Audiologist Information 

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Audiologic Assessment
Providers of Follow-up Infant Hearing Screening
Rules and Regulations
Act 1559 of 1999
Diagnostic Evaluation Form

Audiologic Assessment

The following protocol was developed to facilitate the diagnosis of hearing loss, medical clearance for amplification, and use of amplification for infants with hearing loss as soon as practicable. The Assessment and Amplification ad hoc committee of the Universal Newborn Hearing Screening, Tracking, and Intervention Advisory Board recognizes that individual cases present unique challenges that influence that approach to evaluation and management. Therefore, the protocol should be regarded as a guideline for practice, not as standards, and is not intended or designed to substitute for the reasonable exercise of independent clinical judgment. However, the protocol presented here is consistent with generally accepted "standards of care" in pediatric audiology. It is the opinion of the committee and the Board that an audiology facility should not accept newborn hearing screening failures for diagnostic evaluation unless the appropriate equipment and expertise are available to allow for implementation of the procedures summarized below.

Arkansas' Recommended Audiologic Assessment and Amplification Protocol for 0-12 Month Old Infants

  1. Assessment procedures begin if a child refers on a second, post-discharge rescreen in the absence of indicators external and/or middle ear abnormalities or the child reaches three (3) months of age.
  2. Diagnostic Audiologic Assessment
    1. Otoscopic evaluation
    2. Confirm middle ear status with one or more of the following techniques
      1. High frequency tympanometry
      2. Pneumatic otoscopy by a physician experienced in its application (e.g. otolaryngologist, pediatrician)
      3. Video otoscopy.
    3. Auditory Brainstem Response testing
      1. Obtain a threshold series of reponses to an air-conducted click at a minimum of three (3) intensity levels for each ear
      2. If a repeatable air conduction click threshold is obtained at ≥ 30 dBnHL for each ear, perform OAE testing (either distortion product [DP] or transient evoked [TE]) on each cochlea, if not previously documented as normal. If OAEs are also normal, dismiss patient and provide caregivers with information about hearing, language, and speech milestones
      3. If the air conduction click threshold is obtained at ≥ 30 dBnHL:
        1. Consider performing a bone-conducted ABR, if the middle ear status has not been confirmed by any method stated above
        2. Perform toneburst ABR with at least 500 Hz and 3000 Hz
        3. Perform OAE testing (DP or TE).
    4. Information to Parents
      1. Children without a hearing loss
        1. Discuss results.
        2. Remind parents to watch for development of communication skills and that hearing can be tested at any age
        3. If risk indicators for late onset or progressive hearing loss are present, the primary care provider should be alerted as to the need for communication monitoring, as recommended by the Joint Committee on Infant Hearing.
      2. Children with hearing loss
        1. Discuss results.
        2. (Provide parents with Parent Packet from ADH.)
        3. Discuss communication options
        4. Discuss audiologic intervention recommendations
        5. Discuss early intervention services referral
        6. Make referral within 2 working days to First Connections and ASD Early Intervention Program
        7. Discuss funding and community support services
        8. Discuss medical referral
        9. Obtain consent for exchange/release of information.
  3. Follow-Up
    1. If bilateral or unilateral permanent hearing loss is found, the follow-up process should be initiated to include
      1. Otolaryngology appointment, if not already completed.
      2. Referral to early intervention (First Connections and School for the Deaf Early Intervention Program).
      3. Beginning the amplification process.
    2. If the diagnostic battery indicated normal hearing, retest infants at risk for delayed-onset/progressive hearing loss at six-month intervals. According to the Joint Committee on Infant Hearing (2000), such risk factors include: CMV, rubella, syphilis, herpes, toxoplasmosis, bacterial meningitis, family history of hearing loss, NICU admission of ≥ 48 hours, and syndromes such as Usher, Alport and Pendred.
    3. Incorporate behavioral testing as soon as possible, to include tympanograms and ear- and frequency-specific air-conducted thresholds and perform bone conduction testing using VRA/COR as appropriate.
  4. Amplification: The goal of amplification is to ensure that children receive full-time and consistent audibility of the speech signal at safe and comfortable listening levels.
    1. Pre-selection Amplification Considerations
      1. Binaural amplification should always be provided to young children unless there is a clear contraindication. When there is an asymmetry between ears as evidenced by pure tones and/or speech perception, hearing aids should be fitted binaurally until it is apparent from behavioral evidence that a hearing aid fitted to the poorer ear is detrimental to performance.
      2. FM systems should be considered for all children, but are critical for children with a severe to profound hearing loss.
    2. Verification of Hearing Aid Fit
      1. Time Specifications for Verification
        1. On the day of the fitting.
        2. Every three (3) months for the first 24 months.
        3. When the hearing aid returns from repair.
        4. When parent listening check raises concern.
      2. The Preferred Verification Method
        1. The preferred verification method is to use probe microphone measurements in conjunction with the child's ear, ear mold, and personal amplification system.
        2. The real ear measurement procedure should be combined with a prescriptive technique which estimates target responses appropriate for the characteristics of the amplification system (linear vs. nonlinear, analog vs. digital).
        3. The verification should always include direct measurement of the real ear saturation response and the target maximum output values.
        4. A real ear coupler difference (RECD) should be obtained at least every three (3) months for the first 24 months to ensure appropriate gain is maintained.
        5. The Desired Sensation Level (DSL) method (calculated either manually or in a computer assisted format) is the approach of choice for the RECD procedure.
        6. RECD can be obtained and probe tube measurement performed in a coupler if a child is unwilling to tolerate probe microphone measurement in their ear.
        7. DSL should be used at least until the age of five (5) years so the gain required is not over or underestimated, and the emphasis is placed on the speech spectrum.
        8. In addition to verification, close check of internal settings should be performed when instruments return from repair.