National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people


Chapter 7: Hearing loss
☰ Table of contents


Recommendations: Hearing loss

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Immunisation

Children aged <15 years Vaccination is recommended to prevent infections that may lead to congenital or acquired hearing loss (rubella, measles, Haemophilus influenzae type b, meningococcus) (refer to Chapter 3: Child health) As per National Immunisation Program Schedule (NIPS) and state/ territory schedules I–A 22
Pneumococcal conjugate vaccination (13vPCV) is recommended during infancy to prevent invasive disease, pneumonia and acute otitis media (AOM)* (refer to Chapter 9: Respiratory health) At age six weeks, and at age four, six and 18 months, as per NIPS I–IIA 25, 26,35, 36,37
Annual influenza vaccination (inactivated virus) is recommended for any person aged ≥6 months who wishes to reduce the likelihood of becoming ill with influenza.

Vaccination may reduce the incidence of AOM as a secondary complication of influenza (refer to Chapter 9: Respiratory health)
As per NIPS and state/territory schedules IA 21, 40
All pregnant women Offer testing for rubella immunity and syphilis serology to prevent infections that may lead to congenital hearing loss (refer to Chapter 2: Antenatal care)

Recommend enhanced hygiene practices for cytomegalovirus (CMV) prevention (Box 4)
Refer to Chapter 2: Antenatal care   N/A

Screening

Newborn infants Ensure parents of newborn infants are aware of the universal neonatal hearing screening program being implemented in each state and territory and have had their newborn screened for congenital hearing impairment

Advise parents that infants can fail hearing tests at a subsequent age and at-risk children should be periodically tested to three years of age
Prior to age one month. If missed, prior to age three months

If pass but still at high risk, periodic tests to age three years
I–B 43, 46
42, 45, 47, 48
Children aged <15 years Encourage parents to be aware of child developmental milestones in the early detection of hearing loss (Box 1). Parental or teacher suspicion of hearing loss should always be investigated (Box 2).

Where relevant, provide advice regarding free hearing assessment
Opportunistic, and as part of annual health check GPP 2, 18
Conduct ear examinations (including pneumatic otoscopy or video otoscopy and tympanometry) in order to detect unrecognised acute or chronic otitis media. If detected, refer to clinical practice guidelines for management (refer to ‘Resources’) Opportunistic and as part of annual health check GPP 2
Children aged <5 years and older children at high risk of hearing impairment Maintain a high index of suspicion of hearing loss as there is a high prevalence of undetected hearing loss and disadvantage among Aboriginal and Torres Strait Islander school-age children Opportunistic and as part of annual health check GPP 2, 49
Children aged <5 years and older children at high risk of hearing impairment Use the following audiological tools to monitor for hearing loss: simplified parental questionnaires (Box 1), and three-monthly pneumatic otoscopy or video otoscopy and tympanometry (in children aged >4 months).

Note: These methods do not assess hearing

Note: Pneumatic otoscopy or video otoscopy and tympanometry are used to identify otitis media and document duration (with possible conductive hearing loss). Refer to clinical practice guidelines for the identification and management of persistent otitis media with effusion (OME) or recurrent AOM§1,2 (refer also to ‘Resources’).

Those with suspected hearing loss (or caregiver concerns) should be referred as per Box 2
Opportunistic and as part of regular health check GPP 2, 18
Children at school entry The routine hearing screening of all children upon commencement of their first year of compulsory schooling may have limited public health value and is not encouraged.

Regular surveillance is preferred
Advise parents that absenteeism is associated with hearing loss
  GPP 2
Adults aged >15 years Monitor for hearing impairment by questioning, provide advice regarding free hearing assessment, and make referrals when appropriate

Hearing screening is not recommended for persons aged >50 years

Inform families of increased risk of hearing loss among incarcerated people
As part of annual health check GPP 18, 19, 20

Behavioural

Pregnant women and postnatal period Promote exclusive breastfeeding for at least three months (and preferably to six months) to reduce the risk of infants acquiring AOM Opportunistic, antenatal and postnatal checks, and as part of annual health check IA 2, 57
Refer women to breastfeeding support programs if needed IA 57
Advise pregnant women of risk of CMV infection, particularly when exposed to young children, and emphasise the importance of handwashing (Box 4)

Advise that risk of AOM increases with use of pacifiers
IIA 55
97
All people who smoke Promote smoking cessation and the need to avoid children being exposed to cigarette smoke, as passive exposure increases the risk of acute, recurrent and chronic otitis media (refer to Chapter 1: Lifestyle, ‘Smoking cessation’)

Note: Avoidance of smoke exposure has other health benefits but has not been shown to reduce exposure to or prevent respiratory infections
Opportunistic and as part of annual health check I–A 2, 58, 59, 60, 61 62
All people Swimming (sea, clean fresh water or chlorinated) should be permitted, including in children with a prior history of otitis media (all forms) Opportunistic IA 73
Children with tympanostomy tubes (TTs) or chronic suppurative otitis media (CSOM) Children with TTs may continue to swim unless there is a prior association with discharge after swimming

