Supplement to the JCIH 2007 position statement: principles and guidelines for early intervention after confirmation that a child is deaf or hard of hearing

Coalition for Global Hearing Health Hearing Care Pathways Working Group: Guidelines for Clinical Guidance for Readiness and Development of Evidence-Based Early Hearing Detection and Intervention Programs

Editor's Note: The following article discusses the timely topic Clinical Guidance in the areas of Evidence-Based Early Hearing Detection and Intervention Programs. This article aims to discuss areas of services needed, guidance to countries/organizations attempting to initiate early hearing detection and intervention systems. Expert consensus and systematic/scoping reviews were combined to produce recommendations for evidence-based clinical practice. In Ear and Hearing, our long-term goal for the Point of View article is to stimulate the field's interest in and to enhance the appreciation of the author's area of expertise. Hearing is an important sense for children to develop cognitive, speech, language, and psychosocial skills. The goal of universal newborn hearing screening is to enable the detection of hearing loss in infants so that timely health and educational/therapeutic intervention can be provided as early as possible to improve outcomes. While many countries have implemented universal newborn hearing screening programs, many others are yet to start. As hearing screening is only the first step to identify children with hearing loss, many follow-up services are needed to help them thrive. However, not all of these services are universally available, even in high-income countries. The purposes of this article are (1) to discuss the areas of services needed in an integrated care system to support children with hearing loss and their families; (2) to provide guidance to countries/organizations attempting to initiate early hearing detection and intervention systems with the goal of meeting measurable benchmarks to assure quality; and (3) to help established programs expand and improve their services to support children with hearing loss to develop their full potential. Multiple databases were interrogated including PubMed, Medline (OVIDSP), Cochrane library, Google Scholar, Web of Science and One Search, ERIC, PsychInfo. Expert consensus and systematic/scoping reviews were combined to produce recommendations for evidence-based clinical practice. Eight essential areas were identified to be central to the integrated care: (1) hearing screening, (2) audiologic diagnosis and management, (3) amplification, (4) medical evaluation and management, (5) early intervention services, (6) family-to-family support, (7) D/deaf/hard of hearing leadership, and (8) data management. Checklists are provided to support the assessment of a country/organization's readiness and development in each area as well as to suggest alternative strategies for situations with limited resources. A three-tiered system (i.e., Basic, Intermediate, and Advanced) is proposed to help countries/organizations at all resource levels assess their readiness to provide the needed services and to improve their integrated care system. Future directions and policy implications are also discussed.

Hearing and speech interactions in children with cerebral palsy, in the first 2 years : Focus on cerebral palsy

Children with cerebral palsy (CP) face communication challenges stemming from neural lesions, hearing issues, and executive function impairments, which are further complicated by interactions between motor and hearing impairments. These challenges lead to limitations in daily activities and are compounded by delays in diagnosis and interventions, adversely affecting speech, language, and cognitive function. In infants with CP, impaired motor function disrupts both feedforward and feedback mechanisms crucial for speech sound production, exacerbating the overall impact on communication development. Understanding the interplay between hearing loss and speech production in children with CP, especially in the crucial early developmental stages, is essential for implementing timely interventions and guiding multidisciplinary care teams in both clinical and home settings. IMPACT QUESTIONS: Children with cerebral palsy (CP) face communication challenges due to neural, hearing, and motor issues, impacting speech and language development. Early and comprehensive testing, including auditory brainstem response, is crucial for timely diagnosis and intervention to mitigate adverse effects. The article emphasizes the need for advanced diagnostics and multidisciplinary interventions to improve communication skills and cognitive outcomes in children with CP.

Late-onset, progressive sensorineural hearing loss in the paediatric population: a systematic review

PURPOSE

To review possible risk factors for permanent delayed-onset, progressive sensorineural hearing loss (SNHL) in the paediatric population to recommend follow-up protocols for early detection.

METHODS

PRISMA-compliant systematic review was performed, including observational studies on the paediatric population up to 16 years old who have passed the newborn hearing screening programme (NHSP), investigating the development of late-onset, progressive SNHL. Electronic searches were performed through Medline, Embase, Cochrane, and Emcare.

RESULTS

37 studies were included. 21 showed an association between late-onset SNHL and congenital cytomegalovirus (cCMV) infection (age at hearing loss diagnosis 0.75 to 204 months, mean 45.6 ± 43.9), while 16 between late-onset SNHL and other congenital or perinatal factors, namely Neonatal Intensive Care Unit (NICU) stay, prematurity, neonatal respiratory failure, mechanical ventilation, extracorporeal membrane oxygenation (ECMO) support, hypocapnia, hypoxia, alkalosis, seizure activity, congenital diaphragmatic hernia (CDH), inner ear malformation, and gene mutations (age at hearing loss diagnosis 2.5 to 156 months, mean 38.7 ± 40.7).

CONCLUSIONS

cCMV infection may cause late-onset SNHL, which can be missed on standard NHSP. There is, therefore, evidence to support universal screening programmes to enable detection in even asymptomatic neonates. Ongoing audiological follow-up for all children with cCMV is advisable, to enable timely treatment. In the paediatric population presenting conditions such as NICU stay > 5 days, prematurity ≤ 34 weeks gestation, severe neonatal respiratory failure, mechanical ventilation, ECMO support, and CDH surgery, an audiological follow-up from 3 months of age up to at least 3-4 years of age, and at least annually, should be recommended.

The Not-So-Slight Perceptual Consequences of Slight Hearing Loss in School-Age Children: A Scoping Review

PURPOSE

This study aimed to conduct a scoping review of research exploring the effects of slight hearing loss on auditory and speech perception in children.

METHOD

A comprehensive search conducted in August 2023 identified a total of 402 potential articles sourced from eight prominent bibliographic databases. These articles were subjected to rigorous evaluation for inclusion criteria, specifically focusing on their reporting of speech or auditory perception using psychoacoustic tasks. The selected studies exclusively examined school-age children, encompassing those between 5 and 18 years of age. Following rigorous evaluation, 10 articles meeting these criteria were selected for inclusion in the review.

RESULTS

The analysis of included articles consistently shows that even slight hearing loss in school-age children significantly affects their speech and auditory perception. Notably, most of the included articles highlighted a common trend, demonstrating that perceptual deficits originating due to slight hearing loss in children are particularly observable under challenging experimental conditions and/or in cognitively demanding listening tasks. Recent evidence further underscores that the negative impacts of slight hearing loss in school-age children cannot be solely predicted by their pure-tone thresholds alone. However, there is limited evidence concerning the effect of slight hearing loss on the segregation of competing speech, which may be a better representation of listening in the classroom.

CONCLUSION

This scoping review discusses the perceptual consequences of slight hearing loss in school-age children and provides insights into an array of methodological issues associated with studying perceptual skills in school-age children with slight hearing losses, offering guidance for future research endeavors.

Ototoxic and nephrotoxic drugs in neonatal intensive care units: results of a Spanish and Italian survey

Neonates face heightened susceptibility to drug toxicity, often exposed to off-label medications with dosages extrapolated from adult or pediatric studies. Premature infants in Neonatal Intensive Care Units (NICUs) are particularly at risk due to underdeveloped pharmacokinetics and exposure to multiple drugs. The study aimed to survey commonly used medications with a higher risk of ototoxicity and nephrotoxicity in Spanish and Italian neonatal units. A prospective cross-sectional study was conducted in Italian and Spanish neonatal units using a web-based survey with 43 questions. A modified Delphi method involved experts refining the survey through online consensus. Ethical approval was obtained, and responses were collected from January to July 2023. The survey covered various aspects, including drug-related ototoxic and nephrotoxic management, hearing screening, and therapeutic drug monitoring. Responses from 131 participants (35.9% from Spain and 64.1% from Italy) revealed awareness of drug toxicity risks. Varied practices were observed in hearing screening protocols, and a high prevalence of ototoxic and nephrotoxic drug use, including aminoglycosides (100%), vancomycin (70.2%), loop diuretics (63.4%), and ibuprofen (62.6%). Discrepancies existed in guideline availability and adherence, with differences between Italy and Spain in therapeutic drug monitoring practices.

