Key Points
Question
What factors are associated with preschool-based hearing screening outcomes in a low-income urban population?
Findings
In this cohort study, hearing screening was completed successfully in 99.6% of 6820 children in a resource-limited setting with a low (14%) loss-to-follow-up rate. The prevalence of conductive hearing loss was 2.9% and sensorineural hearing loss was 0.2%; teacher concerns were associated with observed conductive and sensorineural hearing loss.
Meaning
The findings of this study suggest that preschool-based hearing screening is useful for identifying and intervening in childhood hearing loss missed through newborn hearing screening to support children for academic success.
Abstract
Importance
Early identification of childhood hearing loss through newborn hearing screening mitigates permanent speech, language, and developmental delays, but many children are lost to follow-up or develop postnatal hearing loss. Early childhood hearing screening programs may help identify these children, but evidence on their outcomes is limited.
Objective
To assess outcomes from a low-income, preschool-based hearing screening program and risk factors for hearing loss in this population.
Design, Setting, and Participants
A retrospective cohort study of 6820 children aged 2 to 6 years from urban, low-income public preschools who received hearing screening from July 1, 2015, to June 30, 2019, was performed using San Francisco Department of Public Health records. A multivariate logistic regression analyzed risk factors for hearing loss. Data analysis was conducted from January 14, 2020, to April 20, 2021.
Exposures
Annual single-visit, 2-tiered screening was implemented with conditioned play pure-tone audiometry (CPA) and distortion product otoacoustic emissions (OAEs).
Main Outcomes and Measures
Rates of successful screening, referred screening, loss to follow-up, and hearing loss.
Results
Of 6820 children (age, 2-6 years) screened, 3425 (50.2%) were boys, 15% were White/non-Hispanic, and 48% had English as the primary home language. A total of 403 (5.9%) children were referred for full medical or audiologic evaluation after 2-tiered CPA/OAE screening. Only 24 children were unable to complete both CPA and OAE testing for a screening completion rate of 99.6%. After medical evaluation, 114 of 403 children (28.3%) passed hearing rescreening and 55 (13.6%) were lost to follow-up. The prevalence of conductive hearing loss was 2.9% (n = 195), and the prevalence of sensorineural hearing loss was 0.2% (n = 13). Primary language, race and ethnicity, and sex were not associated with rates of referral or hearing loss.
Conclusions and Relevance
The findings of this cohort study suggest that preschool-based screening programs can be a useful method to identify early childhood hearing loss and that teacher concerns are associated with final diagnostic hearing status.
This cohort study examines the use of a hearing screening program in preschool children in a low-income urban setting.
Introduction
Childhood hearing loss has a lasting effect on child psychosocial development, educational success, and long-term financial outcomes.1,2 The World Health Organization estimates that more than half of childhood hearing loss is preventable, and early intervention can mitigate these long-term sequelae.3,4 Consequently, international efforts have worked to increase awareness and detection through universal newborn hearing screening (NHS) programs and early hearing detection and intervention (EHDI) programs. With the rollout of universal NHS, 98.3% of children in the US underwent NHS in 2017, and 1.7% of these children were referred for further evaluation.5,6 After implementation of NHS, the average age at hearing loss diagnosis decreased from 24 to 30 months to 2 to 3 months in some regions of the US.7 An ongoing challenge is that approximately 36% of children with referred hearing screening never receive appropriate follow-up.8 This proportion increases to nearly 50% among higher risk, urban, and/or underserved populations.9 Permanent childhood hearing loss increases 3-fold to 9 to 10 per 1000 in school-age children, likely owing to missed cases by NHS as well as progressive and postnatal-onset childhood hearing loss. An additional 35% of children experience transient conductive hearing loss.2
There are extensive data reporting that childhood hearing screening, often initiated through schools, is a cost-effective method of identifying previously undiagnosed hearing loss.10,11,12 Thirty-eight states now mandate school-based hearing screening, leaving the implementation to public school districts with a disproportionate financial burden on lower-income school districts. However, preschools are not typically included in such mandates. Therefore, hearing loss is often not identified until a child is already engaged in school without adequate auditory and educational support.
