KidsAudiologist

Archive for the ‘BAHA’ Category

Yesterday I attended the launch of the new National Commissioning Framework for Hearing Loss Services.

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This is a document was developed by members of the Hearing And Deafness Alliance (a group of representatives from professional organisations, charity sector and patient groups) with NHS England and follows the launch of the Government’s cross-sector and cross-departmental Action Plan on Hearing Loss last year.

The new framework is aimed at supporting NHS commissioners in ensuring they understand the importance of services for people with hearing loss and the potential impact of un-managed hearing and communication difficulties. The document clearly indicates that it covers the whole age range from birth onwards but understandably given the much larger numbers involved, does have some emphasis on age-related hearing loss. But section 3.1 does make it clear that CCGs should be familiar with their commissioning responsibilities in relation to hearing and wider audiology services and appendix 3 helpfully clarifies the responsibilities of CCGs, NHS England and PHE in the complex environment of commissioning the various parts of a child’s audiology journey. Finally, section 8 stresses the need to move towards more outcome based commissioning and the crucial role of service specifications in setting out the key requirements for delivery of the service.

I was therefore very pleased be invited onto the Children’s Services Content Group and to lead on developing a model service specification for commissioners on paediatric audiology services along with a series of suggested outcome measures for children plus service performance outcomes, that services and commissioners can use to measure quality of the service. A link to this document is contained within the Framework or can be downloaded here. This is the first time we have had children’s outcomes used as commissioning measures of quality and we look forward to feedback and developing these further.

I’m now looking forward to working with NDCS colleagues to share this suite of documents widely with our networks, including service professionals and commissioners.

 

 

Hearing aid wearers are most familiar with their ‘T’ switch to help them hear better in public places fitted with loop systems, such as churches, theatres, banks and post offices. These aren’t situations we generally consider as being very relevant to children and young people but a new generation of assistive devices have the potential to make hearing aids ‘cool’, improve their listening experience, and increase opportunities for language and social development.

Induction loop technology
Induction loop technology is the oldest of the wireless technologies and works with a telecoil, which has been a standard feature in NHS hearing aids for many years. Room loops help overcome some limitations of hearing aids and reduce the negative effects of distance and background noise, improving the signal-to-noise ratio and reducing listening effort for the wearer.

During the analogue era of hearing aids the telecoil was always available and a visual MTO switch meant that wearers were prompted to ask questions about it or go out and research it even if the audiologist didn’t directly tell them about it’s use. New and innovative products which use magnetic induction technology are making mainstream products more accessible to deaf children enabling them to share experiences with their hearing friends. These include inductive earhooks, neckloops and Bluetooth streamers with neckloops. These products allow a child wearing a hearing aid to listen to mobile phones or an entertainment device, such as an iPod, MP3 player, laptop or portable games console.

Modern digital hearing aids now have multiple programme capability but the telecoil setting must be activated. The wearer must be able to reliably change programmes as there is no visual indicator the ‘T’ setting is being used. Our experience at NDCS is that the majority of children and young people attending our events or visiting the Listening Bus do not know what the telecoil is and do not have it activated and so are unable to try out equipment that could be of benefit.

Deaf children and young people asking for more information
In 2007 NDCS carried out a consultation with nearly 1500 children and young people aged nine to 18. The results found significant numbers of children and young people in both the younger and older age groups wanted more information on deafness and the technologies that can support them.

Download the full article – Telecoils – making hearing aids cool for kids? – that was published in March 2013 in the UK edition of Audio Infos magazine to answer some common questions we get asked:

  • Using loop technology with children
  • Not deaf enough for a ‘T’ setting?
  • Too young for a ‘T’ setting?
  • Too hard explaining the technical information to a child?
  • Worried about noise interference?
  • T or M/T?
  • They already have an personal FM system. Isn’t that better?
  • I don’t feel confident recommending assistive listening products?

