1. Noise-Induced Hearing Loss in Adolescents Kristen Williams, MD Thursday February 3, 2011 Legislative Advocacy Department of Pediatrics

2.  Background  Current Pediatric Literature on NIHL  Advocacy and Legislation  Our Role as Pediatricians

4.  Sound Intensity (loudness) = dB  An increase in 10dB = 2x louder  Normal conversation ~60dB Tone = Hz  Low bass 50-60Hz, high pitched >10000 Hz  Normal Hearing Range: 20 -20000 Hz  Normal speech: 500 - 3000 Hz  Normal testing range: 250 – 8000 Hz at 25dB or lower

5.  CDC NOISE METER CDC NOISE METER

6.  Conductive Hearing Loss Mechanical problem in the outer or middle ear  Ex: Ossicles not conducting properly, fluid in the middle ear  Sensorineural Hearing Loss Problem in the inner ear; i.e. injured hair cells

7.  Common Causes Genetic/Congenital Infectious (OM, measles, meningitis) Toxic (medications) Traumatic (acoustic, barotrauma, perforation) Age related (presbycusis) – Minor decreases in hearing common after age 20 Other: acoustic neuroma, idiopathic Temporary: allergies, wax, infections, fluid, foreign body, medications

8.  One of the most common PREVENTABLE occupational illnesses In 1998, 48% of US adults had some hearing loss due to occupational noise exposure (35% of those were 18-29yo) In 2001, 12.5% of children aged 6-10 (5.2million), and 17% of 20-69yo (26million) had permanent damage  10 million Americans have irreversible NIHL, 30 million are exposed daily Dangerous noise exposure can occur one time as an intense sound or can accumulate over time (>85dB) Permissible exposure  114b dB (1/4hr/day), 110dB (1/2hr/d), 100dB (2hr/d), 85dB (<8hr/d)

9.  Symptoms: High frequency sounds often lost first (e.g., fish vs. fist); change in quality of sound, tinnitus Usually develops over a long period of time and is usually painless.  Therefore, mostly ignored because there are no visible effects  Effects of Hearing Loss Problems with communication, socialization and relationships, academic achievement, and vocational choices

11.  Hearing Screens Newborn,2-3y, yearly 4-7, 8, 10, entering a new school Risk assessments:  Parental/Patient concern (take seriously!), family history, genetic syndromes, physical findings, head trauma, chemotherapy, recurrent otitis media  Testing All ages: ABR (auditory brainstem response), evoked OAEs (otoacoustic emissions) 4y +: audiometry

13.  Survey of college students in June 2010: Majority use personal listening devices 1/3 report being distracted while wearing (less aware of enviroment). 51% use while walking, 18% while driving 62% needed to have conversations repeated while wearing headphones 1/3 reported soreness after use 1/3 reported using PLD at max volume levels Those who used earbuds were most likely to increase their volume settings, especially after listening for period of time (second to temporary threshold shifts) Increase number of teens reported symptoms of poor hearing: distortion, tinnitus, hyperacusis Few used protective behaviors: decreased volume, taking breaks, using a noise-limiter

14.  In 2001, date published from the NHANES III study (1988-1994 data) reported that 12.5% of U.S. children (~5million) had NITS (noise induced threshold shifts) in at least one ear. Prevalence: Boys 14.8% vs. girls 10.1% 15% of 12-19yo vs. 8% 6-11yo Of those with NITS, 57% had slight shifts, 19% had mild, and 5% had moderate-profound 88% had one frequency (3, 4, or 6kHz) affected, 3% had all 3  Threshold shifts at 6kHz were most common – this frequency is usually not tested in standard screening hearing exams

15.  In 2008, a study using the 1999-2004 NHANES data published that 16% of adults (29 million) had speech frequency hearing loss (0.5-4 kHz) and 8.5% of 20-29yo did as well. Once again, males were affected more than females.  The authors felt that the increase in prevalence of hearing loss was in part due to the increased aging population and growing use of personal listening devices.  Also noted was that hearing loss was also associated with smoking, DM, and cardiovascular disease.

16.  In January 2011, another report based on NHANES data from 2005-2005 of teens (12- 19yo), did not show an overall significant increase in NITS, HFHL, or LFHL from the prior years. However, it did report an increase in exposure to loud noise/music and an increase in NITS in females who used less hearing protective devices compared to their male counterparts. A similar study using the same data did show HFHL when including testing at 8kHz.

