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Diagnostic Pediatric Audiology from Birth to Intervention

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Infants with hearing loss diagnosed by 3 months ... Timely and Appropriate Diagnosis ... Use B-70 bone vibrator. Use mastoid placement. Pediatric ABR summary ... – PowerPoint PPT presentation

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Title: Diagnostic Pediatric Audiology from Birth to Intervention


1
Diagnostic Pediatric Audiology from Birth to
Intervention
  • Karen M. Ditty, M.S.
  • NCHAM
  • Antonia Brancia Maxon, Ph.D.
  • NECHEAR
  • NCHAM

2
Timely and Appropriate Diagnosis of Hearing Loss
  • Newborns screened by 1 month
  • Infants with hearing loss diagnosed by 3 months
  • Amplification use begins within 1 month of
    diagnosis
  • Benchmarks (JCIH, 2000)

3
Timely and Appropriate Diagnosis of Hearing Loss
  • Infants enrolled in family-centered early
    intervention by 6 months
  • Ongoing audiological management - not to exceed 3
    month intervals
  • Professionals working with these infants are
    knowledgeable about all aspects
  • Benchmarks (JCIH, 2000)

4
Newborns screened by 1 month
  • Approximately 90 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 .

5
Infants with hearing loss diagnosed by 3 months
  • Progress has been made however it is affected by
  • Testing site may influence age of diagnosis
  • Goal is often met in hospital clinics
  • Less likely in non-hospital centers
  • Geographic access to services may influence age
    of diagnosis
  • Rural communities are less likely to meet the goal

6
Impediments to Lowering Diagnostic Age
  • Audiologists lack experience with very young
    infants
  • uncomfortable making the final diagnosis.
  • Defer to and refer for second opinion
  • Facilities do not have the equipment needed to
    assess very young infants.
  • Frequency specific ABR
  • AC and BC ABR
  • High frequency tympanometry

7
Impediments to Lowering Diagnostic Age
  • Audiologists are not familiar with clinical
    protocols necessary for making accurate diagnosis
    with very young infants.
  • Do not have norms
  • Cannot read ABR for this population
  • Inadequate number of audiologists with pediatric
    expertise
  • No academic training to work with very young
    infants
  • No clinical training to work with very young
    infants

8
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
  • http//www.infanthearing.org/states/table.html

9
Aids to Lowering the Age of Diagnosis
  • Audiologists can get training through continuing
    education provided by national associations
  • NCHAM audiology training
  • Pediatric Diagnostics
  • Covers the initial diagnostic procedure
  • Pediatric Amplification Fitting
  • Covers behavioral assessment, hearing aid
    selection, fitting and validation and cochlear
    implants

10
Pediatric Audiologist
  • Have the appropriate audiological equipment and
    protocols for testing newborns and young infants.
  • Can evaluate a childs 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

11
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

12
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.
  • Is willing to continue to explain results at
    follow-up evaluations

13
Pediatric Diagnostic Test Battery
  • Comprehensive Case History
  • Frequency-Specific Auditory Brainstem Response
  • High Frequency Probe Tone Tympanometry
  • Transient and/or Distortion Product Otoacoustic
    Emissions
  • Hearing aid Fitting with Real Ear Measurements
  • Behavioral Audiometry
  • Referrals

14
Comprehensive Case History
15
Frequency Specific Auditory Brainstem Response
  • Air Conduction Clicks
  • Abrupt or rapid onset of a broad frequency
    bandwidth .
  • Greatest agreement in the 2000-4000Hz frequency
    range.
  • Not enough information across the frequency range
  • Low frequencies absent

16
Frequency Specific Auditory Brainstem Response
  • Tonebursts
  • Provides information for narrower frequency
    regions
  • Better relates to pure tone audiogram
  • Bone-Conducted Clicks
  • Should get when either the click or 500-Hz
    tonebursts responses are not present at expected
    normal levels.

17
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)

18
Frequency Specific Auditory Brainstem Response
  • Auditory Steady State Response (ASSR)
  • An electrophysiologic response, similar to ABR
  • Generated by rapid modulation of carrier pure
    tone amplitude or frequency.
  • Signal intensity can be as high as 120 dB

19
Frequency Specific Auditory Brainstem Response
  • Auditory Steady State Response (ASSR)
  • Done in conjunction with ABR Clicks, or on a
    separate occasions
  • Major advantage is it estimates
    severe-to-profound HL
  • Best used in conjunction with ABR and tone burst
    testing.

