|
Perinatal
|
|
|
|
1 |
Family history of early, progressive, or delayed onset permanent childhood hearing loss |
|
|
|
2 |
Neonatal intensive care of more than 5 days |
|
|
|
3 |
Hyperbilirubinemia |
|
|
|
4 |
Aminoglycoside administration for more than 5 days |
|
|
|
5 |
Asphyxia or Hypoxic Ischemic Encephalopathy |
|
|
|
6 |
Extracorporeal membrane oxygenation (ECMO) |
|
|
|
7 |
In utero infections, such as herpes, rubella, syphilis, and toxoplasmosis |
|
|
|
8 |
Certain birth conditions or findings:
-
Craniofacial malformations including microtia/atresia, ear dysplasia, oral facial clefting, white forelock, and microphthalmia
-
Congenital microcephaly, congenital or acquired hydrocephalus
-
Temporal bone abnormalities
|
|
|
|
9 |
Syndrome: _____________________________________ |
|
|
|
|
Perinatal or Postnatal
|
|
|
|
10 |
Infections associated with sensorineural hearing loss, including meningitis or encephalitis |
|
|
|
11 |
Events associated with hearing loss:
-
Significant head trauma especially basal skull/temporal bone fractures
|
|
|
|
12 |
Caregiver concern regarding hearing, speech, language, development delay and/or development regression |
|
|
|
|
Emerging factors from LMICs
|
|
|
|
13 |
Maternal hypertensive disorders in pregnancy |
|
|
|
14 |
Non-elective caesarean delivery |
|
|
|
15 |
Unskilled attendant at delivery |
|
|
|
16 |
Undernutrition |
|
|
|
|
Possible risk-factor for the Pacific Islands
|
|
|
|
17 |
Gestational diabetes |
|
|
|