Children with CSOM do not benefit from swimming, but swimming should not be discouraged
Opportunistic IC 74
III–3 76, 77, 78, 79, 84
All people A video otoscope may assist in helping patients and families to understand ear disease. This may lead to greater engagement in its prevention and management Opportunistic GPP 2
Inform families of the importance of frequent and thorough nose-blowing, facial cleanliness, handwashing and drying of children in order to prevent the transmission of infectious disease Opportunistic IB 63, 69, 70, 72
64, 65, 66, 67,71
8, 65
Promote frequent handwashing in day-care 8, 65 centres and preschools IB

Surgical

Children with hearing loss associated with recurrent AOM or OME Consider referral for TTs (or grommets) to reduce hearing impairment in children with OME and increase otitis-free duration in children with recurrent AOM.

Adenoidectomy may further improve outcomes

Interventions at surgery (saline washouts at surgery, topical antibiotics/steroids) or after insertion of TTs (topical drops, and prolonged oral antibacterial/steroids) reduces the risk of TT otorrhoea, particularly in high-risk groups

Antibiotic eardrops are effective in treating TT otorrhoea
Opportunistic IA 83
80, 81
87
82

Chemo-prophylaxis

Children aged <15 years
Children aged <2 years or bilateral AOM or AOM with perforation
The use of prophylactic antibiotics in order to prevent the onset of AOM is not recommended, except in children at risk of recurrent AOM or tympanic membrane perforation, such as those aged <2 years, with bilateral AOM or AOM with perforation, or children living in high risk populations

Antibiotics for OME reduce prevalence of OME at age 2–6 months but have not been shown to improve hearing
Opportunistic IA 88, 89
The use of prophylactic antiviral drugs in those with confirmed influenza may also prevent the onset of AOM but neuraminidase inhibiters are not recommended as a primary reason for AOM prevention following influenza Opportunistic IA 59, 93
Probiotics are not currently recommended for the prevention of AOM

Note: Some probiotics may be effective in the prevention of AOM episodes in European children
Two to three times daily ID 98,  99, 100, 102
Children aged <15 years
Children aged <2 years or bilateral AOM or AOM with perforation
Zinc supplementation is associated with mixed benefit for AOM prevention and is not currently recommended One dose per week for four weeks IC 104
Vitamin D may reduce recurrence of AOM but is not currently recommended based on current evidence 1000 IU per day IID 96
Autoinflation may be an option for preventing hearing loss associated with OME in children aged >4 years 3x per day IC 107, 108
Antihistamines, decongestants or combination, or topical steroids for OME, are not effective in resolving OME or improving hearing and are not recommended

When combined with oral antibiotics, oral steroids improve OME resolution in the short term only, and have not been shown to improve hearing at six weeks
  IA 105, 106

Environmental

Children aged <15 years Assess children at high risk of hearing impairment with regard to their housing situation (ie if overcrowding is likely, functional condition of housing) and refer to social support services for housing assistance if indicated (Box 3) Annual IIIC 59, 109, 111, 112, 114
All people Inform families of the danger of loud noise (and for prolonged periods), especially for children with a history of ear disease (refer to ‘Resources’) Opportunistic GPP 116, 117

*Aboriginal and Torres Strait Islander children in high-risk areas are recommended to also receive 13vPCV as a ‘booster dose’ between 18 and 24 months of age as indicated for the prevention of invasive pneumococcal disease. High-risk areas include the Northern Territory, Queensland, South Australia and Western Australia. Booster dose of 13vPCV is not recommended for children in New South Wales, ACT, Victoria and Tasmania.21

The Australian Government’s Hearing Service Program119 enables eligible Australians to receive funded rehabilitative hearing services, including hearing and communication assessment, support and fitting of amplification. There are two client service groups: Community Service Obligation (CSO) and Voucher. Voucher client group: a wide range of approved private providers, including Australian Hearing, provide services under the Voucher program. People who are eligible for these services include Australian citizens or permanent residents who are pensioner concession cardholders, Veterans Affairs cardholders, recipients of a Centrelink sickness allowance or a dependent of these eligibility groups; Australian Defence Force members; National Disability Insurance Scheme participants, or people who are referred by Disability Employment Services. CSO client group: Australian Hearing is the sole provider of services under the CSO stream. This includes children and young adults aged <26 years; Voucher-eligible adults who have complex hearing and communication needs, including greater degrees of hearing loss and additional disabilities; Aboriginal and Torres Strait Islander adults aged ≥50 years; Aboriginal and Torres Strait Islander participants in the remote area Community Development Programme; and Aboriginal and Torres Strait Islander adults who meet Voucher program eligibility criteria but who are being seen at one of Australian Hearing’s Outreach locations.

High risk of hearing impairment: those from socioeconomically deprived communities and from regions with a high prevalence of otitis media; and individual children in any community if they have bilateral AOM or AOM with perforation, or have CSOM or AOM and are aged <2 years, or have persistent OME or recurrent AOM.