One more tool in their toolbox!
Loop technology has moved out of dusty meeting halls and has become very relevant to deaf children and young people. At the same time deaf children and young people are reporting that they need more information about both deaf and mainstream technologies and how they can access these. New technologies are making mainstream products more accessible to deaf children enabling them to enjoy the same communication, music, and entertainment devices as their hearing peers. Telecoils are one more tool for children, with the potential to enhance their language, educational and social development.

Further information

For information on the wide range of products and equipment that might be helpful for deaf children at home, at school or when socialising with friends, as well as information on the using the free Technology Test Drive to trial new equipment head to NDCS here.

Telecoils – making hearing aids cool for kids? (Audio Infos, Mar 2013)

Can Kids Benefit From Hearing Loops? (Jane Madell, Jan 2015)

 

 

 

 

 

 

Atresia or microtia is the absence or underdevelopment of the outer ear and is frequently associated with other craniofacial conditions that may impact on all aspects of their lives. It is essential that these patients and their families have access to specialised microtia teams able to provide up to date and unbiased information. A multidisciplinary approach should be taken to provide holistic, individualised assessments and interventions. This should encompass cosmetic, audiological and psychological aspects of their care. Close liaison between local services and the ear reconstruction team is a key component to achieving the best outcomes for these patients. There is a recognised need for agreed care standards for these patients, and this document aims to reflect a consensual view of how this care can be provided in an integrated fashion.

I was pleased to be involved in their development for NDCS along with other patient, parent and carer groups, working together with a passionate group of professionals who work with children and adults born with atresia or microtia.

Download UK Care Standards for the Management of Patients with Microtia and Atresia (Edited by: Henderson, R., Moffat, C., Stewart, K., and Clapperton, K.) March 2015

For further information about microtia and atresia you can also order or download a free booklet on atresia and microtia written for families from NDCS here, contact Microtia UK or join the Microtia Mingle Facebook Group.

 

From this month NHS England (briefly known as the NHS Commissioning Board) takes over responsibility for commissioning specialist services for deaf children. This includes specialist implantable devices such as cochlear implants, bone anchored hearing aids and middle ear implants etc. Bilateral cochlear implants are currently and continue to be funded in line with NICE recommedations which children have a right to access under the NHS Constitution.

This month NHS England have announced their clinical access policies for bone anchored hearing aids and active middle ear implants. These are important because they relate to services that don’t have NICE recommendations and were previously commissioned locally by Primary Care Trusts and were subject to wide variation in provision. In summary:

Bone anchored hearing aids

  • are of safe and of proven benefit
  • should be provided in a specialist centre doing at least 15 a year. The team should include an ENT surgeon, audiologist, paediatric anaesthetist and speech and language therapist.
  • for children with microtia their care must be coordinated by a multidisciplinary team that can provide appropriate hearing and reconstructive support.
  • early intervention is vital and children born deaf should be provided with a bone anchored hearing aid on a soft headband until they are old enough for surgery.
  • funding will be available for children with bilateral conductive hearing loss to have bilateral bone anchored hearing aids if multidisciplinary assessment suggests that this would provide children with the best hearing environment in the classroom situation.
  • although bone anchored hearing aids would not normally be funded for children with unilateral deafness, an ‘exceptional case’ request can be made centred on information regarding the child’s development, audiometry results and communication needs.
  • and for the first time service providers will be expected to collect and provide audit data on request.

“Documents which have informed this policy – The National Deaf Children’s Society. Quality Standards in Bone Anchored Hearing Aids for Children and Young People. 2010″

Middle Ear Implants

Middle ear implants are a relatively new technology and very few children world-wide have been fitted with them. The evidence base is therefore almost non-existent at the current time. For these reasons it was not unexpected that active middle ear implants will not be routinely commissioned and will only be used as part of a recognised and structured clinical research project. However, they will be commissioned in the following limited circumstances:

  • Bilateral sensorineural hearing loss when conventional hearing aids have been used and found to be medically unsuitable due to conditions of the external ear.
  • Mixed hearing loss when conventional hearing aids have been used and found to be medically unsuitable due to conditions of the external ear and when a bone anchored hearing aid has been implanted and been associated with medical problems of the soft tissues or loss of fixture on more than one occasion.