CONCLUSIONS

The study underscores the need for clinical guidelines and uniform practices in managing ototoxic and nephrotoxic drugs in neonatal units. Awareness is high, but inconsistencies in practices indicate a necessity for standardization, including the implementation of therapeutic drug monitoring and the involvement of clinical pharmacologists. Addressing these issues is crucial for optimizing neonatal care in Southern Europe.

WHAT IS KNOWN

• Neonates in intensive care face a high risk of nephrotoxicity and ototoxicity from drugs like aminoglycosides, vancomycin, loop diuretics, and ibuprofen. • Therapeutic drug monitoring is key for managing these risks, optimizing dosing for efficacy and minimizing side effects.

WHAT IS NEW

• NICUs in Spain and Italy show high drug toxicity awareness but differ in ototoxic/nephrotoxic drug management. • Urgent need for standard guidelines and practices to address nephrotoxic risks from aminoglycosides, vancomycin, loop diuretics, and ibuprofen.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Structure Principles

This article is the seventh in a series of eight articles that comprise a special issue on family-centered early intervention for children who are deaf or hard of hearing and their families, or FCEI-DHH. This article, Structure Principles, is the third of three articles (preceded by Foundation Principles and Support Principles) that describe the 10 FCEI-DHH Principles. The Structure Principles include 4 Principles (Principle 7, Principle 8, Principle 9, and Principle 10) that highlight (a) the importance of trained and effective Early Intervention (EI) Providers, (b) the need for FCEI-DHH teams to work collaboratively to support families, (c) the considerations for tracking children's progress through developmental assessment, and (d) the essential role of progress monitoring to continuously improve systems.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Call to Action

This Call to Action is the eighth and final article in this special issue on Family-Centered Early Intervention (FCEI) for children who are deaf or hard of hearing (DHH) and their families, or FCEI-DHH. Collectively, these articles highlight evidence-informed actions to enhance family well-being and to optimize developmental outcomes among children who are DHH. This Call to Action outlines actionable steps to advance FCEI-DHH supports provided to children who are DHH and their families. It also urges specific actions to strengthen FCEI-DHH programs/services and systems across the globe, whether newly emerging or long-established. Internationally, supports for children who are DHH are often siloed, provided within various independent sectors such as health/medicine, education, early childhood, and social and disability services. With this Call to Action, we urge invested parties from across relevant sectors to join together to implement and improve FCEI-DHH programs/services and systems, build the capacity of early intervention (EI) Providers and other professionals, extend research regarding FCEI-DHH, and fund EI supports, systems, and research, all with the aim of advancing outcomes for families and their children who are DHH.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Introduction

This article is the first of eight articles in this special issue on Family-Centered Early Intervention (FCEI) for children who are deaf or hard of hearing (DHH), or FCEI-DHH. In 2013, a diverse panel of experts published an international consensus statement on evidence-based Principles guiding FCEI-DHH. Those original Principles have been revised through a coproduction process involving multidisciplinary collaborators and an international consensus panel, utilizing the best available evidence and current understanding of how to optimally support children who are DHH and their families. This revision (referred to as expanded Principles) was motivated by the need to incorporate (a) input from family leaders and DHH leaders, (b) broader international and cultural perspectives, (c) new empirical evidence, and (d) research in human development. This Introduction provides an overview of the rationale, purposes, and main content areas to be addressed throughout the special issue.

The Association Between Family Resources and Language Among Young Children Who are Deaf and Hard of Hearing

OBJECTIVE

Our study (1) examined demographic factors in families with children with bilateral hearing loss and how they relate to Family Resource Scale (FRS) questionnaire data and (2) examined correlations between FRS data and measures of language.

METHODS

Children aged 6 months to 10 years with bilateral hearing loss were enrolled. Parents completed the FRS questionnaire to assess their access to socioeconomic resources at the first language measurement visit. Assessments measured receptive and expressive language, nonverbal intelligence quotient, and adaptive functioning.

RESULTS

Among the 85 children included in the analysis, approximately 40% had hearing loss classified as mild to moderate and 25% had a cochlear implant. Participants' mean FRS score was 130 (SD 16.6) (with the highest possible score of 150 and indicating better access to resources). Significant positive correlations ( p -value ≤ 0.05) were found between maternal education, paternal education, and family income and several FRS subscales (Growth and Support, Necessities in Health, Childcare, Personal Resources). Significant positive correlations were found between the Necessities in Health subscale and all the language measurements.

CONCLUSION

Children whose parents reported better access to socioeconomic resources related to health care had higher language performance scores. Although early access to intervention services has improved for deaf or hard-of-hearing children, there are other variables contributing to language development, including access to socioeconomic resources. This study highlights the need for further research addressing more specific and modifiable resources to improve language performance for deaf or hard-of-hearing children.

Validation of the Norwegian version of the Parents' Evaluation of Aural/ Oral Performance of Children (PEACH+) for children with typical hearing aged 12-72 months

BACKGROUND

The Parents' Evaluation of Aural/Oral Performance of Children (PEACH+) is a parent reported questionnaire. It was first developed in Australia (2007) to assess the effectiveness of hearing devices in young children, and to register how oral children under the age of five hear and communicate with others.

OBJECTIVE

No validated version of the Norwegian translation of PEACH+ exists. This study therefore aims to evaluate the validity and reliability of a back-translated Norwegian version of the PEACH+, from a sample of Norwegian children with typical hearing.

METHODS

Parents of 255 children with typical hearing between 12 and 72 months were recruited through kindergartens and social media platforms. Participants were asked to fill in the PEACH+ questionnaire on behalf of their child, in a digital format.

RESULTS

High internal consistency (Cronbach's Alpha = .917) and satisfactory item-total correlation were found (.342-.678).

CONCLUSION

The Norwegian translation of PEACH+ shows good psychometric properties that are similar to the original version (Ching and Hill, 2007) and that of other translations. The PEACH+ questionnaire is therefore valid to use in a Norwegian context.

Family ASL: An Early Start to Equitable Education for Deaf Children

Deaf and hard of hearing (DHH) children experience systematic barriers to equitable education due to intentional or unintentional ableist views that can lead to a general lack of awareness about the value of natural sign languages, and insufficient resources supporting sign language development. Furthermore, an imbalance of information in favor of spoken languages often stems from a phonocentric perspective that views signing as an inferior form of communication that also hinders development of spoken language. To the contrary, research demonstrates that early adoption of a natural sign language confers critical protection from the risks of language deprivation without endangering spoken language development. In this position paper, we draw attention to deep societal biases about language in information presented to parents of DHH children, against early exposure to a natural sign language. We outline actions that parents and professionals can adopt to maximize DHH children's chances for on-time language development.

Combined hearing and vision screening programs: A scoping review

Background and aim

The World Health Organization (WHO) estimates that 1.5 billion and 2.2 billion people have hearing and vision impairment, respectively. The burden of these non-communicable diseases is highest in low- and middle-income countries due to a lack of services and health professionals. The WHO has recommended universal health coverage and integrated service delivery to improve ear and eye care services. This scoping review describes the evidence for combined hearing and vision screening programs.

Method

A keyword search of three electronic databases, namely Scopus, MEDLINE (PubMed), and Web of Science, was conducted, resulting in 219 results. After removing duplicates and screening based on eligibility criteria, data were extracted from 19 included studies. The Joanna Briggs Institute Reviewer Manual and the Preferred Reporting Items for Systematic Reviews and Meta-analyzes (PRISMA) Extension for Scoping Reviews were followed. A narrative synthesis was conducted.

