Section 2 - Child health checks

Health check recommendations

• All children have a hearing screen at birth
• All children if clinically indicated opportunistically
• Aboriginal and Torres Strait Islander children < 6 years at each scheduled health check or opportunistically
• Aboriginal and Torres Strait Islander children > 6 years annually

1. Procedure

• Ask child or parent the age appropriate questions, explore any concerns and take the corresponding actions. See Table 1.
• Provide brief intervention
• Determine if the child requires a referral according to the criteria and place on a follow-up and recall register. See Flowchart 1.

Flowchart 1. Hearing health tests and referral procedure

1. Performing otoscopy ^1–3
   • Otoscopy is the visual examination of the ear canal and ear drum. See Figure 1.
   • If there is pain or notable discharge from the ear(s) do not proceed. Refer to the Primary Clinical Care Manual
   • Observe the bone behind the ear (mastoid) and the area under the ear for
     infection, swelling or tenderness
   • Check the pinna for size, shape, colour or lesions
   • Observe the ear canal for:
     • discharge
     • redness/swelling
     • fungal infections
     • lumps or bony growths
     • foreign bodies (excluding grommets)
     • wax
     • fluid
   • Inspect the eardrum (tympanic membrane) for:
     • colour:
       • transparent and shiny is normal
       • dull or opaque represents fluid behind the eardrum
     • cone of light (reflection):
       • right ear at 5 o’clock and left ear at 7 o’clock
       • reflections elsewhere indicates bulging
     • the handle of the malleus
     • perforations
     • abnormalities of the attic region e.g. perforation, mass, growth
   • Repeat procedure for the other ear

Figure 1. Visual representation of the eardrums

2. Performing tympanometry ^1–3
   • Tympanometry is a test of middle ear function and measures:
     • ear canal volume (ECV)
     • middle ear pressure (daPa)
     • middle ear compliance or movement
   • See Resource 1. for further tympanometry support
   • If there is discharge from the ear(s) do not proceed. Refer to the Primary Clinical Care Manual
   • A “Leak” or “Blockage” error can occur for many reasons:
     • clogged probe tip
     • probe tip too large or small
     • head movements or swallowing
     • probe tip against the ear canal wall
     • debris, foreign body or wax in ear canal
   • To rectify try:
     • a different sized probe tip
     • cleaning probe tip
     • reposition the probe tip in the ear canal

Figure 2. Tympanometry traces ^1–4

3. Performing audiometry ^1–4
   • Audiometry measures the ability of the ear to:
     • detect the pitch of a sound as hertz (Hz)
     • detect the loudness of a sound as decibels (dB)
   • For younger children:
     • place the headphones on the desk (not child) and set to 4000 Hz and 90 dB
     • present the tone and encourage them to clap, press button etc. if sound heard
     • praise their response
     • change frequency to ensure they respond when the sound is slightly different
     • once they are able to respond reliably, proceed with testing
     • child ‘fails’ if they do not respond as expected
   • Children will look for visual cues for when to respond. Ensure:
     • child is positioned so they can’t see your hands, face or the audiometer
     • tones are presented at irregular intervals to avoid child anticipating the sound
   • Place headphones on the child. Test one ear at a time
   • Set hertz (Hz) dial to 4000 Hz and decibels (dB) to 50 dB. Test
   • The child ‘fails’ if they do not indicate they hear a sound
   • If the child indicates they hear the sound then reduce to 35 dB and repeat
   • If the child indicates they hear the sound then reduce to 25 dB and repeat
   • Repeat these steps until the child no longer responds, then increase by 5 dB increments until they do
   • Record the result that the child responds to twice at the lowest perceived dB
   • Repeat for the other ear
   • Repeat the procedure for both ears at 2000 Hz and 1000 Hz
   • To ‘pass’, the child needs to respond twice to 25 dB at 1000, 2000, and 4000 Hz

2. Results

• All children should have
  • clean ears, free of pain, discharge or infection
  • pass all tests and hear clearly

3. Brief intervention ^1–5

• Aboriginal and Torres Strait Islander children:
  • experience the highest rates of middle ear disease and hearing loss in Australia
  • develop ear issues earlier and more frequently and severely than the general population
• Educate parents that unresolved hearing loss creates challenges for children later in life, including:
  • school completion rates
  • health literacy levels
  • vocational and job prospects
  • social isolation
  • mental health issues
• Discussion points:
  • regular nose blowing
  • hand and face washing
  • avoid prop bottle feeding
  • avoid bottle feeding a child to sleep
  • avoid leaving bottles in a child’s cot
  • avoid subjecting a child to smoke from cigarettes or camp fires
  • only swim in running water or swimming pools
  • maintain healthy Diet and nutrition
  • avoid putting anything in child’s ears (including cotton buds)
  • there are often no signs or symptoms of hearing loss
  • if concerned, always present to the health centre
  • avoid loud noises (e.g. headphones)
• Provide Resource 2.

4. Referral

• If the child has ear pain or discharge, refer to the Primary Clinical Care Manual
• Perform the PLUM and HATS screening questionnaires (Resource 3.) and email referral to Hearing Australia (Resource 4.) if:
  • < 3½ and parent answers ‘no’ to screening questions
  • the clinician is unable to undertake any hearing testing e.g. child too young, clinician is not experienced
  • the child ‘fails’ audiometry or tympanometry for a second time after a 6 week review
• If clinician or the parent has any immediate concerns about a child’s hearing, refer to the MO/NP and speech pathologist

5. Follow-up

• Review as per Flowchart 1.
• Place the child on a recall register to monitor Developmental milestones, speech, hearing or ear disease if required
• Ensure all referrals are actioned
• Provide the parent with details for the next scheduled follow-up appointment

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. Hearing Australia’s Tympanometry module for primary health providers
2. Australian Governments Care for Kids Ears
3. PLUM & HATS listening and talking skills
4. Hearing Australia