20
ABR (Click and Tone Burst) versus ASSR Clinical
Application
  • Advantages
  • Estimates normal hearing
  • thresholds
  • Ear-specific BC findings
  • Diagnosis of AN
  • Estimates severe to
  • profound HL
  • Disadvantages
  • Cant estimate profound HL
  • Skilled analysis required
  • Limited BC intensity levels
  • No ear-specific BC findings
  • Requires sleep or sedation

ABR ASSR
R. Ruth, 2003
21
Pediatric Sedation for ABR
  • 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)

22
Pediatric Sedation for ABR
  • Negative outcomes associated with
  • overdoses, drug interactions
  • non-trained personnel
  • injuries on the way to facility (administered at
    home)
  • drugs with long half-lives (chloral hydrate,
    pentobarbital)
  • (J. Hall, 2001)

23
Pediatric ABR summary
  • Air conduction measures should be done with
    insert earphones
  • Headphones can affect latency of waveform
  • Bone conduction measures are needed to rule out
    conductive loss or find conductive component.
  • Use B-70 bone vibrator
  • Use mastoid placement

24
Pediatric ABR summary
  • Use earlobe inverting electrodes
  • Use alternating tone burst to minimize artifact
  • A slower rate (e.g., 11.1/sec) enhances Wave I
  • Begin testing near maximum intensity (50 dB nHL)
  • Allows good waveform to be seen
  • Identify Wave I in ipsilateral ear to verify test
    ear
  • Plot I-L function of Wave V

25
Pediatric ABR summary
  • Air conduction measures should include frequency
    specific tone bursts and/or ASSR as part of a
    battery of electrophysiological tests.
  • Of the audiological test battery, only an ABR can
    help determine an auditory neuropathy case
    therefore, ASSR should not be performed alone,
    but as part of a battery of electrophysiological
    tests.

26
High Frequency Probe Tone Tympanometry
  • Tympanometry provides information about middle
    ear status
  • add information to BC results
  • May be affected by conditions in very young
    infants ears
  • Ear canal and eardrum are very compliant
  • Use of high frequency probe tone (800 Hz or
    greater) increases reliability and accuracy in
    young infants.

27
Transient Distortion Product Otoacoustic
Emissions
  • Infants and young children with normal hearing
    have robust
  • transient evoked otoacoustic emissions (TEOAE)
  • distortion product otoacoustic emissions (DPOAE)
  • TEOAEs and DPOAEs are easily measured in infants
    and children.

28
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

29
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
    outer hair
  • cells
  • the most sensitive and vulnerable part of the
  • hearing mechanism tested by OAEs.
  • OAEs provide meaningful information when
  • retrocochlear lesions and/or auditory
    neuropathy
  • are a concern.

30
Amplification Assessment and Fitting
  • Initiate amplification process immediately after
    diagnosis.
  • Includes medical clearance
  • Federal regulation - ENT
  • Includes earmolds
  • overnight mailing to get within 1 week
  • continue to remake to avoid fitting problems

31
Pediatric amplification fitting
  • Does not require exhaustive audiological data
  • Target audiogram
  • Individual ear information
  • Ability to conduct real-ear measures
  • Scheduling flexibility and immediacy
  • Experience with functional measures of benefit

32
Real Ear to Coupler Difference Procedure (RECD)
  • The infant ear is smaller than an adult ear
  • More SPL for same input compared to adult
  • Differences can be as large as 15-20 dB
  • Many hearing-aid fitting algorithms do not take
    these differences into account.
  • RECD affects estimates of
  • Threshold
  • Real-ear gain and output

33
Real ear measurement
  • The insert phone is coupled to the earmold
  • The probe microphone is placed into the ear canal
  • The earmold is inserted into the ear
  • Test stimulus is presented
  • Total test time 5-10 minutes per ear

34
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

35
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

36
Basic Audiological Information Used to Fit
Amplification
  • Cochlear status
  • ABR intensity-latency function
  • OAEs
  • Behavioral Responses
  • target audiogram
  • speech awareness

37
Behavioral Response Audiometry
  • Provides information about how an infant or young
    child uses hearing
  • Behavioral observation techniques can be used to
    give functional information
  • Sometimes only suprathreshold information is
    obtained
  • will get better responses to speech than tones
  • Can look at amplification benefit

38
Behavioral Response Audiometry
  • Look at amplification benefit
  • Need to provide speech at greater than detection
    level
  • Cannot learn language with threshold-only
    information
  • All of normal conversational level speech needs
    to reach child through amplification

39
Speech Sounds
  • Range from softest to loudest speech sound 30
    dB
  • th ah
  • Low frequencies carry suprasegmental, vowel, and
    voicing information.
  • High frequencies carry consonant, perceptual, and
    syntactic cues.

40
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

41
Enrollment in Early Intervention
  • Develop Individualized Family Service Plan (IFSP)
  • All services
  • speech and language development
  • auditory development
  • assistive technology
  • Goals and objectives
  • Timelines

42
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

43
Status of EHDI Programs Early Intervention
  • Many of the programs in the current system
    designed to serve infants with bilateral
    severe-profound losses
  • BUT, majority of those identified have mild,
    moderate, and unilateral losses
  • Programs and professionals not appropriate for
    children and families
  • Therefore, Part C of IDEA is severely under
    utilized

44
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

45
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

46
Pediatric Audiology
  • Pediatric Audiology with newborns and young
    infants can be challenging!

47
Pediatric Audiology
  • But also rewarding!

48
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
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