Results

Most studies (63.2%) were from high-income countries, with 31.6% from middle-income and 5.2% from low-income countries. The majority of studies (78.9%) involved children and the four studies reporting on adults all included adults above 50 years of age. Vision screening was most commonly performed with the "Tumbling E" and "Snellen Chart," while hearing was typically screened using pure tone audiometry. Studies reported referral rates as the most common outcome with sensitivity and specificity rates not reported in any included articles. Reported benefits of combined vision and hearing screenings included earlier detection of vision and hearing difficulties to support functioning and quality of life as well as resource sharing for reduced costs. Challenges to combined screening included ineffective follow-up systems, management of test equipment, and monitoring of screening personnel.

Conclusions

There is limited research evidence for combined hearing and vision screening programs. Although potential benefits are demonstrated, especially for mHealth-supported programs in communities, more feasibility and implementation research are required, particularly in low- and middle-income countries and across all age groups. Developing universal, standardized reporting guidelines for combined sensory screening programs is recommended to enhance the standardization and effectiveness of combined sensory screening programs.

Barriers to and Facilitators of Early Hearing Detection and Intervention in the United States: A Systematic Review

OBJECTIVES

Early hearing detection and intervention (EHDI) is guided by the 1-3-6 approach: screening by one month, diagnosis by 3 mo, and early intervention (EI) enrollment by 6 mo. Although screening rates remain high, successful diagnosis and EI-enrollment lag in comparison. The aim of this systematic review is to critically examine and synthesize the barriers to and facilitators of EHDI that exist for families, as they navigate the journey of congenital hearing loss diagnosis and management in the United States. Understanding barriers across each and all stages is necessary for EHDI stakeholders to develop and test novel approaches which will effectively reduce barriers to early hearing healthcare.

DESIGN

A systematic literature search was completed in May and August 2021 for empirical articles focusing on screening, diagnosis, and EI of children with hearing loss. Two independent reviewers completed title and abstract screening, full-text review, data extraction, and quality assessments with a third independent reviewer establishing consensus at each stage. Data synthesis was completed using the Framework Analysis approach to categorize articles into EHDI journey timepoints and individual/family-level factors versus system-level factors.

RESULTS

Sixty-two studies were included in the narrative synthesis. Results revealed that both individual/family-level (e.g., economic stability, medical status of the infant including middle ear involvement) and system-level barriers (e.g., system-service capacity, provider knowledge, and program quality) hinder timely diagnosis and EI for congenital hearing loss. Specific social determinants of health were noted as barriers to effective EHDI; however, system-level facilitators such as care coordination, colocation of services, and family support programs have been shown to mitigate the negative impact of those sociodemographic factors.

CONCLUSIONS

Many barriers exist for families to obtain appropriate and timely EHDI for their children, but system-level changes could facilitate the process and contribute to long-term outcomes improvement. Limitations of this study include limited generalizability due to the heterogeneity of EHDI programs and an inability to ascertain factor interactions.

Barriers and facilitators to paediatric caregivers' participation in virtual speech, language, and hearing services: A scoping review

Purpose

Virtual care-related technologies are transforming the way in which health services are delivered. A growing number of studies support the use of virtual care in the field of audiology and speech-language pathology; however, there remains a need to identify and understand what influences caregiver participation within the care that is virtual and family-focused. This review aimed to identify, synthesize, and summarize the literature around the reported barriers and facilitators to caregiver participation in virtual speech/hearing assessment and/or intervention appointments for their child.

Methods

A scoping review was conducted following the Joanna Briggs Institute manual for evidence synthesis. A search was conducted using six databases including MEDLINE, CINAHL, SCOPUS, ERIC, Nursing and Allied Health, and Web of Science to collect peer-reviewed studies of interest. Data was extracted according to a protocol published on Figshare, outlining a predefined data extraction form and search strategy.

Results

A variety of service delivery models and technology requirements were identified across the 48 included studies. Caregiver participation was found to vary across levels of attendance and involvement according to eight categories: Attitudes, child behavioral considerations, environment, opportunities, provider-family relationship, role in care process, support, and technology.

Conclusions

This review presents a description of the key categories reported to influence caregiver participation in virtual care appointments. Future research is needed to explore how the findings can be used within family-centered care models to provide strategic support benefiting the use and outcomes of virtual care.

Deaf Children Need Rich Language Input from the Start: Support in Advising Parents

Bilingual bimodalism is a great benefit to deaf children at home and in schooling. Deaf signing children perform better overall than non-signing deaf children, regardless of whether they use a cochlear implant. Raising a deaf child in a speech-only environment can carry cognitive and psycho-social risks that may have lifelong adverse effects. For children born deaf, or who become deaf in early childhood, we recommend comprehensible multimodal language exposure and engagement in joint activity with parents and friends to assure age-appropriate first-language acquisition. Accessible visual language input should begin as close to birth as possible. Hearing parents will need timely and extensive support; thus, we propose that, upon the birth of a deaf child and through the preschool years, among other things, the family needs an adult deaf presence in the home for several hours every day to be a linguistic model, to guide the family in taking sign language lessons, to show the family how to make spoken language accessible to their deaf child, and to be an encouraging liaison to deaf communities. While such a support program will be complicated and challenging to implement, it is far less costly than the harm of linguistic deprivation.

Le suivi de l'extrême prématuré après le congé des soins intensifs néonatals

La survie des extrêmes prématurés (moins de 28 semaines d'âge gestationnel) s'est améliorée au fil du temps. Bon nombre s'en sortent bien et ont une bonne qualité de vie. Ils demeurent toutefois vulnérables à des problèmes de santé, y compris des difficultés neurosensorielles et neurodéveloppementales, que les médecins de première ligne, les pédiatres et les cliniques spécialisées doivent surveiller. Le présent document de principes passe en revue les conséquences médicales et neurodéveloppementales potentielles pour les extrêmes prématurés dans les deux ans suivant leur congé et fournit des stratégies de counseling, de dépistage précoce et d'intervention. Parce qu'ils sont tous liés à l'extrême prématurité, la dysplasie bronchopulmonaire ou les troubles respiratoires, les problèmes d'alimentation et de croissance, le développement neurosensoriel (vision et audition), la paralysie cérébrale et le trouble du spectre de l'autisme doivent faire rapidement l'objet d'une évaluation. Pour évaluer la croissance et le développement, il faut corriger l'âge chronologique en fonction de l'âge gestationnel jusqu'à 36 mois de vie. Par ailleurs, l'attention au bien-être émotionnel des parents et des proches fait partie intégrante des soins de qualité de l'extrême prématuré.

Follow-up care of the extremely preterm infant after discharge from the neonatal intensive care unit

The survival of babies born extremely preterm (EP, <28 weeks gestation) has improved over time, and many have good outcomes and quality of life. They remain at risk for health issues, including neurosensory and neurodevelopmental difficulties requiring monitoring by primary physicians, paediatricians, and specialty clinics. This statement reviews potential medical and neurodevelopmental consequences for EP infants in the first 2 years after discharge and provides strategies for counselling, early detection, and intervention. EP-related conditions to assess for early include bronchopulmonary dysplasia or respiratory morbidity, feeding and growth concerns, neurosensory development (vision and hearing), cerebral palsy, and autism spectrum disorder. Correction for gestational age should be used for growth and development until 36 months of age. Integral to quality care of the child born EP is attention to the emotional well-being of parents and caregivers.

The Feasibility of the Functional Listening Index—Paediatric (FLI-P®) for Young Children with Hearing Loss

(1) Background: There is clear evidence supporting the need for individualized early intervention in children with hearing loss. However, relying on hearing thresholds and speech and language test results to guide intervention alone is problematic, particularly in infants and young children. This study aimed to establish the feasibility of a tool to monitor the development of functional listening skills to inform early and ongoing decisions by parents and professionals. (2) Methods: The FLI-P^® is a 64-item checklist completed by parents and/or a child’s team. The listening development of 543 children with hearing loss enrolled in an early intervention and cochlear implant program was tracked with the FLI-P over a 6-year period. The scores for individual children were grouped according to hearing loss, device, additional needs, and age at device fitting. (3) Results: Results indicate that the FLI-P is a feasible and viable clinical measure that can be used to identify and track a child’s developing listening skills. Its use across a wide range of children supports its broad application. Children’s individual scores and aggregated group data were consistent with indicated expected differences and variations. Children’s individual scores and aggregated group data indicated expected differences and variations. (4) Conclusions: Information provided by children’s listening scores on the FLI-P can guide and support discussions and intervention decisions and bridge the gap between information from audiological assessments and language measures.

