Portal de Periódicos da CAPES

Pediatric Screening Needs Creativity

2015; Lippincott Williams & Wilkins; Volume: 68; Issue: 12 Linguagem: Inglês

10.1097/01.hj.0000475865.28335.b1

2333-6218

Lata A. Krishnan,

Infant Development and Preterm Care

Figure.: © Shay Levy / Alamy Stock Photo“Johnny” failed his newborn hearing screening, and at the age of 7 weeks, following two auditory brainstem response (ABR) tests during natural sleep, he was confirmed to have a unilateral mild to moderate hearing loss. This age of diagnosis was well within the 1994 benchmark set by the Joint Committee on Infant Hearing of a hearing loss diagnosis by the age of 3 months. With the advent of universal newborn hearing screening programs, assessing unilateral hearing loss (UHL) in infancy is accomplished with relative ease using either ABR or auditory steady state response (ASSR) assessment techniques while the infant is asleep.Figure.: Lata A. Krishnan, PhDWhat makes Johnny's story so interesting, then? Children with hearing loss need to be monitored closely, and Johnny was no different. The assessment technique of choice for children from about 6 to 36 months is visual reinforcement audiometry (VRA). In most cases, accurate test results can be obtained for the better ear using VRA in the sound field. For children with UHL, however, testing in the sound field will confirm hearing levels of the normal-hearing ear but won't prove useful in determining hearing levels for the impaired ear. Therefore, in cases of UHL, VRA has to be completed using earphones, which can be more challenging. In Johnny's case, VRA testing was first attempted when he was 5 months old, but he could not be conditioned to the head-turn task. In the interim, Johnny also had persistent fluid in his ears and had surgery for ear tube placement when he was 5 and a half months old. VRA was attempted again between the ages of 6 and 15 months, but no clear results were obtained for his left ear. By the time Johnny was 16 months old, no reliable results had been obtained for his impaired ear since the age of 7 weeks. A repeat ABR test, either in natural sleep or with sedation, was discussed. Johnny's mother was hesitant to sedate him and chose to try the ABR during his naptime. A TECHNIQUE THAT WORKED Some audiologists may scoff at the idea of performing an ABR on a 16-month-old without sedation, but this has been accomplished successfully. Of course, the child has to take a nap and be a good sleeper for this option to work, and the family must be supportive. On the day of Johnny's appointment, his mother arrived with everything he needed to nap, including his large playpen—she was prepared to make sure he had his usual nap environment. The playpen was set up inside the test booth and the room was darkened. Johnny's head was scrubbed to place the electrodes for the ABR, but they were not attached yet because he pulled them off. He fell asleep within a few minutes after doing so. How can an audiologist place electrodes on a baby who is asleep in a playpen in the dark? This audiologist chose to with the faint light shed from an ear light. Because Johnny was sleeping on his right side, the placement of the ground electrode was changed to be on his forehead instead of his right mastoid, as is the usual clinical protocol at this clinic. Fortunately, Johnny slept through the prep, and the testing of his left ear was completed. Test results were consistent with the previous ABR testing done at age 7 weeks, confirming that Johnny's hearing had remained stable. PAY ATTENTION TO THE PATIENT—AND THE FAMILY It is all too easy for busy clinicians to move from one appointment to the next, follow standard protocols and recommendations, and sometimes forget to pay attention to the most important people: the patient and family. From this case, though, we can learn that it is important for the clinician to do all of the following: Monitor the hearing of all children with hearing loss; Counsel families about all available options; Listen to the family's concerns and wishes; Be flexible and creative in assessment strategies; and Choose the methods that work best for the child and the family. Although this procedure was successful for Johnny, the next step would have been to recommend an ABR under sedation if he hadn't fallen asleep naturally. Johnny will continue to receive regular VRA assessments every four to six months.