Community Health Manual
Procedure
Birth to School aged children
6.3
Hearing assessment
6.3.2
Screening audiometry
Aim
To identify possible hearing loss in children from 3 years of age.
Background
Unrecognised or unmanaged hearing impairment can have a significant effect on a
child’s social, psychological and educational progress, including speech and
language development, and long term social and vocational outcomes. 1, 2 The
severity of these effects will depend on a range of factors including age of onset,
type of hearing loss, degree of the loss, and other contributing factors such as
developmental delay .3
Comprehensive baseline ear health screening includes otoscopy and audiometry.
Tympanometry may be conducted in some settings by service providers working with
targeted populations.
Audiometry measures how well a person hears the range of speech frequencies.2
Frequencies are measured in hertz (Hz) and intensity is measured in decibels
(decibels Hearing Level or dB HL).
Universal screening audiometry should be performed for all children from the age of
3.5 years during the School Entry Health Assessment, usually in kindergarten.
Targeted screening audiometry may be performed on any child aged 3 years or older
where there is a concern suggested by parent or professional.
Key points
Prior to performing an audiometry test, it is important to obtain a history from
the parent/carer. The child health Personal Health Record, the School Entry
Health Assessment record (CHS 409) and the Enhanced Aboriginal Child
Health schedule all contain questions which aim to highlight parental concerns
about their child’s hearing and/or ear health. The child or teacher may also
provide information regarding the child’s ability to hear.
A history which includes recent illness, pain or discharge; a change in the
child’s ability to hear and the child’s exposure to swimming or other waterbased activities where water may have entered the ear canal can all be
indicators of a hearing concern.1, 2
Screening audiometry should be undertaken in a room where there is minimal
external noise.
Otoscopy should be performed prior to audiometry. If there is any evidence of
discharge from the ear, audiometry should not be performed and the child
should be referred to a medical practitioner for further assessment and
treatment.4
Date Issued: 2007
Date Reviewed: 2008, 2013, 2014
Next Review: 2016
NSQHS Standards:
1.7, 1.8
6 Procedures
6.3 Hearing assessment
6.3.2 Screening audiometry
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Community Health Manual
Procedure
Birth to School aged children
Hearing is assessed at 50, 35 and then 25 dB HL at 1000 Hz and then 4000
Hz. Starting with a mid-frequency sound such as 1000 Hz will give more
information regarding the child’s overall hearing, whereas starting at a high
frequency sound such as 4000 Hz may cloud the screening process.
Children with hearing aids do not require audiometry screening but any
children in Education Support programs who are capable of performing
screening audiometry should be tested.
Community health professionals should only perform screening audiometry if
they have received appropriate training in the procedure. They should also
make sure they are familiar with the operation of the audiometer before using
it. Different makes or models have different layouts of the controls, but each
machine offers the same functions.
It is important that the examiner checks the audiometer each day before use.
Each frequency (both left and right) should be tested at 50/35/25 dB.
Each audiometer model has specific cleaning requirements. In general,
detergent wipes are appropriate, but staff should refer to manufacturers and
local area infection control guidelines for specific cleaning requirements. It is
recommended that earphones be cleaned between each child.
Community Health staff should follow the organisation’s overarching infection
prevention and management policies and perform hand hygiene in
accordance with WA Health guidelines at all appropriate stages of the
procedure.
Equipment
Calibrated audiometer (calibration date should be indicated on the machine).
Blocks in a container or pegs in a board.
Procedure
Steps
Additional information
1. Engagement and consent:
Encourage parent/carer support and
involvement with the procedure where
Explain the procedure to the child and
possible.
parent/carer if present. Allow
sufficient time for discussion of
concerns.
Ensure either written or verbal
parental consent has been obtained
prior to proceeding with testing.
Refer to ‘Special circumstances’
section in 4.2.4 Early detection subpolicy or 4.4.2 School Entry Health
Assessment guidelines if screening is
indicated and consent not able to be
Date Issued: 2007
Date Reviewed: 2008, 2013, 2014
Next Review: 2016
NSQHS Standards:
1.7, 1.8
Section 337(1) of the Health Act 1911
authorises nurses specified in the
schedule to examine a child without
parent consent if required.