The American Academy of Pediatrics Bright Futures EHDI13 prevention and health promotion program recommends formal hearing screening at age 4 years and a risk assessment for hearing loss at every well-child check between ages 1 and 4 years by asking parents about concerns for hearing loss to identify children who were lost to follow-up after NHS and those with delayed-onset, progressive, or temporary hearing loss. However, previous studies have reported that parental questionnaires are overall not accurate indicators of childhood hearing loss.14,15,16,17 Details on implementation of EHDI screening, testing and retesting methods, and referral practices in clinics, preschools, and elementary schools are not clearly defined.2 The efficacy of early childhood screening is also based on children regularly attending their well-child visits and being retested and referred appropriately. However, a substantial proportion of children do not attend their well-child visits, and almost half of children referred during EHDI screening are not retested or referred to specialists as guidelines recommend.18,19
Therefore, there is a major screening gap between NHS at birth and at least the first well-child check hearing screen at age 4 years, if not at public school entry at 5 or 6 years. Preschool hearing screening addresses this gap, helps identify hearing loss before school entry, and provides interventions to support the education of children who are deaf or hard-of-hearing. However, children in this age group can be very difficult to test with traditional behavioral audiometric screening techniques.20
Given the high rates of loss to follow-up after NHS and postnatal-onset temporary and permanent hearing loss, robust community-based programs for preschool hearing screening are necessary to address this screening gap and support identification and intervention for hearing loss, which is a major cause of childhood disability. The aim of this study was to describe the outcomes from a low-income, community-based preschool hearing screening program to note the utility of such screening programs for detecting early childhood hearing loss and identify risk factors for hearing loss in this population.
Methods
Screening Methods and Follow-up Protocols
This cohort study was conducted in preschools in San Francisco, California, from July 1, 2015, to June 30, 2019. Data analysis was performed from January 14, 2020, to April 20, 2021. The study was exempted from approval by the institutional review board at the University of California, San Francisco, owing to the retrospective design with deidentified data.
Children attending preschool between July 1, 2015, and June 30, 2019, underwent hearing screening through the Office of Childhood Hearing at the San Francisco Department of Public Health as a part of the Early Childhood Audiometric Screening Program. This program targets children from low-income households by performing screening visits to approximately 40 low-income childhood education sites through the San Francisco Department of Public Health jurisdiction. These childhood educational sites are primarily Title 5–funded centers for children whose household income falls below 70% of the state median income or are eligible for state welfare programs.21 Demographic information, including sex, primary home language, race and ethnicity, and teacher concern for hearing loss, speech delay, or language delay, were collected by site personnel. Race and ethnicity data, as reported by each child's parent or guardian, were collected because of known disparities in hearing screening outcomes relating to race and ethnicity.5
Hearing screening was performed with a previously described 2-tiered paradigm using conditioned play pure-tone audiometry (CPA) followed by distortion product otoacoustic emission (OAE) evaluation20 outlined in the Figure. The initial CPA screening detected responses to a 25-dB pure tone at 1000, 2000, 3000, and 4000 Hz, and the OAE screened responses at 2000, 3000, 4000, and 5000 Hz. Children who did not pass the initial screening were further screened to record individual thresholds and given an OAE screening. Children who could not complete the CPA screening were screened with OAE. A referral was given if the child had (1) CPA results of 30 dB or more in 2 frequencies of the same ear or 40 dB or more in any frequency of 1 ear, (2) inability to complete CPA and did not pass the OAE, or (3) inability to complete CPA and OAE screenings because all 3 outcomes would require follow-up hearing evaluation. When indicated, children were referred to their pediatrician or otolaryngologist for follow-up and either rescreening or testing methods based on the physician’s standard protocol. The final audiologic and medical outcomes were documented by the Office of Childhood Hearing upon receipt of a medical documentation form given to parents and completed by the health care professional or direct verbal contact by an Office of Childhood Hearing and/or preschool staff member with the family or the health care professional. If the medical form was not received within 2 to 4 weeks, 3 to 5 attempts to reach the family were made, depending on the severity of the child’s screening results, to determine the results of clinic-based rescreening or testing per the physician’s protocol. Total follow-up time was 10 weeks after each annual screening. Children with normal hearing in at least 1 ear were rescreened annually through the preschool screening program.
Figure. Two-Tiered Hearing Screening Protocol.
A total of 6820 children underwent first-stage pure-tone audiometric screening. Of 265 children referred, 149 were unable to test; these 414 children underwent second-tier distortion product otoacoustic emission (OAE) screening. Of these, 11 children passed OAE screening. The remaining 403 children were either referred on OAE screening (379) or were unable to be tested (24) and were subsequently referred for follow-up evaluation. These 403 children had final screening outcomes as indicated.
