1. What’s Missing Hear? Michigan Academy of Physician Assistants (MAPA) October 11, 2013 Dee Robertson, MA, CRC, Community Consultant Michigan Early Hearing Detection and Intervention (EHDI) Program 517-373-8601; robertsond2@michigan.govrobertsond2@michigan.gov www.michigan.gov/ehdi

3. Early Hearing Detection and Intervention (EHDI) Program National and state initiative promoting “1-3-6 Goals”:  All newborns will be screened for hearing loss no later than 1 month of age, preferably before hospital discharge.  Those not passing screening should have a comprehensive audiologic evaluation no later than 3 months of age.  All infants identified with hearing loss will receive appropriate early intervention services no later than 6 months of age.

4. Why screen for hearing loss? Incidence – National averages 3/1000 normal births 33/day 12,000 every year.

5. Untreated hearing loss, especially in young children, has negative affects on: Speech and language. Developmental skills. Academic achievement. Social-emotional development. Why screen early?

6. “Early Intervention” Is Critical! Children identified and receiving services younger than 6 months of age have larger vocabularies, better comprehension better expressive language than children identified and introduced to services at greater than 6 months of age.

7. Cost savings The importance of early screening early diagnosis and early intervention. Cost of hearing screening versus audiological test battery. Cost and risks of sedated vs unsedated ABR.

8. Cost Savings TAXES – Yours and Mine! Special education. Employment: $1 Million less in earnings over a lifetime!

9. Because it is the law…… Medicaid policy, March, 2000: Hospitals >15 Medicaid births must provide newborn hearing screening. Mandated Reporting of Hearing Screening & Diagnosis – 2006. (Michigan PA 31 of 2006) Mandated Newborn Hearing Screening (April 2008).

10. Mandated reporting Mandated reporting: Public Act 31 of 2006 (SB 794). Medical professionals must report to the state: - all hearing screenings on children less than twelve months of age; and - all diagnosed hearing loss in children under three years of age.

11. FACT: While over 95% of US newborns are screened for hearing loss at birth, national data suggest that approximately 50% of screening referrals are lost to follow up.

12. How Are We Doing in Michigan?

13. National and State EHDI Goal # 1. All newborns will be screened for hearing loss no later than 1 month of age, preferably before hospital discharge. Michigan

14. HEARING SCREENS 1 + 1 2

15. REMEMBER 1 SCREEN + 1 SCREEN 2 (TO) AUDIOLOGY

16. Michigan 2007-2011 Improvement SLOWLY progressing Lost to Follow-Up (LTF) *Number and percent of infants lost to follow-up after refer from final hearing screen: MI EHDI Data, 2007-2011. Birth YearReferredLTF 20071925117661.1% 2008163995458.2% 2009151880052.7% 2010153183354.4% 2011155782252.8%

17. National and State EHDI Goal # 2. Those not passing screening should have a comprehensive audiologic evaluation no later than 3 months of age.

18. Data* tells us:  Michigan 2011: (Births are down over 20% since 2000) 113,229 births 111,411 screened (98%) 105,817 passed within one month of birth. 1,557 did not pass (from all screens performed) o 166 infants had a documented hearing loss. o 18 babies initially passed but were subsequently diagnosed with Late-onset permanent hearing loss. o 822 had no follow-up at all (52.8%). Potentially: we have many more infants with undiagnosed hearing loss (5 more have been diagnosed since this report.) *Centers for Disease Control DSHPSHWA Annual Report January 2013.

19. National and State EHDI Goal #3. All infants identified with hearing loss will receive appropriate early intervention services no later than 6 months of age. Critical Care Unit

20. How Can Physician’s Assistants Help? - Ask parent/guardian about hospital hearing screen at first “well baby” check. - Confirm screen results in MCIR. - Review steps in MCIR action page.

21. How Can Physician Assistants Help? - Encourage parents to follow up with appropriate testing with a Pediatric Audiologist skilled in diagnosing infants. - Do NOT adopt the “wait and see attitude.” - “Just fluid” may mask permanent hearing loss. - Monitor baby’s developmental progress, - Even if hearing is fine at birth, hearing loss can start at any age.

