Artigo Original
Kátia de Freitas Alvarenga1 Eliene Silva Araújo2 Tatiana Mendes de Melo3 Maria Angelina Nardi Martinez4 Maria Cecília Bevilacqua5
Descritores
Monitoramento Perda auditiva Triagem neonatal Questionários Programa saúde da família Audiologia Keywords
Monitoring Hearing loss Neonatal screening Questionnaires Family health program Audiology
Correspondence address:
Kátia de Freitas Alvarenga Department of Fonoaudiologia Al. Octávio Pinheiro Brisola, 9/75, Bauru (SP), Brasil, CEP: 17012-901. E-mail: katialv@fob.usp.br
Received: 8/26/2011
Accepted: 4/9/2012
Study conducted at the Department of Speech-Language Pathology and Audiology, Bauru School of Dentistry, Universidade de São Paulo – USP – Bauru (SP), Brazil; Associação de Pais de Deficientes Auditivos de Soro-caba – APADAS – SoroSoro-caba (SP), Brazil.
(1) Department of Speech-Language Pathology and Audiology, Bauru School of Dentistry, Universidade de São Paulo – USP – Bauru (SP), Brazil; Audiological Research Center, Hospital for Rehabilitation of Craniofacial Anomalies, Universidade de São Paulo – USP – Bauru (SP), Brazil.
(2) Graduate Program (Masters degree) in Language Pathology and Audiology, Department of Speech-Language Pathology and Audiology, Bauru School of Dentistry, Universidade de São Paulo – USP – Bauru (SP), Brazil. (3) Undergraduate Program in Speech-Language Pathology and Audiology, Universidade de Guarulhos – UnG – Guarulhos (SP), Brazil.
(4) Department of Clinical Language Pathology and Audiology, Undergraduate Program in Speech-Language Pathology and Audiology, Pontifícia Universidade Católica de São Paulo – PUC-SP – São Paulo (SP), Brazil; Associação de Pais e Amigos de Deficientes Auditivos de Sorocaba – APDAS – Sorocaba (SP), Brazil. (5) Department of Speech-Language Pathology and Audiology, Bauru School of Dentistry, Universidade de São Paulo – USP – Bauru (SP), Brazil; Graduate Program in Speech-Language Pathology and Audiology, Pontifícia Universidade Católica de São Paulo – PUC-SP – São Paulo (SP), Brazil.
Conflict of interests: None
development in the first year of life
Questionário para monitoramento do desenvolvimento
auditivo e de linguagem no primeiro ano de vida
ABSTRACT
Purpose: To validate a monitoring questionnaire about hearing and language development applied by community health agents in the first year of life. Methods: Seventy six community health agents, previously trained on infant hearing health, administered a questionnaire to the families of 304 children with ages from 0 to 1 year. The questio-nnaire contains questions regarding hearing and language development and, for all age groups, the question “Does your child hear well?” was presented. The validity of the questionnaire was assessed by analyzing false positive and false negative rates of the identified children. A double-blind study was conducted so that all children asses-sed by the questionnaire were submitted to hearing evaluation performed by audiologists. Results: Four children (1.32%) were diagnosed with sensorineural hearing loss (two unilateral), and 69 (22.7%) with conductive hearing loss. The monitoring questionnaire showed specificity of 96% and sensitivity of 67%, with a false-negative rate of 33% for not identifying the unilateral hearing loss, and a false-positive rate of 4%. Conclusion: The questionnaire used has shown to be feasible and relevant to actions of the community health agents of the Family Health Strategy program, with high specificity and moderate sensitivity. The use of the validated instrument should be considered to complement Newborn Hearing Screening Programs, in order to identify late onset or acquired hearing loss. RESUMO
INTRODUCTION
Literature on the subject provides an ample discussion about the scientific evidence regarding the effectiveness of the newborn hearing screening (NHS) programs in promoting the diagnosis of hearing deficiency and making an intervention in the first months of life possible, mainly in developing countries. The main point discussed is the fact that many programs are not inserted in programs of newborn hearing health that guarantee efficient and fast access to diagnosis and (re)habili-tation. Moreover, the difficulty in the monitoring of children who pass the NHS and present a risk for hearing losses of late manifestation(1) is highlighted.
