Acta Otorrinolaringol Esp.

2016;67(1):45---53

www.elsevier.es/otorrino

REVIEW ARTICLE

2014 CODEPEH Recommendations: Early Detection of

Late Onset Deafness, Audiological Diagnosis, Hearing
Aid Fitting and Early Intervention夽
Faustino Núñez-Batalla,∗ Carmen Jáudenes-Casaubón, Jose Miguel Sequí-Canet,
Ana Vivanco-Allende, Jose Zubicaray-Ugarteche

Comisión para la detección precoz de la hipoacusia

Received 6 May 2015; accepted 17 May 2015

KEYWORDS Abstract The latest scientific literature considers early diagnosis of deafness as the key ele-
Hearing loss ment to define the educational and inclusive prognosis of the deaf child, because it allows
(congenital; taking advantage of the critical period of development (0---4 years).
late-onset); Highly significant differences exist between deaf people who have been stimulated early and
Hearing; those who have received late or improper intervention.
Screening; Early identification of late-onset disorders requires special attention and knowledge on
Childhood; the part of every childcare professional. Programmes and additional actions beyond neonatal
Child audiology; screening should be designed and planned to ensure that every child with a significant hearing
Hearing aids; loss is detected early.
Interdisciplinarity; For this purpose, the CODEPEH would like to highlight the need for continuous monitoring of
Family children’s auditory health. Consequently, CODEPEH has drafted the recommendations included
in the present document.
© 2015 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringología y Patología
Cérvico-Facial. All rights reserved.

PALABRAS CLAVE Recomendaciones CODEPEH 2014: detección precoz de la hipoacusia diferida,

Hipoacusia diagnóstico audiológico y adaptación audioprotésica y atención temprana
(congénita;
diferida); Resumen La literatura científica más reciente señala el diagnóstico precoz de la sordera como
Audición; elemento fundamental para definir el pronóstico educativo y de inclusión del niño sordo, pues
permite aprovechar el periodo crítico de su desarrollo (0---4 años).

夽 Please cite this article as: Núñez-Batalla F, Jáudenes-Casaubón C, Sequí-Canet JM, Vivanco-Allende A, Zubicaray-Ugarteche J. Recomenda-

ciones CODEPEH 2014: detección precoz de la hipoacusia diferida, diagnóstico audiológico y adaptación audioprotésica y atención temprana.
Acta Otorrinolaringol Esp. 2016;67:45---53.
∗ Corresponding author.

E-mail address: fnunezb@telefonica.net (F. Núñez-Batalla).

2173-5735/© 2015 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringología y Patología Cérvico-Facial. All rights reserved.
46 F. Núñez-Batalla et al.

Existen diferencias altamente significativas entre las personas sordas estimuladas temprana-
Cribado; mente y las que han recibido esta atención específica de forma más tardía y/o inadecuada.
Infancia; La identificación temprana de los trastornos diferidos requiere de una especial atención y
Audiología infantil; conocimientos entre todos los profesionales que atienden a los niños durante su infancia. Se
Audioprótesis; trata de diseñar programas y de planificar acciones adicionales más allá del cribado neonatal
Interdisciplinariedad; para asegurar que todos los niños con una hipoacusia significativa sean detectados pronto.
Familia Con este propósito, la CODEPEH quiere poner de relieve la necesidad de un seguimiento
continuado de la salud auditiva de los niños, estableciendo para ello las recomendaciones
contenidas en el presente documento.
© 2015 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringología y Patología
Cérvico-Facial. Todos los derechos reservados.

