Australia has an internationally regarded, gold-standard network of universal newborn hearing screening programs. Those programs, operating in every state and territory, serve to identify most babies with hearing loss when they are just weeks old. That early identification and subsequent early intervention gives those babies immeasurable benefits in terms of their communication, language, and social development.
Getting to this point was, like many worthwhile things, somewhat of a journey. The Australasian Newborn Hearing Screening Committee (ANHSC) issued the first Australian Consensus Statement on Universal Neonatal Hearing Screening back in 2001. At the time, less than 6% of all Australian newborns were being screened for hearing loss. Eventually, full population newborn hearing screening was rolled out in every state and territory, resulting in more than 97% of Australian babies being screened in a timely fashion after birth.
It took 15 years to get there.
When we first achieved that consensus on newborn hearing screening more than two decades ago, those at the table were agreed on something else too: that this was in no way the end of the story. We understood that there would be many children who developed hearing loss at a later age and some who wouldn’t be screened at birth. Australia owed it to them to stay vigilant. The developmental consequences were too important to drop that ball.
And while it’s true that the systems we currently have in place are picking up older children with hearing loss—twice as many by the time they start school as those detected at birth through newborn hearing screening programs—what we don’t know is when many of those children began to experience hearing loss. What we do know is that, for some children, late identification may mean missing the chance to access intervention services until much too late in their development.
Early intervention for children with hearing loss works. Australia’s Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study has shown that the greater the degree of hearing loss in a child, the more impact acting quickly will have on their development.
Unlike our approach for newborns, there’s no nationally consistent approach to the way we identify hearing loss in older children. There are targeted surveillance programs in most jurisdictions, but the referral and assessment criteria used, and the way children and families move through the system, varies depending on where you live.
There are also groups who are disproportionately affected by hearing loss, such as Aboriginal and Torres Strait lslander children who have among the highest rates of hearing loss in the developed world and are twice as likely to develop long-term hearing problems that stay with them into adulthood.
Australia’s Roadmap for Hearing Health, published back in 2019, highlighted the importance of a consistent and standard pathway for children and families to access hearing services—including a single, national point of referral for children.
So, we know the goal, and there’s a major ethical imperative: we owe it to children and their families to make sure no-one falls through the cracks. We also need to think hard about how we incorporate co-design principles into any next steps on screening for Aboriginal children.
We have two decades of national experience in newborn hearing screening and a raft of expert knowledge to draw from locally. And there’s been a lot of advocacy groundwork already done in childhood hearing health. So, can we achieve the results we need for older children in less than the 15 years it took us the first time?
Well, that depends. We have a few important gaps in our knowledge.
If we want to advance this issue, we need to commit to an evidence-based approach. And there's an urgent need for more research.
It’s not as simple as introducing school-based screening, as logical and attractive as that sounds.
Identifying hearing loss beyond the newborn period could be achieved by universal screening or targeted screening programs. Which is better? Which will get the best outcomes? Which is most cost-effective? What is the optimal age to screen? Might we be disadvantaging the bulk of children that need our help if we screen them at age four or six, instead of age two? We don’t have definitive answers to any of these questions.
The ANHSC’s recently commissioned systematic review of the evidence shows that, while there is an accurate and validated screening test available, the evidence for population-based screening in older children is inconclusive, and we don’t know enough about the unintended consequences or harms of screening in this group—such as poor follow-up rates and delayed identification of some children with hearing loss. False positive screen results can occur too, particularly when children have temporary middle ear infections at the time of screening. That’s an awfully common occurrence in early education and primary school that could lead to high rates of referral for follow-up which may be unnecessary and overload services that already have limited capacity to see children.
If we do screen large numbers of children, do we have the audiologists and associated health professionals to provide that follow-up and optimal healthcare? And if not, what are we doing about that?
Should we be doing more work with parents and teachers to increase education and engagement on how to recognise hearing loss? That’s an important piece of the puzzle too.
Australia took a great step forward in managing childhood hearing loss when the NHMRC announced late last year that it would fund a prototype child hearing health outcomes registry—an important step towards a national child hearing database that will give us much-needed information. At the time, funding was also announced for a raft of other hearing-related projects, including building the right pathways for Aboriginal and Torres Strait Islander children to access the care they need, building more data on the prevalence of hearing loss from otitis media in Aboriginal children under five, and testing health promotion interventions to prevent hearing loss in that group.
There is still much more to do, and other critical research questions to be answered. But now’s the time to build the momentum and get the knowledge we need to act. This will require a collective effort, from academics, clinicians, governments and communities—so we can’t waste a day.
Let’s do it now, but let’s do it right. Australian kids deserve no less.