Other problems are inherent to this type of program, such as a percentage of newborn babies that do not go through the hearing screening and the high abandonment rate of newborns that do not continue on to the other stages of the identification process (NHS retest) and/or audiologic diagnosis, when ne-cessary. The abandonment rate throughout the identification process – that is, children who do not undergo the diagnostic – is one of the difficulties in the implementation of newborn hearing screening programs both nationally(2-4) and internationally(5-7). In this sense, the audiologic evaluation with a diagnostic purpose must occur a few weeks after discharge from the hospital in order to minimize the number of children who do not return, as the probability of these newborns coming to the appointment is greater in the first weeks of life(8).
When it is verified that the diagnostic process of newborns identified in the NHS already imposes difficulties, the mo-nitoring of those who “pass” in NHS but present some risk indicator requires different and efficient strategies. Periodic follow-up in the reference centers of all newborns with risk indicators but who “pass” the NHS has proven many times to be an unfeasible practice, creating a scheduling flow that requires a large team of specialized professionals, making the cost-effectiveness of the program very high. Because of this reality, it is recommended that the follow-up appointments with the newborns occur according to the risk indicators – that is, the number of evaluations and the moment they will occur must be defined individually, in accordance with the scientific evidences of the possibility of hearing loss with late onset(9). Congenital infection by Cytomegalovirus, many times asymp-tometic, mitocondrial mutation A1555G, and the widening of the initial aqueduct (widened vestibular aqueduct syndrome) are described as being responsible for 60% of the hearing losses of late onset(10,11).
Experience shows that isolated NHS programs are destined to fail if they are not part of a wider program of auditory health that establishes a connection with the several levels of attention to health, thus creating a network of identification, orientation, and support to the families, diagnosis, and intervention. The success of the programs of hearing health depends on the inter-relation of some factors, including the support and the public policies for research and monitoring, continued education of the involved professionals in all levels of attention to health, and the existence of centers of excellence for diagnosis and intervention(12).
Considering the problems presented, the creation of stra-tegies that extend the identification and early detention of the hearing deficiency in all levels of attention to health, and not only the NHS, becomes necessary.
In Brazil, the Family Health Strategy (FHS) started in 1994, having as a precursor the Community Health Agents Program (CHAP) implemented in 1991, supported in international and national experiences of the extension of health coverage by means of assistance to families in their own homes along with the health units(13). In this context, the community health agents (CHAs) are the health professionals who have greater contact with the community, and thus are able to play an im-portant role in infantile auditory health, making diagnosis of and intervention in auditory deficiencies in the critical period of development of the child possible(2,14,15).
The World Health Organization (WHO) since 1998 has recommended the training of CHAs for primary attention to the hearing and ailments of the ear, supported by a reference and counter-reference system(16). The recommendations of the International Workshop onPrimary Ear and Hearing Care re-sulted in three manuals published by the WHO that correspond to the three levels of training of community health agents: basic, intermediate, and advanced(17). A questionnaire to help CHAs identify hearing alterations is proposed in the training manuals for the intermediate and advanced levels. The question “Can your child hear well?” is suggested so that the parents’ suspicions are valued and verified(17).
The use of questionnaires applied to the parents is rec-ommended by the American Academy of Pediatrics for the programs of identification and development alterations, with posterior referral for specialized evaluations, adding to the pediatrician’s clinical observation(18).
As such, the objective of the present study was to validate a monitoring questionnaire of the development of auditory and language functions applied by community health agents in the first year of life.
METHODS
This study was approved by the Ethics Committee in Research of the Bauru School of Dentistry – Universidade de São Paulo (FOB-USP), under n º 73/2006. The parents/ guardians of the participants, as well as the community health agents (CHAs), consented to participate in the research by signing the free and clarified consent form.
Casuistry
Methodology
The CHA that participated in the study had previously participated in the presential qualification course in the area of infantile hearing health, with eight contact hours(14). The content was adapted from the World Health Organization’s,ear and hearingcare training resource(17),involving the subjects: hearing and auditory deficiency, types and causes of hearing losses, identification techniques, diagnosis, and hearing defi-ciency rehabilitation. Another aspect covered was the standard of normality for motor and language development.The CHAs receiveda booklet with the content taught so that they could follow the activities carried out interactively.
The questionnaire applied by the CHAs contained questions about hearing and language development, considering the behaviors expected each month, in the period of 0 to 1 year. The question “Can your child hear well?” was included in every month in order to verify the parents’ opinion about their children’s hearing (Appendix 1).
The validity of the questionnaire applied by the CHAs as an identification tool of children with hearing alteration was veri-fied through the analysis of the false-positive and false-negative rates of the children investigated. A double-blind study was used where all the children investigated for the questionnaire were submitted, in the same week, to an audiologic evaluation carried out by speech and language therapists – thus considered the gold standard.