§Recurrent AOM: the occurrence of three or more episodes of AOM in a six-month period, or occurrence of four or more episodes in the last 12 months.2

Box 1. Hearing-related growth milestones in children2,120,121

Simplified parental questionnaires can elicit a child’s progress through the following hearing-related growth milestones:

  • 3–6 months: not communicating by vocalising or eye gaze; not starting to babble
  • 9 months: poor feeding or oral coordination; no gestures (pointing, showing, waving); no two-part babble (eg gaga)
  • 12 months: not babbling; no babbled phrases that sound like talking
  • 20 months: only pointing or using gestures (ie not speaking); no clear words; cannot understand short requests
  • 24 months: using <50words, not following simple requests; not putting words together; most of what is said is not easily understood
  • 30 months: no two-word combinations
  • 36 months: speech difficult to understand; no simple sentences
  • 48 months: speech difficult to understand; not following directions involving two steps
  • 60 months: difficulty telling parent what is wrong; cannot answer questions in a simple conversation

Box 2. Criteria for referral of children with persistent or recurrent otitis media, suspected hearing loss, hearing-related problems elicited through simplified parental questionnaires (Box 1), and/or caregiver concerns2

Age of child

Referral to

<3 years

Major regional hearing centre to determine the level of loss

<5 years and older children at high risk of hearing impairment*

Paediatrician and an audiologist (for appropriate developmental assessment and hearing tests) and ear, nose and throat (ENT) specialist for surgical restoration of hearing (eg tympanostomy tubes); advise parent of strategies to improve communication, advise child’s school

<15 years

Audiologist (or ENT specialist) for full hearing assessment

*High risk of hearing impairment refers to children from socioeconomically deprived communities and from regions with a high prevalence of otitis media.8

 

Box 3. Definition of overcrowded housing circumstances113 

Households that do not meet these requirements are deemed to be overcrowded:

  • There should be no more than two persons per bedroom
  •  
  • Children aged <5 years of different sexes may reasonably share a bedroom
  •  
  • Children aged ≥5 years of opposite sex should have separate bedrooms
  •  
  • Children aged <18 years and the same sex may reasonably share a bedroom
  •  
  • Single household members aged >18 years should have a separate bedroom, as should parents or couples
 

 

Box 4. Hygiene practices recommended by the Centers for Disease Control and Prevention to reduce risk of cytomegalovirus infection for women who are pregnant or planning to become pregnant122

  • Thoroughly wash hands with soap and warm water after activities such as: nappy changes
    • feeding or bathing young child
    • wiping child’s runny nose or drool
    • handling child’s toys
  • Do not share food, drinks, eating utensils used by young children
  • Do not put a child’s dummy in your mouth
  • Do not share a toothbrush with a young child
  • Avoid contact with saliva when kissing a young child
  • Clean toys, countertops and other surfaces that come in contact with urine or saliva
 

Also refer to ‘Resources’



Background


The National Guide provides recommendations on the primary prevention of otitis media and the early detection of hearing loss, including otitis media–associated hearing loss, predominantly for children under 15 years of age, with some additional recommendations pertaining to Aboriginal and Torres Strait Islander adults. The diagnosis and management of otitis media as a strategy for preventing hearing loss and associated educational and social disadvantage is outside the scope of this guide, as other sources of advice are available.1,2 Brief recommendations for secondary and tertiary hearing loss prevention strategies are included.
Definitions:

  • otitis media with effusion (OME) – intact and non-bulging tympanic membrane (TM) and type B tympanogram
  • acute otitis media without perforation (AOMwoP) – any bulging of the TM and type B tympanogram
  • acute otitis media with perforation (AOMwiP) – middle ear discharge observed and TM perforation recently healed, or present for less than two weeks, or covering less than 2% of the pars tensa of the TM or too small to be readily seen; type B tympanogram
  • dry perforation – TM perforation without any discharge observed; type B tympanogram
  • chronic suppurative otitis media (CSOM) – middle ear discharge observed and perforation present for longer than two weeks and covering at least 2% of the pars tensa of the TM, or readily seen; type B tympanogram.

Where duration of discharge was not known, size of perforation is used to distinguish AOMwiP and CSOM. Recurrent acute otitis media (AOM) refers to three episodes within six months, or four episodes within 12 months.
A prevalence of >1% of CSOM in children in a defined community indicates that there is an avoidable burden of the disease, but which can be dealt with in the general healthcare context. A prevalence of >4% indicates a massive public health problem of CSOM that needs urgent attention in targeted populations.3,4 Grades of hearing loss are defined for children in Table 1.

