Development of the national consensus statement on ear health and hearing check recommendations for Aboriginal and Torres Strait Islander children aged under 6 years attending primary care: systematic scoping review and e-Delphi

BACKGROUND

Early detection of long-term, often asymptomatic, middle ear infection in young Aboriginal and Torres Strait Islander children is more likely to be achieved when ear health and hearing checks are routinely undertaken in primary healthcare. Evidence consistently demonstrates the adverse impacts of this condition on the development and wellbeing of children and their families. We aimed to develop feasible, evidence- and consensus-based primary healthcare recommendations addressing the components and timing of ear health and hearing checks for Aboriginal and Torres Strait Islander children aged under 6 years, not already known to have, nor being actively managed for, ear and hearing problems.

METHODS

A 22-person working group comprising Aboriginal and Torres Strait Islander and non-Indigenous members from the primary healthcare, ear, hearing, and research sectors provided guidance of the project. A systematic scoping review addressed research questions relating to primary health ear health and hearing checks for Aboriginal and Torres Strait Islander and other populations at increased risk of persistent ear health problems. Twelve primary studies and eleven guidelines published between 1998 and 2020 were identified and reviewed. Quality and certainty of evidence and risk of bias ratings were completed for studies and guidelines. In the absence of certain and direct evidence, findings and draft recommendations were presented for consensus input to a 79-member expert panel using a modified e-Delphi process. Recommendations were finalised in consultation with working group members and presented to expert panel members for input on considerations relating to implementation.

RESULTS

Overall, the quality, certainty, and directness of evidence in the studies and guidelines reviewed was low. However, the findings provided a basis and structure for the draft recommendations presented during the consensus-building process. After two e-Delphi rounds, seven goals and eight recommendations on the components and timing of Ear Health and Hearing Checks in primary healthcare for young Aboriginal and Torres Strait Islander children were developed.

CONCLUSIONS

The systematic scoping review and consensus-building process provided a pragmatic approach for producing strong recommendations within a reasonably short timeframe, despite the low quality and certainty of evidence, and paucity of studies pertaining to primary healthcare settings.

Examining relationships between parent-reported factors and recurring ear symptoms among Aboriginal and Torres Strait Islander children

ISSUE ADDRESSED

Aboriginal and Torres Strait Islander child ear health is complex and multiple. We examined relationships between parent-reported sociodemographic, child health, health service access factors and ear symptoms among Aboriginal and Torres Strait Islander children aged 3 to 7 years.

METHODS

The Longitudinal Study of Indigenous Children is a large child cohort study with annual parent-reported data collection. Generalised linear mixed model analyses examined Wave 1 (1309 children 0-5 years; 2008) predictors of being free of parent-reported ear symptoms in both Waves 2 and 3.

RESULTS

A total of 1030 (78.7%) had no reported ear symptoms in either Wave 2 or 3. In the fully adjusted model, children who had been hospitalised in the past year (aOR = 2.16; 95% CI 1.19-3.93) and those with no ear symptoms (aOR = 2.94; 95% CI, 1.59-5.46) at Wave 1 had higher odds of no ear symptoms in both the subsequent waves. There were also relationships between parent main source of income-government pension or allowance as well as parents who reported no history of their own ear symptoms and higher odds of no ear symptoms in Waves 2 and 3 after partial adjustment for sociodemographic factors.

CONCLUSION

These findings suggest relationships between different sociodemographic and health factors and parent-reported ear symptoms among Aboriginal and Torres Strait Islander children that warrant further investigation. So what? Children with parent-reported ear symptoms during the early years need holistic support to prevent future ear symptoms that impact health, social and educational life trajectories.

