Childhood hearing loss, COVID-19 implication and Early Intervention

The 7th of November is internationally known as Children’s Day, and in honour of our children of the world we wanted to highlight the importance of childhood hearing loss and the far reaching implications of this going untreated. According to the World Health Organizations (WHO) there are approximately 34 million children worldwide who have a disabling hearing loss. Disabling hearing loss refers to hearing loss that is greater than 30 dB HL in the better ear, for children. 60% of hearing loss in children is preventable, and if not, early and appropriate intervention can ensure that a child with hearing loss is still able to reach their full potential. 

Hearing is crucial in facilitating communication, social interaction, and verbal learning. In addition, hearing allows children to be alerted to danger and to participate fully in daily activities. In children, hearing is fundamental for speech and language development, mainstream academic learning, and engaging in social activities. 

Causes of hearing loss in children can be grouped into congenital and acquired causes. Congenital causes may lead to hearing loss that is present at or immediately after birth. This type of hearing loss can be caused by hereditary factors or non-hereditary factors such as complications during birth or pregnancy. These include the use of ototoxic drugs by the mother or the child having a low birth weight. Acquired hearing loss is that acquired during any age of a child. These can be caused by excessive noise exposure, use of ototoxic medications, and certain infections such as measles and mumps. 

Although there are a variety of contributors to childhood hearing loss, the main contributor to childhood hearing loss is otitis media with effusion (OME)/ middle ear infection, which is a buildup of fluid in the middle ear cavity behind the eardrum leading to decreased hearing sensitivity.


Impact of untreated childhood hearing loss

Unidentified and untreated childhood hearing loss has been shown to dramatically delay a child’s speech and language development, thus affecting their academic achievement and their vocational opportunities later in life. Even a ‘mild’ hearing loss may result in poor educational performance and a greater difficulty with aspects such as self-esteem, social and emotional abilities.

Difficulties to hear and communicate one’s needs results in children with hearing loss having feelings of loneliness, stress, frustration, and anger. In addition to this, childhood hearing loss can result in a child not being able to be alert to dangerous situations such as a car driving towards the child. 

In a distal sense, untreated childhood hearing loss, over time, affects social and economic development in a country as these children may not be able to effectively contribute to the society and economy. 


COVID-19 pandemic and unidentified childhood hearing loss

Hearing loss is an invisible condition as it might be difficult for parents and hearing care professionals to recognize if a child has a hearing loss, unless appropriate tests are conducted. At times, children continue with life and schooling while their parents, teachers and community are unaware of their hearing loss. In fact, a retrospective study conducted by Watkin and colleagues showed that only 25% of parents of children with significant hearing loss suspected that their children had hearing difficulties. This is especially true with children with a slight, mild and moderate hearing loss that allow them to hear loud voices, noises, and sound source while they can not hear particular parts of the speech. 

The issue of unidentified and untreated hearing loss in children and its impact on their academic progression is especially concerning during the COVID-19 pandemic. During this pandemic, significant modifications have been made to traditional school and learning to facilitate the prevention and control of the spread of COVID-19. Some of the changes made to the traditional learning setting includes online education – which includes children attending to their classes via online video conferencing platforms. Another change is the increase in physical distance between the teacher and the children, and between the children themselves. 

These changes, although used to prevent and control the spread of COVID-19, they result in children with unidentified hearing loss to struggle even more to hear the teacher and their friends speak (as a result of the distance in class and/ or the use of computers speakers for online learning). One could view this as a blessing in disguise, for example, allowing teachers and parents to finally be aware that their children could have hearing difficulties. However, this is not a given as parents and teachers may suspect that ‘’something is wrong’’ without being able to accurately pin-point that the issue is with the child’s hearing ability — or lack of. 

The high prevalence of hearing loss and the concern with unidentified childhood hearing loss during the COVID-19 pandemic calls for mass screenings, early detection, identification and appropriate intervention to minimize hearing-related difficulties, and facilitate optimal learning in an educational and social setting. 


Early identification of childhood hearing loss

Early identification and timely appropriate intervention of childhood hearing loss can facilitate educational and social development, and communication. Multiple research has shown that children born with hearing loss or those who have acquired it at an early age and have received intervention within 6 months of age are at par with their hearing peers in terms of language development by the age of 5 years. For children who acquire hearing loss at a later age, regular school hearing screening programs, timely identification and intervention can significantly reduce the negative impacts of the hearing loss. 

Most children presenting with hearing loss at birth are potentially identifiable by newborn hearing screening programs. In developing countries, such as South Africa, where more than 80% of people living with hearing loss reside, there are limited prospects of early detection of hearing loss due to the lack of hearing healthcare professionals, expensive audiological equipment and legislation or mandates in place to conduct newborn hearing screenings. As a result, in most cases, school-age hearing screenings are the first point of hearing assessments for most children. However, effective implementation of school-based hearing screening presents with a number of challenges.

One of the challenges is the continued use of otoscopy and pure tone audiometry as the golden standard for school-aged hearing screening programs. The reason why this presents as a challenge is the diagnosis of OME using an otoscope has been shown to be unreliable and ineffective as its accuracy depends heavily on the operator. Additionally, pure tone audiometry can confirm hearing loss, however, as it is a subjective test, it is often unreliable as a result of various factors, including; i) the children’s inability to understand the test and ii) the audiometer operator not being adequately skilled. 

Tympanometry is an objective and reliable method of diagnosing OME. Research has shown that the use of otoscopy, pure tone audiometry and tympanometry in combination offers a powerful method of diagnosing OME. 

Therefore, effective and efficient tools should be used to identify children with hearing loss earlier and accurately, and to provide effective and timely intervention.