Presentation on theme: "Diagnostic Pediatric Audiology from Birth to Intervention"— Presentation transcript:
1Diagnostic Pediatric Audiology from Birth to Intervention Karen M. Ditty, M.S.NCHAMAntonia Brancia Maxon, Ph.D.NECHEAR
2Timely and Appropriate Diagnosis of Hearing Loss Newborns screened by 1 monthInfants with hearing loss diagnosed by 3 monthsAmplification use begins within 1 month of diagnosisBenchmarks (JCIH, 2000)
3Timely and Appropriate Diagnosis of Hearing Loss Infants enrolled in family-centered early intervention by 6 monthsOngoing audiological management - not to exceed 3 month intervalsProfessionals working with these infants are knowledgeable about all aspectsBenchmarks (JCIH, 2000)
4Newborns screened by 1 month Approximately 90% of all newborns in the United States have their hearing screened at birthThe number of infants referred for diagnostic audiological evaluations has dramatically increased .
5Infants with hearing loss diagnosed by 3 months Progress has been made however it is affected byTesting site may influence age of diagnosisGoal is often met in hospital clinicsLess likely in non-hospital centersGeographic access to services may influence age of diagnosisRural communities are less likely to meet the goalAlthough this goal is often easily met in hospital based audiological clinics, Audiologists in non hospital based centers or rural sites are having trouble achieving this goal.
6Impediments to Lowering Diagnostic Age Audiologists lack experience with very young infantsuncomfortable making the final diagnosis.Defer to and refer for second opinionFacilities do not have the equipment needed to assess very young infants.Frequency specific ABRAC and BC ABRHigh frequency tympanometryMany audiologists are uncomfortable with the interpretation of their test findings and will put off a diagnosis or refer to a hospital based center for a 2nd opinion.There are currently not enough audiologists in the United States that have the training or expertise to work with the “newborn”.May mention that there is now a push for Pediatric Specialty Certification in Audiology
7Impediments 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 populationInadequate number of audiologists with pediatric expertiseNo academic training to work with very young infantsNo clinical training to work with very young infantsMany audiologists are uncomfortable with the interpretation of their test findings and will put off a diagnosis or refer to a hospital based center for a 2nd opinion.There are currently not enough audiologists in the United States that have the training or expertise to work with the “newborn”.May mention that there is now a push for Pediatric Specialty Certification in Audiology
8Aids 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 websiteFor 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
9Aids to Lowering the Age of Diagnosis Audiologists can get training through continuing education provided by national associationsNCHAM audiology trainingPediatric DiagnosticsCovers the initial diagnostic procedurePediatric Amplification FittingCovers behavioral assessment, hearing aid selection, fitting and validation and cochlear implantsFor 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
10Pediatric 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 stateHow can you determine if you can meet the time-consuming and unique needs of this population, including their families?There can be many answers, but we have put together a few criteria we think make up a Diagnostic Pediatric Audiologist.
11Pediatric 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 availableprovides hearing aids on a trial basishas resources to repair hearing aids quickly
12Pediatric 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
13Pediatric Diagnostic Test Battery Comprehensive Case HistoryFrequency-Specific Auditory Brainstem ResponseHigh Frequency Probe Tone TympanometryTransient and/or Distortion Product Otoacoustic EmissionsHearing aid Fitting with Real Ear MeasurementsBehavioral AudiometryReferralsSo you fit the criteria and know you could be that Pediatric Audiologist we need What about equipment?
15Frequency Specific Auditory Brainstem Response Air Conduction ClicksAbrupt or rapid onset of a broad frequency bandwidth .Greatest agreement in the Hz frequency range.Not enough information across the frequency rangeLow frequencies absent
16Frequency Specific Auditory Brainstem Response ToneburstsProvides information for narrower frequency regionsBetter relates to pure tone audiogramBone-Conducted ClicksShould get when either the click or 500-Hz tonebursts responses are not present at expected normal levels.
