A head start for babies with hearing loss

DR PEGAH NOORIZADEH provides a historic review of speech and language outcomes in children with permanent childhood hearing loss before and after SWISH implementation in NSW, Australia.

By Dr Pegah Noorizadeh

Early detection of hearing loss, and intervention limit auditory deprivation and support typical speech and language development.

Since its implementation in 2002, the Statewide Infant Screening – Hearing (SWISH) program has served as NSW’s universal newborn hearing screening (UNHS) initiative and, alongside equivalent programs nationwide, is now a routine component of perinatal care.

Its introduction represented a critical public health response to longstanding inequities in detection, embedding early hearing screening in maternity services and improving developmental outcomes for children.

Permanent childhood hearing loss (PCHL) is known to adversely affect early language acquisition, literacy, cognitive function, academic performance, social-emotional wellbeing, social participation, and overall long-term quality-of-life (QOL) with consequences that can extend into adulthood. Children who receive early identification followed by timely, consistent, and high-quality intervention demonstrate significantly improved outcomes in these domains.

Each year, approximately 1.1 per 1000 babies in Australia are born with moderate or greater, permanent bilateral hearing-impairment (HI). This figure also aligns with international estimates for congenital or early-onset permanent hearing-loss in children. About six per 1,000 newborns are identified with a unilateral HI exceeding 30-dB. Hearing-loss (HL) remains the most common sensory impairment in childhood.

Early research found intervention in the first year of life and exposure to UNHS were associated with improved speech and language outcomes in children with PCHL although earlier evidence linking identification to long-term outcomes was limited.

Subsequent cohort and review-level evidence strengthened this association, showing intervention before six months supports better language development into mid-childhood.

While Fitzpatrick et al. (2015) controversially suggested degree of hearing loss may outweigh timing of intervention, methodological limitations of this study have reduced the influence of this finding, which has since been superseded by more robust evidence.

THE LOCHI STUDY

Subsequently, the LOCHI study was a large prospective longitudinal cohort study of 470 children with congenital hearing loss, providing strong observational evidence on the impact of early versus later intervention on developmental outcomes up to nine years of age. LOCHI demonstrated statistically significant benefits of intervention before six months on language, speech, psychosocial outcomes, and functional wellbeing.

Further analyses showed that early detection and intervention were associated with better speech perception in noise at age five. Extension of LOCHI to age nine confirmed superior speech perception, language skills, and quality of life in children who received early intervention and highlighted the role of cognitive factors in supporting spoken language development.

Collectively, these findings reinforce robust evidence that early identification by three months and intervention by six months are critical for optimising long-term speech, language, and broader developmental outcomes in children with PCHL.

Children born with PCHL are vulnerable to delayed language-development due to auditory-deprivation during the early ‘sensitive period’ for language learning. Any review of the effectiveness of universal newborn hearing screening must therefore, consider not only early diagnosis but also timely, ongoing intervention.

Before the introduction of UNHS (like SWISH), severe-HI up to deafness was suspected at 12-months on average. The diagnosis was made at a median age of 18-24 months, and hearing aids (HA) were provided at 22-24 months for severe losses.

While specific post-implementation data for NSW is limited, studies from Israel suggested the median age at diagnosis has decreased from 9.5 months to 3.7 months, and the median age for initiating habilitation has reduced from 19 months to 9.4 months post-UNHS programs.

JCIH (2007, 2019) and Nelson et al. (2008) further highlighted that children with PCHL are at high risk for delays in spoken language, cognitive development, psychosocial wellbeing, and literacy skills if not identified and supported early.

Against this backdrop of converging evidence, JCIH published the Early Hearing Detection and Intervention (EHDI) guidelines, recommending a “1-3-6” model: hearing screening by one month, diagnostic confirmation by three months, and initiation of early intervention services by six months of age (with further consideration to strive towards a more accelerated “1-2-3” timeline). This highlighted the importance of timely and coordinated care, in managing childhood HL.

The launch of the SWISH program in NSW was aimed at identifying infants with moderate-to-profound bilateral hearing loss by three months and initiating intervention by six months. Although it’s not aimed at diagnosing progressive or late onset HL, it is effective in identifying sensorineural-HL, which is often permanent and congenital in nature, as well as some permanent or temporary conductive or mixed-losses.

While early identification and intervention for PCHL are known to improve childhood speech, language, and cognitive outcomes, their persistence into adulthood remains unclear. As adult language and literacy outcomes, central to employment, career progression, social participation, and quality of life, are underexplored, further longitudinal research is needed to evaluate the long-term impact of early-intervention programs such as SWISH. 

About the author: Dr Pegah Noorizadeh is an educator and director at the Australasian College of Audiometry (AuCA). She has extensive experience as a university academic and healthcare practitioner.
Qualifications: B.Pharmacy, B.Dentistry (Honours), Graduate Certificate in Higher Education, Fellowship of Higher Education Academy, Masters in Clinical Audiology.

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