Newborn Hearing Screening, Hearing Aids, and Referrals: Interview with Jessica Stich-Hennen, AuD
Douglas L. Beck, AuD, speaks with Dr. Stich-Hennen from the Elks Hearing and Balance Center in Boise, Idaho, about newborn screening, processes and protocols, hearing aids, cochlear implants, referrals, and more.
Academy: Hi, Jessica. It is great to speak with you again.
Stich-Hennen: Hi, Doug, thank you for the invitation.
Academy: My pleasure. Jessica, I recently visited your facility and I have to admit I was very surprised to see the Elks involved so completely with hearing health. There’s quite a lot to learn at your website, but would you mind telling me a little about the Elks Rehab System?
Stich-Hennen: Sure. I work for the Elks Hearing and Balance Center in Boise, which is one of the eight business units within the Elks Rehab System.
Academy: Jessica, please tell me a little about the Elks Rehab System? Who are they and where did they come from?
Stich-Hennen: The quick story is that in 1947 the Idaho State Elks Association opened a convalescent center for children with polio. Over the years our rehabilitation programs expanded to fill other needs such as stroke, spinal cord injuries, CP, etc. In 1957, we moved into a new facility in downtown Boise and in 1972 we became a rehabilitation hospital and that’s when we got involved with hearing testing. Since then, we’ve grown to be the largest free standing rehabilitation facility in the western United States, employing over 700 people across 30 sites in Idaho and Western Oregon.
As part of the Elks Rehab System, The Elks Hearing and Balance Center has five locations and we currently have 20 audiologists, seven vestibular physical therapists, and a speech pathologist on staff. We’ve also been “trail blazers” over the years. For example, we had Idaho’s first ABR equipment in the early 1980s, Idaho’s first cochlear implant center in the 1990s, and we were a pioneer in newborn screening.
Academy: That’s fantastic. How long have you been practicing there?
Stich-Hennen: Well, I started in 2006, as a third-year AuD student and I never left! After I earned my doctorate I became full-time staff audiologist. Quickly, I became very involved with the newborn hearing screening program and began to specialize in pediatrics. Nonetheless, we’re a comprehensive full-service audiology and vestibular rehab center. We do a lot of diagnostic follow-up from newborn hearing screening, but we also do adult diagnostics, amplification, cochlear implants, vestibular diagnostics, rehabilitation, and much more.
Academy: Tell me a little more about the newborn referrals you receive for comprehensive diagnostic tests from the surrounding facilities?
Stich-Hennen: Yes, that’s a large portion of our patient load. In 2010, we had two birthing centers and six hospitals referring to us regularly. Between the high-risk babies and the ones who failed their newborn screenings that totaled about 1,450 referrals in 2010. We have a tracking program for the high-risk babies, which were about 1,000 or so, and the other 450 were referred in for diagnostic testing.
Academy: That’s quite a large number of referrals. So about one-third of the total referrals are ones that failed their initial screening?
Stich-Hennen: Yes, that’s correct. Approximately 450 failed their initial screenings and were referred to us for further evaluation. The others were referred for tracking related to a high-risk indicator.
Academy: And then once the children are referred to you, how do you go about your diagnostics? Do you follow a standard protocol?
Stich-Hennen: Yes, we follow the 2007 Joint Committee on Infant Hearing (JCIH) guidelines, and these are available at www.jcih.org. So we start with the case history, otoacoustic emissions, tympanometry, click ABR, tone burst ABR at 500 and 4,000 Hz and then if the tone burst results (at 500 and 4,000 Hz) are abnormal, we gather 1000 and 2,000 Hz.
Academy: How long does it take for you to go through the entire diagnostic protocol?
Stich-Hennen: We usually book a two-hour time slot—and that usually allows us to do everything and write the report, too.
Academy: And I guess the ABRs are essentially sleep deprived, rather than chloral-hydrate sedation?
Stich-Hennen: Yes. Probably 90 to 95 percent of the newborns are tested using sleep deprivation as most of these children are one to three months of age. We don’t typically recommend sedation for anyone under six months of age. However, we do administer sedated ABRs when indicated for children over six months of age.