17Frequency-Specific ABR Accuracy of pure tone threshold estimates with tone burst ABRHigh 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 dBaudiometric configuration does not affect accuracy of match (Oates and Stapells, 1998)Click and/or tonal stimuli can be used to determine hearing status and loss configuration.Tone pips for frequency specific informationClicks are Hz regionDON’T use only click - will misdiagnose
18Frequency Specific Auditory Brainstem Response Auditory Steady State Response (ASSR)An electrophysiologic response, similar to ABRGenerated by rapid modulation of “carrier” pure tone amplitude or frequency.Signal intensity can be as high as 120 dB
19Frequency Specific Auditory Brainstem Response Auditory Steady State Response (ASSR)Done in conjunction with ABR Clicks, or on a separate occasionsMajor advantage is it estimates severe-to-profound HLBest used in conjunction with ABR and tone burst testing.
20ABR (Click and Tone Burst) versus ASSR: Clinical Application AdvantagesEstimates normal hearingthresholdsEar-specific BC findingsDiagnosis of ANEstimates severe toprofound HLDisadvantagesCan’t estimate profound HLSkilled analysis requiredLimited BC intensity levelsNo ear-specific BC findingsRequires sleep or sedationABRASSRR. Ruth, 2003
21Pediatric Sedation for ABR Who and When4 months to 5 yearsOptionsconscious sedativemild general anesthesiaMonitoringadministered and managed by nursemonitor O2, HR and BPcrash cart and suction available(J. Hall, 2001)
22Pediatric Sedation for ABR Negative outcomes associated withoverdoses, drug interactionsnon-trained personnelinjuries on the way to facility (administered at home)drugs with long half-lives (chloral hydrate, pentobarbital)(J. Hall, 2001)
23Pediatric ABR summaryAir conduction measures should be done with insert earphonesHeadphones can affect latency of waveformBone conduction measures are needed to rule out conductive loss or find conductive component.Use B-70 bone vibratorUse mastoid placementKey Points to remember with Pediatric ABRB-70 vibratorMastoid placementEarlobe inverting electrodesAlternating tone burst to minimize artifactSlower rate (e.g., 11.1/sec) enhances Wave IBegin near maximum intensity (50 dB nHL)Identify Wave I in ipsi ear to verify test earPlot I-L function of Wave V vs AC
24Pediatric ABR summary Use earlobe inverting electrodes Use alternating tone burst to minimize artifactA slower rate (e.g., 11.1/sec) enhances Wave IBegin testing near maximum intensity (50 dB nHL)Allows good waveform to be seenIdentify Wave I in ipsilateral ear to verify test earPlot I-L function of Wave VKey Points to remember with Pediatric ABRB-70 vibratorMastoid placementEarlobe inverting electrodesAlternating tone burst to minimize artifactSlower rate (e.g., 11.1/sec) enhances Wave IBegin near maximum intensity (50 dB nHL)Identify Wave I in ipsi ear to verify test earPlot I-L function of Wave V vs AC
25Pediatric ABR summaryAir 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.Key Points to remember with Pediatric ABRB-70 vibratorMastoid placementEarlobe inverting electrodesAlternating tone burst to minimize artifactSlower rate (e.g., 11.1/sec) enhances Wave IBegin near maximum intensity (50 dB nHL)Identify Wave I in ipsi ear to verify test earPlot I-L function of Wave V vs AC
26High Frequency Probe Tone Tympanometry Tympanometry provides information about middle ear statusadd information to BC resultsMay be affected by conditions in very young infant’s earsEar canal and eardrum are very compliantUse of high frequency probe tone (800 Hz or greater) increases reliability and accuracy in young infants.
