Chapters Transcript Video Sounds of Success: Pediatric Audiology and Speech/Language Pathology Perspectives Today, we have an amazing group of audiologists and researchers from our own department of a audiology. I'm gonna pass it off to Molly Walker who will introduce the group. Molly. Go ahead. Good morning, everyone. Thank you so much for being here with us today. We are so excited to share some information with you. And ahead of that, I just want to introduce my colleagues, Nicole Denny, graduated with her doctorate in audiology from the University of Arizona in 2018. She has worked as a pediatric audiologist at U CS F, the N of Children's Hospital Oakland for nearly six years. She is passionate about auditory electrophysiology and working with Children and their families. Michelle Wang is a clinical research coordinator and patient Navigator for the U CS F Children's Communication Center, a native Peruvian and Spanish speaker. She serves as a culturally congruent care Navigator for DH H Children and their families to support their multidisciplinary clinical care, educational services and engagement in research. Brianna Reid is a pediatric audiologist. She graduated from the University of Arizona in 2014 and has worked at U CS F Benioff Children's Hospital in the audiology Department since 2015. She is also part of the cochlear implant team since 2020 and I am Molly Walker. I've been a speech language pathologist for over 20 years, primarily specializing in working with Children with hearing loss and their families across a variety of settings. I have worked here at Children's Hospital Oakland for a total of 10 years over two different tenure. Thank you. I'm gonna turn it over to Brianna Reid to get us started. Good morning everyone and welcome. We're so excited to be here with you um to share a little bit about um what's going on in the world of pediatric audiology and speech language pathology. Um Just to start, uh we have no disclosures to share um and wanted to especially be acknowledged that May is National Speech Language Hearing Month. So it's especially appropriate that we get to talk to you about all of this today. Um Just to kind of briefly let you know what we're gonna talk about. We're gonna give you an update on audiology, things to start off with um some new screening protocols, monitoring guidelines, um and updates and technology for audiology. And then we're gonna talk a little bit about something specific to U CS FN A Children's Hospital Oakland, our deaf and heart appearing pathway. Um Molly will talk a little bit about some new things in the world of speech language pathology. And then we have um Michelle that will wrap up giving some updates from our current PCORI study starting up with Nicole. Good morning everyone. My name is Nicole. I'm gonna start us off with just some statistics about hearing loss in pediatrics. So, hearing loss is one of the most common birth defects. The CDC has shown approximately 1 to 3 per 1000 Children have hearing loss. Other studies um indicate rates from 2 to 5 per 1000 Children and international. Um data suggests a rate of severe hearing loss between one and three per 1000. Um in the well, baby nurseries and 2 to 4, sorry, that's supposed to be per 1000 for infants in the intensive care unit. So, as you can see already, um those that spend time in the NICU oftentimes are at a little bit higher risk for developing um a sig significant amount of hearing loss. Um The newborn hearing screening started coming about in the 19 nineties and um we've come a really long way since then. So historically, oftentimes Children weren't being identified with hearing loss until they were in between two and three years of age. Uh The newborn hearing screening has um decreased that amount of time um that a child is diagnosed with hearing loss significantly. So I'd like to review um some of the most recent data. Um this is the 2021 documented um early hearing detection and intervention program data. So, um as you can see here, there were over 3 million births in 2021. Among those births, 98% were screened and 95.5% of those babies were screened be between uh before one month of age. And I'd like to highlight that because the joint committee on infant hearing um has specific guidelines that recommend a child is screened before one month of age, diagnosed with hearing loss before three months of age and intervention is in place before six months of age. So we're doing a really great job screening these babies before one month of age. Uh the number of hearing loss uh were 47.4% sorry, no hearing loss, 47.4% and those that were diagnosed with a permanent hearing loss, um were 10.3%. Um out of those, the number that were diagnosed before three months of age. So either diagnosed with no hearing loss, a transient or fluctuating hearing loss or a permanent hearing loss before three months of age dropped down to 42.7%. So this is definitely an area where we could use the help of pediatricians to try and get these families and these babies back in, in a timely manner before three months of age. So we can um we can uh diagnose them or rule out the possibility of a of a permanent or trans inherent loss before three months of age. So we can meet those JCIH 136 guidelines. So um this is just a a call to all of you pediatricians is that when you're following up with a newborn infant, um please, do you know review newborn hearing screening results and if you've noticed that that baby has not passed, um you know, make that urgent referral and encourage the family to get in for a diagnostic evaluation as soon as possible. Uh Moving on, I'd like to cover some risk factors and causes of hearing loss. Um There are new um JCIH uh guidelines on um risk factors in infants and um timeline for follow up. So, um to begin with, I'd like to throw some statistics out here. So, 50 to 60% of Children that are diagnosed with hearing loss uh are likely due to a genetic cause. Um of those Children, um up to 30% are diagnosed with a syndromic hearing loss. So, some examples of some, some more prevalent um syndromic hearing losses would be Usher syndrome, Pendred, uh Dr Collins Alport NF two. And as you can see, there's a vast number of known syndromes that um include hearing loss as uh a septum. Um Other risk factors include infection during pregnancy, environmental causes complications after birth and of course, um family history of permanent childhood hearing loss. Um one significant risk factor in infancy or at birth um is congenital CMV. Um This, this risk factor is really tricky because oftentimes a baby may have congenital CMV. But may be completely asymptomatic at birth. So, um this is another um thing that we would just hope pediatricians would look out for that if you've noticed that an infant that you're following has been diagnosed with a sensory neural hearing loss, um to please refer as soon as possible uh for congenital CMV testing. Um There's a very short window that uh CMV is be able to uh is able to be detected as either congenital or uh L late onset or acquired. And after that point in time, I believe it's around