The Impact of the Lack of Early Intervention for Infants with Hearing Loss

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The Impact of the Lack of Early Intervention for
Infants with Hearing Loss

• Donna C. Maselli, RN, MPH
• Connecticut Department of Public Health
• Hartford, CT

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Faculty Disclosure Information

• In the past 12 months, I have not had a
  significant financial interest or other
  relationship with the manufacturer(s) of the
  product(s) or provider(s) of the service(s) that
  will be discussed in my presentation.
• This presentation will not include discussion
  of pharmaceuticals or devices that have not been
  approved by the FDA.

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Newborn Hearing Screening History in CT

• Legislation to screen high risk infants since
  1985
• Primarily NICU babies
• Well babies were not routinely screened
• Half the children with PCHL do not exhibit risk
  factors (NCHAM, 2002)
• 1994 Strong lobbying began to implement Universal
  Newborn Hearing Screening (UNHS)
• CT Newborn Hearing Screening Task Force formed

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CT Legislation

• 19a-59 amendment in part reads.
• Institutions providing childbirth services
  shall, no later than July 1, 2000, include a UNHS
  program as part of its standard of care.
• Initial legislation was for July 1, 1999
• Source Connecticut State Statutes

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Purpose of UNHS

• To provide early hearing detection intervention
  (EHDI) to infants, in an attempt to minimize
  speech and language delays
• EHDI and treatment before 6 months of age
  facilitate a childs healthy development
  consistent with age and cognitive ability

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Program Goals

• Hearing screening at birth, before discharge
• Diagnostic testing within 2 months of initial
  screen
• Referral to Early Intervention (Birth-to-Three)
• by 4 months

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Screening Methods

• First screen
• May be Otoacoustic emissions (OAE) or Automatic
  Brainstem Response (ABR)

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Second Screening

• Second Screen
• Repeated before discharge if infant does not pass
  the first screen
• ABR screen
• 1/06 ABR screening for all NICU infants

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2004 STATISTICS
Total Screened 97
Passed 1st Screening 91.21
Passed 2nd Screening 6.37
Referred for Diagnostic Testing 1.35 (n324)
Received Diagnostic Testing 84
Lost to Follow-up 16
Hearing Loss 0.14 (n60)
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Types of Hearing Loss Identified 2004
Bilateral Unilateral
Conductive 9 21
Sensorineural 54 37
Undetermined 36 47
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Diagnostic Testing Centers

• DPH Identified Centers for Follow-up Testing
• Used CT UNHS Task Force Best Practice Standards
• Surveyed all CT licensed audiologists
• Identified 16 Diagnostic Testing Centers
• Mechanism to report to DPH
• Referral to E.I.

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Best Practice Recommendations for Diagnostic
Hearing Testing of InfantsCT Newborn Hearing
Screening Task Force

• Auditory Brainstem Response ABR (a.k.a BAERS,
  BAER)
• Threshold measurement with frequency specific
  tone bursts
• Threshold measurement with bone conduction ABR
• Sedation in a medical facility where the child
  can be appropriately monitored
• Immittance Testing
• Tympanometry with high frequency probe tone
  greater than 1000 Hz
• Acoustic reflex testing
•  

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Best Practice Standards cont

• Completed by 2 months of age
• Conducted by a pediatric audiologist
• A battery of tests based on
• Screening results
• Medical history
• Risk factors
• Include an otological evaluation
• May be conducted at different facility and time
•  

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Best Practice Standards cont

• Otoacoustic Emissions (OAE)
• Transient evoked or distortion product
•  Behavioral Audiometry
• May be useful in addition to the above
• Reporting of results to DPH
• Refer to Birth-to-Three

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Degree of Hearing loss

• Mild 26-40 dB HL
• Moderate 41-60 dB HL
• Severe 61-80 dB HL
• Profound 80

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AGE AT DIAGNOSIS (in months)National Goal 3
months
YEAR AGE in MONTHS
2000 1.69
2001 3.07
2002 1.74
2003 0.85
2004 2.29
2005 2.92
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AGE AT Referral to B23 (in months)National Goal
6 months
YEAR CT AGE At Referral
2000 2.13
2001 3.48
2002 2.64
2003 3.23
2004 3.83
2005 4.68
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Early Intervention Services in CT

