Overview
Definition:
Vision and hearing screening are essential components of routine pediatric well-child care, designed to detect potential sensory impairments early in life
Early identification and intervention are crucial for optimal development, learning, and overall well-being
These screenings are typically conducted at specific age intervals or during critical developmental periods.
Epidemiology:
Congenital hearing loss affects approximately 1-3 per 1000 live births, with a higher incidence in premature infants or those with risk factors
Vision impairments, though less common at birth, can develop or become apparent as children grow
Untreated sensory deficits can lead to significant delays in speech, language, cognitive, and social development.
Clinical Significance:
Undetected vision and hearing problems can have profound and lasting effects on a child's academic performance, social interactions, and emotional health
Implementing evidence-based screening protocols at appropriate ages allows for timely diagnosis and management, significantly improving long-term outcomes and reducing the burden of disability
This is a core competency for pediatricians preparing for DNB and NEET SS examinations.
Screening Schedule
Newborn Screening:
Universal newborn hearing screening (UNHS) is recommended before hospital discharge, using Otoacoustic Emissions (OAE) or Auditory Brainstem Response (ABR)
Vision screening at birth includes checking for red reflex and gross ocular movements.
Infancy Screening:
Hearing: Follow-up screening if initial screen is failed
Vision: Ocular alignment, visual acuity (if cooperative), and tracking at 6 months
Assess for strabismus or nystagmus.
Early Childhood Screening:
Hearing: Continue to monitor for otitis media and hearing loss
Vision: Visual acuity testing (e.g., using Allen figures or tumbling E charts) annually or biannually from age 3-4
Screening for amblyopia and refractive errors.
School Age Screening:
Hearing: Annual or biannual audiometry
Vision: Visual acuity testing annually
Screening for common conditions like myopia, hyperopia, and astigmatism
Red flag symptoms for further evaluation.
Adolescent Screening:
Continue annual vision and hearing screenings
Address any visual complaints related to increased near work
Screen for noise-induced hearing loss in adolescents exposed to loud music or other environmental noise.
Vision Screening Methods
Red Reflex Test:
Performed from birth to detect opacities in the cornea, lens, or vitreous
A bright red reflection in both eyes is normal
asymmetric or absent reflexes require further investigation
This is crucial for identifying congenital cataracts or other media opacities.
Occular Alignment And Tracking:
Assessed from infancy to detect strabismus (misaligned eyes)
Observing how the infant follows objects with their eyes helps identify visual pathway issues
Cover-uncover test is used for older infants and children.
Visual Acuity Testing:
Methods vary by age: infant charts (e.g., Teller), picture charts (e.g., Allen), or letter charts (e.g., Snellen, tumbling E)
Visual acuity goals by age are important: 6/60 or better by 6 months, 6/30 by 1 year, 6/20 by 3 years, 6/12 by 5 years.
Photo Screening:
Automated objective screening devices (e.g., PediaVision, Spot Vision Screener) can detect refractive errors, amblyopia risk factors, and strabismus in young children who cannot cooperate with traditional acuity testing
These devices are increasingly used in pediatric practices.
Refraction:
Cycloplegic refraction is the gold standard for detecting refractive errors (myopia, hyperopia, astigmatism) and is particularly important in young children or when amblyopia is suspected
Non-cycloplegic refraction can be used for screening in older children.
Hearing Screening Methods
Otoacoustic Emissions Oae:
A non-invasive screening tool that measures the response of the outer hair cells in the cochlea to sound
It is rapid and can be performed on sleeping infants
It detects cochlear (sensory-neural) hearing loss.
Auditory Brainstem Response Abr:
Measures the electrical activity in the auditory nerve and brainstem in response to sound
It is more sensitive than OAE, especially for detecting neural hearing loss or more severe degrees of hearing impairment
It is used when OAE is abnormal or in infants with risk factors.
Behavioral Audiometry:
For older infants and toddlers, visual reinforcement audiometry (VRA) or play audiometry is used to assess hearing thresholds
Children learn to turn their heads towards a sound stimulus
This becomes more objective as the child matures.
Tympanometry:
Measures middle ear function by assessing the mobility of the tympanic membrane
It is useful for detecting middle ear effusion (otitis media with effusion), which can cause conductive hearing loss
It does not directly assess hearing thresholds but indicates a potential problem.
Pure Tone Audiometry:
The standard diagnostic test for hearing in older children who can cooperate
It measures hearing thresholds across different frequencies
Air and bone conduction thresholds are assessed to differentiate between conductive, sensory-neural, and mixed hearing loss.
Age Specific Considerations And Follow Up
Newborn Hearing Risk Factors:
Family history of childhood hearing loss, congenital infections (e.g., CMV, rubella), craniofacial anomalies, syndromes associated with hearing loss (e.g., Down syndrome, Usher syndrome), hyperbilirubinemia requiring exchange transfusion, low birth weight (<1500g), NICU stay > 48 hours, mechanical ventilation > 10 days, or known ototoxic medications.
Vision Red Flags:
Constant eye turning (strabismus), excessive blinking, eye rubbing, squinting, unusual head positions, milky appearance of the cornea, photophobia, nystagmus, or lack of visual following
Any parental concern about vision should be taken seriously.
Interpreting Screening Results:
Referral criteria should be clearly defined
For hearing, failure of two screening tests (OAE/ABR) in each ear usually warrants diagnostic audiology
For vision, decreased visual acuity (e.g., < 20/40 in 3-5 year olds, < 20/30 in 6 year olds) or significant refractive error warrants ophthalmology referral.
Diagnostic Evaluation:
Children who fail screening require comprehensive diagnostic evaluation by an audiologist and/or ophthalmologist
This includes detailed histories, complete physical examinations, and specialized tests to confirm the diagnosis, determine severity, and identify etiology.
Intervention And Management:
Early intervention services, including hearing aids, cochlear implants, speech therapy, visual aids, vision therapy, and educational support, are crucial
Collaboration between pediatricians, specialists, and families ensures coordinated care and optimal outcomes.
Key Points
Exam Focus:
Understand the standard screening schedule for vision and hearing in well-child care
Know the primary screening methods (OAE/ABR for hearing, red reflex/acuity testing for vision) and their age applicability
Recognize key risk factors for hearing loss in newborns
Be aware of referral criteria for abnormal screening results.
Clinical Pearls:
Always inquire about parental concerns regarding vision or hearing
Even if a child passes screening, persistent concerns warrant further investigation
Document all screening results and follow-up plans clearly in the child's medical record
Emphasize the importance of early intervention to parents.
Common Mistakes:
Assuming a child with normal hearing at birth will remain so without monitoring for later-onset hearing loss
Overlooking subtle signs of vision impairment or attributing them to developmental delay alone
Failing to follow up on abnormal screening results or provide clear referral instructions
Not considering the impact of chronic otitis media with effusion on hearing and speech development.