The Joint Committee on Infant Hearing (JCIH) Year 2019 Position Statement, “Principles and Guidelines for Early Hearing Detection and Intervention Programs,” continues to recommend early identification and immediate access to hearing device technology for infants with hearing loss (JEHDI. 2019;4:1-44). Infants who require medical care in the neonatal intensive care unit (NICU) are at a higher risk not only for hearing loss but also for delayed intervention until after they are discharged from the hospital. While the JCIH recommendations acknowledge this delay, an interdisciplinary approach to hearing health care may promote improvements in timely access to early intervention for these most fragile patients.
At Cincinnati Children's Hospital Medical Center (CCHMC), one goal of our inpatient audiology program is to focus on early diagnostic testing and appropriate sensory intervention for infants with hearing loss. Our team plays an important role in educating the NICU staff and families about sensory development and appropriate sensory stimulation during hospitalization of premature and critically ill infants as well as those with hearing loss. Infants need access to their mothers’ voice because it is familiar and provides more consistency and security compared with recorded voice or music. Access to the mother's voice can result in increased oxygen saturations, increased nonnutritive sucking (promoting feeding), weight gain, improved sleep state, and decreased parental stress (Pediatrics. 2016 Sep;138:e20160971.; Pediatrics. 2013 May;131:902-18). These benefits contribute to an infant's clinical stability. With careful considerations and customized recommendations, our team has been able to provide families with the opportunity to utilize a hearing device with their child shortly after hearing loss is identified, providing benefits recognized by both parents and staff.
AUDIOLOGY CARE IN THE NICU
For almost 20 years, our inpatient audiologists have been active members of both the NICU medical and developmental teams. They incorporate hearing status into developmental care plans when appropriate, measure NICU environmental noise, determine appropriate auditory and vestibular stimulation based on gestational age, assist in hearing device equipment selection, and provide education in areas such as sensory development, the detriments of environmental noise in the NICU environment, and the importance of rapid eye movement (REM) sleep for brain growth and sensory development.
Infants who can go home with their parents after birth commonly experience sensory stimulation with a comforting touch and familiar sounds of their parent's voice and environment. Infants who require NICU care have a very different sensory experience, which includes many unfamiliar providers, excessive ambient noise with competing backgrounds, and noxious smells and tastes during medical care. Infants rely on their hearing and vision to help them organize their environment, anticipate daily routines, and develop appropriate bonding with caregivers. Much of an infant's vision develops after 40 weeks of gestation, causing infants to rely more on their hearing during their time in the NICU. When an infant has hearing loss, additional factors must be considered to help the infant adjust to his or her environment. These include:
- Awareness of environmental cues and impending medical care
- Ensuring the infant is aware that someone is approaching the bed or preparing to start an assessment, diaper change, etc.
- Benefit from interventions to support calming, sucking, weight gain, and sleep such as:
- Providing familiar or calming voice, music therapy, sound machines, toys and mobiles when developmentally appropriate, hand containment, and snoedel with the parent scent.
- Support parent bonding
- Offering kangaroo care and access to the parent's voice, which is the most important sound for infants.
- Vestibular support
- Gently transfer an infant out of the bed space or roll him or her to the side since these movements can be difficult to anticipate especially with an associated vestibular involvement.
- Speech and language development
- Providing opportunities to allow for missed incidental language learning
These scenarios should be considered for NICU infants with hearing loss demonstrating the need for earlier intervention even during their hospitalization.
Infants can be in the NICU for several months, and upon discharge, may be transferred to another unit in the hospital where they can remain throughout the first year of life or longer. To approximate the 1-3-6 guideline recommended by JCIH (hearing screening by 1 month of age, definitive diagnosis by 3 months of age, and access to early intervention as soon as possible following diagnosis), it is critical to move beyond the newborn hearing screening in the NICU. Early intervention in the hospital setting will need to be modified, but it can be initiated. Providing support to infants with hearing loss and their caregivers may include recommendations for communication strategies, working with speech pathologists on early language skills, and in some situations, providing hearing devices.
At CCHMC, audiologists complete a limited diagnostic auditory brainstem response (ABR) on all infants and move immediately to a complete diagnostic test battery at the initial evaluation when hearing loss is suspected. Therefore, the intervention can be initiated shortly after diagnosis.
In 2003, our audiology team created the Cincinnati Children's Sensory Care Plan, a guideline for families and staff that offers modifications on ways to communicate and interact with the infant using various modes of sensory input. The individualized plan is developed with families and bedside caregivers, including neonatologists, nurses, speech pathologists, etc. All bedside nurses receive education on infant hearing, sensory development, and the Cincinnati Children's Sensory Care Plan during their NICU nursing orientation. This document includes recommendations for communication such as:
- “Please approach my bed slowly and gently. If I am awake, let me see you before you touch me. If I am asleep, please place your hands firmly beside me on my mattress so I sense your presence. Then touch me gently on my legs and work your way up to my head and face where I am most sensitive. This will help me from being startled.”