three weeks after after birth. Um After that point in time, um treatment is usually not as effective as it could be if it started um right away and truly a congenital um uh diagnosis. Um 14% of those exposed to CMV during pregnancy develop sensory neural hearing loss. That's a pretty, pretty high number of those exposed and 3 to 5 of those that are exposed to CMV, develop a, a bilateral, moderate to profound sensory neural hearing loss. So, a significant hearing loss that will impact um speech and language development and communication ability. So it's really, really important for us to keep a very close eye on these infants and um try to get them tested as soon as possible and even s um so begin treatment if that's an option for that child. Um This table here is uh the J Joint Commission. Uh Sorry, excuse me, joint committee on infant hearing, um risk factor classifications and recommended um diagnostic follow up for these risk factors. So these guidelines were updated in 2019 with the the most recent guidelines um uh from that, we're from 22,007. So um definitely time for an update there. I would like to highlight on this page um the um guidelines uh specifically for the um ECMO treatment. Um As you can see here if a baby um undergoes ECMO um in the NICU, we want to see that baby back for a diagnostic evaluation no later than three months after they received that treatment. So there's a very short window um between treatment and oftentimes the baby is still in the NICU. So it's really important for um you know, there's attendings and residents in the NICU to um hopefully have an audiologist come and do maybe a diagnostic bedside, a br even if they have passed their newborn hearing screening. Um And as you can see um the risk factors one through five, we want to see those babies back for a diagnostic evaluation by nine month, by nine months of age after they um have gone home. Um a little bit newer um risk factor that has come to light is the congenital zika vi virus. Um although it is quite rare, um it has been identified as an etiology for possible delayed um onset of, of hearing loss. So, it's also important that we um follow up with those babies that have um contracted congenital zika, um very, very stringently and just moving down the table here. Um some more perinatal or postnatal um risk factors. Uh The risk factor that I would like to highlight here um is those that um contract a bacterial or viral um Meningitis, HSV, encephalitis. Um These risk factors can and do cause permanent hearing loss. So we want, even if they do pass their newborn hearing screening, we want to follow up with a diagnostic um artery brain stem response evaluation no later than three months after they've been diagnosed with um one of these um bacterial or viral infections. So, some key takeaway points from the JCIH um 2019 guidelines on risk factors and follow up. Um The most notable change in the 2019 guidelines was uh a more aggressive cadence um for follow up with in infants with, with um risk factors. So previously, um the guidelines we're recommending for most ri risk factors a follow up between 24 to 30 months. Um after occurrence, most of those have shrunk down to at least nine months after after occurrence. Um more notably, no later than one month um for those that have uh zika no later than three months for infants with congenital CMV and uh diagnostic evaluation um no later than nine months for all other risk factors. And then um regardless of the status of the newborn hearing screening results, um for the diagnostic follow up. The use of auto aous emissions is no longer sufficient. The JCIH is recommending a full diagnostic evaluation. So either an auditory brain stem response evaluation on follow up or um a behavioral audiometry including auto acoustic commissions, temp andom Mery and reflexes if you're able to obtain those. And then finally, um in the 2019 guidelines, uh ear pits and ear tags um as long as they are um in solidarity and there are no other um risk factors known risk factors or um anatomical malformations, they are no longer um a risk factor for audiological follow up. Ok. Um and then just uh some information on when to refer to audiology. So anytime there's an abnormal hearing screening in the pediatrician's office, including those that may be just barely refer on their screening or if they only refer in one ear, it's really important that they follow up with a diagnostic evaluation um in a, in a and preferably a pediatric audiology clinic. Um Additionally, Children that are three years and older who fail to respond to any frequency on two screenings that are separated by six weeks, um they also should be referred for a diagnostic evaluation. I will say that if the pediatrician has significant concerns after the first um failed screening or if the parents have concerns for hearing, please um refer right away. No need to wait for a six week and pre toy screen. But let's say they had a cold that day, maybe, possibly they have some fluid behind their eardrums, then maybe give it another six weeks free screen in the office as long as the parents don't have any concerns and, and see how that screening goes. Um Additionally, if a child is not able to perform hearing screening in the office, um whether it's due to behavioral developmental delay, um please refer them to a pediatric um audiology center so that we can try our best to get as much information as possible from them. And then um lastly, and probably most importantly, um if you notice that a child on your case load has been diagnosed with hearing loss recently and there's concern for possible genetic component, please refer their siblings um for a diagnostic evaluation as well. Um Lastly, I'd just like to review this nice flow flow um flow chart here from the uh American Academy of Pediatrics. Um As you can see, um there are recommendations for ages to screen um hearing and um if a child passes the hearing screening at that age or, or refers, um this flow sheet will flow sheet will guide you in the right direction for next steps. Um One thing that I'd like to point out is if a child um is not due for a hearing screening at their wellness visit, um please, you know, probe for risk factors and also um see if the parents have any concern and um if you are noticing risk factors or there's parental concern for hearing um or speech and language development, then please refer to audiology. It's also ok to review um you know, developmental milestones and auditory skill development and speech and language development. And um you know, let the parents know um what's age appropriate um skills and um go from there. And that being said, I'm gonna pass it off to uh my colleague Brianna. Thank you. Um So with the updated guidelines and understanding risk factors better and screening protocols, we are um able to generally identify hearing loss at a much quicker rate and get these kids fit with um amplification of some sort. And then into intervention services just wanted to briefly mention an early start. I'm sure most of you are barely familiar with what they do. It's a program that