Routine ear health and hearing checks for Aboriginal and Torres Strait Islander children aged under 6 years attending primary care: a national consensus statement

This consensus statement provides new recommendations for primary care assessment of ear health and hearing status of young Aboriginal and Torres Strait Islander children who are not known to have, or are not being actively managed for, ear health and hearing problems. Any child identified with otitis media should be actively managed. This national consensus statement extends existing treatment and management guidelines. MAIN RECOMMENDATIONS: Undertake checks at least 6-monthly, commencing at 6 months until 4 years of age, then at 5 years. Undertake checks more frequently in high risk settings for children under 2 years, when acceptable to families, or in response to parent/carer concerns. Ask parents/carers about concerns, signs, and symptoms; check children's listening and communication skills; and assess middle ear appearance and mobility. Otoacoustic emissions testing is suggested when equipment is available, primary health practitioners have capability and confidence to use the equipment, and there is local preference for its use. Video otoscopy is suggested for health promotion purposes, and/or for sharing images with other health practitioners. Audiometry should be done as per existing guidelines: when there are parent/carer concerns, signs of persistent/recurrent otitis media, or when listening and communication development is not yet on track. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: Key practice changes include routine use of tympanometry, and listening and communication skills checklists. Implementation will require access to equipment and training; clear information on immediate, practical actions for families; timely pathways to referral services; and a change management process that shifts perception and tolerance of otitis media and its impacts and raises expectations that Aboriginal and Torres Strait Islander children can have healthy ears and hearing.

Ear and hearing care programs for First Nations children: a scoping review

BACKGROUND

Ear and hearing care programs are critical to early detection and management of otitis media (or middle ear disease). Otitis media and associated hearing loss disproportionately impacts First Nations children. This affects speech and language development, social and cognitive development and, in turn, education and life outcomes. This scoping review aimed to better understand how ear and hearing care programs for First Nations children in high-income colonial-settler countries aimed to reduce the burden of otitis media and increase equitable access to care. Specifically, the review aimed to chart program strategies, map the focus of each program against 4 parts of a care pathway (prevention, detection, diagnosis/management, rehabilitation), and to identify the factors that indicated the longer-term sustainability and success of programs.

METHOD

A database search was conducted in March 2021 using Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Programs were eligible or inclusion if they had either been developed or run at any time between January 2010 to March 2021. Search terms encompassed terms such as First Nations children, ear and hearing care, and health programs, initiatives, campaigns, and services.

RESULTS

Twenty-seven articles met the criteria to be included in the review and described a total of twenty-one ear and hearing care programs. Programs employed strategies to: (i) connect patients to specialist services, (ii) improve cultural safety of services, and (iii) increase access to ear and hearing care services. However, program evaluation measures were limited to outputs or the evaluation of service-level outcome, rather than patient-based outcomes. Factors which contributed to program sustainability included funding and community involvement although these were limited in many cases.

CONCLUSION

The result of this study highlighted that programs primarily operate at two points along the care pathway-detection and diagnosis/management, presumably where the greatest need lies. Targeted strategies were used to address these, some which were limited in their approach. The success of many programs are evaluated as outputs, and many programs rely on funding sources which can potentially limit longer-term sustainability. Finally, the involvement of First Nations people and communities typically only occurred during implementation rather than across the development of the program. Future programs should be embedded within a connected system of care and tied to existing policies and funding streams to ensure long term viability. Programs should be governed and evaluated by First Nations communities to further ensure programs are sustainable and are designed to meet community needs.

INFLATE: a protocol for a randomised controlled trial comparing nasal balloon autoinflation to no nasal balloon autoinflation for otitis media with effusion in Aboriginal and Torres Strait Islander children

BACKGROUND

Otitis media with effusion (OME) is common and occurs at disproportionately higher rates among Indigenous children. Left untreated, OME can negatively affect language, development, learning, and health and wellbeing throughout the life-course. Currently, OME care includes observation for 3 months followed by consideration of surgical ventilation tube insertion. The use of a non-invasive, low-cost nasal balloon autoinflation device has been found beneficial in other populations but has not been investigated among Aboriginal and Torres Strait Islander children.