Communities Helping the Hearing of Infants by Reaching Parents (CHHIRP) through patient navigation: a hybrid implementation effectiveness stepped wedge trial protocol

INTRODUCTION

As the most common neonatal sensory disorder in the USA, infant hearing loss has an incidence of 1.7 per 1000 births. The consequences of delayed diagnosis and failure to obtain timely intervention include significant communication impairment and negative socioeconomic effects. Early Hearing Detection and Intervention (EHDI) national standards dictate that all infants should be screened and diagnosed by 3 months of age and there is a need for interventions that promote adherence to timely diagnosis. Patient navigation (PN) has been shown to be efficacious to decrease non-adherence with infant hearing diagnostic care; however, PN has yet to be tested in diverse communities or implemented into real-world settings.

METHODS AND ANALYSIS

The proposed research is a community-engaged, type 1 hybrid effectiveness-implementation trial of a PN intervention aimed at decreasing infant hearing diagnosis non-adherence after failed newborn hearing screening, delivered in state-funded EHDI clinics. Guided by our community advisory board and partners, we aim to (1) test the effectiveness of PN to decrease non-adherence to receipt of infant hearing diagnosis within 3 months after birth using a stepped-wedge trial design, (2) investigate implementation outcomes and factors influencing implementation and (3) determine the cost-effectiveness of PN from the perspective of third-party payers. The study will be conducted from April 2019 until March 2024.

ETHICS AND DISSEMINATION

This protocol was approved by the University of Kentucky Institutional Review Board. Although all research involving human subjects contains some risk, there are no known serious risks anticipated from participating in this study. We will seek to disseminate our results in a systematic fashion to patients, key stakeholder, policymakers and the scientific community. Our results will impact the field by partnering with communities to inform the scale-up of this innovative patient supportive intervention to create efficient and effective EHDI programmes and maximise public health impact.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (Pre-results phase): NCT03875339.

Validation of the LittlEARS® Questionnaire in Hearing Maltese-Speaking Children

Objectives: To adapt the LittlEARS^® Auditory Questionnaire into the Maltese language and evaluate the psychometric properties of the Maltese version of the questionnaire for hearing children. Methods: The English version of LittlEARS^® Auditory Questionnaire was adapted into Maltese using a translation/back translation procedure. In this cross-sectional study, a total of 398 parents of normal hearing children aged between 5 days and 36 months completed the Maltese version of LittlEARS^®. Psychometric validation was performed through scale analysis, item analysis, and analysis of reliability and validity. A non-linear regression model was derived to obtain normative data for expected and minimum values of total scores from the questionnaire according to age. Results: Predictive accuracy (Guttman’s lambda) was 0.921, the Cronbach’s alpha coefficient value was 0.921, and the split-half reliability coefficient was 0.949. The Pearson correlation coefficient between scores and age was 0.903. The regression analysis showed that 82% of the variance in the total scores can be explained by age. Norm curves were comparable to the original German data. Conclusion: This study confirmed that the Maltese version of LittlEARS^® is a valid and reliable tool to evaluate auditory development in children less than two years of age.

Exploring Parent Support Needs during the Newborn Hearing Diagnosis Pathway

Universal newborn hearing screening (UNHS) facilitates early detection of permanent congenital hearing loss in newborns. In recognition of specific needs among parents, support services have been established within some UNHS programs, including the Victorian Infant Hearing Screening Program (VIHSP). Despite this, there is limited research about how to best support parents in the context of well-established UNHS programs. This project aims to retrospectively explore parental support needs between the newborn hearing screen and enrolment into early intervention services. We used semi-structured interviews with parents three- to- six-months post confirmation of their newborn’s diagnosis of bilateral moderate-profound sensorineural hearing loss. Data were analysed using inductive content analysis. Thirteen parents of ten children were interviewed. Parents described high satisfaction with the support they received. Some parents felt unprepared for a diagnosis of hearing loss, having been reassured that transient causes such as middle ear fluid caused the hearing screen result. Parents reported mixed responses regarding the value of parent-mentor support along the pathway and some parents described needing additional psychological input to adjust to their child’s diagnosis. These findings provide insights into how a well-established UNHS program, VIHSP, supports parents along the hearing diagnosis pathway and how support can be further enriched.

Does universal newborn hearing screening impact the timing of deafness treatment?

OBJECTIVE

To evaluate the impact of the Universal Neonatal Hearing Screening (UNHS) on the age at diagnosis, beginning of treatment, and first cochlear implant surgery.

METHODS

A retrospective cohort study with children up to 12 years old with bilateral hearing loss were divided into two groups: patients who underwent UNHS and the ones who didn't. The groups were compared according to their age at the beginning of the evaluation at a specialized center, at the beginning of the intervention, and, for the ones who had indication, at the cochlear implant surgery. The group who underwent UNHS was divided between the ones who passed the screening test and the ones who didn't. They were compared according to their ages at the same moments as the first two groups.

RESULTS

135 patients were included. The median age at the first appointment in a specialized center was 1.42 (0.50 and 2.50) years, at the beginning of treatment 2.00 (1.00 and 3.52) years, and the cochlear implant surgery 2.83 (1.83 and 4.66) years. Children who underwent UNHS were younger than those who didn't, at the three evaluated moments (p < 0.001). In a subanalysis, children who passed the UNHS but were later diagnosed with hearing loss reached the first appointment with a specialist and started treatment older than those who failed the tests.

CONCLUSION

Performing UNHS interfered with the timing of deafness diagnosis and treatment. However, children who passed the screening but were later diagnosed with hearing loss were the category with the most important delay.

American Cochlear Implant Alliance Task Force Guidelines for Determining Cochlear Implant Candidacy in Children

This article summarizes the available evidence on pediatric cochlear implantation to provide current guidelines for clinical protocols and candidacy recommendations in the United States. Candidacy determination involves specification of audiologic and medical criteria per guidelines of the Food and Drug Administration. However, recommendations for a cochlear implant evaluation also should maintain flexibility and consider a child’s skill progression (i.e., month-for-month progress in speech, language, and auditory development) and quality of life with appropriately fit hearing aids. Moreover, evidence supports medical and clinical decisions based on other factors, including (a) ear-specific performance, which affords inclusion of children with asymmetric hearing loss and single-sided deafness as implant candidates; (b) ear-specific residual hearing, which influences surgical technique and device selection to optimize hearing; and (c) early intervention to minimize negative long-term effects on communication and quality of life related to delayed identification of implant candidacy, later age at implantation, and/or limited commitment to an audiologic rehabilitation program. These evidence-based guidelines for current clinical protocols in determining pediatric cochlear implant candidacy encourage a team-based approach focused on the whole child and the family system.

Factors Associated with Early Intervention Intensity for Children Who Are Deaf or Hard of Hearing

We quantified the intensity of early intervention (EI) services allocated to 1262 children who were deaf or hard of hearing (DHH) within a state program and identified factors associated with intervention intensity. Child specific data were collected on children born between 2008 and 2014. Data from Individualized Family Service Plans of children enrolled in Part C EI programming were evaluated for the type and duration of services during their EI enrollment. Associations between EI intensity and child/family variables were examined. Median age of EI enrollment was 5.3 months. The most frequently received services included primary service coordination, specialized DHH service, special instruction, language therapy, and family training; 60% of children received 4 or more different EI services. The median service intensity was 138.1 min per month across all EI years. The factors associated with higher EI intensity included severe hearing loss, bilateral hearing loss and presence of a disability. Children enrolled in EI at later ages received higher intensity of specialized DHH services, suggesting a need to "catch up" due to late acquisition of services. Evaluating EI service intensity broadens our understanding of effective components of state-based programs that support the developmental needs of children who are DHH.