was started with the Idea Act back in 1986 and provides a lot of support and therapy services for families of kids with a number of conditions including hearing loss as audiologists. We refer every one of our patients who is newly identified with hearing loss to early start for assessment of available services. But anybody can make that referral, including parents and other medical care providers. If you feel like um your patient would qualify and could use that. Um The, the deaf and hard of hearing services that are provided through early start are a huge part of the care team. For our kids with hearing loss and early start works with kids from 0 to 3. Um And as you can imagine, for a family that um just learned that their baby has hearing loss, learning how to navigate the world of hearing loss and learning how to put on the amplification. Keep it on their baby. Um support the development of auditory and listening skills. There's a lot of things for them to learn and the deaf and hard of hearing teachers that are available through early start are able to be in the home with the families up to weekly to support that process. And they are very collaborative with us as their audiologists and it's so helpful to have somebody in the home um supporting the parents and helping to troubleshoot things with us. I've multiple times sent ear mods to a deaf and hard of hearing teacher so that they can help uh put that on instead of the family having to come all the way here from two hours away or troubleshooting a broken hearing aid or whatever it is. So um at UCCN A Children's Hospital, Oakland, our audiology department has a clinical liaison. Her name is Joy. Um and she is available to help support our parents in enrolling in early start services and educating families on how to advocate for the appropriate the appropriate services and placements for their Children. Um And just as part of a care team for somebody that is diagnosed with hearing loss. We just hope that everyone would be a good advocate to help these parents know how important early start services are, especially at the beginning, it can be fairly overwhelming and sometimes the parents don't understand why the early start services are important. Um So if you have a patient who is diagnosed with a hearing loss and is not utilizing their early start services, um Our plea would be to help encourage them to enroll and attend their appointments as much as possible. Um Because the kids that utilize these services are really are able to be so much more successful in their use of amplification and in their um development of language and communication. Um after early start, so after the age of three Children can receive um similar support services through the school district usually be an IEP or a 504 plan. Um And our clinical liaison joy is able to help support those um that transition or advocating for services as well. Ok. So we're gonna transition a little bit into a few updates on current audiological treatment options. Um There have been a few areas of audiology treatment that have been particularly difficult in the past that have made some serious leaps in the last five or six years. One of those areas is in single side of deafness. Um So singles side of deafness is exactly what it sounds like a patient would have one ear with normal hearing and then the other ear has at least uh 70 decibel hearing loss. So has at least a severe to profound hearing loss on the affected side, single sided deafness um affects at least one in every 1000 babies born. Um And even though they have one typically hearing ear, which means that they do have good auditory access and in quiet controlled situations can hear and respond and understand. Um similar to someone with two normal hearing ears. When you only have one ear you don't hear in 3d, you don't have any of the bi neural listening cues that most um typically hearing people do have. And so you have difficulty localizing sounds, um have trouble hearing in noisy environments, have trouble hearing on that, that affected side or from a distance. And this can have a significant impact on a child's quality of life and social interactions. Thinking about school, that's a very um loud and chaotic environment. And so when that type of environment is affected by your hearing ability, it can make things really tough. Um Traditionally, our treatment options were very limited. We had something called a cross hearing aid or a Baha. Both of these basically took sound from the affected side and just moved it over to the typically hearing ear. So our patients still were only hearing with one ear, they did not have my neural hearing, but that we just moved sound from one side to the other ei either via a wireless signal or via bone conduction. Um This really had very limited improvement in speech understanding. It did not help with background noise hardly at all because once again, you don't have that by neural hearing to be able to hear in 3D. Um it had a very limited benefit in sound localization if you could kind of tell the difference between what was amplified sound versus what was natural sound. Um The one place that it did help was in offside listening. So if you had hearing loss in your left ear and somebody was sitting on the left side using a cross hearing aid or a bone connection device would help you hear that person better, but that is so rare. Um And all the other situations happen so often that um anecdotally, I would say um upwards of 80% of my kids that were fit with a cross hearing aid or a bone connection hearing aid eventually became non users. Um So back in 2019, the FDA approved cochlear implants for patients with single sided deafness. Um And this was a huge improvement in our ability to um give options to different patients. A cochlear implant is something that would provide sound to the affected ear in the hopes of restoring as much as possible by neural hearing cues. Um And so this is a big difference compared to the cross and the baja. Um the FDA approved co currently has approved cochlear implants for kids with single sided deafness down to five years of age. Um And the candidacy guidelines basically are that you have single sided deafness. So a normal hearing ear and a hear with severe to profound sensor neural hearing loss with limited benefit from an appropriately fitted unilateral hearing device. Um Also important is that that affected side has a functional auditory nerve. Um Some studies have shown that upwards of 42% of kids with a single sided deafness have some sort of cochlear nerve deficiency, whether it's a hypoplastic or an a plastic nerve on that side, which would obviously affect how beneficial the cochlear implant could be if that auditory nerve was not able to carry the signal to the brain. Um Another really important thing is appropriate motivation and expectations because um for uh any kid um getting them to wear a hearing aid sometimes is a bit of the uh fight. And so especially for a kid that has one normal hearing ear and feels like they hear well, um in a lot of situations, the motivation to wear that cochlear