 

Table 1. Grades of hearing loss as defined for children3,4

Grade

Hearing threshold (decibels)

Impact on function

Mild

26–30 dB

Child has trouble hearing speech, speech from a distance, or speech against a background of noise

Moderate

31–60 dB

Child has difficultly hearing regular speech, even at  close distances

Severe

61–90 dB

Child may only hear very loud speech or loud sounds in the environment, such as a fire truck or siren or slamming door. Most conversational speech is not heard

Profound   

>91 dB      

Child may perceive loud sounds as vibrations

Disabling hearing loss: refers to hearing loss >30 dB in the better hearing ear in children

 

Children


Ear infections are more common in Aboriginal and Torres Strait Islander children than in non-Indigenous Australian children, and the chronic and suppurative consequences represent a major public health problem.5

Chronic otitis media such as OME and CSOM are highly prevalent (50% among children in rural and remote Aboriginal communities).6 Otitis media is managed at a rate of four times for every 100 consultations in Aboriginal Community Controlled Health Services. In comparison, AOM is less commonly managed in private general practice (1.2 per 100 encounters in 2004–05), where over 98% of clients are non-Indigenous.7 Analysis of general practitioner (GP) consultations across Australia also found otitis media was significantly more common and severe in Aboriginal and Torres Strait Islander children.5

An international meta-analysis of factors that increase the risk of AOM include family history of AOM, attending day-care centres and parental smoking; breastfeeding was protective.8 In remote areas, household crowding (more than two children aged <5 years) is associated with a 2.4-fold increased risk of the youngest child having otitis media.9

Middle ear infections commence predominantly in very young Aboriginal infants and persist throughout early childhood,10,11 causing hearing loss during the critical period of child development, with some effects on auditory processing and communication skills that may be lifelong12 and difficult to correct.13 Among over 1000 Aboriginal children aged <8 years living in urban and rural settings, otitis media (in any form) was identified in 37% of children, perforation in 2% and hearing loss in 10%. Speech skills were not ageappropriate, and receptive and expressive language was impaired in approximately 40% of children, and 27% had concurrent receptive and expressive language impairments.14 In remote communities, the prevalence and severity of otitis media are much higher (up to 20% of children aged <3 years have perforation, 90% have some form of otitis media6), but there are no data published on the prevalence of speech and language impairment.

Other guidelines

The National Guide has cross-referenced recommendations in this chapter with forthcoming 2017 updates to the current evidence-based Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations.2


Adults


Few recent studies have examined the extent of hearing impairment in Aboriginal and Torres Strait Islander adults. Overall, self-reported rates of hearing problems/ear diseases were 12% (across all ages) in the National Aboriginal and Torres Strait Islander Health Survey (2012–13), and were higher across all age groups <55 years than reported by non-Indigenous people (rate ratio 1.3).15 A 2006 cross-sectional analysis of at least 50% of the adult Aboriginal prisoner population in Victoria showed no difference in the prevalence of conductive hearing impairment between Aboriginal prisoners and a UK age-matched cohort (6.3% compared to 6.8% adults in the age group 18–40 years, respectively).16 In contrast, among Aboriginal and Torres Strait Islander prisoners in one Northern Territory site who volunteered to have a hearing assessment, 22% had hearing loss of >35 decibels (dB) (Australian Hearing, presentation at Roundtable on Ear Health For Life, Royal Australian College of Surgeons, Canberra, November 2016). At another prison, over 90% had hearing loss >25 dB, of whom 35% had hearing loss >35 dB17 (personal communication, Dr Damien Howard).

Other guidelines

The ninth edition of The Royal Australian College of General Practitioners’ (RACGP’s) Guidelines for preventive activities in general practice (Red Book) recommends annual questioning about hearing impairment for Australians aged ≥65 years (grade B recommendation).18 The US Preventive Services Task Force (USPSTF) review19 and recommendation statement20 concluded that there was insufficient evidence to ascertain the balance of benefits and harms of screening and treatment for hearing loss in older adults (>50 years) and recommended more research.20


Interventions


Immunisation

Antenatal and childhood infections

Congenital and acquired hearing loss can be prevented by immunisation (rubella, measles, Haemophilus influenzae type b [Hib], pneumococcus, meningococcus) in accordance with the National Immunisation Program Schedule (NIPS; and variations within states and territories) from birth/infancy.21,22 Refer to Chapter 3: Child health regarding recommendations to enhance immunisation coverage. In Australia, infection rates with measles and rubella remain extremely low and no cases of congenital rubella have been identified in the Aboriginal population for many years. The risk of congenital rubella remains, especially in immigrants.23 Rates of congenital syphilis in the Aboriginal population are extremely low but still occur. Fewer than 10 cases of congenital syphilis have been diagnosed annually since 2007.24 It is unclear what proportion have congenital hearing loss as a consequence. Antenatal screening is a key part of prevention of the disease (refer to Chapter 2: Antenatal care).

Pneumococcal

Pneumococcal conjugate vaccine (PCV) given to children will prevent a proportion from developing AOM, but the primary indication for the current 13-valent PCV (13vPCV) in the NIPS is for the prevention of invasive pneumococcal disease and pneumonia.22,25 A licensed 10-valent PCV (10vPCV) also includes potential protection from AOM caused by non-typeable H. influenzae (NTHi) but is not currently Therapeutic Goods Administration (TGA) licenced for NTHi otitis media.