Definitions
Screening outcomes were documented as pass, refer, or unable to test. For those with refer and unable to test results, children were categorized as not pass because those with either outcome would need additional testing. In addition, children with pass and refer test results were categorized as able to test. This categorization allowed separate analysis of 2 relevant outcomes of the hearing screening protocol: the ability of the protocol to test the children (able to test vs unable to test) and the referrals for further medical evaluation generated by the protocol (pass vs not pass).
Statistical Analysis
Data were deidentified, aggregated, and transferred to the study team for analysis. Logistic regression modeling with Bonferroni correction for multiple tests was performed to examine whether sex, age, primary English speaker, race and ethnicity, and teacher concern (speech, language, or hearing) were associated with screening pass rates or final outcomes, including pass on rescreen, conductive hearing loss, sensorineural hearing loss, or no follow-up. Analyses were performed using the R statistical programming language, version 3.6.2 (R Foundation for Statistical Computing), and figures were created using the ggplot2 package. Two-tailed, unpaired tests were used throughout. The statistical significance threshold was P = .05 except for logistic regression modeling to evaluate the association of 3 teacher concern factors (hearing loss, speech, and language) on screening outcomes. To account for these 3 comparisons, a Bonferroni correction to the statistical significance threshold was made at P = .017.
Results
Screening Outcomes and Follow-up
During the study period, 6820 children attending low-income preschools were screened through the Early Childhood Audiometric Screening program (3425 [50.2%] were boys, 15% were White/non-Hispanic, and 48% had English as the primary home language). The children, aged 2 to 6 years, were screened with a 2-tiered single-visit CPA/OAE protocol. Twenty-four children (0.4%) were unable to complete either CPA or OAE testing for a screening completion rate of 99.6% (Figure). Of 6820 children screened, 414 were referred on either CPA or OAE. Complete screening outcomes and demographic data on this cohort of 414 children are reported in Table 1 and Table 2. Of the 414 children, 11 were referred on CPA owing to their inability to test, but they subsequently passed OAE and were considered to have passed the 2-tiered screen. The remaining 403 children were considered to have not passed the 2-tiered screen and were subsequently referred for further medical evaluation. Fifty-five of these children were lost to follow-up for a follow-up rate of 86.4%. A summary of screening results is reported in Table 1. Most children screened were between the ages of 3 and 5 years (80.7% [334 of 414]). English was the most common primary language spoken (43.0%). Racial and ethnic groups were Asian (146 [35.3%]), Black (31 [7.5%]), Latino (128 [30.9%]), White (59 [14.3%]), and multiracial (43 [10.4%]); data were not recorded in 7 (1.7%) children. Most children did not have any teacher reports of concern for speech, language, or hearing (361 [87.2%]). A summary of patient demographic characteristics is given in Table 2. After referral, an overall follow-up rate of 86.4% was achieved (Table 3). Demographic factors, such as sex, age, language, and race and ethnicity, were not associated with the ability to complete screening or rates of follow-up (eTable in the Supplement).
Table 1. Pure-Tone and OAE Hearing Screening Outcomes.
| Variable | No. (%) |
|---|---|
| Total screened | 6820 |
| Pass | 6417 (94.1) |
| Pass PT | 6406 (93.9) |
| Refer PT, pass OAE | 11 (0.2) |
| Refer | 379 (5.6) |
| Refer PT and OAE | 254 (3.7) |
| Unable to test PT, refer OAE | 125 (1.8) |
| Unable to test PT and OAE | 24 (0.4) |
Abbreviations: OAE, otoacoustic emission; PT, pure tone.
