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Hearing Problems in Children Glos Care Pathway

In December 2016, Gloucestershire County Council Cabinet approved a remodelling of the Health Visiting and School Nursing services in order to bring them together into a single Public Health Nursing Service focused on promoting the health and wellbeing of children pre-birth to age 19 years.

One of the proposals put forward was to replace the current hearing screening programme for school children in Reception (aged 4-5 years) with a pathway for earlier detection and support of hearing impairment. Following Public Consultation in 2017, it was decided that it would be more effective to replace the current hearing screening programme with an earlier identification pathway.

From October 2018 children’s hearing is no longer being routinely screened in the reception year at school.  The screening of children was an inefficient process: in 2015-2016, Public Health Nurses completed hearing screening on 6646 children.   407 of these children failed the screen and were referred to audiology and of these, 48 children were identified with significant hearing problems (0.7% of those screened). 

This pathway has been developed to ensure that where there are concerns about a child’s hearing a referral can be made to audiology.  Referrals into audiology for children not at school will need to be made by a health professional, as they are currently.  There is no requirement for these children to have an appointment with a GP.  Requests for a referral to audiology may come from Preschools, Early Years Settings or  Social Care. We expect the number of these requests to be small but would appreciate the GP surgeries referring these children for an audiology appointment.

For children already at school whose teachers have concern about a child’s hearing, there is an online referral form which can be completed by education and taken by the parents to the family GP for the administration team to forward it to the Paediatric Audiology service. 

Research including a Health Technology Assessment of children’s hearing assessment suggests we can effectively detect hearing problems earlier than the current hearing screening in reception by making sure that parents and professionals have the right information and support they may need earlier. This change to the current practice has been accompanied by communications to professionals working with young children and families, to improve awareness and the prompt identification of hearing loss in children.

This was a pilot and its effectiveness was reviewed after 6 months and there were no issues with the number of referrals being received through the new system.  We will continue to ensure that children with hearing difficulties are not getting missed by this new process.

Please note:  The midwifery service will continue to deliver new born hearing screening.

Please click the relevant flowchart box to be taken directly to textual information

              

Please note:  The midwifery service will continue to deliver new born hearing screening.

Red Flags
Following the tragic demise of a small infant with meningitis who had previously presented with a discharging ear, any child less than three months of age who presents with a discharging (pus) ear should be referred to GRH and reviewed by both a Paediatrician and ENT Surgeon.  
Presentation

According to National Deaf Children's Society and NHS Choices, these are the main signs/ indicators for hearing loss in children:

  • Does not respond when called
  • Watches faces/lips intently
  • Constantly asks for repetition
  • Does not always follow instructions correctly
  • Often misunderstands or ignore instructions
  • Watches what others are doing before doing it themselves
  • Frequently seeks assistance from peers
  • Talks either too loudly or too softly
  • Appears to be inattentive
  • Makes little or no contribution to class discussions
  • Complains about not being able to hear
  • Tires easily
  • Becomes easily frustrated
  • Seems socially isolated and less involved in social group activities or want to be the leader and controller of all social situations
  • Turns up the volume of the TV/Music/iPad/Mobile Phones higher
  • May respond inappropriately to questions
  • Slow to learn to talk, or aren’t clear when they speak
  • May always want to sit in a specific spot/chair
  • Difficulty hearing other people clearly and misunderstanding what they say, especially in noisy places 
  • Difficulty hearing on the phone
  • Finding it hard to keep up with a conversation

  • Aren't startled by loud noises
  • Seem to hear some sounds but not others
  • Notice you when they see you, but not when you call their name
  • Don't turn towards voices by four months of age
  • Haven't started to say any recognisable words by around 15 months
  • Babbling sounds reduce from around 6 months
Differential Diagnosis
Initial Primary Care Assessment

There is no requirement for a GP to assess children who require a hearing test.  Refer directly to Paediatric Audiology for an assessment of their hearing.

When to Refer

Please refer to Paediatric Audiology when there are any concerns regarding a child’s hearing from parents, health professionals or non-health professionals.