A Cochrane systematic review of randomised controlled trials (RCTs) for the prevention of otitis media using 7-valent PCV (7vPCV) (with CRM197-mutated diphtheria toxin carrier protein) showed marginal (7%) reduction in all-cause AOM, but may mean ‘substantial reductions from a public health perspective’.26 Administering 7vPCV in high-risk infants after early infancy and in older children with a history of AOM had no benefit in preventing further episodes. The review did not include more recent higher valency PCVs. Observational studies show 20% reduced outpatient visits for acute and chronic otitis media in children aged <2 years from 7vPCV.27 Other birth cohort comparisons28 and RCTs29,30 show reduced incidence of recurrent otitis media and pressure-equalising tube insertions from 7vPCV. In contrast, maternal vaccination or booster doses of 23-valent pneumococcal polysaccharide vaccine (23vPPV) have not been shown to prevent otitis media in Australian Aboriginal and Torres Strait Islander children.31,32

In the US, 13vPCV was approved by the Food and Drug Administration in 2010 for the prevention of invasive pneumococcal disease as well as otitis media caused by the seven serotypes also covered by 7vPCV; however, ‘no efficacy data for prevention of otitis media are available for the six additional serotypes’.33 Observational studies show that the incidence rate ratio comparing pre-7vPCV to the 13vPCV period was 0.12 for five additional 13vPCV serotypes.34
Protein D (H. influenzae derived) conjugated pneumococcal vaccine (11-valent) had 34% efficacy in reducing AOM due to action against AOM from both vaccine-type pneumococcus (53%) and NTHi (35%).35 An RCT of the final formulation (10-valent pneumococcal H. influenzae protein D conjugated vaccine, PHiD-CV10 or Synflorix®) had efficacy of 6% against all-cause AOM episodes36 in low-risk populations.

In Australia, PHiD-CV10 was TGA approved in July 2009 as an alternative to 7vPCV for the prevention of childhood pneumococcal infections (including invasive disease, pneumonia and AOM). The Advisory Committee on Prescription Medicines then approved 13vPCV in 2010 for ‘active immunisation for the prevention of disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F (including invasive disease, pneumonia and AOM) in infants and children from 6 weeks up to 5 years of age’.37 This indication was approved by the TGA in May 2010, and announced by the federal Minister for Health in February 2011. It took effect from 1 April 2011 in the Pharmaceutical Benefits Scheme (PBS). Neither vaccine is TGA approved for the prevention of otitis media due to NTHi.

Surveillance in the Northern Territory where PHiD-CV10 was used for two years suggests a beneficial effect of around 27% reduced NTHi-associated AOM compared to either 7vPCV or 13vPCV.6,9,38 Higher quality studies are underway to confirm this.39

Influenza

Influenza vaccination in children will prevent a proportion from developing AOM but is not the primary reason for recommending it. A Cochrane systematic review of influenza versus placebo or no treatment in infants and children aged <6 years found a small 20% reduction in at least one episode of AOM over six months of followup.40 Two trials reported a 30% reduction in the use of antibiotics.40 The NIPS recommends influenza vaccine for the prevention of influenza and its complications.22 Only quadrivalent vaccines are available in 201721 and are funded on the National Immunisation Program (NIP) in 2017 for Aboriginal or Torres Strait Islander people aged six months to <5 years and >15 years, and pregnant women (during any stage of pregnancy).21 The use of influenza vaccine for the prevention of otitis media is not subsidised under the NIPS.


Screening


Newborn

Because 50% of children with hearing loss have no identifiable risk factors, universal screening (instead of targeted screening of high-risk groups) has been proposed to detect children with permanent congenital hearing loss (PCHL) early in life.41 PCHL occurs in one to two infants per 1000 births, significantly higher than prevalence of other conditions for which newborn screening currently occurs. Newborn hearing screening leads to earlier identification and intervention, and ultimately leads to better language development.42 In the absence of newborn hearing screening, three out of four children with PCHL remain undiagnosed by 12 months of age and their capacity for normal language and cognitive development is greatly diminished.
Neonatal hearing screening is believed to have resulted in significant cost savings to the health system.43 In 2011, it was reported that more than 95% of all newborns in Western Australia had received neonatal hearing screening.44 A systematic review identified educational disparity and lack of adequate knowledge of parents to be associated with loss to follow-up.45

Several systematic reviews have examined universal newborn hearing screening. The USPSTF recommends screening for hearing loss in all newborn infants before one month of age. Infants who do not pass the newborn screening should undergo audiology and medical evaluation before three months of age. Those with risk factors continue periodic testing for three years.46 This is based on good quality evidence that early detection improves language outcomes,42 although the net benefit (taking account of risk of harms such as parental stress from false positives/negatives and bacterial meningitis post-Cochlear implant) is more moderate.45 The number needed to screen to diagnose one case is 878 for universal newborn hearing screening and 178 for targeted screening programs.46

