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

Donna C. Maselli, RN, MPHConnecticut Department of Public

HealthHartford, CT

Faculty Disclosure Information

In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation.

This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA.

Newborn Hearing Screening History in CT

• Legislation to screen “high risk” infants since 1985– Primarily NICU babies

• Well babies were not routinely screened– Half the children with PCHL do not exhibit risk factors

(NCHAM, 2002)

• 1994 Strong lobbying began to implement Universal Newborn Hearing Screening (UNHS)– CT Newborn Hearing Screening Task Force formed

CT Legislation

19a-59 amendment in part reads….

“Institutions providing childbirth services shall, no later than July 1, 2000, include a UNHS program as part of it’s standard of care.”

– Initial legislation was for July 1, 1999

Source: Connecticut State Statutes

Purpose of UNHS

• To provide early hearing detection & intervention (EHDI) to infants, in an attempt to minimize speech and language delays

– EHDI and treatment before 6 months of age facilitate a child’s healthy development consistent with age and cognitive ability

Program Goals

• Hearing screening at birth, before discharge

• Diagnostic testing within 2 months of initial screen

• Referral to Early Intervention (Birth-to-Three)by 4 months

Screening Methods

• First screen– May be Otoacoustic

emissions (OAE) or Automatic Brainstem Response (ABR)

Second Screening

• Second Screen– Repeated before

discharge if infant does not pass the first screen

– ABR screen

• 1/06 ABR screening for all NICU infants

2004 STATISTICS

Total Screened 97%Passed 1st Screening 91.21%Passed 2nd Screening 6.37%Referred for Diagnostic Testing 1.35% (n=324)Received Diagnostic Testing 84%Lost to Follow-up 16%Hearing Loss 0.14% (n=60)

Types of Hearing Loss Identified 2004

Bilateral Unilateral

Conductive 9% 21%

Sensorineural 54% 37%

Undetermined 36%36% 47%47%

Diagnostic Testing Centers

• DPH Identified Centers for Follow-up Testing– Used CT UNHS Task Force ‘Best Practice

Standards’– Surveyed all CT licensed audiologists– Identified 16 Diagnostic Testing Centers

• Mechanism to report to DPH

• Referral to E.I.

‘Best Practice Recommendations for Diagnostic Hearing Testing of

Infants’CT Newborn Hearing Screening Task Force

• Auditory Brainstem Response [ABR (a.k.a BAERS, BAER)]– Threshold measurement with frequency specific tone bursts– Threshold measurement with bone conduction ABR – Sedation in a medical facility where the child can be

appropriately monitored

• Immittance Testing– Tympanometry with high frequency probe tone greater

than 1000 Hz– Acoustic reflex testing 

Best Practice Standards cont…

• Completed by 2 months of age

• Conducted by a “pediatric” audiologist

• A battery of tests based on– Screening results– Medical history – Risk factors

• Include an otological evaluation– May be conducted at different facility and time

 

Best Practice Standards cont…

• Otoacoustic Emissions (OAE)– Transient evoked or distortion product

•  Behavioral Audiometry– May be useful in addition to the above

• Reporting of results to DPH

• Refer to Birth-to-Three

Degree of Hearing loss

• Mild 26-40 dB HL

• Moderate 41-60 dB HL

• Severe 61-80 dB HL

• Profound 80+

AGE AT DIAGNOSIS (in months)National Goal = 3 months

YEAR AGE in MONTHS

2000 1.69

2001 3.07

2002 1.74

2003 0.85

2004 2.29

2005 2.92

AGE AT Referral to B23 (in months)National Goal = 6 months

YEAR CT AGEAt Referral

2000 2.13

2001 3.48

2002 2.64

2003 3.23

2004 3.83

2005 4.68

Early Intervention Services in CT

• Mandated reporting (CT General Statutes Sec. 17a-248d)– Report within 2 days of identifying child– Suspected or at risk of having

developmental delay

• Infants referred through Child Development Infoline

CT Early Intervention Eligibility

• Birth-to-Three Eligibility – 40db or greater, bilateral hearing loss– Exclusions!– www.birth23.org

• 27 states that have language in their legislation that includes either unilateral, mild or "any" hearing loss

Why is early intervention important for children with mild or unilateral

hearing loss?

Mild Hearing Loss• Will miss 25-40% of what is said & 50% in noisy

situation

• May not hear consonants such as /s/, /f/, /th/, /p/, /h/, /g/, /ch/, /sh/, /z/, /v/

• Cannot hear plurals or contractions

• Unable to learn incidental learning “common sense”

• 37% with slight-mild hearing loss fail a grade, typically 1st (Bess et. AL. 1998)

Unilateral Hearing Loss

• Difficulty hearing speech if speaking from behind or with background noise

• Difficulty localizing speech

• 35% fail one or more grades, typically 1st

• 27% ages 1-3 present with language delay

Attempts to Change CT Birth-to-Three Eligibility

• To include unilateral and bilateral with any degree

• Multi level support– DPH, DSS, UNHS Task Force, Dx Centers

• Birth-to-Three Medical Advisory meeting– Show us the data that says these kids would

benefit from E.I.

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

Loss”• MD/MPH Student Internship at DPH (Summer 2005)

• Purpose of the Study– Assess speech/language developmental outcomes of

children with hearing loss who did not receive Birth-to-Three services

• Hypothesis– Children with hearing loss who did not receive E.I.

services will show evidence of delayed speech/language by ages 3, 4 or 5 years

Methodology

• Selection Criteria– Used UNHS data– Infants born between 7/1/00 - 12/31/03

• Now 2-5 years old• 80% of the child’s ability to learn speech, language and

related cognitive skills is established by 36 months (White, 2000)

– Bilateral with mild in at least one ear – Unilateral, moderate to profound hearing

loss

Methodology

• 94 Records met criteria– Letters sent to families– Requested parental consent to review audiology records– 22 consents received

• Records reviewed for:– Parental concern– An assessment of speech/language– Referral for speech evaluation– Referral to B23

Results

• 77.3 % Recommended ENT consultation

• 59% No documented audiology visit after ENT

• 68.2% No documented audiology visit after age 2

• 90.9% Status of speech/language development unknown

• 9.1% Had documented delay

Conclusion

Unable to ascertain if lack of early intervention is associated with speech/language delays due to:

• Lack of Audiology visit after ENT referral (59%)

• Lack of reference to speech/language in audiology record (90.9%)

• Lack of documented follow-up after age 2 (68.2%)– The absence of visits after age 2 may be due to

• PCP conducts the screenings in the office• Family moved from the region• The child is not receiving any care• Audiological assessments are being performed by the ENT

So What Do We Do?

• ENT’s – Presented findings at annual ENT

Association meeting• Decrease numbers of undetermined type• Encourage collaboration between diagnosing

audiologist, PCP and ENT• Implemented ENT Reporting to DPH

So What Do We Do?

• Audiologists– Presented findings at Hearing Screening

Symposium– Addressed need for speech/language

assessment along with audiological testing– Revised reporting form to collect name of

ENT– Encouraged better medical home

collaboration

So What Do We Do?

• Families– Can contact study families to assess follow-

up• Ascertain if parental concern• Confirm audiological follow-up

– Implementing Listen & Learn Program• Q 6 mo. Follow-up for infants not eligible for E.I.• Speech/language assessment• Parental education• Hearing evaluation

Donna C. Maselli, RN, MPHAmy Mirizzi, MPH