implant um consistently is not always there. Um And that will have a significant impact on um how much benefit that the patient receives from a cochlear implant. Um speaking of benefit, um studies have looked at how um beneficial the core can be for these patients with single sided deafness. They have shown that there is a significantly improved word recognition ability in that implanted ear. Um So going from essentially no speech understanding in the affected side, we usually see that directly to the cochlear implant, they can start to understand a lot more speech there. Um Also because we're providing the but neural cues, they uh typically have a significant improvement in understanding speech and noise as well as, as well as localization ability. Um And so all of the, the places where we're wanting them to hear better, we're generally seeing improvement there, which is great that being said, um Children with single sided deafness that have a cochlear implant on that side continue to have poor speech recognition, both in quiet, in noise and in localization compared to somebody with normal hearing in both ears. Um So it's not completely, you know, curing the the hearing loss on that side, but we're seeing significant benefits compared to just hearing with one normal hearing ear alone. Um Just to kind of let you know a little bit about why some of the benefits might be limited. Um The studies have shown that depending on how long that patient has been deaf in that ear that can affect how much benefit you get from a cochlear implant. They find that um for somebody born with congenital, single sided deafness, if you are implanted after the age of four, that your uh benefit can be limited or if you acquired hearing loss in that year. Um After birth, then, um, if you have had that hearing loss for over seven years, that the limit uh benefit is uh more limited. Um Probably the biggest thing though for me is the data logging. So how many hours a day the patients use their cochlear implant? Um, in our clinic, we advocate for eyes open ears on. So, wearing whatever your amplification is for as much of your waking hours as possible. Um So for the kids that are wearing their implant 12 plus hours a day, every single day, they get much more benefit than a kid who's wearing it a couple hours a day, a few days a week. Um The brain will just never really learn how to process the sound on that side. I just wanted to give an example of somebody who received a cochlear implant um in this instance, um So LLM is one of my patients, she was born with less profound hearing loss. Um And growing up, she used both a soft and Baha or a cross device at, at times in her life and received very little benefit from either of those devices. She also has a history of a DH D vision difficulty for which she wears glasses and um receives services at school through an IEP for help with reading and writing, as well as support for her hearing loss. Imaging showed that she had a normal auditory nerve. Um And since birth, her family has been very interested in getting a cochlear implant for her left ear, wanting her to be able to hear from both sides. Um But when she was born, this was not FDA approved and so she was not able to get that. Um As soon as the FDA approval came through, her family was on it immediately um and she received her program at age 12. Um which if you think about what I just said on the last slide, um benefit being limited after the age of four, for somebody with congenital hearing loss is pretty late in the game. Um But her family was so motivated and she was so motivated that we decided to move forward. Anyways, she also received a course of oral rehabilitation where she did teletherapy with one of our speech therapists on specifically directed to that implanted ear. And now several years later, um she has a 32% word recognition score when you're talking directly to that implant sounds really low. But honestly, for somebody who was deaf for 12 years is pretty impressive. Um And luckily you don't walk around with just people talking to your implant, you have both ears working for you. And so more functionally, we were able to measure um listening in background noise where we had noise and the speech that she was listening to at the exact same volume and she was able to get 93% correct. So even though um that 32% word recognition score seems low. She perceives a lot of benefit from being able to hear from both ears and wears her device um, full time, which is awesome. Another area where we've made some big leaps in the last few years is un bone connection amplification. Um, bone connection hearing aids work by stimulating the cochlea via vibrations of the skull. This is typically most often used for kids with a conductive hearing loss like microtia atresia, um chronic middle ear problems, um et cetera, but can also be used for kids with a mixed hearing loss or even single sided deafness. When you're born, you start wearing the bone connection, hearing aid with a headband. It looks like this that just holds the processor in place and then um it atta it sits on top of the skin of the mastoid bone and presents the vibrations. Um that way, obviously, most kids don't like wearing headbands um for the rest of their lives. And so, usually, or in the past, we've been able to transition to an implantable abutment as young as five years of age. The abutment is uh something where there's an implant that is osteo integrated into the mastoid bone. And then this piece of metal sticks through the skin and that's where the processor connects to that implant. Um Hearing wise, this worked really well. Kids were able to have a much more consistent and clear sound with the implantable abutment. Um But as you can imagine, um, wound care and just managing this abutment site is really hard, is very susceptible to local skin reactions. Um, some studies shown that up to or over 40% of kids that had an abutment, um, had some sort of uh complications that required revision revision surgery. And as much as 25% of kids that had an abutment ended up having to have the implant taken out. Um, So back in 2018 and then in 2022 different companies were FDA approved for a different kind of bone connection hearing implant that did not require an abutment anymore. This is the best part. Um So there's still an implant that goes underneath the skin and then a processor that sits on the outside. But instead of using that metal abutment through the skin, um the signal is transmitted through uh electric coil and is held on via a magnet. Um This is also proved similar to the, the abutment device. It's approved for kids with conductive hearing loss, mixed hearing loss or single sided deafness down to as young as five years of age. Um and similar to the abutment. Um, it can, provides a much more consistent and clear sound than those with the soft band device. Um, it has been very effective for a lot of our kids that have received this thus far and it's much easier to um help families want to move towards this type of uh amplification rather than thinking about having um a piece of metal