A systematic review found that patient-relevant parameters, such as social aspects, quality of life, and educational development, have not been adequately investigated, thereby limiting understanding of the impact of newborn hearing screening.47 Cost effectiveness in the long term has been difficult to determine due to lack of certainty about the benefits gained from early detection and treatment. Alternative approaches to screening were not available to establish whether universal newborn screening is a good long-term investment.48

Early childhood

The USPSTF recommends periodic testing for three years in children at risk.42 The American Academy of Pediatrics has released screening recommendations for assessing hearing loss in children at all ages, and definitive hearing testing at intervals in those children with risk factors (eg recurrent or chronic otitis media). No specific reference is made to school screening.49 School-entry screening might pick up undetected deafness (usually OME) warranting personal intervention, but it is unclear if this outcome justifies school-entry screening, particularly because hearing loss can fluctuate. Screening for OME in non-Aboriginal children is not recommended by general guidelines.18

Specific recommendations for the Aboriginal and Torres Strait Islander population for hearing surveillance from early childhood are related to the high incidence and prevalence of otitis media in this population. Screening school children in Perth identified 19% (18/94) of Aboriginal children (1998–2004) had unilateral/ bilateral mild–moderate hearing loss.50 There was no cohort or comparison group of non-Aboriginal children, so it is not possible to assess the significance of this level. This is the only recent school screening report in Australia. However, according to the Darwin Otitis Guideline Group, in regions with near universal early and persistent conductive hearing loss due to infection (intermittent/recurrent), it is unlikely that hearing screening at school entry will reveal information that is not already known.2 The Darwin Otitis Guideline Group recommend that regular surveillance (with appropriate testing when indicated) throughout early childhood is preferred to school-entry screening.


Behavioural


Parental and community vigilance for the detection of hearing loss in children is crucial. However, studies report parental perception of a hearing abnormality is a very poor predictor of hearing loss from OME, even after tympanostomy tube insertion.51,52 In the UK, a study reported in 1990 found that approximately only one in five children affected by mild to moderate hearing loss had their loss identified and initiated by parental suspicion. 53 Parental suspicion was only slightly higher (one in four) for severe or profound hearing loss.53 Other sources of identification include well-baby checks (20%) and through risk factors (intensive care admission in the newborn period; small for gestational age; ear, head or throat anomalies; familial hearing loss) (31%).54 In remote Northern Territory Aboriginal communities, unpublished data from a birth cohort study39 shows that no parent initiated a request for a hearing test in their children aged <3 years, yet almost all those tested had hearing loss (25–50 dB).

While 90% of infants with congenital cytomegalovirus (CMV) infection display no manifestations at birth, the remaining 10% do have signs and are at risk of life-long neurological consequences, including cognitive and motor deficits, hearing and visual impairments. There is currently no licensed vaccine against CMV. There are insufficient data to assess whether any interventions for pregnant women with confirmed primary CMV infection make a difference in the prevention of congenital CMV infection and its sequelae or the occurrence of adverse events as a result of an intervention.55 Maternal education and behavioural modification are used to limit women acquiring CMV in pregnancy (eg by improved hand hygiene for them and young children who are the predominant asymptomatic carriers of CMV [Box 4]).56

Breastfeeding

A meta-analysis of observational studies found that any form of breastfeeding was protective of AOM in the first two years of life. Exclusive breastfeeding for six months was most protective and reduced the risk of AOM by almost one-half.57

Smoking

Although exposure to passive smoke is a confirmed risk factor for otitis media,58–60 there is limited evidence that interventions to reduce exposure are effective.61 One RCT in the Northern Territory and New Zealand assessed the effect of an intervention to reduce exposure to second-hand smoke during the first three months of an infant’s life and found no statistically significant impact of the intervention on maternal smoking rates (70% versus 59%) or infant otitis media events.62

Handwashing

Handwashing with soap prevents diarrhoea and acute lower respiratory infections that cause the largest number of childhood deaths globally.63 Handwashing with daily bathing also prevents impetigo.63 Regarding the prevention of transmission of pathogens that cause AOM, poor handwashing was a predictor of NTHi throat carriage in children from day-care centres.64 The risk of pneumococcal or NTHi hand contamination was eight and nine times higher, respectively, in Aboriginal children aged 3–7 years from a remote community compared to non-Aboriginal children aged <4 years from urban day-care centres, further supporting the important role of handwashing in the prevention of otitis media.65
Few high-quality studies have evaluated the effects of handwashing, nose-blowing and facial cleanliness on the prevention of AOM. A Central Australian community-based school program of daily nose-blowing, deep breathing and coughing found respiratory improvements, but no change in hearing, following a five-month period.66 Community preference for this program,67 ‘infomercials’ on community television68 and application of evidence studies65,69–72 have led to ongoing modifications to the program (including nose emptying, hand and face washing, use of soap, and drying with paper towels) that should be evaluated.

