ABC s of Pediatric Audiology Marnie Pomeroy, AuD, CCC A Pediatric Audiologist Little Ears Hearing Center at Open Arms Children s Health a service of Home of the Innocents Home of the Innocents Home of the Innocents (HOTI) was founded in 1880 to care for 8 children of working and destitute mothers. HOTI enriches the lives of children and families with hope, health, and happiness. Little Ears Hearing Center joined HOTI 9/2017.* Divisions of HOTI Open Arms Children s Health (OACH).* Kosair Charities Pediatric Convalescent Center (KCPCC). Residential/Foster Care. Community Based Foster Care. Behavioral Health. Outpatient Pharmacy. Aquatic Therapy Center. Home of the Innocents in 2018 7,676 children completed 30,084 visits at OACH. 96 children received care in KCPCC. 380 children received care in our residential program and emergency shelter. Over 1,100 children received services through our other programs in KY and IN: Safe Exchange, Aftercare, Community Based Services, Therapeutic loving Foster Care and Adoption. ABC's of Pediatric Audiology ACCESS BEST PRACTICES Let's talk about ACCESS Main document that guides access to audiology services: Joint Committee on Infant Hearing (2007). COMPASSION Why are these important? Who is JCIH and why should we follow their recommendations? 1
JCIH Stakeholder organizations: AG Bell, AAA, AAO HNS, AAP, ASHA, CED, DSHPSHWA. EVIDENCE BASED approach for access recommendations: 1 3 6. Surveillance in medical home. EHDI supports families in this process. What is 1 3 6? Why is it important? Screening by 1 month of age. Diagnosis by 3 months of age. Hearing aids to be fitted within 1 month of diagnosis. Intervention by 6 months of age. EI referral to be made within 2 days of HL diagnosis. Studies by Christie Yoshinaga Itano et al provided support for guideline. Impact of 1 3 6 Children who are diagnosed and fit with amplification, and enrolled in early intervention according to 1 3 6 guidelines: By age 5, these children have language development in normal range, assuming no other cognitive concerns. Other Critical ACCESS Issues All children identified with hearing loss need eye health/vision exam, ENT consultation (which may include imaging), and genetic testing. Testing for congenital CMV infection also HIGHLY encouraged for children identified with hearing loss. Ongoing Medical Home Surveillance needed for other developmental issues because 30 40% of children with HL have other disabilities/issues. BEST PRACTICES in Pediatric Audiology What should an evaluation look like by age? How often to evaluate/monitor? What if there is parent/caregiver concern about change in hearing? How should performance with hearing technology be monitored? References for BEST PRACTICES American Academy of Audiology. JCIH 2007. AG Bell Association. ASHA. babyhearing.org. 2
Evaluation: Birth to 6 Months Case history (child and family). Immittance (1000 Hz probe tone). Otoacoustic emissions. ABR: Click stimulus, polarity reversal to rule out ANSD. Threshold ABR: Frequency specific and bone conduction. Evaluation: 6 36 Months of Age All of the birth 6 month evaluations, as needed, PLUS: Behavioral testing. Visual reinforcement audiometry. Conditioned play audiometry. ABR is required to confirm suspected HL if child is < 3 years old. What Do Different Types of Tests Evaluate? (Photo credit to Hearing Health Foundation) This is your ear! Behavioral audiologic testing (VRA, CPA, standard). Speech perception testing with hearing technology. Hearing Assistance Technology Buzzwords: VERIFICATION and VALIDATION. Verification: Are devices working properly? Are settings appropriate for access to spoken communication? Safe? Validation: How is child performing with their technology? Is additional technology needed to optimize performance? Verification for Hearing Aids Parents and Teachers/School Staff: Daily listening check. Ling 6 Sound check. Audiologist: Listening check. Data logging check. Real Ear or Simulated Real Ear Measurements. 3