sticking through your head all the time. Um Quick little case study on this one MB is one of my uh patients who has received this device. She has a history of bilateral microtia and other diss dysmorphic features and had a bilateral maximum conductive hearing. Last since birth, she did an initial trial with behind the ear hearing aids, but they didn't really stay on her pin is very good. So we eventually switched to a sock band Baha and she wore her. So in Baha super consistently, but she was a very like active and energetic little lady. Um And so as she was running around and playing on the playground and other things, her headband was moving around a lot, she had a lot of difficulty with placement and with feedback. Um and even in best case scenario, just make where it was sitting and how um it was attaching to um her uh had the um hearing that she had through the Baha was good but not great. Um When I did her a testing, she had a speech reception threshold down to about 3035 decibels. And so that's the lowest level that she's able to repeat a word back to me. Um which typically I like to see my kids closer to the 2025 decibel range at least. Um And she could only identify three out of six Ling sounds down to that level of 25 decibels. Those are the different speech sounds that kind of go across the different frequencies and making sure that she's hearing all of this speech sounds clearly and accurately. So she was doing ok but not amazing. And so her parents decided to move forward with her first bone bridge implant at age five years, eight months. And she did so well with it that she uh very quickly received her second implant at age six years. Um And now she wears both of her devices full time with great benefit. She can repeat words down to that. 25 decibel level can identify six out of six sounds down to about 25 decibels across the board and has um a word recognition score of close to 90%. So she's doing great. She's doing great in school and her language has made significant progress in switching to this. Um One last thing I wanted to talk about briefly just on the horizon. I don't know if any of you have seen in the news, some articles about advances in gene therapy. Um There's some current studies going on right now about o of Berlin gene therapy and restoring hearing loss for kids that have o of Berlin uh mediated hearing loss. Um Otto Belin is a protein that is in the hair cells inside the inner ear and that's what is takes the sound from a sound wave and transmits it to the auditory nerve, up to the brain variations in the Oto Ferlin gene, um are responsible for only 1 to 8% of congenital non syndromic hearing loss. So, it's a very rare form of hearing loss um that they're currently working on for this gene therapy. Very few of our patients um have hearing loss that is related to O Belin. Um but just kind of exciting to see that there are clinical trials out there that have moved on to, you know, human stages, human trials um that are doing this gene therapy that are causing some changes in um their hearing. These patients with Oberlin generally are born with a profound bilateral hearing loss and we're seeing some significant results for those who have received this therapy. So we're very excited to see what will continue to come from that. And as they learn about gene therapy and other uh situations that might also be um for other types of genetic causes of hearing loss. Great, thanks Brianna. Uh My name is Michelle, I'm a clinical research coordinator and patient navigator um at Cho and I'm gonna talk a little bit about our DH H pathway. It's a novel pathway that our department created for all Children, um ages birth to three years old, um who are newly identified with hearing loss and next line. And so as Nicole and Brit um talked with you all earlier, um we have these Eddie milestones um and they exist to facilitate timely identification and intervention of hearing loss. Um We have the newborn hearing screening um being done by one month of age. We have um the three months of age, we hope to have formal audiological testing and by six months of age, we hope to have um hearing loss intervention. Um And these standards are based on research demonstrating that the language abilities of deaf or hard of hearing Children drop precipitously if intervention occurs after six months of age. Um However, despite these standards, only 45% of Children with hearing loss in the United States are enrolled in early intervention by six months of age. And so we ask ourselves why this is so low. And so that takes us to um the reason being that the care pathway for pediatric hearing loss is complex. And so, one of the primary reasons that families face challenges in achieving timely care is that care, the care pathway requires intense care coordinations. Um And I've had the chance as a patient Navigator to speak with many families on this journey who often don't know who to talk to. They face transportation or financial barriers to making their appointments. Um or they're concerned that there's communication breakdown between the medical and education system. Um And this is all supported by data um by the American Speech Language Hearing Association which cites that multiple barriers to timely care, including lack of primary care referral knowledge. Um family education service provider, coordinations, program funding, um or, or quality assurance all affect um, the timely care for these Children. Um And so our department asked, how can we facilitate communication across our speech language, pathologists, audiology, otolaryngology, primary care, um, and educational providers to improve the percentage of Children who achieve early intervention. And ultimately, how can we make this pathway easier for our families to navigate? Um And so our department decided, um that the intervention that's appropriate is a patient navigator. And so as a patient Navigator, some of my roles um and some things that are included in my role is providing the family with basic education um care coordinations of appointments to ensure timely care and to identify any social needs of the family. Um for example, child care transportation or um things like that. Um And what really makes this intervention powerful was that this was designed by a multidisciplinary team that includes families with Children who are deaf or hard of hearing. And so we performed a pre post cohort study comparing a prospective cohort of Children with newly identified permanent hearing loss who received this patient Navigator intervention to a retrospective pre intervention cohort. Um And so the results of our study is um that after identification of hearing loss, Children who did receive the patient Navigator intervention had a statistically significant shorter time interval to medical clearance and educational intervention. Um Children who were in the prep pathway cohort um it took them 84 days to get medical clearance and post DH H pathway. Um It took 39 days um for educational intervention. So this is um having their IFSP created um pre pathway was 100 and seven days. Um From data divided