An RCT examining handwashing in child day-care centres found that children in the intervention group had fewer visits to a doctor because of OME and received 24% fewer prescriptions for antimicrobials. There was general compliance with the handwashing instructions.69 An Australian cluster RCT of infection control in daycare centres found a significant reduction in respiratory illness in children aged <2 years, particularly when hygiene compliance was high.72

Swimming

The Norwegian Mother and Child Cohort Study (1999–2005), which followed children from birth to the age of 18 months, found that children who were baby swimming (at six months) were no more likely to have lower respiratory tract infections, to wheeze or to have otitis media.73 A Cochrane review of water precautions (mechanical or water avoidance) for prevention of infection following tympanostomy tubes found two studies (413 patients) of low quality and concluded that an average child would have to wear earplugs for 2.8 years to prevent one episode of otorrhoea, and that avoidance of swimming made no clinically significant difference.74

Children with CSOM (‘runny ears’) have the greatest level of hearing loss. These children may benefit from swimming due to mechanical clearance of ear discharge or disinfection (ie swimming may restore hearing). Clearance of pus from the canal can improve hearing by ~5 dB or more in some 41% of children.75 A small case series showed that tissue spears used to clear canal pus can improve hearing in the short term (within at least 30 minutes of cleaning in around 40% of children with CSOM).75 The study did not evaluate longer term outcomes, so the duration of potential benefit is not known.

The introduction of swimming pools in two remote Aboriginal communities was associated with a reduction in the prevalence of tympanic membrane perforations over 18 months.76 A more extensive comparison in Central Australia, however, found no benefit of pools for ear disease.77 Similarly, a small RCT in the Northern Territory found no difference in ear discharge, perforation size or microbiology for children with CSOM who were randomised to swimming after school compared to those randomised to other activities.78 A systematic review of these and other swimming studies found no evidence for a benefit of swimming pools for ear health.79

Surgical

Tympanostomy tubes (TTs) or grommets are inserted in children’s ears to restore hearing loss caused by OME or prevent recurrent AOM (refer below). Adenoidectomy may further improve outcomes of TTs.80,81 Surgeons may be reluctant to insert grommets in the ears of young Aboriginal and Torres Strait Islander children (aged <10 years) because of the risk of TT otorrhoea, CSOM and ultimately a higher level of hearing loss. A current trial is looking into the risks of TT otorrhoea in Aboriginal and Torres Strait Islander children due to surgeon variability. Children with TT otorrhoea treated with antibiotic eardrops compared to saline or no treatment have 31% to 50% more resolution of discharge at 1–2 weeks.82 Some low-quality evidence showed that addition of corticosteroid eardrops may improve this outcome by 15%.82

A Cochrane systematic review found grommets were beneficial in the first six months (4 dB at 6–9 months) for hearing loss associated with OME; one study measured a 12 dB benefit at three months, another reported that otorrhoea was common in infants.83 Another Cochrane systematic review84 and additional RCTs 85,86 have found children with recurrent AOM who received grommets were more likely to remain free of otitis media in the 6–24 months after tube insertion than children not having surgery. Another Cochrane review addressed prophylactic interventions for prevention of otorrhoea following TT insertion.87 Each of the following was effective at two weeks post-surgery: saline washouts at surgery, topical antibiotics/steroids at surgery, prolonged topical drops, and prolonged oral antibacterial/steroids. The benefits were greater (lower number needed to treat for a benefit) in RCTs with higher rates of otorrhoea among controls.


Chemoprophylaxis


Antibiotics

A Cochrane review of 13 RCTs found long-term (>6 weeks) prophylactic antibiotics versus no treatment or placebo in healthy but at-risk or otitis-prone children (recurrent AOM or persistent OME or in population at high risk of CSOM) can prevent (almost halve) episodes of AOM during therapy.88 A 2016 Cochrane review of antibiotics for OME found low-quality evidence of 25% reduction in OME at 2–3 months and 20% reduction at six months;89 limited studies reported no difference in ventilation tube insertion or hearing levels. However, an individual patient data meta-analysis showed that oral antibiotics used in AOM had a marginal nonsignificant effect in preventing subsequent persistent OME (duration >1 month). The authors concluded that, in view of the potential for antibiotic resistance and side effects, routine treatment of AOM to prevent OME could not be warranted.90 Although bacterial resistance is the main concern of antimicrobial use, few trials measure or report on antimicrobial resistance. Further, there is little evidence that AOM can be prevented by commencing treatment with antibiotics at the onset of upper respiratory tract symptoms.91

Prophylactic antiviral drugs

It has been reported that AOM occurs in 20–50% of children aged <6 years after an influenza infection.92 AOM was significantly reduced in patients with confirmed influenza infection treated with neuraminidase inhibitors (NIs) versus placebo.93 Another systematic review examined the effect of antiviral drugs on the secondary effects of influenza; rates of otitis media were no different in older children, but were significantly lower in children aged <5 years.92 A 2012 Cochrane review of NIs for preventing and treating influenza in children found that oseltamivir also significantly reduced AOM in children aged 1–5 years with laboratoryconfirmed influenza (risk difference –0.14 );94 two trials reported that the number needed to harm (from medication-induced vomiting) was 17.