6 Procedures
6.3 Hearing assessment
6.3.2 Screening audiometry
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Community Health Manual
Procedure
Birth to School aged children
Steps
Additional information
obtained for a school aged child.
2. Seating:
Child should be seated facing and
within one arm length of the examiner
but in a position where the child
cannot see the examiner’s use of the
audiometer controls.
3. Tasks:
Different age appropriate tasks
should be used in order to accurately
identify the child’s ability to hear the
test sounds.
Child needs to be adequately
conditioned to the task.
The child must kept be engaged in
order to remain on task throughout
the procedure.
4. Screening procedure: Right ear
Seat the child and give instructions
(task appropriate for age).
Place the earphones on the child’s
ears, ensuring a comfortable fit.
Remove glasses and place hair
behind ears.
Repeat instructions. Set intensity at
50 dB HL at 1000 Hz in the right ear.
Present the tone for 2-3 seconds. If
the child responds, lower to 35 dB HL
and then to 25 dB HL if responses
continue.
The examiner should be seated at the
same level as the child.
The audiometer controls and the
examiner’s operating arm should be
screened from the child.
Instructions may include:
Prior to school age – ‘When you hear
the sound (whistle or noise), give me
the block or peg.’ Blocks need to be
passed easily between the child and
tester.
Kindergarten children – ‘When you hear
the sound (whistle or noise), put the
block in the bucket/on the table or peg
in the board.’
Pre-primary and older children – ‘When
you hear the sound, wave your hand or
clap.’
Ensure red earphone is on the right ear.
Always start at the loudest noise level
50 dB HL in order to obtain a positive
response from the child.
Vary the rhythm in the tone presentation
to ensure you can tell that the child is
responding to the signal rather than
guessing the timing.
If there is no response at 50 dB HL the
result should be documented as ‘no
response’.
Remember to praise the child’s
responses throughout the procedure.
A pass is recorded if the child
responds twice at 25 dB HL,.
Repeat procedure at 4000 Hz in right
ear and record result.
Date Issued: 2007
Date Reviewed: 2008, 2013, 2014
Next Review: 2016
NSQHS Standards:
1.7, 1.8
6 Procedures
6.3 Hearing assessment
6.3.2 Screening audiometry
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Community Health Manual
Procedure
Birth to School aged children
Steps
Additional information
5. Screening procedure: Left ear
Set intensity at 50dB HL at 1000 Hz
in the left ear, repeat above
procedure and record result.
Repeat procedure at 4000 Hz in the
left ear, repeat above procedure and
record result.
The child is required to respond twice at 25 dB HL at both 1000 and 4000 Hz in
each ear to pass the audiometry screening.
6. Reduced response:
If a correct response is not obtained
at 25 dB HL, record the last level at
which the child did respond e.g. 35
dB HL or 50 dB HL.
There is no requirement to assess at 30
and 40 dB if there is no response at
25/35/50 dB HL.
If the child does not respond at 50 dB
HL, re-instruct and try again. If there
is still no response enter NR (no
response) on the record.
The 4-6 weeks time interval prior to
recheck allows for normal hearing to
return following a temporary conductive
If a child has any result greater than
loss which may occur with upper
25 dB HL inform the parent/carer (and respiratory tract infection.
teacher if in school setting) of the
A re-check letter is available if required.
need for a re-test in 4-6 weeks.
Re-test in 4-6 weeks for any result greater than 25 dB HL.
7. Recheck:
Recheck hearing at 1000 Hz and
4000 Hz, starting at 50 dB then 35
dB, then 25 dB should be offered
twice. If a child does not achieve
25/25 dB HL (twice) in either ear,
complete expanded screening.
8. Expanded screening:
Expanded screening involves the
addition of two extra frequencies- 500
Hz and 2000 Hz. Starting at 50 dB,
then 35dB then offer 25 dB twice. The
child needs to hear the sounds at 25
dB twice to pass.