Yesterday I published news that specialist paediatric audiology services are to be nationally commissioned from next April. Discussion with colleagues and on Twitter has confirmed confusion about the plans. And in response to the link posted on the BAA Facebook page I received some varied responses:

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In summary:

The biggest question appears to be how much of a typical paediatric audiology service will fall under “Specialist Audiology Services. Specialised audiology services consist of those audiological services which are part of a paediatric hearing aid service”? We don’t know at this stage – it could mean just the advanced audiological tests such as diagnostic ABRs (used mostly for diagnosis following newborn screening) or it could also include hearing aid fittings since we know that fitting aids to babies is very complex. My working assumption is that they are using the same kind of definition that the Department of Health used in their Transforming services for children with hearing difficulties and their families; A good practice guide (2008) that used the term to mean fitting of hearing aids on the under 3’s and associated testing.

Whichever parts of the service are included the issues remain the same, with the most important of all – how to ensure good integrated care across the child’s care pathway when several different services and commissioning bodies are involved? Lots to tease out and lots of clarity still needed about what this announcement will mean.

UPDATE 18th September 2012: The NDCS response to this news can now be read here

As part of the new Health and Social Care Act 2012 the commissioning (or purchasing) of NHS services will be the responsibility of local Clinical Commissioning Groups (CCGs) except where the service is prescribed in legislation. Prescribed services will be commissioned by the NHS Commissioning Board (NHSCB). Yesterday the DH published the recommendations of the Clinical Advisory Group for the services that should be nationally commissioned from April 2013. (The document is dated June 2012 but it was only publically available yesterday!)

The recommended services that are included and of interest to the audiology and ENT profession, as well as parents of deaf children are:

  • Specialist Ear, Nose and Throat Services for Children and Young People including surgical management of rare conditions, surgical management of more common conditions when the child or the procedure is high risk (including the need for PICU or Specialist Anaesthetic management), provision of specified procedures and Specialist Audiology Services. Specialised audiology services consist of those audiological services which are part of a paediatric hearing aid service. In some cases specialised audiology services may not be co-located with specialised ENT surgery services. (p21 & 130)
  • Cochlear Implantation Services (p26 & 200)
  • Bone Anchored Hearing Aid Services (p26 & 201)
  • Auditory Brainstem Implantation Service (p26 & 203)
  • Middle Ear Implantable Hearing Aid Services (p26 & 205)
  • Other Specialised Ear Surgery (the plastic surgery element is included within the proposed regulation on Specialist Plastic Surgery for Children and Young People.) (p26 & 207)
  • Specialist Mental Health Services for Deaf Adults & Deaf Children & Adolescents (p17 & 103)

Also of interest to us because of the populations involved:

  • Specialist Services to support patients with complex physical disabilities which including Specialist Augmentative and Alternative Communication Aids (p11 & 44)
  • Cleft Lip and Palate Services (p15 & 77 & 152 & 158)
  • Specialist Genetic Services (p20 & 95)
  • Specialist Plastic Surgery Services for Children and Young People which includes congenital malformations of the ear including: absence of ear, absence/atresia/stricture of auditory canal, macrotia, microtia, misshapen ear, misplaced ear. And congenital malformation syndromes predominately affecting facial appearance incl Goldenhar syndrome, Robin syndrome and Treacher-Collins syndrome. (p23 & 158)

There are also some exisitng services that are already regionally or nationally commissioned that are recommended for transfer to new regulations:

  • Alström services (p28)
  • Complex neurofibromatosis type 1 services  (p29)
  • Mental health services for Deaf children and adolescents will include services provided by Highly Specialist Deaf Child and Adolescent Mental Health centres including outreach when delivered as part of a provider network. (p29)
  • Craniofacial services (p29 & 152)
  • Neurofibromatosis type 2 services (p31)
  • Primary ciliary dyskinesia management services (p32 & 166)
  • Rare mitochondrial disorders services (p32)
  • Stickler syndrome diagnostic services (p34)

What do you think?