The audiologic evaluation was carried through in the Nucleus of Health, in which the Family Health Strategy is inser-ted by means of anamnesis, transient evaluation of the auditory behavior with the Ling sounds(19), transient evoked otoacoustic emissions, and acoustics immittanciometry(tympanometry and research of the acoustic reflex). The criteria adopted for analysis were, respectively: auditory behavior in accordance with the standard expected for their age, based on a national study(20); presence of transient evoked otoacoustic emissions in at least three non-consecutive frequencies, including 4 kHz, with reproductibility ≥70% and relation signal noise ≥6dB; tympanometric curve with complacency of 0.3 and 1.3 ml and
pressure of +90 to -100 daPa; and the presence of acoustic consequences in the intensity <100dB.
Children who presented alterations in any of the applied tests were referred to the clinic of the Language and Speech Therapy Course of the Faculdade de Odontologia de Bauru, Universidade de São Paulo for medical evaluation and supple-mentation of the audiologic evaluation with the research of the brainstem auditory evoked potentials (BAEP) and audiometry with visual reinforcement, and if necessary, specific treatment. For BAEP analysis, the presence of waves I, III, and V was considered, with absolute latencies and inter-peak intervals within the normality standards for the age group and in the visual reinforcement audiometry, with a threshold of 20 dB HL in the frequencies from 500 HZ to 4 kHz. The speech and language therapists that performed the audiologic evaluation had not had previous contact with the information in the ques-tionnaire applied by the CHAs.
Children were identified as “at risk for auditory alteration” if the response “no” was obtained for at least one of the questions on the questionnaire for the age of the child. On the other hand, when all the answers were adequate, the child was considered as presenting development expected for his or her age. For the analysis of the data, the possible results of the audiologic evaluation were: normal hearing, conductive hearing loss, and sensorineural hearing loss.
Data analysis
The data were tabulated in the Microsoft Office Excel database, version 14.0, and later submitted to statistical des-criptive analysis by means of the calculation of the sensitivity index, specificity, false positive, false negative, positive, and negative predictive values; the reliability interval was 95% for all the measurements. Additionally, the reason of likelihood ratio was calculated.
RESULTS
In the audiologic evaluation, out of the 304 children, 75
(24.67%) presented hearing alteration and 229 (75.33%) pre-sented normal results. The hearing alteration classification in regard to type, in accordance with the audiologic evaluation, is described in Table 1. As for the degree, the observed auditory alterations were mild or moderate, regardless of type.
Of the 69 children with conductive hearing loss due to serous otitis media, according to the audiologic evaluation and the diagnosis carried out by the ENT doctor of the institution, only one (1.45%) was identified by the applied questionnaire. Considering only the sensorineural hearing losses, Table 2 presents the distribution of the casuistry according to the results obtained in the follow-up questionnaire and the audio-logic evaluation.
The analysis of the validity of the follow-up questionnaire applied by the CHAs for identification of sensorineural hearing loss, including the reliability interval of 95% and the analysis of the reason of positive likelihood, can be found in Table 3.
DISCUSSION
The use of questionnaires as a way of identifying alterations
in the auditory development in different age groups is widely discussed in the literature(21-24).
In the present study 69 children (22.7%) were diagnosed with conductive hearing loss and four with sensorineural losses (1.32%), both with a mild or moderate degree.
A high rate of middle ear alteration was not identified by the questionnaire (Table 1). In this case, the hearing loss found is conductive, generally of a mild degree, which makes identi-fying it through the questions answered by the parents difficult; once the child reacts to and observes medium/strong-intensity sound, as well as observes verbal language acquisition and development, what turns to suspicion of auditory alteration on the part of the extremely difficult family. Previous studies demonstrated that questionnaires are not considered effective tools for the identification of conductive hearing losses, since they do not differentiate children with or without conductive disorders(25,26).
However, the fact that the questionnaire does not identify conductive hearing losses presented itself as an advantage for the program that uses it, since early identification of the serous otitis media in asymptomatic children does not improve the results of the intervention; thus, the hearing screening in this situation is not recommended(27).
