ICU and You · The Australia Page · Number 1

The child who is not ignoring you

Ear disease, hearing, and every bedside assessment that quietly assumes a child can hear

A new column

The Australia Page is for issues that belong particularly to Australia — ancient, modern, and everything in between. Some pieces will be about the oldest continuing cultures on earth, some about the way medicine is done in a country of very long distances, and some about things that are simply ours. This is the first.

You are taught to judge a small child from the end of the cot. Are they engaged? Do they track you? Do they respond to your voice? Every part of that assessment assumes the child can hear it.

For a great many Aboriginal and Torres Strait Islander children between one and five, that assumption is wrong, and the way it fails is unhelpfully quiet.

The scale of it

Middle ear disease in Aboriginal and Torres Strait Islander children starts earlier and lasts longer than almost anywhere on earth. The first episode commonly occurs within the first weeks of life. In remote communities in the Northern Territory, only about one child in ten under the age of three has healthy ears: roughly five have glue ear, and four have suppurative disease — acute infection, perforation, or chronic discharge.

1 in 10

remote NT children under three with healthy ears

>4%

chronic suppurative otitis media — the World Health Organization calls 4% a major public health problem

>50%

perforated eardrums in the worst-affected communities — higher than anywhere else in the world

It is not only a remote problem. Aboriginal and Torres Strait Islander children in rural and urban Australia are also at increased risk, and the true prevalence there is not well described — which is itself worth knowing, because it means the child in front of you in a coastal regional unit is not exempt.

The part that catches everybody out

It usually does not hurt

The severe pain we associate with a bulging eardrum is frequently absent in Aboriginal infants and young children. Nobody knows why. The consequence is that the warning sign we all rely on never arrives: the child does not scream, does not pull at the ear, and does not present. The infection is not treated, and it becomes chronic.

So a small child can be sitting in front of you with significant middle ear disease and give you nothing at all to go on. If you wait to be told about the ears, you will not be told.

What the disease takes is hearing, during precisely the years in which language is assembled. One Western Australian birth cohort found moderate to severe hearing loss in about a third of Aboriginal children over twelve months of age, against roughly seven per cent of non-Aboriginal children. The downstream consequences — language delay, difficulty at school entry, and everything that follows from those — are among the best documented chains in Australian child health.

The causes sit in housing rather than in children: crowding, exposure to tobacco and campfire smoke, and bacterial colonisation of the nasopharynx within days of birth. Breastfeeding in the first six months is substantially protective.

These are the conditions children are born into. They are not a reflection of how they are being raised, and they are not something any community has chosen for itself — household crowding follows from how many houses were built, funded and maintained, not from how families would prefer to live.

Choices were certainly made. They were made about housing programmes, infrastructure, repairs and money, over generations, and overwhelmingly by people a long way from the households now living with the results. That is what the phrase social determinants of health actually means. It is not a gentler way of saying the same thing — it points at a different set of decisions, taken by a different set of people, and it is the reason this is a problem you cannot prescribe your way out of.

The mechanism is worth understanding, because it explains why housing is causal rather than merely associated. In most infants a small bacterial inoculum is cleared, the inflammation switches off and the mucosa recovers. An infant in a crowded house is colonised with all three otopathogens at around five per cent per day, against one per cent and a single organism elsewhere, because the other children in the house carry them at rates approaching one hundred per cent. That early, dense, mixed load keeps the inflammatory cascade running: it damages the middle ear lining without ever eradicating the bacteria, biofilm establishes, and every subsequent cold restarts the discharge.

So the immune system is behaving normally, against a bacterial load no immune system was going to clear. This is immunology driven by exposure, not an immunological difference between populations — and the distinction matters, because the second version is not what the evidence shows.

Why this belongs in an intensive care unit

Because almost everything we do at a small child's bedside is scored on response. Alert, responds to voice. Engagement and eye contact in the paediatric assessment triangle. Sedation and delirium scales built on whether a child reacts to being spoken to. Whether they follow a simple instruction. Whether they settle when a parent talks to them.

A child who cannot hear you will fail several of those, and the failure looks like something else. It looks like drowsiness, or flat affect, or a frightened child who will not cooperate, or — and this is the one that should worry us — like a child who is simply not very responsive, which is a phrase that has done a lot of quiet damage.

Ask, in plain words“Does he hear you alright at home?” and “Has he ever had runny ears?” Families know, and will tell you, and nobody has usually asked.
Look, and expect to find somethingExamine both ears on any Aboriginal or Torres Strait Islander child, whatever they were admitted for. Discharge, a dull immobile drum, a perforation. Absent pain does not mean absent disease.
Change how you approach, not how loudly you shoutGet to the child's eye level and let them see your face. Reduce the noise in the room if you can. Use gesture and demonstration alongside words. Shouting distorts speech and frightens people; it rarely helps.
Say it in the notesIf a child is not responding as expected, record that hearing has been considered. It changes how the next person reads the same child at three in the morning.
Use the admissionThese children are difficult to get to audiology, and you have one in a bed with a cannula already in. An ear examination and a referral made now may not be made otherwise.
Work with the people who do this properlyAboriginal Health Workers and the Aboriginal Liaison team will know the family, the community and the local services, and they will get an answer to a question that you will not.

And the obvious caution

This is a piece about a population risk, not a rule about a person. Plenty of Aboriginal and Torres Strait Islander children hear perfectly well, and plenty of non-Indigenous children have glue ear. Assuming hearing loss because of who a child is would be its own kind of error, and a worse one.

The instruction is not to assume. It is to ask and to look, in a group where the disease is common, starts early and does not announce itself — and to hold the possibility open before writing down that a three-year-old is uncooperative.

I am not Aboriginal, and this piece is written from the outside. If it is wrong anywhere, or lands badly, I would rather be told than left alone — there is a button below.

Over to you

Have you watched a child's non-response be read as something it was not?

I would particularly like to hear from Aboriginal and Torres Strait Islander readers, from anyone working in remote or rural practice, and from Aboriginal Health Workers — what do you wish colleagues in a city or regional unit understood about this? And what should this column cover next?

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