Home language environment in relation to language outcome in Brazilian toddlers who are hard of hearing and controls with typical hearing - a pilot study including reliability analyses of the LENA recording system

PURPOSE

The purpose of this pilot study was to explore the home language environment and language outcome of Brazilian toddlers who were hard of hearing, (HH) and controls with typical hearing (TH), and investigate the reliability of using the LENA recording system within a Brazilian Portuguese context.

METHODS

Fourteen families participated in the study (seven children who were HH and seven controls with TH. Each family contributed with one all-day recording. A smaller portion of the recordings of the typically hearing toddlers were manually transcribed by two transcribers. An interrater agreement was conducted, and then the human transcript results were compared against the LENA-generated data for three measures: Adult Words (AW), Child Vocalizations (CV) and Conversational Turns (CT).

RESULTS

Data analyses revealed a moderate to strong interrater agreement for CV and AW. Weak to moderate agreement was found between the LENA estimates and the means of the human counts for CV and AW. Seemingly, LENA overestimated human counts for AW and underestimated numbers of CV. Comparative analysis suggested similarities in the language and listening environment of the two groups (TH vs. HoH). Children's language development was supported by higher numbers of parent-child interactions (CT).

CONCLUSION

The findings imply that LENA may contribute as an ecologically valid tool in preventive family-centered intervention programs for Brazilian toddlers who are hard of hearing and their families, although further validation studies are needed.

Hearing rehabilitation of children and adolescents with unilateral hearing loss

PURPOSE

To describe the audiological characteristics and the type of intervention chosen on unilateral hearing loss cases in children and adolescents as well as to analyze correlations between the degree of hearing loss, the indication and the use of electronic devices.

METHODS

Observational, descriptive and retrospective study, carried out with information of 34 medical records from children and adolescents with unilateral hearing loss, assessed by two auditory rehabilitation services of medium complexity, throughout 2016 to 2019. Descriptive and Inferential statistical analysis were performed with the data.

RESULTS

A predominance of profound sensorineural unilateral hearing loss in the right ear, of pre-lingual character, with 20.6% of malformations. The most adopted intervention was the hearing aid indication, although its use is low, regardless of the degree of the hearing loss. An association was found between the degree of the hearing loss and the healthcare professionals in indicating the use of the devices.

CONCLUSION

The indication of hearing aids is the most frequent and this decision is influenced by the degree of the hearing loss, in which the devices are mostly indicated for mild to severe losses, with bigger divergence of conduct for profound hearing losses.

Newborn Hearing Screening and Intervention in Children with Unilateral Hearing Impairment: Clinical Practices in Three Nordic Countries

Studies have limitedly considered children with early-identified unilateral hearing impairment (UHI), and clinical practices regarding screening, diagnostics and habilitation in this group are rarely documented. In this study, routines for newborns with UHI from screening to diagnostics and habilitation were explored in Norway, Sweden and Finland. An online survey was sent to hospitals responsible for the hearing diagnostics of children requesting information about their practices regarding congenital UHI. Responses covered 95% of the children born in the three included countries. The results revealed large variations in ways of organising healthcare and in clinical decisions regarding hearing screening, diagnostics and habilitation of children with congenital UHI. Finally, implications for policy making and research are also discussed.

A systematic scoping review of early interventions for parents of deaf infants

Background

Over 90% of the 50,000 deaf children in the UK have hearing parents, many of whom were not expecting a deaf child and may require specialist support. Deaf children can experience poorer long-term outcomes than hearing children across a range of domains. After early detection by the Universal Newborn Hearing Screening Programme, parents in the UK receive support from Qualified Teachers of the Deaf and audiologists but resources are tight and intervention support can vary by locality. There are challenges faced due to a lack of clarity around what specific parenting support interventions are most helpful.

Methods

The aim of this research was to complete a systematic scoping review of the evidence to identify early support interventions for parents of deaf infants. From 5577 identified records, 54 met inclusion criteria. Two reviewers screened papers through three rounds before completing data extraction and quality assessment.

Results

Identified parent support interventions included both group and individual sessions in various settings (including online). They were led by a range of professionals and targeted various outcomes. Internationally there were only five randomised controlled trials. Other designs included non-randomised comparison groups, pre / post and other designs e.g. longitudinal, qualitative and case studies. Quality assessment showed few high quality studies with most having some concerns over risk of bias.

Conclusion

Interventions commonly focused on infant language and communication followed by parental knowledge and skills; parent wellbeing and empowerment; and parent/child relationship. There were no interventions that focused specifically on parent support to understand or nurture child socio-emotional development despite this being a well-established area of poor outcome for deaf children. There were few UK studies and research generally was not of high quality. Many studies were not recent and so not in the context of recent healthcare advances. Further research in this area is urgently needed to help develop evidence based early interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02893-9.

Pediatric Hearing Loss Guidelines and Consensus Statements-Where Do We Stand?

A large number of guidelines and position statements have been published with the aim of improving outcomes for children with hearing loss. The purpose of this article is to review the current state of clinical practice guidelines as they relate to screening, diagnosis, and management of hearing loss in children. This summary is intended for the practicing otolaryngologist.

Audiologists' perspectives on management of mild bilateral hearing loss in infants and young children

OBJECTIVE

Universal newborn hearing screening programs have led to early identification of infants with congenital mild bilateral hearing loss (MBHL). The current lack of evidence-based protocols to guide audiological management of infants with MBHL has led to clinical equipoise about fitting of hearing aids. The purpose of this study was to increase understanding about the perspectives of paediatric audiologists on factors influencing their management of MBHLin infants and young children.

DESIGN

A qualitative descriptive research methodology involving semi-structured interviews with audiologists.

STUDY SAMPLE

Twenty-three paediatric audiologists in diagnostic and rehabilitation settings in Victoria, Australia.

RESULTS

Three main themes that influenced management were identified. These include: (1) evidence, or the lack of it, influences audiologists' practice; (2) audiologists recognise the need to be fluid; and (3) family characteristics and parents' perspectives. "Audiologists delivering family-centred practice" was identified as an overarching theme across these factors.

CONCLUSIONS

Audiologists recognised the importance of adopting a family-centred approach in their management of MBHL in infants and young children. Embodied in their practice was the acknowledgement of limited evidence, the consideration of multiple child and family factors, and the incorporation of perspectives of parents and families in adopting a fluid approach to provide individualised services.

Spoken Language Skills in Children With Bilateral Hearing Aids or Bilateral Cochlear Implants at the Age of Three Years

Early hearing aid (HA) fitting and cochlear implants (CIs) aim to reduce the effects of hearing loss (HL) on spoken language development. The goals of this study were (1) to examine spoken language skills of children with bilateral HAs and children with bilateral CIs; (2) to compare their language skills to the age-norms of peers with normal hearing (NH); and (3) to investigate factors associated with spoken language outcomes.