The Commission for Early Detection of Hearing Loss
(CODEPEH, the Spanish acronym), in agreement with its
previous recommendations,1 wishes to stress the need for
continued follow-up of the auditory health in the infant pop-
ulation. It is true that the results back up universal neonatal
screening for hearing loss, given that it makes it possible to
initiate early treatment. However, neonatal screening pro-
grammes have their ‘‘Achilles heel’’ in the rate of dropouts
in the follow-up of the children that present altered results
in the tests carried out at birth. That is the reason for
the current debate as to the need to perform screening
at specific ages, which would allow picking these cases up
again. In addition, some infant hearing disorders are unde-
tectable in neonatal screening because they are not yet
present, such as late-onset hearing loss or acquired hear-
ing loss; there are also other hearing losses that, although
present congenitally, are not serious enough for them to
be detected in neonatal screening.2---4 Another consideration
is that there are deficiencies in planning, in addition to
organisational difficulties and difficulties in availability of
resources related to these screening programmes. These
factors make it impossible to guarantee diagnostic confir-
mation and access to quality early intervention. These facts
do not affect the intrinsic justification of universal neonatal
screening for hearing loss. Quite the opposite; what these
problems imply is that additional actions have to be carried
out and that programmes that go beyond neonatal screening
have to be designed, to ensure that all children with a sig-
nificant hearing loss are detected quickly. Consequently,
many programmes include some type of re-screening
aimed at specific children that present factors of risk
for late-onset or progressive hearing loss. Even establish-
ing programmes for preschool and school screening (which
have already demonstrated their usefulness) should be
considered.3,4
Early identification of these late-onset disorders requires
special attention and knowledge at the healthcare level,
as well as information among educators, which must be
developed through educational programmes and informa-
tion strategies. With this goal, this Commission considers
it appropriate to establish the following recommendations
aimed at all the specialists that take care of these children
during their infancy.
Early Detection of Late-onset Hearing Loss
Almost half of the newborns that have a hearing loss do not
have any of the known factors of risk for this alteration:
this fact backs up universal screening. When populations
selected depending on specific clinical factors of high risk for
hearing loss are studied, the incidence of hearing disorders is
increased by between 10 and 14 times,5 with special follow-
up being important for these patients. It should also be
remembered that more than 95% of the parents of children
with auditory deficiencies have normal hearing.6 The exten-
sive implementation of programmes of neonatal screening
for hearing loss can lead to thinking that, once this pathol-
ogy is ruled out at that times, it can no longer affect the
child throughout his/her development. This is a false belief
that can seriously damage the future of these children,
given that not infrequent postnatal factors can cause hear-
ing loss. Several sudies4,7 show that up to 0.75---0.77 per
thousand preschool children present permanent hearing loss
in spite of having passed neonatal screening. Added to these
children are the 0.25---0.56 per thousand that acquire or
present hearing loss in a postnatal period and that like-
wise need these check-ups to diagnose hearing problems.
According to Watkin,8,9 the prevalence could exceed 2.52
per thousand at birth (any type and degree of hearing loss),
rising to 3.64 per thousand in the primary education stage.
It has been seen in wide cohorts of children that neonatal
tests, even in the cases of highly sensitive ones, identify
only 56%---59% of school-age children with hearing loss. Con-
sequently, up to 1 in 10 children with congenital hearing
loss would need detection through postnatal check-ups in
spite of having well established screening protocols. The
prevalence of childhood hearing loss in the school stage is
therefore thought to double what is expected in the neona-
tal stage; however, there are other studies that raise this
figure to 5 times higher,10 and there are even authors that
indicate that the overall prevalence of late-onset hear-
ing loss is 10% over all the infant hearing losses, possibly
reaching 20%.3,11 All of this suggests the need for diagnos-
tic protocols that make it possible to identify the cases of
postneonatal hearing loss.
The majority of late-onset hearing loss cases in child-
hood seem to be due to genetic defects. For that reason,
2014 CODEPEH Recommendations 47