Generally, the studies pointed out that questionnaires direc-ted to the identification of alterations in the hearing function present specificities between 94% and 100% and sensitivity varying from 10% to 75%(21-24). This variability in sensitivity can be justified by the methodological differences in regard to the age group studied, comprised of children between 6 months and 7 years of age; or with regard to the value of au-dibility considered as hearing loss, which in some studies had been considered 40 thresholds above the dB HL definition of incapacitating loss of the WHO(16) or above 20 dB HL when considering children of 0 to 1 year(28).
As observed in Tables 2 and 3, when the sensorineural hea-ring loss is considered, the applied questionnaire demonstrated specificity of 96% and sensitivity of 67% – data consistent with the previous studies that used the questionnaire as methodo-logy(21-24). It is important to highlight that the sensitivity of the tool and the false negative index obtained (33%) were the result of the non-identification of the two children with unilateral sensorineural hearing loss. This should not be analyzed as a weakness in the procedure, since a point that must be conside-red is the family’s perception of the development of the child’s auditory and language function(23).
In general, regardless the socio-economic level, the non--reaction to sound(29) and the non-acquisition of the language(30) are the main indications that make families suspect hearing alterations. In the presence of unilateral hearing loss such indi-cations are minimized, which makes it difficult for the families to suspect something is wrong. The monthly application of the questionnaire increases the possibility of identifying these al-terations without increasing the cost of the procedure since the proposal is that such action be included in the routine of the NHS.
As for the false positive rate (4%), it is within the proposed rate of the committees for the hearing screening programs, thus suggesting that the procedure does not require extreme costs by
Table 1. Distribution in regard to the type of hearing alteration of the diagnosed children
Hearing alteration Number of children %
Unilateral conductive 28 37.3
Bilateral conductive 41 54.7
Unilateral sensorineural 2 2.7
Bilateral sensorineural 4 5.3
Total 75 100
Table 2. Distribution of the casuistry according to the results obtained in the monitoring questionnaire and the audiologic evaluation, considering the sensorineural hearing losses
Questionnaire result Audiologic evaluation
Normal Abnormal Total
Identified as at risk 11 4 15
Identified as not at risk 287 2 289
Total 299 6 304
Table 3. Analysis of the validity of the monitoring questionnaire ap-plied by the community health agents for identification of sensorineural hearing loss
Measurements Rates
Confidence interval of 95% Lower
limit
Upper limit
Sensitivity 67% 29% 100%
Specificity 96% 94% 98%
False positive 4% 1.5% 5.8%
False negative 33% -4% 4%
Positive predictive value 27% 4% 49%
Negative predictive value 99% 98% 100%
virtue of a large amount of children referred to the audiologic evaluation who do not present alteration. Such data are also evidenced by the likelihood ratio, defined as the possibility of the positive result to diagnose the true illness and not a false result. The obtained value was 18, which is equivalent to saying that the possibility of the result in the questionnaire being a true-positive is 18 times greater than the possibility of it representing a false-positive result.
Considering the results presented, we can consider the use of the questionnaire effective, not as a screening tool for hea-ring, but as a complement to the NHS Program, using the tool as a way to monitor the development of the auditory and language functions of all children in the first year of life, regardless of whether they were submitted to the NHS by professionals such as the CHAs. The characteristic of the HFS allows for the mon-thly follow-up by the CHAs, with the application of the ques-tionnaire in the home visits. The quesques-tionnaire assumes, thus, an informative role for the family, who start to value hearing and observe the children’s responses. The questionnaire had, therefore, an educational and multiplying role in the prevention of the hearing deficiency.
However, it is necessary to understand that when this tool is used, it is possible to identify bilateral hearing losses of higher severity, not detecting unilateral cases of mild losses or unilateral auditory losses. In the first year of life the family’s suspicion of mild alterations is extremely uncommon due to the fact that speech and language development in these cases can be similar to that of children with normal hearing (22).
The proposal to restrict the monitoring to the first year of life has as its objective the gradual insertion of this procedure in the NHS routine, in an effort to improve organization and understand the difficulties. However, it is a fact that in the future this age group will have to be extended, in view of the occurrence of acquired hearing losses or late manifestation.
CONCLUSION
The use of the questionnaire proposed in this study pro-ved to be viable and pertinent to the actions developed by the community health agents of the Family Health Strategy teams. Associated with this, it stirred the families’ interest and observations of the hearing development of their children, in addition to raising questions about the causes of the hearing loss, playing, thus, an educating and multiplying tool in the prevention of hearing deficiency.
ACKNOWLEDGEMENTS
The National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPq) for the research grant pro-vided for the accomplishment of the study, process number 403719/2004-6.