Date Issued: 2007
Date Reviewed: 2008, 2013, 2014
Next Review: 2016
NSQHS Standards:
1.7, 1.8
Expanded screening gives more
information about the child’s hearing
and can begin to suggest a pattern of
hearing loss to the person receiving the
referral.
6 Procedures
6.3 Hearing assessment
6.3.2 Screening audiometry
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Community Health Manual
Procedure
Birth to School aged children
Steps
Additional information
9. Explain results to parent/carer (if
present) or inform parent over the
phone or in writing.
If abnormal refer the child for further
audiology screening and
tympanometry, if available.
For referral processes see below.
10. Documentation:
Document findings in any one of the
Documentation of screening audiology following:
should include the following:
Child Health- CHS 800
Initial screen
1000Hz
School Health- CHS 409-2 or
CHS 412- School health progress
notes
4000Hz
Right
CHS 142- Referral to Community
Health Nurse
Left
Expanded screen
500Hz
1000Hz
2000Hz
CHS
423Ear
Assessment Results.
4000Hz
Health
Documentation may include electronic
data.
Right
Left
Referral pathway
No action is required if the results are 25 dB HL in both ears at
500/1000/2000/4000 Hz.
Recheck should be conducted for any results greater than 25 dB HL in either
ear, preferably 4-6 weeks after initial testing.
Any result on recheck above 25 dB HL in either ear at 500/1000/2000/4000
Hz requires referral. Discuss results with parent or carer and seek consent for
referral to an audiologist and/or medical practitioner. Otoscopy results should
be included in referral. Tympanometry results should also be included where
available.
Use CHS 663 - Referral from Community Heath form for all referrals. Where
audiology referral is indicated, use CHS 300 - Child Development Service
Referral form.
Local area referral pathways may be used for private audiology assessments.
Always obtain parental consent for referral.
Date Issued: 2007
Date Reviewed: 2008, 2013, 2014
Next Review: 2016
NSQHS Standards:
1.7, 1.8
6 Procedures
6.3 Hearing assessment
6.3.2 Screening audiometry
Page 5 of 6
Community Health Manual
Procedure
Birth to School aged children
Related policies, procedures and guidelines
1.11
Infection Control
3.7.3 Hearing (including effects of hearing loss)
4.4.2 School entry health assessments
6.3.1 Otoscopic examination
6.3.3 Tympanometry
Community health professionals should also refer to any service specific policies
where applicable.
Useful resources
World Health Organization. Primary ear and hearing care training resource.
Switzerland: WHO Press; 2006
Bestic J. CARPA Standard Treatment Manual. 5th ed. Alice Springs, NT, Australia:
Centre for Remote Health; 2010.
Coates H, Vijayasekaran S, Mackendrick A, Leidwinger L. Aboriginal Ear Health
Manual. Perth, WA; 2008.
Paediatric Nursing Practice Manual; Princess Margaret Hospital.
Commonwealth Department of Health and Ageing, Recommendations for clinical
care guidelines on the management of otitis media in Aboriginal and Torres Strait
Islander populations., Menzies School of Health Research, Editor 2011
Commonwealth Department of Health and Ageing: Canberra.
References
1. Rosen J, Johnson C & Wilkinson H. School-entry hearing screening: An audit
of referrals in a three year period. The Australian and New Zealand Journal of
Audiology. 2004 vol. 26, no. 2, pp. 142-148
2. Coates H, Vijayasekaran S, Mackendrick A, Leidwinger L. Aboriginal Ear
Health Manual. Perth, WA; 2008.
3. Department of Health Western Australia. Assessment of hearing in childrenBackground. Government of Western Australia Department of Health. 2011.
4. Commonwealth Department of Health and Ageing. Recommendations for
clinical care guidelines on the management of otitis media in Aboriginal and
Torres Strait Islander population. Menzies School of
Health
Research,Commonwealth Department of Health and Ageing: Canberra. 2011.
Date Issued: 2007
Date Reviewed: 2008, 2013, 2014
Next Review: 2016
NSQHS Standards:
1.7, 1.8
6 Procedures
6.3 Hearing assessment
6.3.2 Screening audiometry
Page 6 of 6