identification to ifsp um post pathway, we brought it down to 55 days. Um And there was no significant difference in the interval to medical intervention. Um But from, from our data, it shows that this patient Navigator intervention really um supported our families in navigating the pathway but also providing timely care. Hello, we're gonna shift gears a little bit. Now, now you've heard about all the hearing loss and what happens next? The kids been diagnosed and where do they go from here? Um I have worked 20 years in this field of Children with hearing loss. And one of the things that became most important to me very early in my career was being able to communicate with Children in whatever language they need to use as Children with hearing loss. So I have uh earned a special certification to teach listening and spoken language to Children with hearing loss if that is their family's communication choice. And I'm certainly not fluent, but I am proficient in sign language also. So I can confidently work with families of Children who are different hard of hearing no matter their language choice. And that reduces at least one barrier to care. And communication. So speech language pathology and audiology, we are all one department at this hospital. Um obviously they're connected. But how do we view this in our department, a renowned leader and practitioner in our field named Carol Flexor says, ears are the doorway to the brain. The audiologist addresses the doorway problem. They work their magic to allow access to sound and then they pass them off to our speech pathology team and we get the fun work with the brain. We have to be in constant communication and collaboration to support these Children in reaching their potential. We are obviously from the audiology department and very passionate about what we do. But I do want you to consider today the other Children that you may have in your case load or who you're providing care to in terms of services being offered for any speech or language delay or disorder. And as this first slide shows with the pictures on picture of a family on there, right? It really should be a family affair. I think you go to the next side caregiver coaching. It has taken our field by storm in the best possible ways over the past decade or so. When I graduated high school, I knew I would be a speech therapist and I absolutely knew I would only work with Children. But fast forward 20 years and I am actually working with more adults than Children. I need to learn about adult learning styles because I'm working with the grownups that belong to my actual patients. My responsibility as a speech pathologist is to empower each caregiver to become the very best language teacher to their child. And I can only do this if I get to know them as individuals and as learners, I also let them get to know me. So you may have heard this term caregiver coaching. What does it mean? The goal of caregiver coaching is to empower caregivers to support communication, skill development in the child's most comfortable home environment through education strategies and modeling therapists might be with a child. What an hour a week. So how can we maximize the language learning that needs to happen all the other hours of the day, we teach the caregivers to do it next slide. Thank you. We really do get to know each other. So well, all these families get to meet my dog who work with me every day and I get to eat breakfast with them. Uh I wanted to tell a little story about my dog. She sits on her little bed over here in my office and um I serve a family currently that is experiencing homelessness and they do their sessions from their car each week. And last week the little baby was, look, the phone is on the dashboard right in a little holder and she's like looking around and she's looking back at them, looking at me, looking around like establishing join him and she's trying to tell us something and we were like, what is going on. And after a couple of minutes, she said, well, she was asking to see my dog, so I had to move my computer so she could see my dog. So the communication that happens is beautiful. Next slide, please. So I just wanted to share some coaching, caregiver, coaching strategies that we use in therapy. And to be clear, these are not strategies for language learning that we use in speech therapy. These are strategies for how I as a therapist can effectively coach caregivers to be the very best language teachers, they could be. So let's just look at a couple so you can kind of get an idea of what we do. So, secret message is one that I employ when a child is particularly distracted by their screen. Unfortunately, in this day and age, a lot of times when kids have a screen in front of them, their parents phone or anything else, what they're expecting is something for them, right? A show or a game or something that they're interested in playing and that's not what we're doing during that time. So if they're distracted by the screen, I cannot simply observe their interactions and play in order to give feedback on improving their communication skills. So I might ask the family to set the phone, uh you know, on a bookshelf or somewhere where the camera is focused on their play area. And the parent can use an ear bud and I can communicate with the parent about, um you know, I can send them secret messages about what to try next, how to elicit some language or when to reinforce a behavior without interrupting the natural flow of their play. Um For other caregivers, the test guide that together might be a better strategy. So we try and act activity all together with me doing it through the screen with them and then I turn it over to the caregivers like a rehearsal, right? For them, what they're going to do the rest of the week when I'm not there, I can get, then give them real time feedback and we can make a really good plan about how they'll practice this task until we see each other again. OK. Next slide, please. So who does well in teletherapy, especially with the caregiver coaching approach? I wanna be honest when I was writing this, I was only thinking about the patients and families and then it hit me. It's the same strategies and skills and characteristics for a therapist to be successful in this setting. It's different. It's a different way that we're doing it. So while you look over these characteristics to their hair, I'm gonna share a typical day in teletherapy with some stories of our actual patients so that you can get an idea about how broad the spectrum of patients who benefit from teletherapy really is. And remember we work with kids with hearing loss. But imagine your patient caseload. Maybe a child with Down Syndrome, a child who's been diagnosed with autism spectrum disorder or maybe like a two year old run of the mill language delay kid. How could they benefit here? So, my first patient might be a 20 year old child student who recently received her first cochlear implant because her hearing loss was impacting her. So significantly, she had to take a leave of absence for from school. She was congenitally deaf and