* KFA contributed substantially to acquisition, analysis and interpretation of data, drafting the article, critical review and final approval of the manuscript.
ESA contributed substantially to analysis and interpretation of data, drafting the article, critical review and final approval of the manuscript. TMM contributed substantially to acquisition, analysis and interpretation of data, drafting the article and final approval of the manuscript. MANM contributed substantially to acquisition, analysis and interpretation of data, drafting the article, and final approval of the manuscript. MCB contributed substantially to analysis and interpretation of data, drafting the article, and final approval of the manuscript.
REFERENCES
1. White KR, Forsman I, Eichwald J, Munoz K. The evolution of early hearing detection and intervention programs in the United States. Semin Perinatol. 2010 Apr;34(2):170-179.
2. Barreira-Nielsen C, Futuro Neto, HA, Gattaz G. Processo de implantação de Programa de Saúde Auditiva em duas maternidades públicas. Rev Soc Bras Fonoaudiol. 2007 Jun;12(2):99-105.
3. Bevilacqua MC, Alvarenga KF, Costa OA, Moret ALM. The universal newborn hearing screening in Brazil: from identification to intervention. Int J Pediatr Otorhinolaryngol. 2010 May;74(5):510-5.
4. Alvarenga KF, Melo TM, Lopes AC, Bevilacqua MC, Moret ALM. Participação das famílias em Programas de Saúde Auditiva: um estudo descritivo. Rev Soc Bras Fonoaudiol. 2011 Jan-Mar;16(1):49-53. 5. Korres SG, Balatsouras DG, Gkoritsa E, Eliopoulos P, Rallis E,
Ferekidis E. Success rate of newborn and follow-up screening of hearing using otoacoustic emissions. Int J Pediatr Otorhinolaryngol. 2006 Jun;70(6):1039-43.
6. Mukari SZ, Tan KY, Abdullah A. A pilot project on hospital-based universal newborn hearing screening: lessons learned. Int J Pediatr Otorhinolaryngol. 2006 May;70(5):843-51.
7. Hatzopoulos S, Qirjazi B, Martini A. Neonatal hearing screening in Albania: results from an ongoing universal screening program. Int J Audiol. 2007 Apr;46(4):176-82.
8. Datzell LE, MacDonald MS. Follow up. In: Spivak LG (ed). Universal newborn hearing screening. New York: Thieme; 1998. p. 187-224. 9. Joint Committee of Infant Hearing, (2007). Year 2007 position statement:
principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007 Oct;120(4):898-921.
10. Pryor SP, Madeo AC, Reynolds JC, Sarlis NJ, Arnos KS, Nance WE et al. SLC26A4/PDS genotype-phenotype correlation in hearing loss with enlargement of the vestibular aqueduct (EVA): evidence that Pendred syndrome and non-syndromic EVA are distinct clinical and genetic entities. J Med Genet. 2005 Feb;42(2):159-65.
11. Nance WE, Lim BG, Dodson KM. Importance of congenital cytomegalovirus infections as a cause for pre-lingual hearing loss. J Clin Virol. 2006 Feb; 35(2):221-5.
12. Vohr B, McDermott C, Hess MC, Dorros C. The journey from newborn hearing screening to EHDI system: a historical perspective. In: NHS 2004 Book of Abstracts,Como, Italy, 2004. p. 2-8.
13. Assis AMO, Santos SMC, Freitas MCS, Santos JM, Silva MCM. O Programa Saúde da Família: contribuições para uma reflexão sobre a inserção do nutricionista na equipe multidisciplinar. Rev Nutr.2002 Set;15(3):255-66.
14. Alvarenga KF, Bevilacqua MC, Martinez MANS, Melo TM, Blasca WQ, Taga MFL. Proposta para capacitação de agentes comunitários de saúde em saúde auditiva. Pro Fono. 2008 Jul-Set;20(3):171-6.
15. Melo TM, Alvarenga KF, Blasca WQ, Taga MFL. Capacitação de agentes comunitários de saúde em saúde auditiva: efetividade da videoconferência. Pro Fono. 2010 Apr-Jun;22(2):139-44.
16. World Health Organization. Report of the International Workshop on Primary Ear and Hearing Care, Cape Town, South Africa, 12-14 March, 1998. Geneva: World Health Organization; 2000.
