Protocol for Audiological Assessment, Hearing Aid and Cochlear Implant Evaluation, and Follow-up

This audiological protocol is intended to support programs for early detection and management of hearing loss in infants and children. 

This protocol also is a guide to appropriate and ongoing audiology services recommended for children participating in listening and spoken language (LSL) programs.

• Contributors and Reviewers
• I. Introduction
• II. Overview of Audiological Management
• III. Recommended Elements of the Initial Audiological Diagnostic Assessment
• IV. Recommended Procedures to Assess Amplification
• V. Recommended Audiological Management for Children with Cochlear Implants
• VI. Recommended Audiologic Management Regarding FM Systems
• VII. Disclaimer and Copyright

• Joint Committee on Infant Hearing (JCIH) (2007).Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics, 120(4), 898-921.
• American Speech-Language-Hearing Association (2004a). Guidelines for the audiologic assessment of children from birth to 5 years of age. Available at http://www.asha.org/policy/GL2004-00002.htm
• American Speech-Language-Hearing Association (2006). Roles, knowledge, and skills: Audiologists providing clinical services to infants and young children birth to 5 years of age. Available at http://www.asha.org/policy/KS2006-00259/
• American Academy of Audiology (2013). Clinical practice guidelines: Pediatric amplification. Available at http://audiology-web.s3.amazonaws.com/migrated/PediatricAmplificationGuidelines.pdf_539975b3e7e9f1.74471798.pdf 

• Initial screening, diagnosis, and confirmation should be completed within the first three months of life—as soon as possible after birth—in order to ensure that appropriate amplification and habilitation is underway prior to age 6 months. JCIH (2007) recommends that screening be accomplished by age 1 month, diagnostic testing be accomplished by age 3 months, and intervention begin by age 6 months.
• When hearing loss is diagnosed, routine evaluation should occur ideally at four- to six-week intervals until full audiograms are obtained, and at three-month intervals through age 3 years.
• Assessment at six-month intervals from age 4 years is appropriate if progress is satisfactory and if there are no concerns about changes in hearing.
• Immediate evaluation should be undertaken if parent or caretaker concern is expressed or if behavioral observation by parent, therapist or teacher suggests a change in hearing or device function.

• Otoscopic inspection
• Child and family history
• Auditory Brainstem Response (ABR) testing using air-conducted click and tone burst stimuli and bone-conducted stimuli when indicated. When a hearing loss is detected, frequency-specific ABR testing is needed to determine the degree and configuration of hearing loss in each ear for fitting of amplification devices.
• Click-evoked ABR testing using both condensation and rarefaction single-polarity stimulus, if there are risk indicators (e.g., hyperbilirubinemia or anoxia) for neural hearing loss (auditory neuropathy spectrum disorder or ANSD) to determine if a cochlear microphonic is present.
• Auditory Steady State Response (ASSR) testing may be used as another means of assessing ear and frequency specific thresholds. ASSR testing can also be used to assess auditory nerve function when no ABR is present.
• Distortion product or transient evoked otoacoustic emissions (OAE) testing
• Tympanometry using a 1000-Hz probe tone, and acoustic reflex testing
• Parent and clinician observation of the infant's auditory behavior as a cross-check in conjunction with electrophysiologic measures. Behavioral observation alone is not adequate for determining whether hearing loss is present in this age group, and it is not adequate alone for the fitting of amplification devices.

• Otoscopic inspection
• Child and family history
• Parental report of auditory and visual behaviors and communication milestones
• Behavioral audiometry (either visual reinforcement or conditioned-play audiometry, depending on the child's developmental level), including pure-tone audiometry across the frequency range for each ear and speech detection, speech audibility (e.g., using the Ling 6-sound test) or speech recognition measures
• OAE testing
• Acoustic immittance measures (tympanometry and acoustic reflex thresholds)
• Electrophysiological testing as described above, if responses to behavioral audiometry are not reliable.

1. Descriptions of test procedures, conditions of testing, and reliability estimate
2. A complete audiogram (if available at the initial diagnosis) with symbol key, calibration, and stimuli identified, as well as an explanation of results using tools such as a "Familiar Sounds" audiogram to support parent/teacher counseling
3. Copies to parents, as well as to primary care provider, Listening and Spoken Language Specialist, and other health/education providers as requested in writing by parents
4. Referral to medical, otolaryngological, or other resources (e.g., genetic counseling, social services, psychological counseling, occupational therapy) as appropriate.