- “When you hold me, please sit or stand near an overhead light so that your face is softly illuminated. This helps me focus on your face and use my vision as well as my hearing.”
- “Please give me time to use my sense of touch to know what is coming next. Give me a tactile cue for activities whenever you can. For example, before a diaper change, please let me see the diaper, then touch it gently on the back of my hand. This will help me learn what is coming next.”
All infants with hearing loss have a Cincinnati Children's Sensory Care Plan with specific criteria and customized recommendations. In some situations, a hearing device may be offered to patients while they are in the NICU. These devices include hearing aids and bone conduction devices. However, many factors need to be considered prior to hearing device fitting during hospitalization. In addition to the type and configuration of the hearing loss, inpatient audiologists work with the medical team to determine when an infant is medically appropriate for a hearing device fitting. The medical stability of the infant must be discussed with the neonatology team, and all should agree to proceed before offering the device to the family. Device fitting may need to be avoided during treatments that involve the head or neck, such as mandibular distraction or newly placed ventriculoperitoneal shunt. If a device is deemed appropriate and timely, parents can choose to utilize a hearing device for their infant on a loaner basis or proceed with a personal device. If a parent is not interested in a hearing device, the Cincinnati Children's Sensory Care Plan is followed, and speech pathologists provide ongoing education regarding early language acquisition and communication options.
Many of our patients who have been fitted with a hearing device are infants with a conductive hearing loss craniofacial anomaly. Therefore, a bone conduction device (BCD) with a softband is the most appropriate for several reasons such as:
- Appropriate treatment for the type of hearing loss
- Ease of placement and use
- Flexibility of device position for reduced feedback
- Adjustable softband for child growth
- Consistent auditory access with frequent or fluctuating middle ear fluid
Our inpatient hearing device program offers loaner bone conduction devices or hearing aids that can be fitted shortly after diagnosis. The parents and the medical team are educated regarding device care and recommended use. Hearing device recommendations are specific to certain times during communication and adult supervision. Communication opportunities for hearing device use include: while caregivers are talking, reading, or singing to the infant, during longer periods of medical care and developmental therapies, including occupational, physical, speech, and music therapy. Parents and staff are taught to monitor the infant's cues for discomfort or overstimulation and remove the device when warranted. When the infant is not wearing a hearing device, recommendations within the Cincinnati Children's Sensory Care Plan should be supported.
Frequent audiologic follow-up and monitoring are completed with the infant, family, nursing staff, and therapists who manage the device. Unfortunately, no appropriate validated outcome measurements are available for infants admitted to the hospital. To determine the perceived benefit, our inpatient audiologists have developed a set of qualitative questions appropriate for parents and the caregiving team. Questions include the patient's auditory awareness of environmental sounds and voices, comfort level, the benefit of therapies, and parent bonding and communication. Data regarding the infant's responses to medical care and parent bonding are collected, discussed, and documented.
PARENT FEEDBACK & KEY CONSIDERATIONS
Parents and the staff find the benefit of utilizing the Cincinnati Children's Sensory Care Plan and hearing devices with the infant population. Comments from parent and staff questionnaires include the following:
On the Cincinnati Children's Sensory Care Plan:
- The staff used to approach my child and startle him, making him upset. Sometimes it would make him upset for a while. Once the staff approached him gently, by touching his feet first, he would not become upset.
Positive responses with the hearing device:
- My child is more engaged, gets excited, and has more eye contact with me.
- My child startles when her vent pops off, which I didn't realize that she was not able to hear before.
Negative responses with the hearing device:
- I think we needed to slowly build up his tolerance and if the monitors started beeping or too many people were talking, he would let us know he was overwhelmed by crying.
- When he was done with wearing it, he would swat at it with his hand to take it off.
On the perceived benefit of being fitted with a hearing device while in the hospital:
- He wasn't able to hear people and know what was going on. He was more engaged and interested in me talking instead of just going to sleep.
We have received incredibly positive responses from families and the medical team regarding the Sensory Care Plan and the opportunity of providing hearing devices to our inpatient population (read more parent feedback online: https://bit.ly/32RIqWF) Our experience resulted in significant learnings, including these considerations regarding an inpatient device program:
- Careful selection and programming of devices for medically fragile infants
- Ongoing communication regarding medical stability with the managing medical team
- Structured education with the family, nurses, and therapy staff. Written plans at the bedside should include pictures and how to access audiology staff with questions
- Portable equipment for bedside hearing device programming
- Loaner hearing device availability and management
- Availability and flexibility of audiology staff
In our experience with fitting many infants, a successful inpatient device program is dependent on timing, communication, and parent motivation: Is the infant medically able to tolerate additional sensory stimulation? Are the parents ready and motivated to proceed with a device? And are the audiologists, inpatient care team, and parents available and dedicated to ongoing communication to support the infant throughout hospitalization? With significant commitment and considerations, an inpatient team can provide earlier hearing intervention for medically fragile infants in a hospital setting.