17. World Health Organization. Primary ear and hearing care training resource. 4v. Geneva: Switzerland; 2006.
Appendix 1. Questionnaire of monitoring of the development of the hearing and the language
Name: Date of birth:__/__/__
Area: Micro area:
Family:
1st day to 30/31 days 1st month
1. Can your child hear well? ( ) yes ( ) no
2. Does your child get startled with loud noises? ( ) yes ( ) no
1. Can your child hear well? ( ) yes ( ) no
2. Does your child get startled with loud noises? ( ) yes ( ) no
2nd month 3rd month
1. Can your child hear well? ( ) yes ( ) no
2. Does your child pay attention to sounds? ( ) yes ( ) no 3. Does your child recognize your voice? ( ) yes ( ) no
1. Can your child hear well? ( ) yes ( ) no
2. Does your child calm down with music? ( ) yes ( ) no 3. Does your child make cooing sounds? ( ) yes ( ) no
4th month 5th month
1. Can your child hear well? ( ) yes ( ) no
2. Does your child turn his/her head towards sounds? ( ) yes ( ) no 3. Does your child make more sounds, i.e. fffff, oooo? ( ) yes ( ) no
1. Can your child hear well? ( ) yes ( ) no 2. Does your child look for sounds? ( ) yes ( ) no
3. Does he/she make sounds as trying to talk? ( ) yes ( ) no
6th month 7th month
1. Can your child hear well? ( ) yes ( ) no
2. Does your child look when you call? ( ) yes ( ) no 3. Does he/she say mamama, dadadada as trying to talk? ( ) yes ( ) no
1. Can your child hear well? ( ) yes ( ) no
2. Does your child recognize names of family members? ( ) yes ( ) no
3. Does your child say several different syllables? ( ) yes ( ) no
8th month 9th month
1. Can your child hear well? ( ) yes ( ) no
2. Does he/she turn quickly when called? ( ) yes ( ) no 3. Does he like to play with toys that make noise? ( ) yes ( ) no
1. Can your child hear well? ( ) yes ( ) no
2. Does he understand when people say no? ( ) yes ( ) no
10th month 11th month
1. Can your child hear well? ( ) yes ( ) no 2. Does he/she try imitating sounds? ( ) yes ( ) no
1. Can your child hear well? ( ) yes ( ) no
2. Does he/she wave when he hears bye bye? ( ) yes ( ) no 3. Does he babble as if talking? ( ) yes ( ) no
12th month
1. Can your child hear well? ( ) yes ( ) no 2. Does he say his first words? ( ) yes ( ) no
3. Does he understand commands such as “where’s it” and “give it to me”? ( ) yes ( ) no
Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006 July;118(1):405-20.
19. Ling D. Foundations of Spoken Language for Hearing-Impaired Children. Washington: Alex Graham Bell, Association for the Deaf; 1989. 20. Azevedo MF, Vilanova LCP, Vieira RM. Desenvolvimento auditivo de
crianças normais e de alto risco. São Paulo: Plexus;1995.
21. Newton VE, Liu X, Ke X, Xu L, Bamford JM. Evaluation of the use of a questionnaire to detect hearing loss in babies in China. Int J Pediatr Otorhinolaryngol. 1999 May 5;48(2):125-9.
22. Newton VE, Macharia I, Mugwe P, Ototo B, Kan SW. Evaluation of the use of a questionnaire to detect hearing loss in Kenyan pre-school children. Int J Pediatr Otorhinolaryngol. 2001 Mar;57(3):229-34. 23. Olusanya BO. Early detection of hearing impairments in a developing
country: what options? Audiology.2001 May-Jun;40(3):141-7. 24. Bu X, Li X, Driscoll C. The Chinese hearing questionnaire for school
children. J Am Acad Audiol. 2005 Oct;16(9):687-97.
25. Stewart MG, Ohlms LA, Friedman EM, Sulek M, Duncan NO, Fernandez
AD et al. Is parental perception an accurate predictor of childhood hearing loss? A prospective study. Otolaryngol Head Neck Surg. 1999 Mar;120(3):340-4.
26. Gomes M, Lichtig I. Evaluation of the use of a questionnaire by non-specialists to detect hearing loss in preschool Brazilian children. Int J Rehabil Res. 2005 Jun;28(2):171-4.
27. American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion. Pediatrics. 2004 May;113(5):1412-29.
28. Northern JL, Downs MP. Hearing in children. 4th ed. Baltimore: Williams and Wilkins;1991.
29. Pagnossim DF, Oliveira TMT. Comparação das informações que os pais de diferentes classes sociais têm sobre audição. Pro fono. 1998 Mar;10(1):8-16.