Table 2. Demographic Characteristics of Children Who Were Tested and Referred on Conditioned Play Audiometry Screening.
| Variable | Referred, No. (%) |
|---|---|
| Total referred | 414 |
| Sex | |
| Male | 226 (54.6) |
| Female | 188 (45.4) |
| Age, y | |
| 2.0-3.0 | 41 (9.9) |
| 3.1-4.0 | 174 (42.0) |
| 4.1-5.0 | 160 (38.6) |
| 5.1-6.0 | 39 (9.4) |
| Primary language | |
| Arabic | 3 (0.7) |
| Cantonese | 87 (21.0) |
| English | 178 (43.0) |
| Japanese | 2 (0.5) |
| Mandarin | 8 (1.9) |
| Russian | 2 (0.5) |
| Spanish | 110 (26.6) |
| Tagalog | 5 (1.2) |
| Vietnamese | 7 (1.7) |
| Other | 12 (2.9) |
| Race and ethnicity | |
| Asian | 146 (35.3) |
| Black | 31 (7.5) |
| Latino | 128 (30.9) |
| White | 59 (14.3) |
| Multiracial | 43 (10.4) |
| Not recorded | 7 (1.7) |
| Teacher concern | |
| Speech | 37 (8.9) |
| Language | 28 (6.8) |
| Hearing | 28 (6.8) |
| None | 361 (87.2) |
Table 3. Final Diagnostic and Intervention Outcomes of Children With Referred Screening.
| Final outcome | No. (%) |
|---|---|
| Passed rescreen | 114 (28.3) |
| Conductive hearing loss | 195 (48.4) |
| Cerumen | 130 (32.3) |
| Otitis media | 43 (10.7) |
| Tympanostomy tubes | 21 (5.2) |
| Tonsillectomy | 1 (0.2) |
| Sensorineural hearing loss | 13 (3.2) |
| Unable to complete evaluation | 26 (6.4) |
| No follow-up | 55 (13.6) |
Hearing Outcomes
Based on the 6820 children who underwent screening, the overall prevalence of sensorineural hearing loss in those who completed a medical evaluation after referral was 0.2% (n = 13), and the prevalence of conductive hearing loss was 2.9% (n = 195). Of the 195 children with conductive hearing loss, 130 children (66.7%) had cerumen impaction, 43 (22.1.7%) had otitis media, and tympanostomy tubes were placed in 21 children (10.8%) (Table 3).
Logistic Regression Outcomes
Table 4 reports the risk of a referred hearing screen and diagnosis of conductive or sensorineural hearing loss with teacher concerns for speech, hearing, and/or language development. When there was teacher concern for hearing loss, the likelihood was increased for a referred screen (odds ratio [OR], 14.1; 95% CI, 8.9-25.0), conductive hearing loss (OR, 12.2; 95% CI, 6.7-22.3), and sensorineural hearing loss (OR, 21.2; 95% CI, 4.6-97.6). Similarly, when there was teacher concern for language development, the likelihood was increased for a referred screen (OR, 13.1; 95% CI, 7.8-21.9), conductive hearing loss (OR, 11.7; 95% CI, 6.4-21.3), and sensorineural hearing loss (OR, 9.2; 95% CI, 1.2-72.0). When there was teacher concern for speech development, the risk increased for referred screening (OR, 9.7; 95% CI, 6.4-14.8) and conductive hearing loss (OR, 8.1; 95% CI, 5.0-13.3). All of these findings were statistically significant at P < .001. Additional univariate analyses demonstrated that no other demographic factors (age, sex, race and ethnicity, or primary language) were associated with referral or hearing loss screening outcomes (eTable in the Supplement).
Table 4. Outcomes of Teacher Concerns for Speech, Hearing, and Language.
| Variable | Referral | No referral | OR (95% CI) | P valuea |
|---|---|---|---|---|
| Referred screening | ||||
| Speech concern | ||||
| Yes | 36 | 64 | 9.7 (6.4-14.8) | <.001 |
| No | 367 | 6353 | ||
| Hearing concern | ||||
| Yes | 28 | 32 | 14.1 (8.9-25.0) | <.001 |
| No | 375 | 6385 | ||
| Language concern | ||||
| Yes | 27 | 35 | 13.1 (7.8-21.9) | <.001 |
| No | 376 | 6382 | ||
| CHL | CHL | No CHL | NA | NA |
| Speech concern | ||||
| Yes | 21 | 100 | 8.1 (5.0-13.3) | <.001 |
| No | 174 | 6720 | ||
| Hearing concern | ||||
| Yes | 15 | 45 | 12.2 (6.7-22.3) | <.001 |
| No | 180 | 6580 | ||
| Language concern | ||||
| Yes | 15 | 47 | 11.7 (6.4-21.3) | <.001 |
| No | 180 | 6578 | ||
| SNHL | SNHL | No SNHL | NA | NA |
| Speech concern | ||||
| Yes | 1 | 99 | 5.7 (0.7-43.8) | .062 |
| No | 12 | 6708 | ||
| Hearing concern | ||||
| Yes | 2 | 58 | 21.2 (4.6-97.6) | <.001 |
| No | 11 | 6749 | ||
| Language concern | ||||
| Yes | 1 | 61 | 9.2 (1.2-72.0) | <.001 |
| No | 12 | 6746 |
Abbreviations: CHL, conductive hearing loss; NA, not applicable; OR, odds ratio; SNHL, sensorineural hearing loss.