 

Other preventive strategies


Xylitol

There is moderate quality evidence from a 2016 Cochrane systematic review showing that the prophylactic administration of xylitol among healthy children attending day-care centres can reduce the occurrence of AOM.95

Vitamin D supplementation

Vitamin D for AOM prevention has not been evaluated in high-quality trials. One RCT of vitamin D (1000 IU/ day) versus placebo in children at increased risk of AOM showed a reduction in the proportion of children in the vitamin D group experiencing one or more AOM episodes.96

Pacifier use

Instructions and information about reducing pacifier use was evaluated in one cluster RCT. The intervention reduced continuous pacifier use in children aged 7–18 months and reduced the occurrence of AOM per person month by 29%.97

Probiotics

A Cochrane 2011 systematic review concluded that probiotics were better than placebo in preventing acute upper respiratory tract infection (URTI).98 One RCT for AOM prevention was included, which found no benefit of probiotics.99 Another systematic review found no benefit for URTI or AOM.100 A meta-analysis of four RCTs using the same probiotic (Lactobacillus rhamnosus GG) found a significant 24% reduction in the incidence of AOM.101 An RCT of mixed probiotics versus placebo for prevention of AOM in at-risk children found no benefit over a 12-month follow-up.102 Intranasal twice-daily Streptococcus salivarius 24SMB for five days per month for three months has recently been evaluated in a placebo-controlled trial in children for prevention of AOM. Compared to controls, there was a non-significant reduction in AOM in S. salivarius 24SMB recipients, and significantly less
AOM in the subgroups of children successfully colonised by S. salivarius 24SMB after treatment.103

Zinc

A Cochrane systematic review identified mixed evidence of zinc supplementation (at least once per week for at least one month) versus placebo for preventing otitis media in healthy children aged <5 years living in low- to middle-income countries.104

Antihistamines, decongestants, topical/oral steroids

Neither antihistamines nor decongestants, singly or together, or topical (intranasal) steroids alone reduce the risk of OME or improve hearing and are not recommended.105,106 Oral steroids combined with oral antibiotics compared to placebo and oral antibiotics improve OME resolution by 23% in the short term (7–28 days) but do not improve hearing by 10 dB or more at six weeks.106

Autoinflation

Autoinflation (balloon inflation via nose blowing) for prevention of hearing loss associated with OME was found in one Cochrane systematic review107 and one subsequent RCT in 2015108 to show short-term to medium-term clinical improvements (tympanometry or audiometry changes combined) and benefits for children and parents in ear-related quality of life.


Environmental interventions


Housing

Early and persistent otitis media could potentially be prevented if overcrowding in Aboriginal communities was alleviated.59 For Aboriginal and Torres Strait Islander peoples, poor quality and overcrowded housing are key determinants of adverse health outcomes, including for ear health109 in both urban110 and remote regions.111,112 More than a quarter of the Aboriginal population live in a house deemed to need extra bedrooms, compared to just 5.7% of non-Indigenous people. In some remote areas in the Northern Territory, the highest rates of overcrowding were reported, with over 70% of people living in overcrowded conditions (ie needing more bedrooms).113 The causal relationship between housing and health remains poorly understood. Interestingly, overcrowded housing has also been shown to be associated with increased nasopharyngeal carriage of otitis media pathogens S. pneumoniae, Moraxella catarrhalis and NTHi in both Aboriginal and non-Aboriginal children.114 Nasopharyngeal carriage of these pathogens is a well-established predictor of early onset AOM and chronic otitis complications.114 In New South Wales, an Aboriginal public housing improvement program was associated with improved respiratory, skin and intestinal infections but not otitis media.115

Noise induced hearing loss

Few studies have explored the prevalence of noise-related hearing disorders affecting Aboriginal and Torres Strait Islander peoples. The hearing status of 109 Aboriginal prisoners in Victoria revealed that 36% had highfrequency hearing loss and that this was most consistent with a noise-induced loss. Ninety-two per cent had reported exposures to loud noise.16 One study in the Northern Territory found that noise exposure exceeded the allowable daily exposure of 85 dB averaged over an eight-hour working day (occupational standards).116 A significant risk of noise-induced hearing loss is believed to occur in the majority of persons exposed to levels that exceed this on a long-term basis. Overcrowding is likely to contribute to excessive noise exposure. Such exposure may create ‘a “second wave” of preventable noise-induced sensori-neural hearing loss for those in Aboriginal and Torres Strait Islander communities.’116 Few health professionals and families are aware of the fact that excessive exposure to loud noise over prolonged periods can damage hearing. In terms of interventions, Aboriginal and Torres Strait Islander health workers have an important role to play since they can best inform families about the dangers of too much loud noise, and of the particular dangers for children with a history of ear disease.116 A recent Cochrane review reported that reduced noise exposure can be achieved with use of personal earmuffs and earplugs, with instruction.117 Stricter legislation might reduce noise levels, and effects of hearing loss prevention programs are unclear.117 A review of occupational noiseinduced hearing loss in Australia identified the need for both regulatory enforcement and education, but found that the expense, difficulty and being low priority for employers were barriers to implementation.118

 

 

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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