used hearing aids since she was a few months old. But she was in this very protected environment of public school system with all the support services she needed. And then she entered the big bad real world and realized how much support that she needed with listening. So she decided to go ahead with the cochlear implant and it has been so incredibly life changing with her. Just six weeks later, she asked to schedule the sequential implant also for her other side. So next hour at 10 AMI have a five month old baby whose family is attending hearing aid orientation sessions after her recent diagnosis and hearing aid, fitting in these hearing aid, orientation orientation sessions. We talk about things like retention. How Brianna mentioned it earlier. How do you keep these things on these little tiny heads and ears and they're so curious and they're always in their mouths. Um getting connected to early start services, which we also talked about briefly earlier and why, why do you even need to have speech therapy when typically hearing babies aren't even talking at five months old? Why is this important to their future? The next hour, 11 and 1130 is back to back nine year old twins with a progressive loss who were very, very late identified and received unilateral cochlear implants and are learning to be bimodal listeners with one cochlear implant and one hearing aid. And we're gonna talk about them a little later if we have some time and to finish up my day at noon because I only work part time. I have a preschooler who communicates with a sl and the family just wants to maximize their listening skill that the child has with their hearing aids. So what do we all have in common to make this kind of therapy successful? These characteristics that you've been looking at being flexible, risk takers, self motivated and at least somewhat technologically inclined. It's really interesting. The biggest challenge of for me in teletherapy is that I have to give up all the control of therapy, right. In traditional therapy setting, the therapist is in control of everything from goals and activities to the reinforcement schedule. And we kind of mastermind this therapeutic experience in a patient will balance that fine line of being pushed to the next level but still really successful. And the problem that arises is that we're not there to change everything and fix everything. Our communication has to be so on point in order for that family to really understand their goals and what's happening. So challenges in therapy, teletherapy, the uh teenagers and teenagers get real wily and you gotta really get creative with those groups. But it is certainly not impossible. I have never had a family, not be able to participate in teletherapy because of technology, whether device or internet, that's just not the world we live in anymore. Fortunately, but sometimes actual communication that happens when we get together can be stilted and difficult. And again, it's, that's on me to communicate with them, what the intention and expectations are of teletherapy. Ok. Turning it back to Michelle. Thanks Molly. Um And so given all the benefits of teletherapy, um my P I, Doctor Dylan Chan um and our team were running a randomized clinical trial um with uh 199 participants enrolled. Um And our study is aiming to evaluate the hypothesis that access to supplemental teletherapy compared to our usual care being um normal audiology care. Um speech language therapy and early start um will help address the disparities and outcomes imposed by um these demora these demographic disparities and some of the challenges that um Molly also described. Um And so we're really comparing the effectiveness of this usual care versus families who have the usual care plus the supplemental speech language teletherapy um and our participants are from the ages of 0 to 27 months. Um They have to be diagnosed with a permanent hearing loss and speak a home language of Spanish or English. Um And this is just, this is something that we're currently still working on enrollment is active and um we're uh actively um yeah, collecting data. So this is kind of what our, our department has been doing lately. And um yeah, uh we had a case study but we're kind of running out of time. So I think we'll do Q and A first. Um And then if we have time, we'll go back to that last one. That sounds great. Thank you all so much. This was such a cool um glimpse into both the kind of exciting technological updates that are going on in your world and also into the research and therapeutic techniques you guys are using. We are very grateful to be able to refer to you guys. Um We do have a number of questions. We have a couple first about um the in office um hearing screen that we use in pediatricians offices and of what utility is that to you guys? And what is the significance of a child not being able to hear certain tones on an in office screen? Yeah, that's a, that's a very uh really great question. Um I, I don't know exactly what the um American Academy of Pediatrics recommends for a, a value um that is considered to be failed. But I know that the American Speech um and Hearing Association recommends a value of 20 DB to be uh passing and anything greater than that would be a refer. Um And it is important that if a child can't hear at one or more frequencies that they're referred on to audiology. Um Just last week, I had a teenager that only referred 500 um hurts in one of her ears. That's a low frequency tone. Um When she came for a diagnostic evaluation, she was diagnosed with a moderate rising to um normal um sensory neural hearing loss in her left ear only. So if she had not failed at that one frequency at the pediatrician's office, um then, and they hadn't referred her to for a diagnostic evaluation, she could have been missed. Uh And, and um she may have been missed in the past, it's difficult to tell whether or how long she's had this hearing loss. But as I said, she was 17 when we identified her with, with this permanent hearing loss. So it does have diagnostic value. Um Sometimes you could have a notch in your hearing at one or two frequencies. Um So I think it's, it's um better to refer and um be safe um than have a, a missed missed hearing loss. I think another thing that's really nice about the hearing screenings that are done in the office is we can kind of get an idea of when the hearing loss started if they had a past hearing screening one year and then two years later, they came back and it referred and ended up being a permanent hearing loss. And that kind of gives us an idea of, you know, progression and when it onset and all those kinds of things, sort of to piggyback on this question. Um A scenario that I see often in clinic is that we have a kiddo whose well check is kind of near them having had an ear infection and so they fail their hearing screen. But when we look in, we see fluid in the ear and we say, well, it's probably because of that and we have them come back in one or two months and repeat the hearing screen. Is that from your perspective appropriate or is that kind of neglecting possible