With Bonferroni correction, the statistical significance threshold was set at P = .017.
Discussion
Hearing Screening Outcomes
In this study, 0.2% of all children were identified as having sensorineural hearing loss, and 2.9% were identified as having conductive hearing loss. The high screening success (99.6%) and follow-up (86.4%) rates of our study suggest that these prevalence rates are likely close to the true prevalence of hearing loss for the diverse, low-income urban population studied. The largest study of preschool hearing screening outcomes was conducted in Hubei, China,22 which evaluated 28 000 children who had passed their NHS using OAEs, with an overall referral rate of 1.9%, conductive hearing loss rate of 1.2%, and sensorineural hearing loss rate of 0.8%. The slightly higher prevalence identified in our study may be due to a higher risk, more ethnically diverse population. In a more comparable study of a diverse metropolitan region in which 1.7% of 8220 public kindergarten children in Milwaukee, Wisconsin, were referred after hearing screening, 0.5% had conductive hearing loss and 0.2% had sensorineural hearing loss.10 Other preschool hearing programs identified hearing loss in 0.15% of toddlers.23,24 Compared with our study, the follow-up rate in prior studies was lower (62%-65%),10,23 which may have underestimated the true prevalence. The prevalence difference could also be attributed to our study population being at higher risk of previously undiagnosed hearing loss; prior studies have found that children from low-income households are less likely to have follow-up after a referred NHS.9 Overall, the higher proportions identified in our study suggest an even greater need for preschool hearing screening than previous studies have shown.2
Although one goal of hearing screening programs is to identify permanent hearing loss, which is predominantly sensorineural, our study suggests the potential value of identifying both permanent and intermittent conductive hearing loss, which can be addressed to optimize a child’s hearing and educational opportunities. Twenty-one (5.2%) children referred underwent tympanostomy tube placement during our study interval.
The 2-tiered preschool hearing screening successfully screened 99.6% of the children studied—a larger proportion than what has been cited through primary care screening programs.19 This testing protocol may be a framework for other preschool-based hearing screening programs nationally. Only 13.6% of these low-income children were lost to follow-up after a referral for hearing loss diagnosis, and no disparities in follow-up were seen based on age, sex, race and ethnicity, or primary home language. In comparison, previous studies looking at similar low-income urban populations found loss-to-follow-up rates of approximately 36% to 64% after referred NHS with referrals placed for diagnostic hearing testing,9,10,25,26 with even higher rates among low-income publicly insured patients.9 To our knowledge, our study had the highest follow-up rate among any study of this size, evaluating an ethnically diverse, low-income population within the US. Consequently, the prevalence estimates for conductive and sensorineural hearing loss in this low-income preschool population may be more reliable than previous studies.
Factors Associated With Hearing Outcomes
Our study found that teacher concern for hearing loss, speech, or language development was associated with an approximately 10-fold increased risk of referred hearing screening and confirmatory diagnosis of hearing loss. Previous studies have noted that parental concern for hearing loss is a poor indicator of hearing status,16,17 yet clinical guidelines recommend that pediatricians perform a risk assessment at each well-child appointment. The size of the ORs demonstrate the value of asking about teacher concerns to inform the risk assessment for hearing loss. The Joint Commission on Infant Hearing 2019 guidelines specify that “caregiver/parent” concerns be assessed, which should include childcare providers and teachers.27 The difference between previous findings of the poor predictive power of parental concern and the strong predictive power of teacher/childcare provider concern noted herein may be because, compared with parents, childcare providers have exposure to many more children for comparison to identify those who are at particular risk for hearing, speech, and language delays.
Hearing Screening Operations
The financial burden of childhood hearing loss falls on the child, family, and education system. Within this study population, most children diagnosed with hearing loss were found to have conductive hearing loss, commonly due to cerumen impaction or middle ear effusions. Early identification and follow-up are necessary because the educational and financial costs associated with hearing loss can easily be addressed with medical or surgical management.