National commissioning has the potential to be a very positive move for those low volume, highly complex, high cost interventions such as cochlear implants, and this could mean much greater equity of access across the country to these types of procedures. The big surprise to me is the paediatric hearing aid services included in the recommendations as it neither fits the low incidence or high cost descriptions used to identify national specialist services. More so than many of the other services this recommendation has the potential to have a very major impact on how current services are provided in terms of location, staff, and integration with the rest of the paediatric audiology service. Specialist services are likely to have more experienced staff who see larger numbers of children and build up more expertise. But how is this organised? It isn’t fair to expect families with young deaf children to travel great distances on a regular basis to attend specialist services so how will care closer to home be managed? With a split between local and specialist centres? With a network arrangement where staff travel to see children in outreach centres and/or work with local teams? Or another way?

What are your views? What would you like to see happen?

Update 14th September 2012: Some of your views can be found here.

Update 18th September 2012: The NDCS response to this news can now be read here.

How long a battery lasts depends on the type and power of hearing aid, how long it is worn each day, what kinds of situations the hearing aid is worn in (it’s processor has to work harder in noisier environments for example) and whether it is also supplying power to integrated FM or wireless FM receivers. Most children in the UK are issued with disposable batteries and many of them are using several hundred every year – wow! What are you doing with your used ones?

All used batteries should be disposed of safely and preferably recycled. Some audiology services will ask you to return old batteries when requesting new ones and they will recycle the old ones. It is good practice to keep your used batteries in the original packaging so that you can be sure that no old batteries have gone missing and to keep the batteries safe. If you are not asked to return old batteries you can safely dispose of them in your household rubbish. However, many local councils now have recycling schemes for batteries including household collection. Alternatively many large stores that sell batteries offer boxes to keep old batteries in and recycling schemes. For more informaton on recycling batteries in your area go to the Directgov website or visit Battery Back and type in your postcode to find the collection point nearest your home.

Updated 29th December 2018 to include additional references and 14th February 2020 to include a safety alert issued to NHS audiology clinics

A recent study looked at 20 years worth of data from emergency departments in the USA about children who had attended following a battery related incident. Whilst incidents were rare at 4.6 hospital visits per 100,000 children in the population that amounted to an average 3289 visits annually. The study looked at four scenarios – swallowing batteries (which accounted for 76.6% of visits), and putting them in the mouth (7.5%), the ear canal (5.7%) and the nose (10.2%). And it was most likely to happen in the under 5’s (mean age 3.9 years). More than 8 out of 10 visits were related to button batteries which are widely used in hearing aids, cochlear implants and other electronic devices. It’s also worth considering that the magnets used in some cochlear implant coils are a similar size and shape to button batteries and could also be a potential hazard. In December 2019 a National Patient Safety Alert was released to all NHS audiology clinics about battery safety in children’s hearing aids. The safety alert states that all hearing aids fitted to babies and children under five years of age must have secure battery compartments. And where hearing aids are issued to older children and adults, the audiology clinic is required to consider the need for a secure battery compartment for anyone living with young children and babies, or with a person with additional risk factors, such as those with a significant learning disability, dementia or other cognitive or sensory impairment. This safety alert follows an investigation by the Healthcare Safety Investigation Branch into the case of a three year old child who had an unknown and undetected ingestion of a button battery and sadly died. The child was not deaf and the battery in question had come from another household device.