Referral Criteria for Preschool Hearing Screening in Resource-Constrained Settings: A Comparison of Protocols

Purpose This study aimed to describe and compare the performance of two screening protocols used for preschool hearing screening in resource-constrained settings. Method Secondary data analysis was done to determine the performance of two protocols implemented during a preschool hearing screening program using mobile health technology in South Africa. Pure-tone audiometry screening at 25 dB HL for 1000, 2000, and 4000 Hz in each ear was used by both protocols. The fail criterion for the first protocol (2,147 children screened) constituted a no-response on one or more frequencies in either ear. The second protocol required two or more no-responses (5,782 children). Multivariate logistic regression models were used to investigate associations between outcomes and protocol, age, gender, and duration. Results Fail rates for the one-frequency fail protocol was 8.7% (n = 186) and 4.3% (n = 250) for the two-frequency fail protocol. Children screened with the two-frequency fail protocol were 52.9% less likely to fail (p < .001; OR = 0.471; 95% confidence interval [0.385, 0.575]). Gender (p = .251) and age (p = .570) had no significant effect on screening outcome. A percentage of cases screened (44.7%) exceeded permissible noise levels in at least one ear at 1000 Hz across both protocols. True- and false-positive cases did not differ significantly between protocols. Protocol type (p = .204), gender (p = .314), and age (p = .982) did not affect the odds of being a true-positive result. Average screening time was 72.8 s (78.66 SD) and 64.9 s (55.78 SD) for the one-frequency and two-frequency fail protocols, respectively. Conclusions A two-frequency fail criterion and immediate rescreen of failed frequencies significantly reduced referral rate for follow-up services that are often overburdened in resourced-constrained settings. Future protocol adaptations can also consider increasing the screening levels at 1000 Hz to minimize the influence of environmental noise.

Maternal knowledge on infant hearing loss and acceptability of hearing aids as an intervention at a Referral Hospital in southwestern Uganda

OBJECTIVE

Infant hearing screening enables early detection and management of hearing loss (HL) so that speech and language development delays are minimized. Parents play a critical role in successful screening and management of Infant Hearing loss (IHL) but there is limited data from resource limited settings on parental knowledge about HL and acceptability of IHL interventions. This study was aimed at exploring the maternal knowledge on the various causes of IHL and their acceptability of hearing aids as an intervention for IHL.

METHODS

A cross-sectional study was conducted at a referral hospital in southwestern Uganda. A semi-structured questionnaire was used to interview postpartum mothers to assess their knowledge on causes of IHL and acceptability of a hearing aid if prescribed. Logistic regression was used to calculate odds ratio (OR) for the factors associated with hearing aid refusal.

RESULTS

401 mothers with a mean age of 25 years (Standard Deviation = 5.6 years) were recruited. Half of the mothers correctly identified at least five causes of IHL. The most well-known causes were measles (63.3%) and a positive family history of HL (61.6%). 60% of mothers held at least one superstitious belief as a cause of IHL. Majority of mothers (86%) would accept a hearing aid as an IHL intervention. Mothers with a positive family history of HL (OR = 0.42, p = 0.04), in middle or higher socioeconomic class (OR = 0.45, p = 0.01) and those with more than 3 antenatal visits in their recent pregnancy (OR = 0.44, p = 0.01) were less likely to refuse a hearing aid while mothers that were either widowed or separated from their spouses (OR = 15.64, p = 0.01) were more likely to refuse a hearing aid.

CONCLUSION

Although mothers had limited knowledge on some causes of IHL, there was a high acceptability of hearing aids as an intervention for IHL. Marital status, family history of hearing loss, socioeconomic status and antenatal care attendance are factors that could be used to identify mothers that might accept or refuse a hearing aid for their infant. There is need to increase awareness about causes of hearing loss to improve knowledge as well as dispel any non-biological beliefs held by communities.

Diagnosis and patterns of hearing loss in children with severe developmental delay

INTRODUCTION & OBJECTIVE

Children with cognitive delay often experience challenges with obtaining hearing thresholds through behavioral audiometry (BA). This necessitates sedated Auditory Brainstem Response (sABR) testing. This study aimed to evaluate diagnostic and hearing patterns in children with Down Syndrome (DS), Autism Spectrum Disorder (ASD), Global Developmental delay (GDD), and Cerebral Palsy (CP) who were unable to complete reliable BA testing due to severe cognitive delay.

METHODS

Retrospective chart review on a cohort of children aged 0.5-18 years with a diagnosis of DS, ASD, GDD, or CP who underwent sABR due to unsuccessful BA testing. This was performed at a tertiary care institution from 2014 to 2019. Testing patterns and audiometric data were collected.

RESULTS

Across 15 DS, 39 ASD, 10 GDD, and 11 CP patients, the average time from first nondiagnostic BA to sABR ranged from 8.6 months (in GDD) to 21.8 months (in DS). The average number of BAs performed before sABR ranged from 1.6 (in ASD and GDD) to 2.7 (in DS). Hearing loss (HL) was diagnosed in 10%, 13%, 36% and 46% of patients with GDD, ASD, CP and DS respectively. Up to 75% of the HL was sensorineural (in CP patients).

CONCLUSION

In children with significant cognitive delays, a high incidence of HL (especially SNHL) was identified, therefore high suspicion for HL should be held in these patients. Multiple unsuccessful BAs contribute to prolonged time to diagnosis and treatment, thus prompt sABR should be performed in patients whose severe cognitive delay inhibits reliable testing with BA.

Auditory Brainstem Response Pass Rates Correlate with Newborn Hour of Life and Delivery Mode

OBJECTIVE

To determine whether hour of life and mode of delivery affect auditory brainstem response (ABR) results in healthy infants with a gestational age of >35 weeks.

STUDY DESIGN

This retrospective cohort study reviewed 31 984 infants tested during a standard birth hospitalization from 2014 to 2016 at Prentice Women's Hospital of Chicago. Per policy, ABRs were performed after 6 and 12 hours of life for vaginally and cesarean-delivered infants, respectively. Testing was repeated before discharge for infants who were referred once. For those infants who referred again, a third ABR was offered at no cost to families 10-14 days after discharge starting in 2016.

RESULTS

ABR pass rates consistently and significantly increased with advancing hour of life at testing, starting at 10-11 hours of life for vaginally born infants and 30-32 hours for cesarean-born infants. This steady, incremental increase in the pass rate was maintained overall until the vaginal and cesarean groups reached plateaus at 42-44 and 48-52 hours of life, respectively. In 2016 and beyond, a third hearing screen after discharge lowered the referral rate to just 0.77%.

CONCLUSIONS

This study of the results of ABR tests in over 30 000 well newborns demonstrates that delaying hearing screening until 10-11 hours for vaginally born infants and 30-32 hours for cesarean-born infants results in a statistically significant improvement in hearing pass rates.

Auditory perception skills in children receiving simultaneous bilateral cochlear implants: early speech-discrimination results

PURPOSE

The objective of the present study is to evaluate early speech-perception abilities using VRISD in toddlers who received simultaneous bilateral CIs between 12 and 36 months of age and to compare them with the findings in NH infants and to monitor the development of speech-perception skills within 6 months after cochlear implantation.

METHODS

The VRISD test was performed using video visual reinforcement to assess speech-discrimination ability in the CI and NH groups. Four stimuli were used for testing in the present study: /a/, /i/, /ba/, and /da/. The two contrasts used for the research were /a-i/ and /ba-da/. Auditory and listening skills in the CI group were assessed using the IT-MAIS.

RESULTS

The responses to the /a-i/ and /ba-da/ phoneme contrast were found to be similar in the NH and CI groups. No statistically significant difference was found between the groups (p > 0.05). VRISD test result and the IT-MAIS score were highly correlated in CI group (p = 0.001, r = 0.822).

CONCLUSION

The VRISD test can be effectively used to evaluate the development of speech-discrimination skills in hearing-impaired babies before and after CI. This research suggests that the development of speech-perception ability with CI is seriously influenced by environmental exposure and sound access. To the best of our knowledge, this is the first study to evaluate the speech-perception skills in toddlers with simultaneous bilateral CI.

Family-Centered Care in the Transition to Early Hearing Intervention

This study aimed to explore and compare families' and professionals' perspectives on the implementation of family-centered care (FCC) (Moeller, Carr, Seaver, Stredler-Brown, & Holzinger, 2013) during the period between diagnosis of hearing loss (HL) and enrollment in early intervention (EI). A convergent mixed-methods study incorporating self-report questionnaires and semistructured in-depth interviews was used. Seventeen family members of children with HL and the 11 professionals who support these families participated in this study. The results suggested that the services engaged during the transition period partially adhered to the principles of FCC, including the provision of timely access to EI services and provision of emotional and social support. However, areas for improvement identified include strengthening family/professional partnerships, shared decision-making processes, collaborative teamwork, program monitoring, and consistency in the provision of information and support. Qualitative and quantitative research findings also indicated a lack of consistency in service provision during the transition period.