METHODS/DESIGN

This multi-centre, open-label, randomised controlled trial will determine the effectiveness of nasal balloon autoinflation compared to no nasal balloon autoinflation, for the treatment of OME among Aboriginal and Torres Strait Islander children in Australia. Children aged 3-16 years with unilateral or bilateral OME are being recruited from Aboriginal Health Services and the community. The primary outcome is the proportion of children showing tympanometric improvement of OME at 1 month. Improvement is defined as a change from bilateral type B tympanograms to at least one type A or C1 tympanogram, or from unilateral type B tympanogram to type A or C1 tympanogram in the index ear, without deterioration (type A or C1 to type C2, C3, or B tympanogram) in the contralateral ear. A sample size of 340 children (170 in each group) at 1 month will detect an absolute difference of 15% between groups with 80% power at 5% significance. Anticipating a 15% loss to follow-up, 400 children will be randomised. The primary analysis will be by intention to treat. Secondary outcomes include tympanometric changes at 3 and 6 months, hearing at 3 months, ear health-related quality of life (OMQ-14), and cost-effectiveness. A process evaluation including perspectives of parents or carers, health care providers, and researchers on trial implementation will also be undertaken.

DISCUSSION

INFLATE will answer the important clinical question of whether nasal balloon autoinflation is an effective and acceptable treatment for Aboriginal and Torres Strait Islander children with OME. INFLATE will help fill the evidence gap for safe, low-cost, accessible OME therapies.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12617001652369 . Registered on 22 December 2017. The Australia New Zealand Clinical Trials Registry is a primary registry of the WHO ICTRP network and includes all items from the WHO Trial Registration data set. Retrospective registration.

Otitis media guidelines for Australian Aboriginal and Torres Strait Islander children: summary of recommendations

Introduction

The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Main recommendations

We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions.

Changes in management as a result of the guidelines

A GRADE approach is used.

Targeted recommendations for both high and low risk children.

New tympanostomy tube otorrhoea section.

New Priority 5 for health services: annual and catch‐up ear health checks for at‐risk children.

Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children.

Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration.

Concurrent audiology and surgical referrals are recommended where delays are likely.

Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis.

The use of autoinflation devices is recommended for some children with persistent otitis media with effusion.

Definitions for mild (21–30 dB) and moderate (> 30 dB) hearing impairment have been updated.

New “OMapp” enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Remediating spatial processing disorder in Aboriginal and Torres Strait Islander children

OBJECTIVE

Australian Aboriginal and Torres Strait Islander children are much more likely than non-Indigenous children to experience early onset, chronic otitis media and associated hearing loss. This can result in the child developing spatial processing disorder (SPD). The aim of this study was to assess the efficacy of Sound Storm auditory training in remediating SPD in Aboriginal and Torres Strait Islander children at a regional school in Queensland, Australia.

METHOD

Fifteen Aboriginal and Torres Strait Islander children (males = 8, females = 7, age range = 6-13 years, mean = 8 years; 6 months) with SPD were tested on audiometry, the Listening in Spatialized Noise - Sentences Test (LiSN-S), and Listening in Spatialized Noise - Universal Test (LiSN-U). Teachers completed the Listening Inventory for Education - Revised Teacher Questionnaire (LIFE-R) and Auditory Processing Domains Questionnaire (APDQ). These measures were taken pre- and post-training with Sound Storm.

RESULTS

Children's Sound Storm noise-to-signal ratio improved significantly and was positively correlated with the number of games they played. Eight of the nine children who completed at least 40% of the training were retested on the LiSN-S, LiSN-U, LIFE-R, and APDQ post-training. SPD was remediated in seven children according to the LiSN-S. All five children who were retested on the LiSN-U post-training showed spatial advantage scores within the normal range. Questionnaire results were mixed with only some children showing improved scores on the LIFE-R and APDQ.

CONCLUSIONS

Sound Storm auditory training can be used in school with Aboriginal and Torres Strait Islander children to remediate SPD, however, it has its challenges. Maintaining the child's motivation to complete the training can be difficult. Additionally, the impacts of school holidays, events, and absences must be managed, as well as the impacts of the program on the child's school day.