• Electro-acoustic analysis of hearing aids to document hearing aid performance at the following times:
• At initial fitting
• At regular intervals (e.g., at follow-up appointments)
• Upon return from repairs
• If parental concerns arise from behavioral observation or listening check.
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• Real-Ear-to-Coupler Difference (RECD) measures
• Used with prescription method such as DSL (Desired Sensation Level ) or NAL (National Acoustic Laboratories) to establish target gain and output
• To convert hearing aid performance in 2cc coupler to real ear hearing aid performance
• To convert hearing levels in dB HL to ear canal SPL (Sound Pressure Level)
• To assess change in earmold style and fit.
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• Cortical-evoked response testing to validate hearing aid fittings, where available.
• Sound Field Aided Response
• To demonstrate the child’s response to speech for parent education purposes
• To monitor the child’s auditory progress
• To assess speech perception at soft (e.g., 35 dB HL) and at average conversational levels (e.g., 50 dB HL) in quiet and in the presence of noise to evaluate the effectiveness of amplification technology. Each hearing aid should be evaluated separately and then both tested together.
• Assessment of speech audibility using the Ling 6-Sound Test at varying distances (e.g., through 6 meters or approximately 20 feet)
• Comparison of Ling results with NAL speech-o-gram if available to evaluate hearing aid fitting
• Functional auditory assessments (e.g., PEACH [Parents' Evaluation of Aural/oral performance of Children], LittlEARS Auditory Questionnaire) to validate hearing aid fitting.
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• If adequate access to the full spectrum of acoustic information of spoken language cannot be achieved for an infant or child through conventional amplification, information should be provided to the family regarding cochlear implant (CI) technology, including benefits and risks as documented in published, peer-reviewed literature along with referral to a pediatric cochlear implant center.
• Upon parental consent, the cochlear implant team will review the audiologic information obtained to date and perform further assessments to evaluate the child’s suitability for cochlear implantation. Speech perception testing should be included in the pre-CI evaluation and used both in determining candidacy and to compare to post-CI evaluations.
• The LSLS should participate in the cochlear implant candidacy process.
• Following initial mapping of the cochlear implant speech processor(s), re-mapping should be conducted on the schedule recommended by the cochlear implant team given the child's age, device(s) implanted, number of electrodes activated, and additional individual considerations such as a bilateral or bimodal fitting.
• Once the speech processor is programmed to provide optimal access to the speech spectrum, ongoing evaluation at regular intervals is recommended (e.g., at three-month intervals for the first year). After this period, routine assessment of performance with the cochlear implant continues to be recommended at six- to 12-month intervals if progress is satisfactory.
• Sound Field warble tone or narrowband noise thresholds and speech perception testing should be performed whenever the speech processor is programmed and may be helpful along with other troubleshooting techniques whenever problems are suspected. Additional purposes of sound field testing are:
• To demonstrate the child’s response to speech for parent education purposes
• To monitor the child’s auditory progress
• To assess speech perception at average (e.g., 50 dB HL) and at soft (e.g., 35 dB HL) conversational levels in quiet and in the presence of noise, to evaluate the effectiveness of the cochlear implant, or of each cochlear implant in the case of bilateral fitting
• Subjective assessment of distance hearing using the Ling 6-Sound Test to demonstrate the range of audibility provided by the technology. In a quiet environment, the child should be able to detect all of the Ling sounds at close distances (e.g., one meter or approximately 3 feet) and at substantial distances (e.g., approximately 12 meters or approximately 40 feet).
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• Immediate evaluation is recommended if parent, caregiver, or educator/therapist observe behaviors suggesting a negative change in performance or express concern regarding device function.
• Functional auditory assessments (e.g., PEACH, LittlEARS) to validate hearing aid fitting.

• Every child with hearing loss will benefit from the use of an FM system to reduce the negative effects of distance and competing noise.
• All technology selected for children should be FM compatible.
• Validation and verification should be included in evaluations for children using FM systems. See Clinical Practice Guidelines for Remote Microphone Hearing Assistance Technologies for Children and Youth Birth-21 Years (American Academy of Audiology, 2008; available at http://www.audiology.org/publications-resources/document-library/hearing-assistance-technologies).