Academy: What’s the most common finding from your diagnostic protocol?
Stich-Hennen: Well, that’s hard to say, but for newborns with abnormal diagnostic findings, around 60 percent of the children have a conductive issue, the others have sensorineural hearing loss (SNHL).
Academy: And I suspect the children with the conductive loss are sent directly to the otolaryngologist?
Stich-Hennen: Yes. We usually refer directly back to their medical homes as well as their local ENT when medical or surgical treatment might be appropriate.
Academy: And then as far as referring children who appear to be cochlear implant candidates, how do you handle that?
Stich-Hennen: The quick answer is we follow the U.S. Food and Drug Administration (FDA) guidelines and we’re very fortunate here because here at the Elks Hearing and Balance Center, we have an in-house cochlear implant team.
Academy: And going back to what we were discussing earlier, if you have 1,450 children referred through your newborn program and about 450 of them were referred because they failed their initial screening, what can you tell me about the roughly 1,000 referrals who were in the high-risk category?
Stich-Hennen: Well, again if the child has the JCIH risk factors, we’ll generally do their initial comprehensive examination between six to nine months of age. However, we may see them sooner if the risk is greater, as outlined in Appendix 2 of the 2007 JCIH statement. I’ll list most of those here, but the reader should really go to the JCIH Web site and download the entire document.
- Caregiver concerns regarding hearing, speech, language, or developmental delay.
- A family history of permanent childhood hearing loss.
- Neonatal intensive care of more than five days or ECMO assisted ventilation.
- Exposure to ototoxic medications (gentimycin and tobramycin) or loop diuretics (furosemide/Lasix)
- Hyperbilirubinemia that requires exchange transfusion, inutero infections, such as CMV, herpes, rubella, syphilis, or toxoplasmosis.
- Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags, ear pits, and temporal bone anomalies.
- Physical findings such as a white forelock associated with a syndrome known to include a sensorineural or permanent conductive hearing loss.
- Syndromes associated with hearing loss or progressive or late-onset hearing loss such as neurofibromatosis, osteopetrosis and Usher syndrome. Other frequently identified syndromes include Waardenburg, Alport, Pendred, and Jervell and Lange-Nielson.
- Neurodegenerative disorders such as Hunter syndrome, or sensory motor neuropathies, such as Friedreich ataxia and Charcot-Marie-Tooth syndrome.
- Culture-positive postnatal infections associated with sensorineural hearing loss including confirmed bacterial and viral (especially herpes viruses and varicella) meningitis, head trauma, especially basal skull/temporal bone fractures that requires hospitalization and of course, chemotherapy.
Academy: Jessica, what about moms, dads, and caretakers complying with your recommendation for follow-up diagnostics?
Stich-Hennen: Yes, that’s a significant challenge. I think all of us who do this work and report our results find that approximately 30-50 percent don’t follow up with the recommendations we give. They’re more or less “lost to follow-up” for a variety of reasons including cost, time, and misunderstanding recommendations given. Also, there are some who may end up in other clinics or relocate to another state, but not all audiologists or facilities report back results, so these ones are difficult to track.
Academy: That’s really amazing. I recall my interview with Anne Marie Tharpe, PhD, from Vanderbilt in 2009. She said up to half the kids were lost to follow-up and she mentioned it may actually represent more of an issue such that one professional fails to communicate with the other! At least I hope that’s where the failure is.
Stich-Hennen: Right. I think most of us are very good at communicating our results and recommendations to the parents and I do think a large part of the issue is failure to communicate result to the state EHDI programs…so we’re trying a few things to make sure the Idaho EHDI program gets the information, such as a 48-hour turnaround time for documentation, and scanning to e-mail as well as faxing…so as to make sure the information gets where it needs to go as quickly as possible.
Academy: Okay, well I know our time is up and you’ve got to get back to the clinic. I want to thank you for telling us about the Elks Hearing and Balance Center and thanks too, for discussing the issues related to hearing screenings.
Stich-Hennen: My pleasure, Doug.
Jessica Stich-Hennen, AuD, is an audiologist with the Elks Hearing and Balance Center in Boise, Idaho.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology.