Infant Hearing Screening - Reflection

University Degree Subjects allied to Medicine

Infant Hearing Screening

The aim of this assignment is to examine the benefits of infant hearing screening tests and to look at initiatives set up through the child Health Surveillance programme. It will demonstrate how the infant hearing screening tests are incorporated into the general health promotion programme targeted at children and carers and evaluate how effective it is in a community setting.

The specific case that will be examined in this assignment will include twenty two month old twins who were originally assessed by their Health Visitor at eight months of age and were referred to an Audiologist for a hearing test. Following two non-attendances at the Audiologist department, the Health Visitor, using the Schedule of Growing Skills (SOGS), again assessed the twins at twenty-two months old. The twins scored extremely low in most areas including Hearing and Language skills and the Health Visitor again referred the twins to an audiologist for hearing tests. The author will look at how these tests are performed and the outcome of these tests more closely in this assignment.

The Children’s National Service Framework (NSF) (1998) was initially a ten-year programme set up by the government to improve the health and well being of children from birth to nineteen years. The UK Child Health Surveillance programme has now been replaced with the Child Health Promotion Programme which was launched by the Children’s NSF (2002), this

now looks at a holistic and systematic process to assess the individual child and family’s needs, which includes childhood screening.

Child Health Surveillance is defined as a programme of screening tests and development checks; it is about supporting families to bring up their children to be healthy through support and education of appropriate advice given through health promotion (Hall 2003).

Health promotion is about what we can do to combat ill health, as it is generally accepted by medical professionals that prevention is better than cure. There are many different definitions defining Health Promotion, and the World Health Organisation (1994) defines health promotion as the process of enabling people to increase control over and to improve their health (WHO, 1994), whereas Ewles and Simnet (2003) state that health promotion is about raising the health status of individuals and communities, this means improving health, advancing, supporting, encouraging and placing it higher on personal and public agendas.

As part of the pre-registration nursing assignment criteria, a practice outcome is health promotion and this provides an opportunity to personally undertake a review of how needs are assessed for children presenting signs of hearing loss, and then respond to those needs utilising an appropriate child health promotion approach, backed by theory. In addition this assignment will look at why it is necessary to test for hearing as well as the different types of hearing

tests used and how they are performed. The author will also look briefly at the causes of hearing loss.

During my placement with a Health Visitor, I assisted her on a visit to a family, to carry out a SOGS assessment on twin boys. The twins were twenty-two months old and seemed to be presenting some sort of developmental delay. The SOGS assessment is an invaluable tool for professionals who need to establish the developmental levels of young children. The assessment involves undertaking a range of questions directed at the child’s carer, about the child’s ability to do certain tasks such as walk, talk, point at objects, wave and say bye bye. The Health Visitor also observes the child and carries out some simple tests using toys such as building bricks. During the SOGS test with the twins this is exactly what happened.

To fully address professional guidelines of the N.M.C’s professional code of conduct (2004) and the Data Protection Act (1998) the twins will be known as Bill and Ben and their mother will be known as Jane. Confidentiality will be maintained and information provided will not identify wards, individuals or localities (Dimond, 2005; Nursing and Midwifery Council, 2004).

Following the birth of Bill and Ben they both received the Newborn Hearing Screening test, which took place when they were two days old. The results of this test showed unclear responses for both Bill and Ben, who were subsequently referred for further testing. For reasons unknown the twins failed to attend their initial appointment and were later referred again following their six-week developmental check. Due to the family moving house this second appointment was also not attended and the result of these two missed appointments has meant that the issues associated with the twins hearing has still not been addressed with the twins now twenty-two months old. According to Hodgkin (2002) both parents have primary responsibility for the upbringing of their children and the best interests of the child will be their basic concern. Although as a consequence of the SOGS test undertaken by the Health Visitor and myself a plan of action has been made and the twins have been referred again to an audiologist.

At the time of the appointment it was explained to Jane that I was a student nurse on a four-week placement with the Health Visitor and that she could request that I was not included in the twins assessment. Jane however was quite happy for me to be present whilst the Health Visitor carried out the SOGS assessment on Bill and Ben. It should be recognised however, that the Nursing and Midwifery Council state that consent must be obtained before giving any treatment or care. The nurse must be sure that when obtaining valid consent, that it is given by a legally competent person and it is given voluntarily and that it is informed consent (NMC 2004).

During the assessment it quickly became apparent that the twins were scoring well below their expected age level and in some areas such as Hearing, Speech and Language they were only scoring at the level expected to be attained by six-month-old baby. The test demonstrated that neither Bill or Ben was walking and Jane informed the Health Visitor that they had only been crawling for the past month. They also did not appear to acknowledge their mother leaving or coming into the room and they were in no way phased by either myself, or the Health Visitor being present in the room with them.

After the assessment was completed, the Health Visitor expressed her concerns about the twins hearing and developmental progress and asked for permission from Jane to refer both Bill and Ben to various health professionals such as a Psychologist, Speech and Language therapist and the Audiologist for hearing tests. I was very impressed by the professionalism of the Health Visitor and the way she reassured Jane about the whole process.

I was fortunate enough to spend some time at the audiology department in a local community hospital, during the day there were a number of patients who did ...

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I was fortunate enough to spend some time at the audiology department in a local community hospital, during the day there were a number of patients who did not turn up for their appointment, the audiologist informed me that infant hearing screening tests are not compulsory, and the department has a zero tolerance to non-attendances and therefore patients will not be issued with another appointment automatically. However she also said that this does not mean that appointments will not be given, the patient or health visitor can book another appointment.

Fortunately, the Health Visitor was able to obtain appointments for the following week for the twins to receive the hearing tests and I was able to be present during these tests. Both the boys received the ABR tests and the results showed signs of severe hearing loss for both Bill and Ben. The twins were immediately referred to the main Audiology department for further tests.

There is not an explicit answer when asking the question – ‘what is the definition of health?’ but there are many associations by people who have attempted to define it (Blaxter, 1990). Health can be considered solely as a matter of opinion (Kiger, 1995), as the population have many rationales for what it means. Promoting health encompasses a vast range of activities, but health promotion is primarily a strategy for improving the health of the population by providing individuals, groups and communities with the tools to make informed decisions about their well-being (Ewles and Simnett 2003).

Nurses, along with other members of the health team, play a key role in helping patients/clients to maximise their potential for good health. It is important to help people understand the value of health and freedom from disease, and to understand the known causes of disease, both physical and psychological. As health promoters, nurses are not always recognised as effective promoters (McBride, 1994), but this could be associated with nurses moving towards a more holistic approach and away from medical models (Whitehead, 2000). However, a Health Visitor is quite different because although they are qualified and registered as a nurse or midwife, they are also specially trained to assess the health needs of individuals, families and the wider community and their aim is to promote good health and prevent illness in the community.

The NMC (2004) clause 2.4 also identifies that nurses must promote the interests of patients and carers by helping them gain access to health and social care, information and support relevant to their needs.

Part of the child health promotion programme is childhood screening and the one aspect of this, which the author will look at in this assignment, is Hearing Screening. There are many possible strategies for hearing screening for hearing loss, and the Government wants to make sure that every child gets the best possible start in life. The Department of Health states that:

Early detection of deafness and hearing impairment improves language and communication skills leading to better educational achievement and quality of life, if babies are identified with a hearing loss very early in their life, precious time is gained to help them and their family develop vital communication skills.’

(DOH 2004) p.1

For over thirty years children’s hearing was screened in the UK using the Infant Distraction Test (IDT), the screening was carried out between six and eight months of age by two trained personnel (McCormick 2002). The IDT is a behavioural hearing test, which relies on the ability of infants from the age of six to eight months to locate sounds by turning their heads towards it (Weir 1985).

John Bowis the Minister for Health in 1994 announced that a review of the screening arrangements, which identified children with permanent hearing loss in the UK would be sort, in particular to examine the possible role for UNHS (Bamford et al 2001).

Two years later the review was completed and published (Davies et al 1997) and the introduction of the UNHS was recommended and the existing eight-month IDT would be phased out. Bamford et al (2001) highlights some of the key points upon which this recommendation was based, He points out that about 800 children are born each year in England with a permanent bilateral hearing loss that could be identified at birth. Current screening services identify only a small proportion of the children by one year of age.

Another one of the recommendations highlights that earlier identification allows earlier assessment of progress, with earlier management decisions and the starting point for intervention is not, therefore, from a position of developmental deficit (Bamford et al 2001).

Stevens (1998) points out that the cost of UNHS, including follow up appointments, is about £14,000 per 1,000 births compared with the IDT costing about £25,000 per 1,000 children.

Davies (2003) also points out that there are elements affiliated to the decision to implement UNHS that demonstrated that newborn hearing screening was considerably more effective and efficient than the IDT. He also goes on to say that there was a high probability that early intervention increased the potential for better language and communication (Davies 2003).

The future of the IDT has promoted considerable debate in recent years and it is suggested that where UNHS has already been in place for more than eight months, IDT should be abandoned (Hall 2004). At present the IDT has now been phased out in most areas of the UK in favour of a newer and more accurate screening performed on newborn babies, of which the majority will receive this screening to detect hearing loss within the first two days of their life. The UNHSP was implemented in 2001/2 and to be fully completed in 2005/6 (Bamford et al 2001).

The NHSP is also known as the Oto-Acoustic Emissions test (OAE) and is performed in the baby’s first few days, this is a quick and simple test that shows whether the outer hair cells of the cochlea are responding normally, and this has no risk of harm to the baby (Rademacher 2004). The screening test is usually done while the baby is settled or sleeping, it only takes a few minutes and parents and guardians are welcome to stay with their baby while the test is being performed. The test entails a small probe being placed just inside the outer part of the baby’s ear and this produces a gentle clicking sound that can then be measured by a computer (Rademacher 2004).

In the case of the twins Bill and Ben they both received the OAE test when they were two days old, the results of the test did not show a clear enough response and therefore Bill and Ben were referred to have an Auditory Brainstem Response Test (ABR), (Rademacher 2004) which can give better information about their hearing. The ABR test is carried out at the audiology clinic in local hospitals, three small sticky pads are put on the baby’s head and neck, and small headphones are put over the baby’s ears and a computer measures and records the function of the auditory nerve and its connections in the lower part of the brain, a cochlea microphonic test also shows evidence of how the cochlea’s hair cells are working (Rademacher 2004).

Unfortunately and for unknown reasons, the twins failed to attend their initial follow up appointment for this type of testing. Karzon (2006) carried out a study to evaluate the effectiveness of assessment appointments for babies referred from the UNHS test.

The ABR test was the method used by 10 audiologists, to carry out the study on 375 babies. Some additional test options such as the Otoacoustic emissions and the high-frequency tympanometry were also used, depending on the ABR findings.

The results showed that in 88% of the test sessions, at least 4 ABR threshold estimates were obtained. The incidence of hearing loss was significantly different across nursery levels, 18% for the well baby, 29% for special care baby and 52% for neonatal intensive care unit babies (Karzon 2006).

Karzon (2006) concludes that the findings indicate that test appointments are appropriate for all nursery levels to diagnose the severity and type of hearing loss in the majority of infants referred from the UNHS.

As children’s nurses we need to be patient advocates for our most vulnerable children (McHale 2003) and educate parents about the multiple advantages of having their babies hearing screening performed in order to achieve the goals set out in government targets.

Advocacy is an important principle of children’s nursing, where adults are able to make choices that children and babies do not have the same sound knowledge and are unable to make decisions for themselves. Children’s nurses have to speak out on behalf of them and need to have a good sense of argument and persistence, but with the avoidance of bias to effectively communicate the message (Hall & Ellimon 2003).

Records show that following the twin’s six-week check up with the doctor, there again were some concerns with their development, particularly hearing responses and Bill and Ben were again referred to the Audiologist for hearing tests. Sheridan (2004) suggests that at six weeks of age a baby should respond to loud noises with a startled reaction, for example, when a small bell is rung gently, any movements from the baby are momentarily ‘frozen’. The baby may move their eyes and head towards a sound or sauce. According to the twins records neither Bill nor Ben were doing any of these responses at six weeks of age. However, due to the parents circumstances which involved moving house, the twins did not keep their second appointment with the audiologist, this resulted in a further delay in addressing the suspected hearing problems that the six week check had indicated. The issues associated with the twins hearing was not picked up again until they were twenty-two months old, where the Health Visitor and Student Nurse carried out the SOGS assessment with Bill and Ben.

After gaining the parents’ permission, the twins were again referred to the Audiology clinic and the Health Visitor was able to get an appointment for the following week in the local community hospital. After gaining consent the student nurse was able to be present during the hearing tests for the twins. The Audiologist carried out the ABR test on each of the twins in turn and the results of this test showed that both Bill and Ben were showing signs of a severe hearing loss. It was explained to the twins’ mother, Jane that a severe hearing loss had been detected and the twins would now have to be referred to the Audiology department in the main hospital for further tests to find out the cause of the hearing loss.

As the twins are still receiving tests to find out the cause and severity of their hearing loss, the author is unable to give evidence of the outcome. Hearing loss commonly falls into two categories, which are conductive and sensorineural (Elssmann 1987).

A conductive hearing loss occurs when sound cannot pass from the outer ear to the inner ear due to a blockage or fault in the middle ear that prevents sound waves from moving through the ear (Karchmer 1999). For ears to work properly the middle ear needs to be kept full of air, the Eustachian tube, which usually does this, runs from the middle ear to the back of the throat (Ross 2004). In children this tube is not as vertical and wide as it will be when they get older and as a result does not work as well. If the Eustachian tube becomes blocked, air cannot enter the middle ear and when this happens, the cells lining the middle ear begin to produce fluid that can be like a runny liquid and can get thicker as it fills the middle ear. With fluid blocking the middle ear, it becomes harder for sound to pass through to the inner ear and this can make quieter sounds difficult to hear, this condition is often known as Glue ear (Seikel 2005).

A sensorineural hearing loss occurs when the cochlea or hearing nerve which is commonly known as the inner ear, is not working properly, this can be due to damage to the pathway for sound impulses from the hair cells of the inner ear to the auditory nerve and the brain (Kezirian 2001). There are a number of possible causes for this such as Acoustic Trauma to the hair cells which is an injury caused by loud noises (Karchmer 1999).

Viruses such as Mumps or Measles can cause viral infections to the inner ear and certain drugs such as aspirin, quinine and some antibiotics that can affect the hair cells. There are also some viral infections such as Rubella and the Shingles virus that can cause infection of the auditory nerve, also infections or inflammation of the brain or brain covering, such as Meningitis can cause viral infections to the inner ear (Seikel 2005).

Some people do not realise they have hearing impairments because they are too young to know something is wrong, such as newborn babies, or because the hearing loss has come on gradually. The critical period for learning speech and language begins at birth, therefore, identification and intervention of infant hearing loss at birth is critical (Moeller 2000).

Deaf and hard of hearing children who received early intervention at birth or before twelve months of age, catch up to their hearing peers in terms of speech and language. Children detected at a later age tend not to develop at the same rate as their peers regarding speech and language (Rimell 2004).

Kennedy (2006) conducted a study on 120 children with permanent hearing impairment at an average age of eight years, 61 of these children were screened at birth using the UNHSP and 57 were not detected until they were screened using the IDT at 6 – 8 months of age.

The results of the study showed that the children who were screened using the UNHS, had better language skills but there was not much difference between the two groups with their speech (Kennedy 2006).

During the visit to the twin’s family with the Health Visitor, I have gained a greater understanding of the need to carry out assessments such as the SOGS, as this can give a holistic understanding of the whole family.

After the assessment was completed, the Health Visitor discussed various options with Jane and included me in this discussion looking for options of how the family’s health and well-being could be improved. Jane has not lived in her current location for very long, she has no family living nearby and her husband works away during the week. She does not drive and finds it difficult to get about using the twins double buggy, therefore she has not integrated into her new community very well. I asked Jane if she attended a mother and toddler group, as I felt this would help her develop the twins interactive skills, but Jane said that she did not think there was one in the area. Jane told us that the only time she left the house with Bill and Ben was when her husband was home at weekends. A positive outcome was achieved from this conversation as the Health Visitor provided Jane with the details of a mother and toddler group within walking distance of her home.

Jane’s relationship with her twins seemed to be quite distant as her interactions with them were mostly non-verbal, neither of the boys could talk and it appeared that they could not understand what was being said to them. One of the questions relating to the assessment was to see if a simple command such as ‘can you go and get your shoes’ could be understood, but there appeared to be no understanding of the command at all from either Bill or Ben. It can be suggested that their lack of understanding and responsiveness is due to the fact that the twins have missed two appointments for hearing tests in the past and have only now at twenty-two months been diagnosed with severe hearing loss. If left without treatment their hearing loss could have a devastating effect on their language acquisition, communication development, confidence and social skills, which can last a lifetime.

During the SOGS assessment with Bill and Ben, the Health Visitor was both calm and reassuring with Jane’s situation. I however, felt annoyed that Jane had missed two appointments with the Audiologist and had not made arrangements herself to make a further appointment for the twins. I also felt that she could have made more of an effort to find out about playgroups.

Later back at the office, I discussed these issues with the Health Visitor and realised that Jane could have been suffering from depression and had not felt that she could cope with going out alone with the twins. However with a care plan for Jane and the twins now in place and appropriate support from health professionals I am now optimistic about the twins future and potential development as there is no reason why the twins cannot develop and eventually catch up with their hearing peers (Davies 2003).

My recommendations for the future would be, firstly to the Midwife to make sure that all babies have received the Newborn Hearing Screening test, especially those babies not born in hospitals where the test is routinely carried out and secondly to the Health Visitor to make sure that any follow-up appointments are attended or re-booked if missed.

In conclusion it has been found that the role of health promotion and the Health Visitor does raise health promotion awareness. As the author has been looking at the benefits of infant hearing screening in this assignment, it has been found that the Government have set targets to make sure that every child gets the best possible start in life and that early detection of deafness and hearing impairment can indeed improve language and communication skills to such a level that it can be comparable to the development of a child with normal hearing.

The case study of Bill and Ben has highlighted the lack of their early treatment but it has also shown how advantageous an integrated approach is in promoting health care. The Chief Executive of the National Deaf Children’s Society Susan Daniels States that;

We are delighted that the NHS Newborn Hearing Screening

Programme is being implemented in so many sites all around

the UK and we look forward to seeing a complete nationwide

role out. Early diagnosis of a hearing loss is extremely important

for a child’s language and social development. If a baby is identified

by the age of six months, and a good early intervention support

programme is developed; a deaf child can develop language at

the same rate as a hearing child.

(DOH 2004) P. 2

The UNHSP is now fully implemented across the UK and the IDT has now been phased out in favour of the OAE test, which, indeed has been found to be more efficient and effective. Following a research study it has also been found that early detection and intervention of a hearing impairment can be beneficial to improve communication and language skills. The author has found that although every baby receives the OAE test within a few days of birth, it has been seen that some of these babies have not been properly followed up. Although in the case of Bill and Ben, it could be argued that the parents were at fault due to missing a number of appointments with the Audiologist. It could also be suggested that due to the importance of addressing hearing problems early in child’s life that the issues associated with Bill and Ben should have been followed up by the Health Visitor well before the twins reached the age of twenty two months. It should be recognised however that both the parents and Bill and Ben are now fully integrated into the health care system with their Health Visitor, which should result in a full diagnoses from the Audiologist and a package of support to help address the family’s needs.

References

Bamford J Battersby C Beresford D Davies A Gegory S Hind S Moore L and Reeve K (2001) Assessing service quality in paediatric audiology and early deaf education. British Journal of Audiology. 35 329-338.

Blaxter M (1990) Health and Lifestyles. London, Tavistock/Routledge.

Crow E (1990) Advocacy for the Advocate. (2nd edn.) London: Longman.

Davies A Bamford J Wilson I Ramkalawan T Forshaw M and Wright S (1997) A critical rewiew of the role of neonatal hearing screening in the detection of congenital hearing impairment. Health Technology.

Davies A and Hind S (2003) The newborn hearing screening programme in England. International Journal of Paediatric Otorhinolaryngology. 67 (1) 6-193.

Department of Health (2004) Choosing Health: Making Healthier Choices Easier. London, HMSO.

Department of Health (2004) Update on screening hearing impairments in newborns.

Accessed: 3/01/2007.

Dimond B (2005) Legal Aspects of Nursing (4th edn.) Harlow: Longman.

Elssmann S (1987) Early identification of congenital sensorineural hearing impairment. Hearing Journal. 40 (9) 7-13.

Ewles L and Simnett I (2003) Promoting Health: A Practical Guide. (5th edn.) London, Scutari Press.

Hall D and Elliman D (2003) Health for all Children. (4th edn.) London: OUP.

Hodgkin R and Newell P (2002) Rights of the Child (4th edn.) New York: UNICEF.

Karchmer M & Allen T (1999) The functional assessment of deaf and hard of hearing students. Journal for the Deaf. 144 (2) 68-77.

Karzon R (2006) Initial audiologic assessment of infants referred from well baby, special care, and neonatal intensive care unit nurseries. American Journal of Audiology. 15 (1) 14-24.

Kennedy C and McCann D (2006) Language ability after early detection of permanent childhood hearing impairment. Medical Journal. 354 (20) 2131-2141.

Kezirian E (2001) Cost and cost-effectiveness of universal screening for hearing loss in newborns. Otolaryngol Head Neck Surgery. 124 (4) 67-359.

Kiger A (1995) Teaching for Health. (2nd edn.) London. Churchill Livingstone.

McBride A (1994) Health promotion in hospitals: the attitudes, beliefs and practices of hospital nurses. Journal of Advanced Nursing. 20 92-100.

McCormick B (2002) The distraction test as a procedure for hearing screening.

Accessed 14/04/2007

McHale I & Gallager A (2003) Nursing and Human Rights. Butterworth: Heinemann.

Moeller M (2000) Early intervention and language development in children who are deaf and hard of hearing. Paediatrics. 14 43-106.

Nursing and Midwifery Council (2004) Code of Professional Conduct. London: NMC.

Rademacher R and Kliegman R (2004) Common Issues and Concerns in the Newborn Nursery. Philadelphia: Saunders.

Rimell F (2004) Diagnosing infant hearing loss. Family Practice News 34 (1) 8-12 Expanded Academic ASAP. Thomson Gale.

Seikel J (2005) Anatomy & Physiology for Speech, Language and hearing (3rd edn.) Clifton: Thompson.

Sheridan M (2004) From Birth to Five Years. Padstow: Cornwall.

Stevens J Hall D and Davies A (1998) A survey of the cost of hearing screening in the first year of life in England and Wales. Arch Dis Child. 78 14-19.

The National Deaf Children’s Society (2006) Auditory neuropathy and auditory dys-synchrony. Factsheet.

Accessed:02/01/2007.

Weir C (1985) Use of behavioural tests in early diagnosis of hearing loss. Acta Otolaryngology. 421 86-92.

World Health Organisation (1984) Health Promotion: A discussion document on the concept and principles. Copenhagen: WHO.

Whitehead D (2000) What is the role of health promotion in nursing? Professional Nurse. 15 (4) 257-259.

Infant Hearing Screening - Reflection