Table 1 Causes of Conductive Hearing Loss. Table 2 Causes of Sensorineural Hearing Loss.
Outer ear Middle ear Congenital
Hereditary
Congenital Congenital
Non-hereditary
Infection Infection
Acquired
Trauma Ruptured eardrum
Prematurity
Obstruction Tumours
Hyperbilirubinemia
Otosclerosis
EMO
Trauma
Neonatal hypoxia/asphyxia
Intraventricular Haemorrhage grades 3---4, periventricular
the current diagnostic tendency should aim at performing leukomalacia
genetic studies that allow simultaneous study of many genes Infection
involved in hearing loss (at the current time, there are more Ototoxic drugs
than 150 loci and 64 genes).12 This could open the door to Exposure to noise
genetic therapy in patients with a mutation related to hear- Traumatisms
ing loss, which would totally change the current panorama.13 Tumours
If genetics does not explain the auditory pathology in a spe- Neurodegenerative syndromes (Charcot Marie, Friedreich
cific case, other causes would have to be considered, such ataxia)
as congenital cytomegalovirus (CMV) infection or vestibular Intoxication with heavy-metals
aqueduct disorders, which would make CMV infection study EMO: extracorporeal membrane oxygenation.
and complementary imaging studies necessary.14 Children
with diseases or situations of risk of hearing loss with possi-
ble onset in infancy should be closely watched, following this
in 5%---18%.16 Early diagnosis is important for consider-
classification of the types and causes of late-onset hearing
ing drug treatment with ganciclovir or valganciclovir,
loss.15
given that several studies have shown their usefulness
for improving hearing loss or preventing its progression
• Conductive hearing loss (Table 1). in these children.
• Sensorineural hearing loss (Table 2). 2. Serious head injury.
• Central hearing loss (Table 3). 3. Neonatal Intensive Care Unit stay greater than 5 days: All
children admitted to intensive care for more than 5 days
Among all these causes, the following stand out for their should be considered as at very high risk of hearing loss,
frequency and importance: given that many of the associated pathologies affect this
group of patients.
1. Cytomegalovirus (CMV): congenital CMV infection is the 4. Serous otitis.
most common cause, with prevalence of 0.5% in new 5. Genetic auditory neuropathy: These can affect the hear-
newborns, of which more than 94% are asymptomatic; of ing as the only clinical manifestation.
these, 22% develop either neonatal or late-onset hear-
ing loss. Approximately 6% are symptomatic and, of
these, 33%---60% develop hearing loss. The hearing loss CODEPEH Recommendations with respect to early detec-
is progressive in 11%---50% of the cases and late-onset tion of late-onset hearing loss:

Table 3 Causes of Central Hearing Losses.

Idiopathic Acquired neuropathy (30%) Genetic neuropathy
neuropathy (30%)
Associated with sensory-motor Not associated
processes with other
processes
Hyperbilirubinemia with Charcot-Marie-Tooth disease Q829X Mutation in
exchange transfusion, 50% (Kovach et al., 2002) the OTOF gene
(Shapiro et al., 2001)
Infectious causes, 10% Friedreich ataxia
(Race, 2005)
Prematurity Ehlers Danlos syndrome
Neonatal hypoxia Refsum disease
(Oysy et al., 2001)
Erythrokeratodermia
(López-Bigas et al., 2001)
48 F. Núñez-Batalla et al.

Paediatric control

The paediatrician will verify that the screening tests have been performed and passed, in
agreement with the programme for early detection of infant hearing loss, as well as checking for risk factors

1.- Does the child turn its head towards voices or a sound?
6 Months 2.- Does it respond with vocal sounds when it is spoken to? Evaluate
No?
3.- Reacts to his/her name referral to ENT

1.- Does the child locate the source of the sound?

2.- Does it point to objects and familiar people when they are named? Evaluate
12 Months No?
3.- Does he/she say daddy/mummy? referral to ENT

1.- Does the child point to parts of the body when asked?
18 Months 2.- Does it pay attention to children’s songs? Evaluate
No?
3.- Does he/she make 2-word sentences? referral to ENT

1.- Does the child understand simple orders without the

support of gestures? Evaluate
24 Months No?
2.- Does it come when called from another room? referral to ENT
3.- Does he/she use the pronouns my/I/you?

1.- Does the child repeat phrases without visual support?