17.  In 2003, despite continued efforts to standardize regulations concerning occupational and leisure noise, adults continued to develop NIHL (although with decreased incidence), therefore showing that the present health promotion initiatives seemed insufficient. Norway’s NIOSH estimated at that time 10% of youth will have 10dB NIHL after 10yrs of music exposure. The hearing shifts in teens at that time was similar to that of 20-30year old age-related threshold shifts.

18.  Discussion/Recommendations “Chronic exposure to less intense sounds (i.e., loud music) can painlessly accumulate over time leading to irreversible damage.” “There is a need for hearing conservation programs, increased screening, and public health initiatives.” “Hearing loss prevention through modifiable risk factor reduction and screening should begin in young adulthood.” “Studies show that hearing conservation programs aimed at youth about damaging noise can have a positive impact on behavior.” “Keep cranking up the volume on your earbuds and your next fitting could be for a hearing aid.”

19.  In 2009, a panel comprised of health care professionals, educators, researchers, and those involved in youth advocacy and the entertainment industry met to discuss strategies to prevent NIHL, especially from personal media devices. The conclusion was that changes needed to be made at the manufacturing level and public health level.

20.  “Decibel Bud”  www.ListenToYourBuds.org www.ListenToYourBuds.org  “Turn it to the Left”

21.  Arkansas and NY are considering proposals that would place restrictions on pedestrians, runners, and cyclists using headphones.

22.  ASHA 2011 Public Policy Agenda “The time may be right for federal initiatives in the form of new policies or funding opportunities. ASHA will monitor federal activities and support those that will effectively prevent noise- induced hearing loss.”

23.  Do you have a problem hearing over the phone?  Do you have trouble following the conversation when 2 or more people are talking at the same time?  Do people complain that you turn the TV volume up too high?  Do you have to strain to understand conversation?  Do you have trouble hearing in a noisy background?  Do you find yourself asking people to repeat themselves?  Do many people you talk to seem to mumble?  Do you misunderstand what others are saying and respond inappropriately?  Do you have trouble understanding the speech of women and children?  Do people get annoyed because you misunderstand what they say?

24.  If you have to shout to hear yourself or someone else, the volume is too loud.  If you have ringing in your ears, decreased hearing, or fullness after any exposure, avoid it in the future.  Check the volume limit on your personal music player.  Use protective headphones.  Take breaks  Let your PMD know if you have persistent ringing or suspect any hearing loss.

25. [1] Demillo, Andrew. “Fight on distracted walking widens.” Newsday 25 Jan 2011. Print. [3] Niskar, A. S., S. M. Kieszak, et al. (2001). "Estimated prevalence of noise-induced hearing threshold shifts among children 6 to 19 years of age: the Third National Health and Nutrition Examination Survey, 1988-1994, United States." Pediatrics 108(1): 40-43. [4] Borchegrevink, H.M. (2003). “Does health promotion work in relation to noise?” Noise and Health 5(18): 25-30. [5] Agrawal, Y., E. A. Platz, et al. (2008). "Prevalence of hearing loss and differences by demographic characteristics among US adults: data from the National Health and Nutrition Examination Survey, 1999-2004." Arch Intern Med 168(14): 1522-1530. [6] Vogel, I., J. Brug, et al. (2008). "MP3 players and hearing loss: adolescents' perceptions of loud music and hearing conservation." J Pediatr 152(3): 400-404. [7] Vogel, I., J. Brug, et al. (2009). "Strategies for the prevention of MP3-induced hearing loss among adolescents: expert opinions from a Delphi study." Pediatrics 123(5): 1257-1262. [8] Ha, Peter. “Custom-Made Headphones: Listen Up Before It’s Too Late.” Time 26 April 2010. Print. [9] Hoover, A. and S. Krishnamurti (2010). "Survey of college students' MP3 listening: Habits, safety issues, attitudes, and education." Am J Audiol 19(1): 73-83. [14] Snyder, N. (2010). “Capitol Hill Office Debuts Decibel-Detecting “Bud.” ASHA 15(8): 22- 23. [15] Moore, Marat. (2010). “Teens at Risk.” ASHA 15(11): 1,4,38. [17] Henderson, E., M. A. Testa, et al. (2011). "Prevalence of noise-induced hearing-threshold shifts and hearing loss among US youths." Pediatrics 127(1): e39-46.