1. Antonia Brancia Maxon, Ph.D. Texas ENT Specialists, P.A.
Screening, Diagnosis and Early Intervention: The Pediatric Audiologist’s Role
Antonia Brancia Maxon, Ph.D.
NECHEAR
Karen M. Ditty, M.S.
Texas ENT Specialists, P.A.
NCHAM

2. Timely and Appropriate Diagnosis of Hearing Loss
Benchmarks (JCIH, 2000)
Newborns screened by 1 month
Infants with hearing loss identified by 3 months
Amplification use begins within 1 month of diagnosis
Infants enrolled in family-centered early intervention by 6 months
Ongoing Audiological management - not to exceed 3 month intervals
Professionals are knowledgeable

3. Newborns screened by 1 month
Currently approximately 86% of all newborns in the United States have their hearing screened at birth
The number of infants referred for diagnostic audiological evaluations has dramatically increased .

4. Infants with hearing loss diagnosed by 3 months
Progress has been made
Testing site may influence age of diagnosis
Geographic access to services may influence age of diagnosis

5. Impediments to Lowering Diagnostic Age
Audiologists lack experience with very young infants and are uncomfortable making the final diagnosis.
Facilities do not have the equipment needed to assess very young infants.
Audiologists are not familiar with clinical protocols necessary for making accurate diagnosis with very young infants.
Inadequate number of audiologists with pediatric expertise

6. Aids to Lowering the Age of Diagnosis
Although there are no national protocols or standards many states have guidelines for their audiologists.
These guidelines can be obtained via the following link on the NCHAM website:
NCHAM audiology training
Pediatric Diagnostics
Pediatric Amplification Fitting
For many audiologists, ABR test protocols for the adult population are well known and accepted. However, when addressing infants, protocols and practices need to be revised. Eventually, standardized infant protocols will be developed and will become widely accepted. Let’s look at this particular benchmark that JCIH set up and discuss what is the appropriate infant diagnostic test battery

7. Pediatric Audiologist
Have the appropriate audiological equipment and protocols for testing newborns and young infants.
Can evaluate a child’s hearing within a short period of time after being contacted for an appointment.
Specializes in working with infants and young children.
Wants to work with infants and young children.
Has worked with Part C program in their state

8. Pediatric Audiologist
Is familiar with the procedures of the Part C system, including IFSP development and procedures for acquiring hearing aids or assistive technology.
If dispenses hearing aids:
can make earmolds,
has loaner hearing aids available
provides hearing aids on a trial basis
has resources to repair hearing aids quickly

9. Pediatric Audiologist
Is willing to review the test results of the audiological evaluation face to face with the family, respecting the Cultural Differences of family units.
Is willing to provide a comprehensive written report with a copy of the test findings in a timely manner.

10. Pediatric Diagnostic Test Battery
Comprehensive Case History
Frequency-Specific Auditory Brainstem Response
High Frequency Probe Tone Tympanometry
Transient and/or Distortion Product Otoacoustic Emissions
Behavioral Audiometry
Referrals
So you fit the criteria and know you could be that Pediatric Audiologist we need What about equipment?

11. Frequency-Specific ABR
Accuracy of pure tone threshold estimates with tone burst ABR
High correlation (>.94) for infants and older children (Stapells, et al, 1995)
90% of ABR thresholds within 20 dB of PT thresholds with most within 10 dB
audiometric configuration does not affect accuracy of match (Oates and Stapells, 1998)

12. Pediatric ABR
Air conduction measures should be done with insert earphones - can affect latency
Bone conduction measures are needed to rule out conductive loss or find conductive component.
Without BC will extend time until diagnosis

13. Pediatric ABR-Sedation
Who and When
4 months to 5 years
Options
conscious sedative
mild general anesthesia
Monitoring
administered and managed by nurse
monitor O2, HR and BP
crash cart and suction available
(J. Hall, 2001)

14. Pediatric ABR-Sedation
Negative outcomes associated with
overdoses, drug interactions
non-trained personnel
injuries to facility (administered at home)
drugs with long half-lives (chloral hydrate, pentobarbital)
(J. Hall, 2001)

15. Pediatric Immittance Measures
Provide information about middle ear status to add to BC information
May be affected by conditions in very young infant’s ears - highly compliant
Use of high frequency probe tone (800 Hz or greater) increases reliability and accuracy in young infants.