4 years 2.- Does he/she carry on a conversation? Evaluate
No?
3.- Can the child count a series of simple numbers (e.g., from 1 to 10)? referral to ENT

Figure 1 Algorithm recommended for early detection of late-onset hearing loss in childhood.

1. Carrying out Primary Care monitoring is needed after Table 4 Factors of Risk for Childhood Hearing Loss.
neonatal screening.
2. At each periodic visit under the ‘‘Healthy Child Pro- Family suspicion of hearing Bacterial meningitis*
gramme’’, the following must be assessed: auditory loss*
skills, middle ear status and developmental milestones. Family history of hearing Syndromes with hearing
Using the algorithm proposed by the CODEPEH is recom- loss loss*
mended, applying it at 6, 12, 18, 24 and 48 months of age Hypothyroidism Neurodegenerative
(Fig. 1). Children not passing these assessments must be diseases*
referred to an ENT specialist immediately. NICU stay of more than Craniofacial anomalies*
3. Careful examination of the middle ear is required for the 5 days
children in whom a serous otitis is found and, if it lasts Exposure to ototoxic Extracorporeal membrane
for at least 3 consecutive months, the children must be substances oxygenation*
referred for otological assessment. Assisted ventilation Serious head injury*
4. Children with developmental and behavioural anomalies Chronic otitis Hyperbilirubinemia* with
must be assessed in the auditory sphere at least once by exchange transfusion
the ENT specialist, paying special attention in this case Perinatal infections* (CMV, Chemotherapy
to recurrent or persistent serous otitis that can make the herpes, rubella, syphilis
prognosis worse. and toxoplasmosis)
5. All children with an indicator of risk for hearing loss
NICU: Neonatal intensive care unit.
(Table 4), regardless of the findings in their check-ups, * Very high risk factor for postnatal hearing loss.
must be sent for audiological assessment at least once
between 24 and 30 months of age. Children with indi-
cators of risk that are closely associated with late-onset
hearing loss, such as extracorporeal membrane oxygen- Infant Audiological Evaluation and Hearing Aid
ation or a CMV infection, must undergo more frequent Adaptation
hearing assessments.
6. Confirming a hearing loss is a child is considered a fac- The audiological diagnostic process, together with aural and
tor or high risk with respect to the siblings, who must language habilitation, have the same priority and have to
undergo audiological assessment. be carried out in the first months of life to maximise the
7. All children whose family or teachers are particularly child’s optimum development. Both processes begin sequen-
concerned about their hearing or communication, what- tially, but they develop simultaneously. The methods used
ever their ages, must be referred immediately for the for assessment vary in function of the age and the child’s
relevant assessments of hearing and language. acquisition of different skills and capacities for participating
2014 CODEPEH Recommendations
in the evaluation. Assessment protocols change with age. Six
months is the age at which the electrophysiological tests are
given, as the primary procedure for threshold estimation, in
behavioural methods, which provide reliable results.
The brainstem auditory evoked potentials (BAEP) are usu-
ally the first test applied, although this should not be in
isolation, without other tests. The reason for this is that
the responses to the clicks correlate better with audio-
metric findings in the high frequency range, between 1000
and 4000 Hz.17---19 And, given that the click responses can-
not be considered as referring to a specific frequency, they
are unable to detect disorders at particular frequencies.
That is why isolated BAEP use can lead to underestimat-
ing or not detecting a hearing loss at a specific frequency,
depending on the degree and configuration of the hearing
loss.20,21 However, the prediction of the audiogram through
the auditory evoked potentials is possible, as long as they are
obtained within the appropriate conditions and parameters.
Behavioural thresholds correspond well to those obtained
through potentials, with there being a difference around 10
or 20 dB.20,22,23
The auditory steady-state evoked potentials (ASSEP) have
the advantage of predicting specific thresholds for differ-
ent frequencies in the patients when they are unable to
be obtained reliably and validly.24---26 It is an objective test,
not only because it requires no collaboration from the
patient, but also because the presence or absence of
the response is based on statistical analysis and not in meth-
ods of visual assessment such as the BAEP. The ASSEP are
used to complement the BAEP, not as a single test, to esti-
mate the thresholds, given that sufficient information about
and experience with them is unavailable as yet. Another