This means that audiologists and parents of young deaf children need to be aware of the risks and ensure children’s equipment is used safely:

  • Make sure young children have childproof battery locks fitted to their hearing aids so that they can’t remove the battery themselves.
  • Try not to let young children see batteries being changed. It is safer if they do not know that the battery compartment opens.
  • Ensure both the used and new batteries are stored safely and out of sight of young children.
  • Keep your used batteries in the original packaging so that you can be sure that no old batteries have gone missing and to keep the batteries safe.
  • Remember that even if you trust your own child not to fiddle with their batteries there may be other children in their school or nursery who don’t understand that they shouldn’t play with them.

Fortunately the majority of battery related injuries aren’t serious and can be easily treated. But occasionally injuries are serious so it is important to follow up any concerns you may have immediately. If you are concerned that your child may have swallowed a battery or put one somewhere they shouldn’t – take them to your nearest A&E department. Take a similar battery and the packaging with you so that the hospital staff can identify the type of battery and know what action they need to take.

References:

Button Batteries Pose Dangers to Children, Advance for Speech-Language Pathologists & Audiologists [Published online December 2011]

George, A.T., & Motiwale, S. Magnet ingestion in children – a potentially sticky issue? The Lancet, Volume 379, Issue 9834, Pages 2341 – 2342, June 2012

Hearing Aids; Information for families, NDCS, January 2012

Sharpe, S.J., Rochette, L.M., & Smith, G.A. Pediatric Battery-Related Emergency Department Visits in the United States, 1990–2009, Pediatrics [Published online May 2012]

UK’s top paediatric doctors warn of devastating impact of button batteries, GOSH Sept 2016

Hearing aid battery compartments need locks, CHI+MED Making medical devices safer, 2016

Keeping children safe from button batteries during the festive season and beyond! PHE Dec 2018

 

Having recently joined the iPad revolution I’ve been thinking about apps which might be useful in our day-to-day work. Tina Childress is an Educational Audiologist and keeps a very comprehensive list of Apps for Kids (and Adults) with Hearing Loss. Also, the Apps in Education blog includes a good section on So what’s on the iPad for the kid in your class with a Hearing Impairment? and the Earmeter site includes How an iPad can be an incredibly useful tool for hearing aid practices. But here are a few that I’ve downloaded, had a play with and that I think have the potential to be useful tools in counselling children, young adults and families about the ears and hearing:

Auditory Verbal Price – £2.49
This little app uses sound, pictures and text of the 6 Ling sounds. The Ling sounds are a fantastic daily check for parents to do with their child to check their child’s hearing aids are working properly and that they are picking up the frequency range of speech sounds. You could download a free sheet of the Ling sounds with pictures from The Listening Room but some parents / teachers may like the convenience of having it on their iPad for daily checks.

Hearing Aid TicTacToe Price – £5.99
This is a game for 2-4 players aged 4+ years to help kids develop independence in using and understanding their hearing aids – first by matching pictures, then matching pictures with labels, and finally pictures with function. This app is one the the most expensive I’ve ever purchased but I can see that it could be a really useful tool for audiologists and Teachers of the Deaf that can be used over and over with different cohorts of children and at different times as they develop.

Cochlear Baha Support Price – £free
Love this and want to see many more of them for the various products around. It’s basically a manual for your Baha on your iPad, but because it’s on your iPad you have all the information to hand during the day if something goes wrong and you can troubleshoot it easily. There is also advice on travelling, using the telephone and MRI scans and includes helpful videos to follow on cleaning etc. Brilliant, really useful.

Blue Tree Publishing Price – £1.99 each
Have produced a range of iEducate apps which include animations and video which are really useful for demonstrating how the parts of the ears work. I think I would use this one quite a lot and it’s worth the £1.99. Bluetree have also produced a range of Drag & Drop Identification apps. These are basically jigsaws although I found them quite hard to do and think they might be good revision aids for students. There might also be the older child who is very interested in the ear or science more generally who would enjoy the challenge. I wasn’t sure if the content alone and the fact that you’re unlikely to use it very often was enough to justify the £1.99 each as it becomes quite expensive to get the full set. So try with one and see how you go first. Inner Ear, Middle Ear and Labyrinth all available.