Paediatric Audiology - GHNHSFT

Hearing loss in childhood can be either permanent or temporary.  Approximately 1 in a 1000 children are born with permanent hearing loss and about the same number of children will develop a permanent hearing loss during their childhood years, even though their hearing was normal at birth.  Many of these children would need to wear hearing aids.  There are many causes of permanent hearing loss, sometimes, for instance, related to inheritance, sometimes to viral infection or problems at birth, but frequently no specific cause is found within the boundaries of current scientific knowledge. 

There are also many children, usually in their preschool or primary school years, who develop a temporary hearing loss which recovers over time.  In this case the hearing loss is usually due to a condition known as ‘glue ear’, where fluid – an effusion - develops in the small space behind the eardrum, the middle ear cavity.   This condition is associated with an immature ventilation system to the middle ear and children usually grow out of it.  Not all children with ‘glue ear’ require specific treatment, but where the hearing loss is persistent and causing difficulties with speech development or academic progress, for example, hearing aids may be prescribed until the glue ear resolves, or temporary ventilation tubes, known as ‘grommets’, may be fitted  by an Ear, Nose and Throat surgeon.

Paediatric Audiology is a service that assesses the hearing of children and provides onward management of any problems identified. The service is jointly staffed by community paediatricians and audiologists specifically trained to test children.  The information provided on the referral form assists in making a decision on how the referral will be processed within the department.

Paediatric Audiology currently provide this specialist service for preschool children at two centres - one at Gloucestershire Royal Hospital and the other Cheltenham General Hospital, with a further two clinics held in Tewkesbury and Cirencester only for children over 4 years of age..

Some children may need additional specialised assessments and, if this is the case, they will be seen at the Hearing Services department at Gloucestershire Royal Hospital.

Ongoing Care

If a child is assessed by the Paediatric Audiology Service as having hearing difficulties further support can be accessed from:

Qualified Specialist Advisory Teachers of the Deaf work with children and young people from birth to 25 years with a diagnosed hearing loss.They will:

  • Give advice and support to families / carers of newly diagnosed deaf babies and children
  • Introduce Early Support materials
  • Assess and monitor language development
  • Advice on specific listening and language programmes, including the use of sign language and accessing signed support where necessary
  • Provide, check and monitor radio aids and additional audiological equipment, where appropriate
  • Give advice on specialist resources / equipment available on loan or to purchase
  • Give advice to class / subject teachers, SENDCos and TAs on teaching strategies, amplification and communication methods to support access to teaching and learning for pupils with a hearing impairment
  • Provide and deliver a range of training linked to hearing loss including understanding deafness
  • Support school to evaluate new / existing programmes / teaching methods as appropriate
  • Evaluate curriculum and teaching methods for individual pupils, through review process with staff

Referrals At pre-school stage referrals are made either through a health professional or via their early years setting.

At school age the SENCo or a Health Professional refers to the Hearing Impairment Team using the "Request for Advisory Teacher Involvement" form available online.

The children are referred if:

  • The primary difficulty is related to an identified hearing loss or there is a hearing loss diagnosed in addition to other disabilities
  • The child has been prescribed a hearing aid or has been referred for cochlear implant
  • There is evidence to suggest that the child or young person is unable to access teaching and learning as a direct result of hearing loss
  • There is evidence to suggest that the child or young person is not making appropriate progress as a direct result of their hearing loss

Speech & language therapists are qualified professionals with an in-depth knowledge of difficulties with communication (understand & using spoken language and social communication skills) and eating & drinking disorders.

The service provides assessment, advice and treatment planned around the individual needs of the child & family. Advice, training and support may also be provided to teaching & support staff or other professionals as appropriate, to facilitate the development of communication skills.

Referrals

Please use the referral forms located here.
Children can be referred to the service by their parents or by another health or educational professional with the parent’s permission.
Address: Speech and Language Therapy, The Independent Living Centre Village Road, Cheltenham, Gloucestershire, GL51 0BY
Telephone: 0300 421 8937
Email: AdminILC@glos-care.nhs.uk

Note - Speech and language therapists will always conduct a hearing test alongside a speech and language examination

For more information on the service follow this link to their website.

Record Keeping and Audit

This is a pilot and will be reviewed after 6 months when we have been able to collate data on the number of children requiring a hearing assessment when hearing screening is no longer in place.

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