advantage of the ASSEP is that they make it possible to
test both ears simultaneously. Predicting thresholds using
the ASSEP has been shown to be reliable for estimating
the results of behavioural audiometry.27,28 The thresholds
in adults with normal hearing or with hearing loss are esti-
mated with this test with an error of between 10 and
15 dB.29 There is less information for children, but the test
is known to obtain, generally speaking, a reliable prediction
of thresholds in moderate hearing loss and in normal hearing
in children.25
Tympanometry. Using high-frequency waves (1000 Hz)
offers more reliable results on middle ear function in chil-
dren younger than 4 months old.30
Behavioural audiometry. Audiometry through observing
behaviour provides information about the type of responses
that the child produces and about his/her auditory devel-
opment. For children aged more than 5 or 6 months, the
technique of choice is visual reinforcement audiometry. For
the conditioning, a good place to start is to use a verbal
stimulus, because children find that more interesting than a
tonal stimulus and respond naturally by turning their heads,
which can be reinforced. The presentation of the frequen-
cies, alternating lows and highs, will make it possible to
construct an audiogram that contains part (if not all) of the
information needed to predict the threshold of hearing loss.
If the child becomes conditioned, his/her developmental
and maturation level will not affect the thresholds found.
Play audiometry is a term used to describe a technique in
which playing is used to obtain the thresholds. It can be
used from the age of 24 months, but it is more indicated at
49
2.5 years or 3 years. Conditioning is achieved after showing
the child 4 or 5 guided responses or demonstrations. Con-
ventional audiometry can be used when the child reaches
the age of 5 or 6 years. The response is typically the same
as that used for adults, showing the child to raise his/her
hand when the stimulus is heard. As in all behavioural tech-
niques, chronological age is not decisive in the test, the
child’s developmental level is.
Childhood Hearing Aid Adaptation
It has been demonstrated that all hearing loss causes mod-
ifications in the central auditory system and that early
hearing aid adaptation will make these lesions revert. This
phenomenon is known as ‘‘auditory acclimatisation’’.31 At
present, the need for bilateral adaptation is extensively
documented; auditory amplification is also recommended
for monaural hearing losses, independently of their level,
although individualisation depending on each situation is
required in severe cases.32
Deciding to proceed to a hearing aid adaptation has to
be based on audiological data, on language development
and on the child’s family, school and social environments.
These data can also contribute to the decision-making pro-
cess in selecting a device for the children with hearing loss.33
Each hearing aid adaptation for a child must be accom-
panied by proper long-term speech therapy treatment, as
well as including the educational sphere. The Ear, Nose
and Throat (ENT) specialist is in charge of coordinating all
the activities of the interdisciplinary team and is the only
one that can indicate the surgical or hearing aid treat-
ments that are necessary (Royal Decree 414/1996, 1 March,
regulating medical devices). Hearing aid establishments
are considered medical establishments and, as such, they
have to comply with the requirements (local, professional,
resources, etc.) specified in the standards regulating them.
They also have to have material for performing specific
childhood audiometric diagnosis, such as a sound-proof
booth and calibrated toys. Among the main functions of
hearing aid establishments are: interpreting hearing aid pre-
scriptions, determining anatomical and physiological ear
characteristics, carrying out audiometries and all the actions
required for adaptation, such as taking the impressions for
the moulds and control and follow-up of the hearing aid
adaptation. The results and responses of the child perceived
during the hearing aid adaptation process must be con-
trasted with the teaching and speech therapy assessment
carried out by the child’s speech therapists and teachers.
Fundamentally, the adaptation and follow-up programme is
developed in 3 areas: medical (ENT), hearing aid and speech
therapy.
At present, with the programmes for early detection of
hearing loss, a clear diagnosis of hearing loss is reached
at very early ages. Consequently, the hearing aid special-
ists have to face very small ear canals and children that
are incapable of indicating if they perceive the sounds or
not; the specialists therefore have to orient themselves
through observing the children’s reactions and physiologi-
cal tests.34 It is undeniable that amplification is indicated