Why are Real Ear/Simulated Real Ear Measurements (REMs/SREMs) Important? Based on evidence based research! Ensures sounds are: AUDIBLE, COMFORTABLE, TOLERABLE. For infants and young children, it can be difficult to observe behavior to know what is happening with amplification. REMs/SREMs are essential starting point for device fitting. When Should Real Ear/Simulated Real Ear Measurements Be Performed? Any time hearing aid settings are changed due to change in hearing. Any time child is fitted with new earmolds (ear has grown). Any time there is concern about performance with amplification. Options for Real Ear Measurements RECD: Real Ear to Coupler Difference (can be used for SREMs and REMs). Probe tube placed in ear canal. Stimulus delivered to ear through insert (or earmold) and acoustic properties measured. Generates correction factor converting dbhl (hearing thresholds) to dbspl (sound pressure level) in 2cc coupler (ear simulator). SREMs can then be conducted in test box or RECDs can be used for Real Real Ear Measurements. What Do RECD Measurements Look Like and How Do We Get Them? Non compliant Children What to Do? Distraction distraction distraction! Lighted toys, puppets, YouTube videos, anything to distract child from what you are doing. 2 3 seconds of quiet = all it takes! Age average RECD measures available, ok to use in cases where measurement cannot be obtained. Real Ear Measurements For most older children, measurements can be completed on ear: 4
Verification for Bone Anchored Devices In clinic: Skull simulator. In situ bone conduction audiometry via manufacturer software. Listening checks. Data logging checks. In booth: Soundfield thresholds. Ling 6 thresholds in soundfield. Right device alone, left device alone, both ears (if applicable). Verification for CIs In clinic: Listening checks. Data logging checks. Ling 6 sound checks. In booth: Soundfield thresholds. Ling 6 thresholds in soundfield. Right CI alone, left CI alone, both ears (if applicable) Soundfield Thresholds We want children to hear at top of speech banana. May need to adjust from DSL child targets to achieve this. We do not listen to warble tones or narrow band noise in real life. Ideal to use recorded speech signals (Ling 6) to assess aided thresholds. Audiogram of Familiar Sounds and Ling 6 Audiogram Technology Validation Performance based metric: How does child perform with hearing technology? How is child progressing in auditory skills development? Speech Perception Testing Can be completed with children developmental age 2+. Many different tests available some have normative data to compare to children with normal hearing. Younger children closed set/picture pointing (easier to complete). Older children open set, repeat words. 5
We Want to Know... How does child hear in quiet at normal conversational level? How does child hear soft level speech (correlates to faint or distant speech)? How does child hear in background noise (correlates to classroom or similar noisy environment)? What is Acceptable Aided Performance? If it's not a good score on a math test, it's not a good speech perception score. Jane Madell If child isn t achieving necessary level of performance: Reprogram (or replace) hearing aids. Add assistive technology (e.g. DM/FM, Bluetooth). Consider cochlear implant eval as appropriate. Validation through Questionnaires Questionnaires available to evaluate auditory skill development, based on age; some normed, some not. Great tools to monitor progress and watch for plateaus. Last, But Not Least... COMPASSION (and support) Audiologists diagnose hearing loss in children every day. ~ 90% of children with hearing loss are born to hearing parents. In most cases, child is the first person the parent has met with hearing loss. Support from Managing Audiologist How we communicate diagnosis of hearing loss affects how parent moves forward. Time for questions is critical. Written information is critical. FAMILY SUPPORT is critical. Denial Denial can be healthy... if it is short lived. If family is stuck in denial, it may impact ability to make decisions regarding child's care. Referral to trained support professional (psychologist, LCSW) may be needed for families having difficulty accepting child's hearing loss. 6
Hands and Voices Unbiased parent support and education; Guide by Your Side program. Other State and National Resources Many JCIH stakeholder organizations have information for parents which contain variety of communication options. Local EHDI program can help parents connect with state organizations that support children with hearing loss. EHDI PALS Resource to find audiologists who specialize in diagnosis and treatment of pediatric hearing loss. Wrapping Up... Remember your ABC's. Parents/caregivers are child's best advocate and should be informed about best practices. Develop relationship with your parents based on clear and honest communication. Second opinions are always ok if there are unanswered questions/concerns. Thank you! 7