Draw MD ENT Price – £free
At it’s most basic this is a lovely tool for showing an older child, teenager and family more about the workings of the ear. It gives some really nice detailed pictures of the ear that you can draw on with your finger to highlight parts as you discuss the anatomy and cause of hearing loss etc with them. At it’s most impressive, you can use your own photos which I’m sure ENT surgeons would find useful for showing patients photographs of their own ears. You can add labels and even email the finished picture to the patient if they want it!

Hearing Loss Simulator Price – £2.49
I think this app has the potential to be a great counselling tool for use with families. There are graphics to show where the common sounds, speech, and individual speech sounds are located for loudness and frequency, and there are lots of options in terms of audiogram configurations. All the recorded voices have an American accent but it is possible to record your own voice for use in simulations.

Play it down Price – £free
Pick a song from your library and crank up the age dial for a feel of what music may sound like in the future. It’s a bit gimmiky but it could be a useful tool in couselling teenagers about the potential effects of noise damage.

Relaxing Sounds of Nature Price £0.69 (lite version free)
Finally, there are masses of nature sound apps out there to choose from. I really like this one as it has a really large range of sounds to choose from, you can mix sounds to your taste, and there’s some beautiful pictures of scenary to accompany the sounds. It also includes a variety of white/pink noise to choose from. I wouldn’t hesitate to recommend this one to my tinnitus patients (and anyone else who wants to relax!)

Families who have a child with a mild, moderate or unilateral deafness frequently report that their child’s needs are poorly understood. This is often because the effect of their hearing loss may be more subtle than for those children with a more severe hearing loss. For example a mainstream teacher will find the child can hear them fine when working one-to-one with the child and not appreciate that the they can’t hear voices from further away and when there is background noise. This means that children have very reduced opportunities to benefit from hearing what is going on around them – incidental learning – and are therefore more likely to show delays in speech, language, educational, & social development than their normally hearing peers. Sadly, due to funding and capacity issues, local specialist support resources are often prioritised towards those children with more severe hearing losses so that training and awareness in schools may be low. Parents understanding and advocating for their child’s needs becomes even more important.
In 2010, NDCS was awarded a 2 year grant from the Department for Education under the SEN and Disability “Improving Outcomes” theme. We have been working with parents and professionals, providing specialist information and support on key barriers to achievement and to specific groups with a significant attainment gap. One strand of this work that I’ve been involved with has been to provide new information resources for parents that are available free to download – ‘Mild deafness’ and ‘Unilateral deafness’. This weekend I was involved in developing our first weekend for families of children who have a mild, moderate or unilateral deafness. All the deaf children were between 3 and 7 years old and they and their siblings appeared to have a great time occupied in the children’s activities sesssions. Parents attended sessions sharing their experiences, and heard from a young adult role model who grew up with moderate hearing loss in both ears. They also attended information sessions on audiology, technology, education, and NDCS events and services. 12 families attended and for 10 of them it was the first time they or their children had ever attended an NDCS event. Many had been told or held the perception that their child wasn’t ‘deaf enough’ to access specialist services, Disability Living Allowance, resources that help children develop listening skills, and even NDCS. A few families had shown an interest in learning sign language to help communication at times when their hearing aids couldn’t be used and to mix with other deaf children, but many had been poorly advised including that it would have a negative impact on their child’s spoken language development. This may have been one dimension of why families often hadn’t persued joining local groups and meeting other families with deaf children. Most of the children had never met another child that uses hearing aids and it was a real joy watching them playing together and making new friends ‘like them’ over the weekend. I believe the parents have all gone away feeling more confident that they understand their child’s needs and will be better able to make informed choices on behalf of and with their child.

So if you have a child with a mild, moderate or unilateral deafness remember that “NDCS uses the word ‘deaf’ to refer to all levels of hearing loss” and that all of our current services and events are open to you.


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