when the loss exceeds 35 dB.35 In the case of profound hear-
ing loss, adaptation for at least 3 months is recommended
50
so that, if the response is inadequate, the hearing aid spe-
cialist can indicate the desirability of a cochlear implant.
Unilateral hearing, even if mild, produces problems in the
binaural integration of the message and in discrimination in
noisy environments, as well as in proper sound location.36
Adaptation is currently indicated in these cases, given that
amplification in this ear could be beneficial. Using hearing
aids for a trial period is recommended, with follow-up during
the first years of life.37,38
The 3 steps that have to be implemented in childhood
hearing aid adaptation are: selection, verification and vali-
dation. (a) Selection: the response to hearing aid adaptation
is conditioned by the auditory pathology, the type of hear-
ing loss and other neurological alterations, and not as much
by the intensity of the loss. The correctly selected hearing
aid is the one that provides the best amplification, bear-
ing in mind the residual hearing of the child. Until the child
is 10---12 years of age, conventional hearing aids have to be
retroauricular and different types of moulds should be avail-
able to be able to achieve correct adaptation of the mould to
the external acoustic meatus, especially for infants. In mid-
dle ear problems, such as ageneses or chronic suppurating
lesions, bone conduction adaptation is usually necessary.39,40
With infants (who usually crawl around), directional micro-
phones are not the best choice; omnidirectional ones are
preferable. Mould design is also extremely important when
children are involved. Great care is needed, given that their
physical-acoustic characteristics vary according to the hear-
ing loss, the volume of the external acoustic meatus and the
hearing aid output pressure. Consequently, they have to be
replaced when these parameters change. (b) Verification:
the programme for hearing aid adaptation is normally estab-
lished by the audioprosthologist. However, a consensus must
be agreed with the ENT specialist, give that follow-up con-
cerns them both; the programme has to be crossed-checked
with the speech therapist as well. The basic references are
found in Northern and Downs,41 who follow the criteria of
‘‘from shorter time of use to longer, from less sound expo-
sure to greater sound exposure and from less complexity of
sounds to greater complexity’’. In the adaptation of small
children, it is always good to be a bit conservative, because
we do not have adequate information in early phases about
recruitment thresholds of discomfort and about other fac-
tors, which will gradually be discovered as the child grows.
(c) Validation: validation is the continuous process that tells
us the benefits and limitations of correct hearing aid adap-
tation. The goal is for the audioprosthologist to ensure that
the child receives the optimum signal, of both his/her own
emission and that of the other people. It involves supervising
both the hearing aid and the behaviour of the child during
its use.
CODEPEH Recommendations related to audiological
assessment and hearing aid adaptation:
1. The processes of audiological diagnosis and auditory
accommodation are of the same priority and need to
be developed in the first months of life to maximise
optimum development of the child. These 2 processes
begin sequentially, but they must be developed simul-
taneously.
2. The follow-up periods are as follows: for the first
18 months of life, continuous as demanded by each
F. Núñez-Batalla et al.
situation: from 18 months to 3 years, every 3 months;
from 3 to 6 years, every 6 months; children aged over
6 years with stable hearing losses, each year.
3. The ENT specialist is the one in charge of coor-
dinating the actions of the multidisciplinary team
involved in hearing aid adaptation, together with the
audioprosthologist and the speech therapist; the ENT
specialist is responsible for indicating the hearing aid
treatment.
4. Work groups should be formed for the diagnosis and
comprehensive treatment of the children with hearing
losses.
5. It is essential to involve the parents the treatment pro-
cess of children with hearing deficiencies. To do so,
throughout the entire process, the parents should be
given extensive, understandable and true information,
which adjusts expectations about the prognosis.
6. The results of the brainstem auditory evoked potentials
(BAEP) should be complemented by performing auditory
steady-state evoked potentials (ASSEP).
7. The results obtained in the brainstem auditory evoked
potentials and those of steady-state have to be rounded
out and confirmed through behavioural audiometry
appropriate for the age of the child.
8. To perform a tympanometry on children younger than
4 months old, the use of high-frequency waves (1000 Hz)
is recommended.
