Many children and adolescents with "mild to moderate" hearing loss are not getting the help they need, either because their impairment is not recognized or because its consequences are not fully appreciated, according to several experts.

"I am challenging the whole concept of 'mild' hearing

loss in children as a benign condition, as well as existing paradigms on who should receive treatment. I am absolutely convinced that a huge number of children are being left behind and their hearing loss is being minimized," said Sergei Kochkin, Ph.D., executive director of the Better Hearing Institute (BHI), a nonprofit educational organization in Washington, D.C.

According to Dr. William Luxford, a board member of BHI and an otolaryngologist at a heating treatment center in Los Angeles, "while severe-to-profound hearing loss is generally considered a 'true' hearing loss, many people think that individuals with milder loss don't really have anything to worry about."

However, even mild hearing loss, if not addressed, "can markedly affect a child's academic and social development," he said. "Those are the individuals who will have a fair amount of difficulty but will still be labeled okay."

"These are the kids who often fall [off] the radar screen," agreed Alison Grimes, Au.D., president of the American Academy of Audiology and head of the audiology clinic at the University of California, Los Angeles, Medical Center.

"If parents and physicians hear the word 'mild,' they tend to think it's unimportant, but this type of hearing loss in a young child who is learning language is incredibly important, and should be attended to," she said in an interview.

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Now that newborn auditory screening programs--either mandatory or voluntary--are in place in all states, Dr. Grimes said infants with severe hearing difficulties tend to be flagged for early intervention.

But milder impairments may not be detected in the newborn screen, and even if they are, they may not be followed up. Nationally, on average about half of babies who fail the newborn screen are not followed up with a diagnostic evaluation, "which is horrifying. Not all of those babies have hearing loss, but a certain proportion [does]," she added, suggesting that mild to moderate impairments are most likely overrepresented in this category.

In addition, an increasing amount of noise-induced mild to moderate hearing loss is now occurring in older children and adolescents whose hearing tests were normal at birth.

Although parents, primary care physicians, and schools provide several theoretical safety nets for detecting mild to moderate hearing difficulties, the diagnosis of such hearing losses does not necessarily lead to their treatment. According to a study by the BHI, an estimated 1.4 million American youth younger than 18 years of age have a diagnosed hearing loss, but only 12% of them wear hearing aids (Hearing Review 2005;12:16-9).

The BHI found that nonusers of hearing aids are more likely to be mildly to moderately impaired, rather than severely impaired. In a study of 274 hearing-impaired dependents aged younger than 21 years, a comparison of the 225 persons who did not wear hearing aids (median age 12 years) and the 49 who did (median age 13 years) found that 82% of the nonusers had mild to moderate loss, compared with 49% of users (Heating Review 2007;14:10-36).

There are a number of legitimate reasons why a hearing-impaired child might not wear hearing aids, explained Dr. Grimes. These include profound deafness; a preference for communication through American Sign Language; transient impairment resulting from ear infections; a preference for other forms of amplification, such as FM or sound-field systems; or specific types of hearing loss that are not well served with hearing aids.

In the BHI survey, although 76% of parents specified "degree or unique nature of hearing loss" as one of the reasons why their dependent had not adopted hearing aids, 80% also indicated that they were following the recommendation of a professional, and 84% also gave reasons suggestive of "minimization" of the hearing loss, said Dr. Kochkin. These reasons included having more serious priorities (19%); believing that the child's hearing loss was not disruptive to life (49%); and believing that the child's hearing was "good enough" in most situations (58%).

Many children with mild to moderate hearing loss simply don't appreciate the severity of their impairment.

"Kids with minimal hearing loss, especially if they've already developed language, can fake it pretty well. They can miss a key word here and there, and keep going. And so although these kids do get by, they may not be doing as well in school as they could be," Dr. Grimes noted.

Indeed, according to the BHI survey of parents, 77% indicated their child experienced problems resulting from heating loss in the areas of social skills (52%), school grades (50%), speech and language development (51%), emotional health (42%), relationships with peers (38%), self-esteem (37%), and family relationships (36%).

Dr. Luxford said that primary care physicians have an important role to play in both assessing and treating mild to moderate hearing loss. "They need to be able to recognize when there is a hearing problem, and to not minimize the problem," he said, explaining that many primary care hearing assessments involve little more than a "do you hear me?" test from across the room, which is not adequate.

"If the physician has any sense from the parent there is some trouble, the patient should have a formal audiology test," said Dr. Luxford, also of the department of otolaryngology at the University of Southern California, Los Angeles.

BY KATE JOHNSON

Montreal Bureau