Practitioners' Self-Assessment of Family-Centered Practice in Telepractice Versus In-Person Early Intervention

For infants and young children who are identified as deaf or hard of hearing (DHH), best practice principles indicate the provision of family-centered early intervention (FCEI). However, factors such as geographical inaccessibility and workforce shortages can limit families' access to FCEI in their local area. One strategy for overcoming these barriers is telepractice-a method of connecting families and practitioners using synchronous, two-way audiovisual technologies. This study compared the self-assessed use of family-centered practices by a group of practitioners delivering FCEI through telepractice with that of a similar group delivering FCEI in-person. A sample of 38 practitioners (15 telepractice and 23 in-person) from two early intervention programs for children who are DHH completed a self-assessment tool: the Measures of Processes of Care for Service Providers. Results indicated that there were no significant differences between telepractice and in-person sessions with regard to practitioners' self-assessment of their use of family-centered practices.

A new training package (3Cs: Connect, Communicate and Collaborate) for improving family responsive service delivery in early intervention for children with hearing loss: A proof of concept study

BACKGROUND

An objective of early intervention for children with hearing loss is to enhance family engagement in therapy to maximise a child's speech and language potential. However, requiring a service provider to work collaboratively with a child's family can create problems in developing and underdeveloped countries, where skilled service providers and services for children with hearing loss are lacking and where an expert model of intervention prevails.

OBJECTIVES

To determine the preliminary effectiveness of a new training package Connect, Communicate and Collaborate (3Cs), in improving the knowledge and confidence of service providers in the delivery of family responsive services in an early intervention program for children with hearing loss.

METHODS

Five learning modules were developed based on service provider experience working with children with hearing loss, and parents of children with hearing loss. Six participants completed the training package comprising five training modules and an introductory session over a 6-week period. Participants' confidence and knowledge in providing family responsive practice was measured pre and post training using visual analogue scales, and participants were also invited to provide their reflections on the program.

RESULTS

Pre- and post-training confidence ratings revealed significant improvements in the perceptions of participants in the implementation of responsive family practice across four of five of programme learning modules (p < 0.002). Participant reflection statements indicate they became more considerated in their family responsive practice. Despite positive experiences working with parents, participants stated they had ongoing difficulties guiding families through the decision-making processes of habilitation. The reflection process assisted learning and improved practice by supporting participants to build on their strengths.

CONCLUSION

The 3Cs package improved the confidence in and knowledge of delivery of responsive family services for six participants in Kuwait. It also improved the participant's self-evaluation skills. The 3Cs provides professional development that meets the needs of service providers working with children with hearing loss to improve inclusion of families in the therapy process.

Effective Masking Levels for Bone Conduction Auditory Brainstem Response Stimuli in Infants and Adults with Normal Hearing

OBJECTIVE

The purpose of the present study was to investigate effective masking levels (EMLs) for bone conduction (BC) auditory brainstem response (ABR) testing in infants and adults. Early hearing detection and intervention programs aim to limit delays in identifying ear-specific type/degree of hearing loss in infants using the ABR. Ear-specific assessment poses challenges as sound delivered to one ear can travel across the skull and activate the contralateral cochlea. Wave V amplitude and latency measures ipsilateral and contralateral to the bone oscillator can be compared to isolate the test cochlea in some cases; however, when these findings are equivocal, clinical masking is required. This study aims to determine EMLs for ABRs elicited to 500- and 2000-Hz BC stimuli for normal-hearing infants (0 to 18 months) and adults.

DESIGN

Participants were 21 adults (18 to 54 years) and 24 infants (5 to 47 weeks) with normal hearing. BC 500- and 2000-Hz brief tonal stimuli at intensities approximating normal levels were presented via a B-71 oscillator (infants: 20 dB nHL at 500 Hz and 30 dB nHL at 2000 Hz; adults: 500 and 2000 Hz at 20 and 30 dB nHL, respectively). White noise masking was presented binaurally via ER-3A earphones (22 to 82 dB SPL; 10-dB steps). The lowest level of masking to eliminate a BC response was deemed the EML.

RESULTS

For stimuli presented at 20 dB nHL, adult mean (1 SD) EMLs for 500 and 2000 Hz were 65 (9) and 53 (6) dB SPL, respectively. Mean EMLs for infants were 80 (6) dB SPL for 500 Hz at 20 dB nHL and 64 (9) dB SPL for 2000 Hz at 30 dB nHL. Compared to adults, infants required approximately 13 dB more masking at 500 Hz but a similar amount of masking at 2000 Hz. Infants required 26 dB more masking at 500 versus 2000 Hz, whereas, adults required only 12 dB more masking.

CONCLUSIONS

Maximum binaural EMLs for infant BC responses elicited to 500 Hz at 20 dB nHL are 82 dB SPL, and for 2000 Hz at 30 and 40 dB nHL, respectively, are 72 and 82 dB SPL. Monaural masking levels for the nontest ear (assuming 10 dB of interaural attenuation) recommended clinically are as follows: (1) 500 Hz: 72 and 82 dB SPL at 20 and 30 dB nHL, respectively; and (2) 2000 Hz: 62, 72, and 82 dB SPL at 30, 40, and 50 dB nHL, respectively. Unsafe levels of white noise would be needed to effectively mask at greater stimulus levels.

Global Regulatory Review Needed for Cochlear Implants: A Call for FDA Leadership

INTRODUCTION

Using the United States Food and Drug Administration (FDA) as example, we argue that regulatory agencies worldwide should review their guidance on cochlear implants (CIs).

METHODS

This is a position paper, thus the methods are strictly argumentation. Here we give the motivation for our recommendation. The FDA's original approval of implantation in prelingually deaf children was granted without full benefit of information on language acquisition, on childcaregiver communication, and on the lived experience of being deaf. The CI clinical trials, accordingly, did not address risks of linguistic deprivation, especially when the caregiver's communication is not fully accessible to the prelingually deaf child. Wide variability in the effectiveness of CIs since initial and updated approval has been indicated but has not led to new guidance. Children need to be exposed frequently and regularly to accessible natural language while their brains are still plastic enough to become fluent in any language. For the youngest infants, who are not yet producing anything that could be called language although they might be producing salient social signals (Goldstein et al. Child Dev 80:636-644, 2009), good comprehension of communication from caregiver to infant is critical to the development of language. Sign languages are accessible natural languages that, because they are visual, allow full immersion for deaf infants, and they supply the necessary support for this comprehension. The main language contributor to health outcomes is this combination of natural visual language and comprehension in communication. Accordingly, in order to prevent possible language deprivation, all prelingually deaf children should be exposed to both sign and spoken languages when their auditory status is detected, with sign language being critical during infancy and early childhood. Additionally, all caregivers should be given support to learn a sign language if it is new to them so that they can comprehend their deaf children's language expressions fully. However, both languages should be made accessible in their own right, not combined in a simultaneous or total communication approach since speaking one language and signing the other at the same time is problematic.

RESULTS

Again, because this is a position paper, our results are our recommendations. We call for the FDA (and similar agencies in other countries) to review its approval of cochlear implantation in prelingually deaf children who are within the sensitive period for language acquisition. In the meantime, the FDA should require manufacturers to add a highlighted warning to the effect that results with CI vary widely and CIs should not be relied upon to provide adequate auditory input for complete language development in all deaf children. Recent best information on users' experience with CIs (including abandonment) should be clearly provided so that informed decisions can be made. The FDA should require manufacturers' guidance and information materials to include encouragement to parents of deaf children to offer auditory input of a spoken language and visual input of a sign language and to have their child followed closely from birth by developmental specialists in language and cognition. In this way parents can align with providers to prioritize cognitive development and language access in both audio-vocal and visuo-gestural modalities.