9. Until the child is 10---12 years of age, the conventional
hearing aid must be retroauricular. Different types of
moulds have to be available to be able to achieve cor-
rect adaptation of the mould to the external acoustic
meatus, especially in infants.
10. The most appropriate hearing aids for infants are those
with omnidirectional microphones, because they are
always in the correct position to receive the sounds.
11. Binaural adaptation must always be carried out, unless
the child shows behaviours that lead one to think that
the adaptation in the poorer ear reduces the overall
performance.
12. It is important to individualise each case, given that
there may be children in whom a poor hearing aid per-
formance can be explained by the presence of auditory
neuropathy or because they present central lesions in
the auditory areas.
Early Intervention
In relation to the treatment and follow-up of the child that
is found to have a hearing problem, the 2010 CODEPEH Rec-
ommendations concluded that the action protocol should be
followed under the following premises: immediacy of inter-
vention with respect to the time of diagnosis; existence
of referral itineraries that are easily identifiable by fami-
lies and professionals; interdisciplinary coordination, with
the intervention of qualified specialists and Early Interven-
tion experts, as well as specialists in attention for children
with hearing losses and family support; and the forecast of
healthcare, educational and social benefits, which help the
families.
Early Intervention are included in and affected by, to
a greater or lesser extent, an extensive legal framework
2014 CODEPEH Recommendations
produced in Spain since the beginning of the 1980s. The
most relevant documents of the last 3 decades emphasise
an evolution from a concept of intervention focused on the
child, to a wider and overall concept that covers the child,
his/her family and his/her environment. In this scenario,
we must currently include the international Convention on
the Rights of Persons with Disability (2006), a binding inter-
national standard ratified by Spain. This document, fully in
force since 2008, highlights everything that Spanish legis-
lation had already anticipated, although still insufficiently,
from another less interactive and less social model.
Almost 15 years after the publication of the White Paper
on Early Intervention42 in Spain, there is still no basic
state regulation on this material. The development of stan-
dards by the various autonomous communities is uneven,
in both forecasts and in precepts, as well as in the appli-
cation of resources and funding. The White Paper on Early
Intervention provided a necessary framework and produced
sufficient technical consensus, evolving from the concept
of ‘‘early stimulation’’ to that of ‘‘early attention’’, and
defined this as ‘‘The set of interventions aimed at the child
population of 0---6 years in age, at the family and the envi-
ronment, with the objective of answering as quickly as
possible the transitory or permanent needs that children
with developmental disorders or at risk of having such disor-
ders present’’. Another of its considerations was that ‘‘the
modern conception of early intervention makes it necessary
to have integrative diagnostic models available that con-
sider, in addition to health pathologies, developmental and
learning aspects and the other emotional and environmental
contextual factors that affect the growth, maturation and
development of the child’’. Added to this is the fact that
early intervention is not only indicated when the deficiency
is already present, but also in cases at risk of developing
it. This implies vigilance over the factors of risk that can
cause the condition. These are goals inherent in this atten-
tion: reduce the effects of a deficiency or deficit on a child’s
overall development; optimise, to the extent possible, the
course of the development of the child; introduce the nec-
essary mechanisms of compensation, elimination of barriers
and adaptation to specific needs; prevent or reduce the
appearance of secondary or associated effects or deficits
produced by a high-risk disorder or situation; stretch a hand
out to and cover the needs and demands of the family and of
the environment in which the child lives; and consider the
child as an active subject in the intervention.
In turn, the European Agency for Development in the Edu-
cation of Students with Special Educational Needs indicated
3 priorities with respect to Early Intervention in 2010: 1.
Reach the entire population that needs Early Intervention
and support, and do so as soon as possible. 2. Guarantee the
quality of the offer within specific quality standards, well
defined and assessable, homogeneous in all of the State,
without territorial differences signifying an added handicap.