Detection of hearing problems in Aboriginal and Torres strait islander children: a comparison between clinician-administered and self-administrated hearing tests

Objective: This study evaluated the agreement of self-administered tests with clinician-administered tests in detecting hearing loss and speech-in-noise deficits in Aboriginal & Torres Strait Islander children.Design: Children completed clinician-administered audiometry, self-administered automatic audiometry (AutoAud), clinician-administered Listening in Spatialised Noise - Sentences test and self-administered tablet-based hearing game Sound Scouts. Comparisons were made between tests to determine the agreement of the self-administered tests with clinician-administered tests in detecting hearing loss and speech-in-noise deficits.Study sample: Two hundred and ninety seven Aboriginal and Torres Strait Islander children aged 4-14 years from three schools.Results: Acceptable threshold differences of ≤5 dB between AutoAud and manual audiometry hearing thresholds were found for 88% of thresholds, with a greater agreement for older than for younger children. Consistent pass/fail results on the Sound Scouts speech-in-quiet measure and manual audiometry were found for 81% of children. Consistent pass/fail results on the Sound Scouts speech-in-noise measure and LiSN-S high-cue condition were found for 73% of children.Conclusions: This study shows good potential in using self-administered applications as initial tests for hearing problems in children. These tools may be especially valuable for children in remote locations and those from low socio-economic backgrounds who may not have easy access to healthcare.

Hearing loss and speech understanding in noise in Aboriginal and Torres Strait Islander children from locations varying in remoteness and socio-educational advantage

OBJECTIVE

Otitis media resulting in conductive hearing loss is a major health issue for Aboriginal and Torres Strait Islander children, which can also lead to the child developing spatial processing disorder (SPD). This study examined the prevalence of hearing loss and deficits in speech understanding in noise, including SPD, in Aboriginal and Torres Strait Islander children from schools varying in remoteness and socio-educational advantage.

METHOD

288 Aboriginal and Torres Strait Islander children aged 4-14 years from three schools varying in remoteness and socio-educational advantage completed audiological assessment and the Listening in Spatialized Noise - Sentences test to assess for hearing loss and SPD. Children also completed Sound Scouts, a self-administered tablet-based hearing test which screens for these deficits. The prevalence of hearing issues was compared to what is expected from a typical population.

RESULTS

The proportion of children with hearing problems was related to the school's socio-educational advantage, with higher proportions in schools with a lower socio-educational advantage. Proportions of children with speech-in-noise deficits (including SPD) was related to the remoteness of the school, with higher proportions in schools that were more remote.

CONCLUSIONS

The prevalence of hearing loss and SPD is much higher in Aboriginal and Torres Strait Islander children than described for non-Aboriginal populations, and is related to the socio-educational advantage or remoteness of the school. Resources are needed to reduce the incidence of hearing loss and health disparity in Aboriginal communities, especially those in remote areas with lower socio-educational advantages.

A program to respond to otitis media in remote Australian Aboriginal communities: a qualitative investigation of parent perspectives

Background

Indigenous infants and children in Australia, especially in remote communities, experience early and chronic otitis media (OM) which is difficult to treat and has lifelong impacts in health and education. The LiTTLe Program (Learning to Talk, Talking to Learn) aimed to increase infants’ access to spoken language input, teach parents to manage health and hearing problems, and support children’s school readiness. This paper aimed to explore caregivers’ views about this inclusive, parent-implemented early childhood program for 0–3 years in an Aboriginal community health context.

Methods

Data from in-depth, semi-structured interviews with 9 caregivers of 12 children who had participated in the program from one remote Aboriginal community in the Northern Territory are presented. Data were analysed thematically. Caregivers provided overall views on the program. In addition, three key areas of focus in the program are also presented here: speech and language, hearing health, and school readiness.

Results

Caregivers were positive about the interactive speech and language strategies in the program, except for some strategies which some parents found alien or difficult: such as talking slowly, following along with the child’s topic, using parallel talk, or baby talk. Children’s hearing was considered by caregivers to be important for understanding people, enjoying music, and detecting environmental sounds including signs of danger. Caregivers provided perspectives on the utility of sign language and its benefits for communicating with infants and young children with hearing loss, and the difficulty of getting young community children to wear a conventional hearing aid. Caregivers were strongly of the opinion that the program had helped prepare children for school through familiarising their child with early literacy activities and resources, as well as school routines. But caregivers differed as to whether they thought the program should have been located at the school itself.

Conclusions

The caregivers generally reported positive views about the LiTTLe Program, and also drew attention to areas for improvement. The perspectives gathered may serve to guide other cross-sector collaborations across health and education to respond to OM among children at risk for OM-related disability in speech and language development.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1081-3) contains supplementary material, which is available to authorized users.