Updated guidelines from the American Academy of Pediatrics call for prompt intervention when infants fail hearing tests and for ongoing surveillance of all infants--regardless of risk factors for hearing loss--during well baby exams and other office visits.

Since the last policy statement

in 2000, the proportion of infants screened each year has soared from 38% to 95%. Intervention has not kept up with surveillance, however. Nearly half of all infants who fail their initial screenings do not receive appropriate follow-up, according to the document (Pediatrics 2007;120:898-921).

A growing body of literature cited by the guidelines' authors shows that intervention before age 6 months can raise performance on school-related measures by 20-40 percentile points when children are deaf or hard of hearing. Additional studies have found that starting intervention during the baby's first year can lead to a normal range of language development at age 5.

The panel wanted to ensure that all children would be checked repeatedly to catch delayed onset heating loss before the child falls behind his or her peers, said Dr. Betty R. Vohr, chair of the Joint Committee on Infant Hearing that developed the new guidelines, said in an interview.

Dr. Vohr, a professor of pediatrics at Brown University, Providence, R.I., represented the AAP on the joint committee. Representatives of the American Speech-Language-Hearing Association, American Academy of Audiology, Council of Education of the Deaf, and other organizations were also on the committee. The updated guidelines include:

* Consider neural hearing loss. The definition of targeted hearing loss was expanded to include "neural hearing loss" in infants admitted to a neonatal intensive care unit (NICU). It also includes congenital permanent bilateral, unilateral sensory, and permanent conductive hearing loss.

* Ensure hospital screening at birth. All infants should be screened by a physiologic measure such as noninvasive otoacoustic emission (OAE) or auditory brainstem response (ABR) during the first month of life. For infants admitted to a NICU for more than 5 days, testing should include ABR to ensure neural hearing loss is not missed.

Infants that fail testing are to be referred to an audiologist for rescreening in both ears and a comprehensive examination. Babies that fail ABR in the well infant nursery should not be retested by OAE and "passed."

Repeat screening is recommended when a child is readmitted to a NICU or well infant nursery with a condition associated with hearing loss, such as hypertension, bilirubinemia that requires exchange transfusion, and culture-positive sepsis.

* Facilitate communication with families. Families should be told screening results immediately and in a sensitivie manner. "There are uninsured families, families that don't speak English, families that may not understand the letter that comes in the mail that says they need follow-up."

* Confirm hearing loss. Any infant that meets criteria for referral should receive follow-up audiologic and medical evaluations by no later than 3 months of age. This includes the fitting of amplification devices, should they be deemed appropriate.

Although it specifies roles for audiologists, otolaryngologists, and other specialists, the policy statement places the onus for ensuring proper care on the child's pediatrician or other primary care provider.

* Ensure early intervention. Federal guidelines require that a child be referred to an early intervention program within 2 days of the confirmation of hearing loss. The committee called for early intervention services to start as soon as possible after diagnosis and not be delayed beyond 6 months of age. Intervention services can be "any type of habilitative, rehabilitative, or educational program provided to children with hearing loss."

* Provide surveillance. All infants should be monitored for auditory skills, middle-ear status, and developmental milestones at each visit with a primary care physician. A validated global screening tool should also be used at 9-, 18-, and 24 to 30-month visits, as well as any time that parental or physician concerns arise.

Any child that fails the speech-language portion of global screening or about whom concerns persist should be referred for to an audiologist and a speech-language pathologist for further testing. If hearing loss is detected, siblings also should be evaluated.

BY JANE SALODOF

MACNEIL

Senior Editor