3. Respect the rights of the boys and girls and their families,
configuring responsible, family-centred services.
In early diagnosis of hearing loss, notable advances have
been made under this change in paradigm, where (going
beyond the purely clinical aspects) both support for the
families as well as the hearing aid and speech therapy
adaptation process are taken into account, incorporating
them as part of the whole that constitutes comprehensive
51
treatment for children with hearing loss. The Programme
for Early Detection of Infant Hearing Loss, approved by the
Spanish Ministry of Health and by the Autonomous Commu-
nities in 2003, is the most advanced country in our setting in
this aspect. And, today, we can say that it is fully in agree-
ment with the contemporary concept of Early Intervention
and the social model that the international Convention on
the Rights of Persons with Disability supports.
Hearing loss is a clear example of how what is specific
to each administrative sector that intervenes in these ages
(Healthcare, Social Services and Education), together with
the different professionals (paediatrician, ENT physician,
audioprosthologist, speech therapist, teacher, etc.) have
to come together and participate, from a comprehensive,
interdisciplinary focus, about the child and his/her family in
a joint action that is planned, coordinated and convergent
in resources, benefits and services.43
As provided for in the programme jointly approved in
2003 by the Ministry of Health and the Autonomous Com-
munities, the Public Administrations must guarantee this
itinerary of attention and the continuity of the process, by
interdisciplinary coordination through Reference Units.1
According to the Report of the European Agency for the
Development of Special Educational Needs (2003/04), in
the countries in our European setting the policies related
to attention and support for individuals with disabilities are
planned based on 4 fundamental agreements: take action as
soon as possible, guarantee the continuity of the process,
avoid lack of coordination between services and benefits,
and prevent the families’ bewilderment and searching from
place to place.
From what has been presented, we can deduce the rele-
vance of having an itinerary that is easily recognisable by
all those involved and that can provide a coherent, appro-
priate and sufficient response to the needs and demands of
the children with hearing loss and of their families. Along
these lines, nobody debates the scientific role that the fam-
ily plays any longer; this role is unequivocally recognised and
studied with interest. This is because it is no longer possi-
ble to understand or take care of a case without paying due
attention to the family that lies behind it. It is accepted
that attention, guidance and support for the family forms
part of the treatment for and attention to the child with
disability.44
CODEPEH Recommendations related to early interven-
tion for child with hearing loss and his/her family:
1. The regulation and universalisation of early interven-
tion, establishing the ages of 0---6 years as the scope of
attention.
2. The inter-administration and inter-sector coordination
necessary.
3. The plurality of responses in attention to diversity.
4. The updating of competencies and specialised training
for the professionals from the different settings that
converge in the attention for the child with hearing loss
and his/her family.
5. The incorporation of the families into the systems that
concern them in relation to their children with hearing
losses and their involvement at each level of interven-
tion.
52
6. The establishment of referral circuits and itineraries of
attention for the child and for his/her family; these are
resources that are to be easily identified and coordi-
nated, and that guarantee the continuity of the process.
7. The participation of the family association movement
that acts as an agent and as a social network, developing
family support programmes.
8. The creation of a basic common registry of the results
from applying the Programme for Early Detection of
Infant Hearing Loss in the entire country.
9. The establishment of scientific, terminological, proce-
dural, technical (etc.) agreements that make it possible
to describe and classify the needs existing in the child
population affected or at risk.
10. The social information and awareness-raising, as well
as among the agents involved, of the transcendence of
early detection and diagnosis, of follow-up and moni-
toring of the factors of risk, and of the need to act as
quickly as possible.
11. The continuous, exacting evaluation of services,
resources, procedures and results, with quantitative
and qualitative measurement using indicators of effi-
cacy.
Conflict of Interests
The authors have no conflicts of interest to declare.
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