true hearing loss? Yeah, I think that as long as there are no other risk factors for a permanent hearing loss, I think that's, that's completely fine. Um And I think, you know, you're using your best discretion um to bring them back and rescreen. Um, like I said, you know, you're doing that risk assessment while the patients in the office. So if there are no other risk factors, but they have had a cold or an ear infection recently, I think it's appropriate to rescreen in, in 66 to 8 weeks. Awesome. Thank you. Um OK. And then I'm sure this is a, a challenging point, but we have a question about access to getting into audiology at co right now and that the wait list time appears to be increasing. Is that what you guys are also experiencing on the front lines? And is there any ways planned to improve access to audiology in Oakland coming? Um Yes, I will say that we all are feeling that pinch. Um The voice has just been so long. It is something that we are actively recruiting for another audiologist and we really hope to get that waitlist down a lot smaller. So cross all your fingers and send all your referrals. We did have some challenging um uh or some staffing challenges in the last year as well. One of our full time audiologists was, was out for a great, you know, greater part of the year. So that definitely, um you know, has a um an impact on, on um our scheduling abilities as well. That's I think over 200 patients a month that aren't able to be scheduled. So, so, well, we will keep our fingers crossed. Thank you guys. And then um OK, a couple more questions. Uh any recommendations for patients over 18 that need a audiology. Um So our partners over at U CS F um in the on the peninsula in San Francisco, they have an adult audiology clinic. I think they actually just opened one up in like Emeryville too. Um So there's a um option there. We also work very closely with seed um which is in Berkeley ce ID. Um The Center for Early intervention on Depo um and they have both an adult and pediatric clinic there. Um So those are a couple of our favorite referrals to send out. Ok. And then a couple of questions about the um increased screening frequency for kiddos that have had um like serious medical issues happen. So for the culture positive infections, I assume that's not for things like urinary tract infections, but only for things like a meningitis or possibly a severe like bacteremia. Yeah, that's, that's a great question. Um I, I think you're probably correct on that and to refer back to that, um JCIH 2019 guidelines table, they do list um you know, the, the risk factors for, for um hearing loss for the the infections. Um So I think if it's not listed there, um it's probably not a major risk factor. Ok. And kiddos that have, um, had ECMO, not in the neonatal period, should they also be referred like a nine year old who's had ECMO? Should they be referred several months out? I'm thinking, yes, that's definitely a good idea because um it, it can be damaging to the auditory system and, and cause cause permanent damage. Although I, I don't know how common it is, but it's, it's good to, to always um, have a diagnostic evaluation following that. Ok. We have one more question um or a couple more about uh from a pediatrician saying how do you guys approach the dreaded ear wax? And do you have any specific management te techniques or tips? Uh ear wax? Yes, always an issue. Um So like all of you, I'm sure you're telling the patients not to put anything into the ear canal. So not using Q tips, not cleaning anything out. Um, but doing the ear lages in the office can only be semi successful most of the time, which is kind of tricky. Um, I often tell my family just to kind of like do that a similar thing, wash it out with water in the bath or in the shower. Um, wiping anything on the outside over the counter, ear wax drops can sometimes be helpful. But if it's way back in there and if it's hard and it really needs um, like tools to get it out, then a referral to Ent is usually where I sit Nicole. Do you do anything different? Uh, I would only add that a referral to Ent before they're sent for an audiological evaluation would be helpful. Oftentimes a patient will come in from a failed hearing screening and their ears are full of wax. Um And so it, you know, we have, we have to refer them to Ent and then see them back again. So, um, just making sure that their ears are clear before they're sent for an audiological evaluation is helpful as well. Ok. That's really helpful to know. Um And then any exciting updates that are coming down the pipeline in the world of audiology in terms of devices or implants or other things. Um I would say the biggest thing I'm really interested to see what happens with the the gene therapy part of things, but also just as far as like the implantable devices lowering the age of access for those, um we know that um hearing loss treated earlier is always better for language development. Um And so finding ways or having the FDA lower those um age of implantation guidelines is gonna be um a big thing. OK. Awesome. And one last one, which is that a common um question that this pediatrician gets in the office is when uh concerns around hearing are raised, the parents say well, but the speech is fine. I don't think that there's any issues with hearing loss. Um And how do you kind of respond to that and encourage them to make use of a, a referral to audiology? Um I would say um hearing loss can come in many different forms and sometimes it impacts some parts of the speech um he uh frequencies and not others. And so, and especially if it's one year, not both. Um And if it is a progressive thing where they like learned language first and then the hearing changed. Um And so hearing loss can be a very invisible condition. Um And sometimes the impacts of that hearing loss, take a while to uh present and manifest. Um And so getting the evaluation done and finding like the more thorough amount of data to be able to really know um what we're looking at with each kid is just helpful, more information never hurts, right? Um And so knowing or thinking that someone's speech is fine um is not always a rule out of hearing loss. We've seen lots of the situations where um you can have hearing loss and good speech um for many different reasons. So I just say more information is always better, just kind of ruling out things is important. Um And hearing loss is a hidden enough condition that it is worth exploring. I would do that to that. So I see the question of kids with speech delay. Sorry, I misread that. Thank you. Yeah, that's ok. That's ok. But I would say and what I say to families all the time is what goes in is what comes out, right? So what the child is hearing is what they're going to produce. So if the speech is a little off or delayed or whatever that really hearing is really something that needs to be considered despite a past hearing test. Awesome. Thank you all so much for your time and your teaching. We are really grateful to have you here today. I think that's all the time we have and we will see everyone else next week. Created by