16. Infants and young children with normal hearing have robust
Pediatric Evoked OAEs
Infants and young children with normal hearing have robust
transient evoked otoacoustic emissions (TEOAE)
distortion product otoacoustic emissions (DPOAE)
TEOAEs and DPOAEs and easily measured in infants and children.

17. Middle Ear Effects on OAEs
Middle ear effusion may
obliterate emission
eliminate low frequency component
Negative middle ear pressure may
reduce amplitude, particularly in high frequencies

18. OAE Summary OAEs are objective evidence of healthy cochlear function
The vast majority of hearing impairment in the low-risk population is a result of malfunction of the cochlear / outer hair cell system, the most sensitive and vulnerable part of the hearing mechanism tested by OAEs.
OAEs provide meaningful information when Retrocochlear and/or auditory neuropathy are a concern.

19. Behavioral Response Audiometry
Provides information about how an infant or young child uses hearing
Behavioral observation techniques can be used to give functional information
only suprathreshold information is obtained
will get better responses to speech than tones
Can look at amplification benefit

20. Amplification Assessment and Fitting
Initiate amplification process immediately after diagnosis.
Includes medical clearance
Includes earmolds - overnight mailing to get within 1 week
Does not require exhaustive audiological data

21. Pediatric amplification fitting
Ability to conduct real-ear measures
Scheduling flexibility and immediacy
Experience with functional measures of benefit

22. Basic Audiological Information Used to Fit Amplification
Hearing Sensitivity
ABR frequency specific information - low, mid and high frequency
Individual ear measures: insert phones
Middle Ear Status
Tympanometry - high frequency
BC to rule out conductive loss

23. Basic Audiological Information Used to Fit Amplification
Cochlear status
ABR intensity-latency function
OAEs
Behavioral Responses
target audiogram
speech awareness

24. Prescriptive Approach to Hearing Aid Fitting
Prescriptive methods designed to consider earmolds and person’s own ear canal, etc.,
Select targets (gain, output)
real ear measures
coupler measures

25. Real Ear to Coupler Difference Procedure (RECD)
The infant’s ear is smaller than an adult ear
More SPL for same input compared to adult
Differences can be as large as dB
Many hearing-aid fitting algorithms do not take these differences into account.
RECD affects estimates of:
Threshold
Real-ear gain and output

26. RECD
After the RECD is obtained, all hearing aid testing can be done in the test box
RECD values are entered into the hearing aid fitting program to provide a more accurate estimate of real-ear aided gain and output
The RECD will change as the child grows. A good rule of thumb is to obtain a new RECD when a new earmold is needed

27. Prescriptive Approach to Hearing Aid Fitting
Desired Sensation Level - DSL (Seewald, et al, 1996)
Uses minimal audiometric data
Real ear measures
Adjustments for pediatric ears
Used to determine target gain and output settings

28. DSL Goal
Provide children with amplified speech that is audible, comfortable, and undistorted across broadest relevant frequency range possible.
Infant acquiring language has access to speech of others
Infant acquiring language has access to own speech

29. Speech Sounds Range from softest to loudest speech sound = 30 dB
Low frequencies carry suprasegmental, vowel, and voicing information.
High frequencies carry consonant, perceptual, and linguistic cues.

30. Referral to and Enrollment in Early Intervention
Know established Part C guidelines in state
Know child eligibility criteria
automatic enrollment - diagnosed condition
significant developmental delay
Know state guidelines for selecting a program

31. Enrollment in Early Intervention
Develop Individualized Family Service Plan (IFSP)
All services
speech and language development
auditory development
assistive technology
Goals and objectives
Timelines

32. Components of IFSP for I/T with Hearing Loss
Amplification provision
parent education
Audiological monitoring
Development of auditory skills
Communication development
listening skills - speech perception
speech production
language development
Monitoring middle ear status

33. Status of EHDI Programs: Early Intervention
State Coordinators estimate:
Only 53% of infants with hearing loss are enrolled in EI programs before 6 months of age
Only 31% of states have adequate range of choices for EI programs

34. Barriers to Early Intervention
30-40% of children with hearing loss demonstrate additional disabilities that may affect communication and related development.
Families who live in under-served areas may have less accessibility, fewer professional resources, deaf or hard of hearing role models, or sign language interpreters available to assist them.
A growing number of children with hearing loss in the United States are from families that are non-native English Speaking.
JCIH 2000

35. Some babies are born listeners..
If we:
use the elements of an effective EHDI program
use the JCIH 2000 Benchmarks
use appropriate diagnostic protocols and procedures
refer to early intervention
are active participants in early intervention