22. Michigan Care Improvement Registry Hearing (EHDI) tab will show all hearing results reported approximately 1 week after report.

23. MCIR - EHDI Screens

25. PHYSICIAN and HEALTH DEPARTMENT FOLLOW-UP Screen ResultsACTION Fail ▪ If this is an initial failed screen then a hearing re-screen needs to be completed no later than one month of age. ▪ If this is a failed re-screen then immediately send child for a diagnostic evaluation by a pediatric audiologist. Refer to www.michigan/ehdi for a list of pediatric audiologists in your area.www.michigan/ehdi Incomplete ▪ Hearing screen needs to be completed no later than one month of age. (If newborn was in neonatal intensive care unit (NICU) it is recommended to have an automated auditory brainstem response screen (A-ABR). ▪ If incomplete screen is due to parent refusal encourage family to have hearing tested. Pass ▪ Monitor speech-language development. ▪ Review risk factors for late onset and progressive hearing loss (www.jcih.org) and ensure that diagnostic evaluation is completed at least once by 3 years of age.www.jcih.org Diagnostic Results ACTION Undetermined and Conductive (Transient) ▪ Further diagnostic testing needs to be completed. Send child to a pediatric audiologist immediately for appropriate follow-up testing. Refer to www.michigan/ehdi for a list of pediatric audiologists in your area. ▪ Do not assume it is only middle ear effusion. Sensorineural Auditory neuropathy Mixed Conductive (permanent) ▪ Enrollment in intervention, contact Early On (1-800-Early On). ▪ Medical evaluations to determine etiology, identify related conditions, and recommend treatment. Includes referrals to ophthalmology, genetics, otology, developmental pediatrics, neurology, cardiology, and nephrology if appropriate. ▪ Ensure ongoing pediatric audiology services. ▪ Ensure parent support for families, refer to the Guide-By-Your-Side parent support program. Call 517-335-8273. Within Normal Limits Monitor speech and language development milestones. ▪ A child is still at risk for late onset or progressive hearing loss (www.jcih.org). Provider Guidelines Revised November 2008

26. Run a Batch Report of all children coming in for the day for hearing status and who needs follow-up!

27. Is it a Pass? Baby John Doe is born at 11:00 p.m. on Tuesday. He has his Newborn Hearing Screening at 2:00 p.m. on Wednesday. He passes in his Left ear, but refers/fails in his Right ear. Before discharge on Thursday morning, he has another hearing screen. He refers/fails in his Left ear, but passes in his Right ear. How would you interpret these results in MCIR? Is follow-up needed?

28. Early is better, but it’s not over! Remember – it’s now or MUCH later. 1. Infant hearing screen, etc. 2. Kindergarten hearing screen.

29. Provider Guidelines, November 2008 ONGOING CARE OF ALL INFANTS Provide parents with information about hearing, speech, and language milestones. Identify and aggressively treat middle ear disease. This is especially critical in children with confirmed hearing loss as middle ear effusion may further compromise hearing. Vision screening and referral as needed. Referrals to otolaryngology and genetics, as needed Monitor risk indicators for late onset hearing loss.

30. After diagnosis – then what? Michigan EHDI sponsors the Guide-By-Your-Side program. - Experienced, trained parent of a child with hearing loss. - Unbiased discussion of communication modes and options. - Free resource for parents. For more info: www.michigan.gov/ehdi

31. After diagnosis – then what? Michigan Hands & Voices Peer support group for parents and families of children of all ages with hearing loss. Organization for professionals working with these families and children. www.mihandsandvoices.org Loss & Found™ DVD

32. Joint Committee on Infant Hearing (JCIH) Recommendations For rescreening, a complete screening on both ears is recommended, even if only one ear failed the initial screening. For infants who do not pass Automated ABR in the NICU, referral should be made directly to an audiologist … for comprehensive evaluation including ABR. www.jcih.orgwww.jcih.org.