DISCUSSION

The arguments and recommendations in this paper are discussed at length as they come up.

The Input Matters: Assessing Cumulative Language Access in Deaf and Hard of Hearing Individuals and Populations

Deaf and hard-of-hearing (DHH) children present several challenges to traditional methods of language assessment, and yet language assessment for this population is absolutely essential for optimizing their developmental potential. Whereas assessment often focuses on language outcomes, this Conceptual Analysis argues that assessing cumulative language input is critically important both in clinical work with DHH individuals and in research/public health contexts concerned with DHH populations. At the individual level, paying attention to the input (and the person's access to it) is vital for discriminating disorder from delay, and for setting goals and strategies for reaching them. At the population level, understanding relationships between cumulative language input and resulting language outcomes is essential to the broader public health efforts aimed at identifying strategies to improve outcomes in DHH populations and to theoretical efforts to understand the role that language plays in child development. Unfortunately, several factors jointly result in DHH children's input being under-described at both individual and population levels: for example, overly simplistic ways of classifying input, and the lack of tools for assessing input more thoroughly. To address these limitations, this Conceptual Analysis proposes a new way of characterizing a DHH child's cumulative experience with input, and outlines the features that a tool would need to have in order to measure this alternative construct.

How the World's Children Hear: A Narrative Review of School Hearing Screening Programs Globally

Objective

School hearing screening may mitigate the effects of childhood hearing loss through early identification and intervention. This study provides an overview of existing school hearing screening programs around the world, identifies gaps in the literature, and develops priorities for future research.

Data Sources

A structured search of the PubMed, Embase, and Cochrane Library databases.

Review Methods

A total of 65 articles were included according to predefined inclusion criteria. Parameters of interest included age groups screened, audiometric protocols, referral criteria, use of adjunct screening tests, rescreening procedures, hearing loss prevalence, screening test sensitivity and specificity, and loss to follow-up.

Conclusions

School hearing screening is mandated in few regions worldwide, and there is little accountability regarding whether testing is performed. Screening protocols differ in terms of screening tests included and thresholds used. The most common protocols included a mix of pure tone screening (0.5, 1, 2, and 4 kHz), otoscopy, and tympanometry. Estimates of region-specific disease prevalence were methodologically inaccurate, and rescreening was poorly addressed. Loss to follow-up was also a ubiquitous concern.

Implications for Practice

There is an urgent need for standardized school hearing screening protocol guidelines globally, which will facilitate more accurate studies of hearing loss prevalence and determination of screening test sensitivity and specificity. In turn, these steps will increase the robustness with which we can study the effects of screening and treatment interventions, and they will support the development of guidelines on the screening, diagnostic, and rehabilitation services needed to reduce the impact of childhood hearing loss.

Cost-effectiveness of School Hearing Screening Programs: A Scoping Review

Objective

School hearing screening is a public health intervention that can improve care for children who experience hearing loss that is not detected on or develops after newborn screening. However, implementation of school hearing screening is sporadic and supported by mixed evidence to its economic benefit. This scoping review provides a summary of all published cost-effectiveness studies regarding school hearing screening programs globally. At the time of this review, there were no previously published reviews of a similar nature.

Data Sources

A structured search was applied to 4 databases: PubMed (Medline), Embase, CINAHL, and Cochrane Library.

Review Methods

The database search was carried out by 2 independent researchers, and results were reported in accordance with the PRISMA-ScR checklist and the JBI methodology for scoping reviews. Studies that included a cost analysis of screening programs for school-aged children in the school environment were eligible for inclusion. Studies that involved evaluations of only neonatal or preschool programs were excluded.

Results

Four of the 5 studies that conducted a cost-effectiveness analysis reported that school hearing screening was cost-effective through the calculation of incremental cost-effectiveness ratios (ICERs) via either quality- or disability-adjusted life years. One study reported that a new school hearing screening program dominated the existing program; 2 studies reported ICERs ranging from 1079 to 4304 international dollars; and 1 study reported an ICER of £2445. One study reported that school-entry hearing screening was not cost-effective versus no screening.

Conclusion

The majority of studies concluded that school hearing screening was cost-effective. However, significant differences in methodology and region-specific estimates of model inputs limit the generalizability of these findings.

Medical Referral Patterns and Etiologies for Children With Mild-to-Severe Hearing Loss

OBJECTIVES

To (1) identify the etiologies and risk factors of the patient cohort and determine the degree to which they reflected the incidence for children with hearing loss and (2) quantify practice management patterns in three catchment areas of the United States with available centers of excellence in pediatric hearing loss.

DESIGN

Medical information for 307 children with bilateral, mild-to-severe hearing loss was examined retrospectively. Children were participants in the Outcomes of Children with Hearing Loss (OCHL) study, a 5-year longitudinal study that recruited subjects at three different sites. Children aged 6 months to 7 years at time of OCHL enrollment were participants in this study. Children with cochlear implants, children with severe or profound hearing loss, and children with significant cognitive or motor delays were excluded from the OCHL study and, by extension, from this analysis. Medical information was gathered using medical records and participant intake forms, the latter reflecting a caregiver's report. A comparison group included 134 children with normal hearing. A Chi-square test on two-way tables was used to assess for differences in referral patterns by site for the children who are hard of hearing (CHH). Linear regression was performed on gestational age and birth weight as continuous variables. Risk factors were assessed using t tests. The alpha value was set at p < 0.05.

RESULTS

Neonatal intensive care unit stay, mechanical ventilation, oxygen requirement, aminoglycoside exposure, and family history were correlated with hearing loss. For this study cohort, congenital cytomegalovirus, strep positivity, bacterial meningitis, extracorporeal membrane oxygenation, and loop diuretic exposure were not associated with hearing loss. Less than 50% of children underwent imaging, although 34.2% of those scanned had abnormalities identified. No single imaging modality was preferred. Differences in referral rates were apparent for neurology, radiology, genetics, and ophthalmology.

CONCLUSIONS

The OCHL cohort reflects known etiologies of CHH. Despite available guidelines, centers of excellence, and high-yield rates for imaging, the medical workup for children with hearing loss remains inconsistently implemented and widely variable. There remains limited awareness as to what constitutes appropriate medical assessment for CHH.

Progressive Hearing Loss in Children With Mild Bilateral Hearing Loss

Purpose This study investigated progressive hearing loss in a cohort of children who were identified with permanent mild bilateral hearing loss. Method This population-based study included 207 children with permanent mild bilateral hearing loss, diagnosed and followed from 2003 to 2016 in 1 region of Canada. Clinical characteristics and initial audiologic results were collected prospectively at diagnosis, and audiologic information was updated. Changes in hearing levels between the 1st and most recent assessment were analyzed to determine progressive hearing loss. Clinical characteristics were compared between children with progressive and stable hearing loss. The association between risk indicators and progressive hearing loss was explored through logistic regression. Results A total of 47.4% (94 of 207) had progressive hearing loss in at least 1 ear, and 50% (47 of 94) of those experienced more than 20-dB average drop in thresholds. For these 94 children, a total of 147 ears were affected, and 116 (78.9%) ears experienced sufficient change in thresholds to be coded as a worse category of hearing loss. In the subset of 85 children with more than 5 years of audiologic follow-up, 56.4% (53/85) showed a decrease in hearing. Of the total sample of 207 children, 137 (66.2%) continued to have mild hearing loss in the better ear. There was no association between the risk factors examined (family history of hearing loss, admission to the neonatal intensive care unit, or presence of a syndrome) and progressive hearing loss. Conclusion This study found that almost half of children with mild bilateral hearing loss showed a decrease in hearing in at least 1 ear. One third of the children first diagnosed with mild hearing loss in the better ear now have moderate or worse hearing loss in both ears. These findings point to the importance of careful long-term monitoring of children who present with mild hearing loss.