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  Surveillance needs to be performed in the primary care setting following neonatal screening.

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  On each regular visit in the “Healthy Child” Programme the child's auditory abilities, middle-ear status and developmental milestones should be assessed. It is advisable to use the algorithm proposed by CODEPEH for application at 6, 12, 18, 24 and 48 months of age (Fig. 1).

  
  

  Figure 1.

  Guidelines for detecting hearing problems in children.

  (0.6MB).

If a child does not pass the assessment he or she should immediately be referred to an ear, nose and throat (ENT) specialist or a Children's Hearing Unit for examination.

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  The state of the middle ear needs to be carefully examined. Children found to have serous otitis media that persists for at least 3 consecutive months must be referred for an otological assessment.

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  Children with developmental and behavioural abnormalities should be given a hearing evaluation at least once by an ENT specialist, paying special attention in this case to relapsing or persistent serous otitis media that may worsen their prognosis.

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  All children with a risk indicator for hearing loss (Table 1), regardless of the findings in their followup, must be referred for an audiological assessment at least once between the ages of 24 and 30 months. Children with risk indicators strongly associated with delayed-onset hearing loss, such as extracorporeal oxygenation or a cytomegalovirus (CMV) infection, should be subjected to more frequent audiological assessments.

  Table 1.

  Risk factors for hearing loss in children.

  Family suspicion of deafnessa	Bacterial meningitisa
  Family history of deafness	Syndromes with deafnessa
  Hypothyroidism	Neurodegenerative diseasesa
  More than 5 days in NICU	Craniofacial abnormalitiesa
  Exposure to ototoxic substances	Extracorporeal membrane oxygenationa
  Assisted ventilation	Severe cranial traumaa
  Persistent otitis	Hyperbilirubinaemia with exchange transfusiona
  Perinatal infections (CMV, herpes, rubeola, syphilis and toxoplasmosis)a	Chemotherapy

  a

  Very high risk factor for postnatal deafness.
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  Confirmation of hearing loss in a child is considered a high risk factor for his or her siblings and they must be subjected to an audiological assessment.

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  All children in whose families there is significant concern about their hearing or communication should be referred without delay to an ENT specialist or to the Children's Hearing Unit for the appropriate audiological and language assessments, regardless of their age. The same procedure should be followed if the suspicion comes from their educators.

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  The processes of audiological diagnosis and aural rehabilitation are of equal priority and need to be pursued in the first months of life in order to maximise the child's optimum development. These 2 processes begin sequentially but must be conducted simultaneously.

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  The follow-up intervals should be:

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    In the first 18 months of life: continuously, as each situation demands;

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    From 18 months to 3 years: every 3 months;

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    From 3 to 6 years: every 6 months;

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    Over 6 years of age with stable deafness: every year.

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  The ENT specialist must be in charge of coordinating the actions of the multidisciplinary team involved in fitting a hearing aid, together with the hearing-aid specialist and the speech therapist, and is responsible for prescribing the hearing-aid treatment.

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  Working groups, distributed according to the structure of each autonomous community, also need to be formed for comprehensive diagnosis and treatment of children with deafness.

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  It is essential to involve parents in the process of treating children with hearing deficit, and in order to achieve this throughout the process they must be given abundant, comprehensible and truthful information so as to create accurate expectations regarding the prognosis.

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  The results of the brainstem auditory evoked potentials (BAEP) test should be supplemented by performing a steady-state auditory evoked potentials (SSAEP) test.

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  The results obtained in the brainstem and steady-state auditory evoked potentials tests must be completed and confirmed using conduction audiometry appropriate to the age of the child.

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  For tympanometry in children younger than 4 months of age it is recommended that high-frequency (1000Hz) probes should be used.

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  The decision to fit a hearing aid should be based on the child's audiological data, language development and family, school and social environment.

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  Until 10–12 years of age the conventional hearing aid should be behind the ear. Various types of moulds should be available so as to achieve a correct fit of the mould to the external auditory canal, especially in infants.

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  Hearing aids with omnidirectional microphones are the most suitable for infants, who normally crawl, as they are always in the right position to receive sound.

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  A binaural fitting should always be carried out, unless the child's behaviour suggests that the fitting in the worse ear impairs overall performance.

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  Each case should be treated individually, since, among other reasons, there may be children in whom poor performance of the hearing aid can be explained by the presence of an auditory neuropathy or by central lesions in the auditory areas.

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  Regulating and universalising early care, establishing 0–6 years of age as the care period.

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  Achieving the necessary coordination between administrations and sectors to ensure joint planning of the services and assistance provided for children and their families, and also compatibility of support and services with the needs of the child and his/her background and development, and with the decisions taken by families.

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  Providing multiple responses to diversity in care: there is no single pattern of response, and it is important to adapt to individual variability and to new developments in all areas: social, technological, legislative, etc.

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  Updating the competencies and specialised training of professionals in the various spheres jointly involved in caring for deaf children and their families.

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  Incorporating families into the systems that concern them regarding their deaf children and involving them at every level of intervention, leading to increased knowledge of family support among all the agents involved.

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  Establishing easily identifiable and coordinated referral routes and care pathways for children and their families, so as to ensure the continuity of care.

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  Fostering the participation of the family associations movement, which not only acts as a social agent and network, developing family support programmes, including mutual help groups for families, but also helps to avoid regional inequalities, provides specialised technical advice and promotes necessary change.

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  Creating a basic common register of the results of applying the Early Detection Programme for child deafness, incorporating data from the various autonomous communities. This will be crucial for conducting epidemiological studies, adopting preventive measures, planning public healthcare and educational resources addressing the needs of the affected population and making it possible to carry out comparative studies at a national and international level, among other things.

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  Establishing consensus on scientific, terminological, procedural, technical, educational and other issues so as to make it possible to describe and classify the needs that exist among the child population currently affected by auditory problems or at risk of having such problems.

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  Informing and raising awareness in society and among the agents involved on the vital importance of early detection and diagnosis, monitoring and surveillance of risk factors and the need to act as quickly as possible to institute medical and hearing-aid treatment, together with early speech therapy intervention.

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  Conducting an ongoing and rigorous assessment of services, resources, procedures and results, with quantitative and qualitative measures in all these areas, through efficacy and success indicators, with respect not only to the level of clinical intervention but also the child's progress and the satisfaction of the family and the professionals, as well as the benefits of the community.