ball.”
  • You’ll notice them bouncing to music.
  • They are using 10 or more words.
  • When asked, they will point to specific people, body parts, or toys.
• 18 to 24 months
  • They are now using 20 or more words.
  • They listen to simple stories or songs.
  • They’re now able to combine two or more words, such as “more juice.”
• 2 to 3 years
  • They can follow two-step instructions, like “pick up the block and put it in the box.”
  • They’re using sentences with two or three words.
  • At age 2, your child’s speech is understood some of the time—maybe as much as 50%.
  • By age 3, you should be able to understand most of their speech—at least 75% of the time.

If your child is a little older and can communicate with you, pay attention to them, especially to the following:

• Your child frequently asks “What?” and seems to be doing it more often. This is normal and acceptable behavior in husbands.
• When watching the TV, they turn the volume up louder than other members of the family.
• When talking with you, they focus on your face, especially your mouth.
• They turn their head when listening, and may even mention “that’s my good ear.”
• Your child doesn’t seem to pay attention.
• Their hearing seems fine at some times and not so good at others.
• They are beginning to experience problems in school, and their teacher, if astute, may bring a potential hearing problem to your attention.
• Your child begins to speak more loudly—an early tip-off.

If you notice any of these things, or if you just have a “gut feeling”, it’s time to have your child examined. As we noted earlier, the sooner this is addressed, the better off your child is going to be.

The American Academy of Pediatrics has established some guidelines for hearing screening. They recommend that all children be tested at the ages of 4, 5, 6, 8, and 10 years. After 10, the guideline calls for testing once between 11 and 14 years, once between 15 and 17 years, and once between 18 and 21 years. That seems like a lot of testing, but it’s the only way to diagnose a hearing problem before it causes significant complications or becomes permanent.

We want our child’s first words to be “mama” or “papa,” not “What?”

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This is an excerpt from the new book I’m writing with pediatrician Dr. Robert Alexander. The book will address 100 questions from parents regarding their children’s health. Feel free to email us with questions: askthedox@yahoo.com