The major goals are to determine if the position, shape, and features ofthe ear are normal and to detect abnormalities. Note the position of the ears in relation to the eyes. An imaginary line drawn across the inner and outer can-thi of the eyes should cross the pinna or auricle; if the pinna is below this line then the infant has low-set ears.

Small, deformed, or low-set auricles may indicate associated congenital defects, especially renal disease.

Examination of the newborn's ear with an otoscope can only detect patency of the ear canal because the tympanic membrane is obscured by accumulated vernix caseosa for the first few days of life. In infancy, the ear canal is directed downward from the outside; therefore, you may want to pull the auricle gently downward rather than upward for the best view of the ear drum. Once the tympanic membrane becomes visible, you may note that the light reflex is diffuse and does not become cone-shaped for several months.

A small skin tab, cleft, or pit found just forward of the tragus represents a remnant of the first branchial cleft and usually has no significance.

The acoustic blink reflex is a blinking of the infant's eyes in response to a sudden sharp sound; you can produce this by snapping your fingers or using a bell, beeper, or other noisemaking device about a foot from the infant's ear. Be sure that you are not producing an airstream that may cause the infant to

Perinatal problems raising the risk for hearing defects include birth weight <1500 grams, anoxia, treatment with potentially ototoxic blink. The reflex may be difficult to elicit during the first 2 to 3 days of life. After it is elicited several times, the reflex will disappear, a phenomenon known as habituation. This is a crude test of hearing, and certainly does not determine normal hearing. Currently, there is an increased movement toward universal hearing screening of all newborns in addition to those at high risk for hearing problems.


Signs That an Infant Can Hear

0-2 months

Startle response and blink to a sudden noise Calming down with soothing voice or music

2-3 months

Change in body movements in response to sound Change in facial expression to familiar sounds

3-4 months

Turning eyes and head to sound

6-7 months

Turning to listen to voices and conversation

medications, congenital infections, severe hyperbilirubinemia, and meningitis.

Many children with hearing deficits are not diagnosed until as old as 2 years. Clues to hearing deficits include parental concern about hearing, delayed speech, and lack of developmental indicators of hearing.

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