The ‘radical overhaul’ needed to children’s hearing services, should start with glue ear management

What is it about?

In 2025, the UK government commissioned the Kingdon Review of Children’s Hearing Services, which identified ‘major problems’ across NHS services causing children to be ‘harmed’. The conclusion was that services need a ‘radical overhaul’ which could potentially start with the most common hearing loss presenting to paediatric audiology services: glue ear, also known as otitis media with effusion (OME)

Featured Image

Photo by Jon Tyson on Unsplash

Photo by Jon Tyson on Unsplash

Why is it important?

THE MOST COMMON PATHWAY IN CHILDREN'S HEARING SERVICES Although hearing services can tend to focus on babies or children with permanent (often sensorineural deafness affecting the inner ear), glue ear (a conductive hearing ditterence attecting the middle ear) 1s ~100 times more common in children and represents one of the core workloads of paediatric audiology services. School hearing screening programmes identified that glue ear affects around 1 in 10 children in their first year at school when access to clear speech is critical for vocab-ulary, phonics and early reading develop-ment. Across childhood, up to 80% of children will experience glue ear. Despite this, it is not routinely highlighted to new parents nor included in teacher training, even though as many as 30% of a classroom can potentially be affected during winter months. Identification depends on school hearing screening programmes, which have been shown to be cost-effective* but have been reduced in several regions. Compounding this, children rarely report hearing difficulties themselves, and adults may not recognise or act on subtle signs. As a result, delays are common: In one study. parents reported concerns for a mean of 2.9 years before their child reached an intervention. Children therefore often present not with hearing complaints but with downstream consequences, such as speech and language delay, behavioural changes educational difficulties, Reflecting a system that intervenes too late (National Institute for Health and Care Excellence guidance). Following referral, children may wait up to 6 weeks for an initial hearing assess-ment. In early childhood, this represents a meaningful proportion of developmental time.' 2 The Centre on the Developing Child at Harvard University has identified that the fast, early development of hearing pathways lays the foundations for further cognitive pathways, with the first 1000 days being a critical window of opportunity. The hearing assessment itself was not designed for children but for men's noise-induced hearing loss as thev returned from the World Wars in the early 1900s: a threshold audiogram, typically testing frequencies in a quiet, soundproof setting. Listening in real life, however, is not conducted in silence and this is particularly important for children who are still developing the ability to understand speech in noise. This means that even those with good hearing thresholds depend heavily on good acoustic environments to access language and learning.® Listening itself is a cognitive task: when effort is diverted to decoding degraded speech, fewer cognitive resources remain for comprehension, memory and learning. For this reason, measures such as speech-in-noise testing and speech intelligibility indices could contribute to a more meaningful assessment of functional hearing. Listening is also shaped by wider developmental domains, including attention and executive function. Pure-tone audiometry in a soundproof environment does not reliably predict real-world listening. Children with similar thresholds can demonstrate markedly different speech intelligibility and listening effort." Current conventions define 0-20 dB as 'normal, yet even minimal losses in the 15-20dB range can impair speech perception in noise for some chil-dren, suggesting that a 15 dB threshold may be more appropriate. Importantly, listening difficulties may persist even after audiometric thresholds return to 'normal’ following glue ear, but this is not routinely recognised within National Health Service pathways. Glue ear itself is a fluctuating condition, and can result in unilateral losses, which can impair listening but are often under-estimated.Despite this, children are frequently discharged once thresholds fall within nominal 'normal' ranges, regardless of clinical history or functional concerns TERMINOLOGY AND ITS CONSEQUENCES Terminology plays a powerful role in shaping clinical behaviour and parental understanding. The label 'mild hearing loss (typically 20-40 dB) risks minimising impact, despite representing a level of hearing that can significantly degrade speech clarity. While those with mild hearing loss may fare well in good acoustic conditions, listening may be particularly difficult in background noise. Evidence shows that such levels of loss can have lasting developmental and educational consequences. The term mild therefore obscures the lived reality of children's listening. It fails to capture the cumulative cognitive burden of degraded auditory input, background noise and developmental listening skills, conceptualised here as Listening Load Affecting Cognition (LiLAC). A mild or moderate hearing loss could be framed as the addition of a mild or moderate listening load, potentally affecting cognition . If this is not explicitly recognised or explained, opportunities for early, supportive intervention are lost. FUTURE OF HEARING SERVICES Children's hearing services could extend beyond threshold detection to consider functional listening. educational access and emotional well-being. Hearing difficulties attect not only the child but the wider family." When concerns are not adequately recognised addressed, parents may feel compelled to 'fight the system' to secure support. Misalignment between stakeholders adds further complexity. Research shows that parents, teachers and clinicians often prioritise different aspects of the child's experience.contributing to misunder- standing and fragmented care. It glue ear persists across repeat assessments, children are referred to Ear, Nose and hroat services. This introduces further delay before consideration of interventions such as grommets (also known as tympanostomy tubes or ventila- tion tubes) insertion. However, evidence remains limited regarding which children benefit most and to what extent from such procedures. The pathway therefore has historically been set up to lead towards a surgical decision without fully addressing earlier, modifiable factors affecting listening, learning and development. Early identification of glue ear through school and special-school programmes works well in some remaining areas of the UK. Several American organisations use the lower hearing threshold of 15 dB. Speech in noise testing is considered 'imperative' by some research studies. Managing hearing differences early and proactively at school and at home with involvement of the family is key to ensure good child outcomes. Assistive listening technology support in the classroom could be routinely considered." Using terminology that does not minimise the importance of hearing differences (such as the term 'mild') but acknowledges LiLAC can improve the understanding of adults caring for the child and ensure the child accesses education. Glue ear management could be moved externally peer reviewed. into the community, " which is a current government priority for healthcare in the Fit for the Future 10 year healthcare plan 2025 . Child development needs to be central to discussions and emotional health consequences of glue ear need to be considered.

Perspectives