27Transient & Distortion Product Otoacoustic Emissions Infants and young children with normal hearing have robusttransient evoked otoacoustic emissions (TEOAE)distortion product otoacoustic emissions (DPOAE)TEOAEs and DPOAEs are easily measured in infants and children.Reflect Outer Hair Cell integrity, whereas the audiogram measure hearing. Is pre-neural, whereas the audiogram is dependent on retrocochlear pathways.Essential component of Pediatric Diagnostic test battery
28Middle Ear Effects on OAEs Middle ear effusion mayobliterate emissioneliminate low frequency componentNegative middle ear pressure mayreduce amplitude, particularly in high frequenciesComplications can arise with OAEs, and the importance of the battery approach is critical when working with newborns and young infants
29OAE Summary OAEs are objective evidence of healthy cochlear function The vast majority of hearing impairment in the low-riskpopulation is a result of malfunction of the outer haircellsthe most sensitive and vulnerable part of thehearing mechanism tested by OAEs.OAEs provide meaningful information whenretrocochlear lesions and/or auditory neuropathyare a concern.
30Amplification Assessment and Fitting Initiate amplification process immediately after diagnosis.Includes medical clearanceFederal regulation - ENTIncludes earmoldsovernight mailing to get within 1 weekcontinue to remake to avoid fitting problems
31Pediatric amplification fitting Does not require exhaustive audiological dataTarget audiogramIndividual ear informationAbility to conduct real-ear measuresScheduling flexibility and immediacyExperience with functional measures of benefit
32Real Ear to Coupler Difference Procedure (RECD) The infant ear is smaller than an adult earMore SPL for same input compared to adultDifferences can be as large as dBMany hearing-aid fitting algorithms do not take these differences into account.RECD affects estimates ofThresholdReal-ear gain and output
33Real ear measurement The insert phone is coupled to the earmold The probe microphone is placed into the ear canalThe earmold is inserted into the earTest stimulus is presentedTotal test time 5-10 minutes per ear
34RECDAfter the RECD is obtained, all hearing aid testing can be done in the test boxRECD values are entered into the hearing aid fitting program to provide a more accurate estimate of real-ear aided gain and outputThe RECD will change as the child grows. A good rule of thumb is to obtain a new RECD when a new earmold is needed
35Basic Audiological Information Used to Fit Amplification Hearing SensitivityABR frequency specific information - low, mid and high frequencyIndividual ear measures: insert phonesMiddle Ear StatusTympanometry - high frequencyBC to rule out conductive loss
36Basic Audiological Information Used to Fit Amplification Cochlear statusABR intensity-latency functionOAEsBehavioral Responsestarget audiogramspeech awareness
37Behavioral Response Audiometry Provides information about how an infant or young child uses hearingBehavioral observation techniques can be used to give functional informationSometimes only suprathreshold information is obtainedwill get better responses to speech than tonesCan look at amplification benefit
38Behavioral Response Audiometry Look at amplification benefitNeed to provide speech at greater than detection levelCannot learn language with threshold-only informationAll of normal conversational level speech needs to reach child through amplification
39Speech 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.
40Referral to and Enrollment in Early Intervention Know established Part C guidelines in stateKnow child eligibility criteriaautomatic enrollment - diagnosed conditionsignificant developmental delayKnow state guidelines for selecting a program
41Enrollment in Early Intervention Develop Individualized Family Service Plan (IFSP)All servicesspeech and language developmentauditory developmentassistive technologyGoals and objectivesTimelines
42Components of IFSP for I/T with Hearing Loss Amplification provisionParent educationAudiological monitoringDevelopment of auditory skillsCommunication developmentlistening skills - speech perceptionspeech productionlanguage developmentMonitoring middle ear status
43Status of EHDI Programs Early Intervention Many of the programs in the current system designed to serve infants with bilateral severe-profound lossesBUT, majority of those identified have mild, moderate, and unilateral lossesPrograms and professionals not appropriate for children and familiesTherefore, Part C of IDEA is severely under utilized
44Status of EHDI Programs Early Intervention State Coordinators estimateOnly 53% of infants with hearing loss are enrolled in EI programs before 6 months of ageOnly 31% of states have adequate range of choices for EI programs
45Barriers 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
46Pediatric AudiologyPediatric Audiology with newborns and young infants can be challenging!
48Some babies are born listeners.. If weuse the elements of an effective EHDI programuse the JCIH 2000 Benchmarksuse appropriate diagnostic protocols and proceduresrefer to early interventionare active participants in early intervention