This study noted significantly higher rates of follow-up compared with pediatric clinic–based programs. Although the reason for this discrepancy is unclear, hearing screening in schools may help place hearing loss into the greater context of educational opportunities and provide tangible evidence of the consequences of hearing loss on educational success. School-based hearing screening may also lead to more direct communication with teachers regarding the necessity of individualized education programs to provide both support and acknowledgment of the need for ongoing evaluation of hearing and development. In addition, school-based hearing screening eliminates the initial burden on parents to take time off work to take their children to audiology and clinic appointments for hearing assessments, possibly making follow-up appointments more manageable.
There are limitations and discrepancies across hearing test methods, and studies have found that the reliability of hearing screening varies substantially in young children.16,20 In one study, although only 7% of children aged 4 years were unable to complete CPA, nearly half of those aged 3 years were unable to complete the test.16 Another study found that, although 5% of preschool-aged children could not be tested by CPA, this rate decreased to 0.7% who could not be tested with OAE, obviating the need for additional evaluation.20 For this age group, OAE can be valuable for screening but not diagnostic purposes. One limitation of OAE is that low-frequency hearing loss at less than 1000 Hz can be difficult to detect in a school setting without a sound booth. In addition, OAE can still be present in mild hearing loss (20-30 dB) as well as auditory neuropathy spectrum disorder in which the cochlea is intact but there is a distal processing disorder. However, when OAE is performed in combination with CPA, children with distal processing disorders, such as auditory neuropathy spectrum disorder, will be identified.
Limitations
This study has limitations. The principal limitation relates to the retrospective observational design of this community-based project, which limited the acquisition and analysis of individual-level data for all children. Consequently, we were able to perform only univariate analyses of demographic factors on screening program outcomes. This design, however, enabled the inclusion of an underserved population, for these preschools provide income-based tuition subsidies. The absence of any association between demographic factors and screening outcomes may suggest that the screening program served our population equitably, and the finding that teacher concern was associated with referral and subsequent diagnosis of hearing loss is meaningful. However, in regions in which a smaller proportion of low-income families enroll their children in preschool, the overall efficacy of preschool-based screening may vary.
In this study, 13.6% of patients with referred hearing screening were lost to follow-up. Although this rate is significant, it represents a smaller proportion than what has been cited in the literature.10,23 It is possible that these 10-week follow-up periods were longer than in other studies, which may have led to higher follow-up rates; however, a more likely cause was the intensive, biweekly contact by San Francisco Department of Public Health staff.
Another limitation was that we did not perform formal diagnostic testing for individuals who passed their hearing tests and thus do not know the true sensitivity and specificity of the screening methods, so we were unable to determine the true prevalence of conductive and sensorineural hearing loss. Furthermore, we did not have data available to analyze socioeconomic factors, such as household income.
In addition, we did not identify any demographic factors, including sex, age, primary home language, and race and ethnicity, that had a clinically significant association with screening outcomes. This nonsignificance may reflect an underpowered study given other studies have found hearing loss to be associated with ethnic minority group status and lower socioeconomic status.28 However, it may be that socioeconomic status is a more likely indicator of hearing outcomes or likelihood of follow-up compared with age, race and ethnicity, sex, or primary home language. For our population of children from uniformly low-income settings, with the majority non-English speaking and 85% of the children in minority racial and ethnic populations, the nearly 100% screening rate and 86% follow-up rate may have reduced disparities in screening and follow-up access that may have contributed to the racial, ethnic, and language disparities seen in other studies. A larger study population that is powered for multivariate analysis of these complex demographic contributors could help clarify this association.
Conclusions
The findings of this cohort study suggest that community preschool-based 2-tiered hearing screening programs can be a useful method to identify early childhood hearing loss in children who were either lost to follow-up after NHS or developed delayed or progressive hearing loss after infancy. Initiating screening in preschool-aged children may aid in hearing optimization before they start school to maximize educational success. Teacher concern for hearing loss, language, or speech development was associated with identification of hearing loss, which illustrates the value of asking teachers about any concerns when following current pediatric practice guidelines to perform a risk assessment for hearing loss during well-child appointments.
eTable. Risk of Referred Hearing Screen Across Demographic Factors
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Supplementary Materials
eTable. Risk of Referred Hearing Screen Across Demographic Factors