• Mandated reporting (CT General Statutes Sec.
  17a-248d)
• Report within 2 days of identifying child
• Suspected or at risk of having developmental
  delay
• Infants referred through Child Development
  Infoline

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CT Early Intervention Eligibility

• Birth-to-Three Eligibility
• 40db or greater, bilateral hearing loss
• Exclusions!
• www.birth23.org
• 27 states that have language in their legislation
  that includes either unilateral, mild or "any"
  hearing loss

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Why is early intervention important for children
with mild or unilateral hearing loss?
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Mild Hearing Loss

• Will miss 25-40 of what is said 50 in noisy
  situation
• May not hear consonants such as /s/, /f/, /th/,
  /p/, /h/, /g/, /ch/, /sh/, /z/, /v/
• Cannot hear plurals or contractions
• Unable to learn incidental learning common
  sense
• 37 with slight-mild hearing loss fail a grade,
  typically 1st (Bess et. AL. 1998)

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Unilateral Hearing Loss

• Difficulty hearing speech if speaking from behind
  or with background noise
• Difficulty localizing speech
• 35 fail one or more grades, typically 1st
• 27 ages 1-3 present with language delay

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Attempts to Change CT Birth-to-Three Eligibility

• To include unilateral and bilateral with any
  degree
• Multi level support
• DPH, DSS, UNHS Task Force, Dx Centers
• Birth-to-Three Medical Advisory meeting
• Show us the data that says these kids would
  benefit from E.I.

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The Impact of the Lack of Early Intervention
for Infants with Hearing Loss

• MD/MPH Student Internship at DPH (Summer 2005)
• Purpose of the Study
• Assess speech/language developmental outcomes of
  children with hearing loss who did not receive
  Birth-to-Three services
• Hypothesis
• Children with hearing loss who did not receive
  E.I. services will show evidence of delayed
  speech/language by ages 3, 4 or 5 years

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Methodology

• Selection Criteria
• Used UNHS data
• Infants born between 7/1/00 - 12/31/03
• Now 2-5 years old
• 80 of the childs ability to learn speech,
  language and related cognitive skills is
  established by 36 months (White, 2000)
• Bilateral with mild in at least one ear
• Unilateral, moderate to profound hearing loss

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Methodology

• 94 Records met criteria
• Letters sent to families
• Requested parental consent to review audiology
  records
• 22 consents received
• Records reviewed for
• Parental concern
• An assessment of speech/language
• Referral for speech evaluation
• Referral to B23

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Results

• 77.3 Recommended ENT consultation
• 59 No documented audiology visit after ENT
• 68.2 No documented audiology visit after age 2
• 90.9 Status of speech/language development
  unknown
• 9.1 Had documented delay

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Conclusion

• Unable to ascertain if lack of early intervention
  is associated with speech/language delays due to
• Lack of Audiology visit after ENT referral (59)
• Lack of reference to speech/language in audiology
  record (90.9)
• Lack of documented follow-up after age 2 (68.2)
• The absence of visits after age 2 may be due to
• PCP conducts the screenings in the office
• Family moved from the region
• The child is not receiving any care
• Audiological assessments are being performed by
  the ENT

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So What Do We Do?

• ENTs
• Presented findings at annual ENT Association
  meeting
• Decrease numbers of undetermined type
• Encourage collaboration between diagnosing
  audiologist, PCP and ENT
• Implemented ENT Reporting to DPH

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So What Do We Do?

• Audiologists
• Presented findings at Hearing Screening Symposium
• Addressed need for speech/language assessment
  along with audiological testing
• Revised reporting form to collect name of ENT
• Encouraged better medical home collaboration

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So What Do We Do?

• Families
• Can contact study families to assess follow-up
• Ascertain if parental concern
• Confirm audiological follow-up
• Implementing Listen Learn Program
• Q 6 mo. Follow-up for infants not eligible for
  E.I.
• Speech/language assessment
• Parental education
• Hearing evaluation

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Donna C. Maselli, RN, MPHAmy Mirizzi, MPH