Napping in car testing for OAE & Acoustic Reflexes

Non-sedated Testing Little Ones
While They are Napping in Car - carseat or at home

Background: Once in awhile a child presents from whom we can only obtain very little or no audiological information (won't condition in booth and is very touch sensitive), yet we would love to get at their ears to obtain acoustic reflexes and OAE's as a possible alternative to needing sedated ABR testing. E.G., the presence of ipsi-lateral acoustic reflexes at 2-separate frequencies, (1000Hz & 2000Hz or other combination) in each ear, rules out auditory dys-synchrony/auditory neuropathy.

Possible Solution: Most little children are notorious for sleeping well in the car. I have successfully tested the few children who need this per year by arranging a time for them to arrive asleep in the family car outside our building. Here's a few - perhaps obvious - tips:

• child a bit worn out before the car trip to your office
• no other children in the car
• advise family that hooded jackets, turtle neck sweaters interfere with access to ears
  
• child not up against a door, i.e. in center of back seat so you can get to each ear with the car/van door closed
• full tummy or snack on trip to your office
• family keeps child awake until about 5-10 min before arriving at your office (if they sleep too long on the way, they will likely wake up when you open the car door)
• have family call you on their cell phone when they arrive with child asleep, or 2nd adult rider comes in to let you know they have arrived
  
• while inserting probe tip, child may reach up in sleep. Be ready to gently place child's arm down, while stroking their head or temple gently as they go right back to sleep
• if successful in one ear and child wakes up while you are turning head to other side, drive around a little and they may go back to sleep to obtain results for other ear - or can obtain other ear results in the same fashion another day.
  

What to take to the car/home with you:

• hand-held, battery-operated tympanometer with acoustic reflexes. The Interacoustics MT-10 will do 4 ipsi-frequencies, at your pre-set dB level with visually readable tracings of acoustic reflexes.

• hand-held, battery-operated OAE

• take a few extra size tips for both tymps and OAE's
  
• notepad for recording results - e.g, recalling log numbers if needed

• otoscope

• bring your non-spillable bubbles along (see bubble distraction post below) because even though this may not have worked with the child on previous visit while awake in your office, it can work in their own environment (their family car or at home while trying to nap)

Instant Recall of all 4 frequency results - Acoustic Reflex Thresholds

Robin Morehouse - Clinical Professor Extraordinaire
Teaches us a Trick or Four

You too can speed up your testing without writing everything down as you go

How aptly and gently Robin pointed out to a few students in clinic one day the following trick and tip. As the students painstakingly looked back and forth from the immittance unit to their clipboard, wrote down, one-by-one, each Acoustic Reflex Threshold (ART) they had obtained (on the GSI-33, now replaced by the GSI Tympstar), he suggested and felt certain they could recall the 1st three of those thresholds, finish the 4th one, and then quickly write them all down before moving onto the next in the battery of tests an active child would need. But what about the 4th ART? Being the last one, it was right there still on the screen.

Perhaps you can find other ways to apply this principle. . .

Clinical inspirations gleaned from Marion Downs & Chuck Berlin

Follow your Clinical Intuitive Gut Until Proven Otherwise

Marion Downs, as most of us know is an extraordinary leader in our field, perhaps even the Founder of Pediatric Audiology as we know it.

I have come to know Marion and Love her spirit, however before I really knew her personally she inspired me in many ways through presentations I attended, videos I saw in grad school, and her publications.

One thing I observed time and time again, is how Marion would propose a protocol for testing or amplifying children that she had learned through her experience or had been led to by her intuition. "No" she often calmly explained, the research wasn't necessarily there, but she went for it and it often made a difference. Years later, researchers typically proved what Marion had been espousing.

Check out the Research Pages at: The Marion Downs National Center for Infant Hearing

By the way, to get a copy of Marion's Book,
Shut Up and Live! (You Know How)

send a $20 dontation to:
Marion Downs Hearing Center
Attn: Sandra Gabbard
1792 Quentin Street, Unit 2
Aurora, CO  80045

"Do the experiment!"

Dr. Charles I. Berlin ("Chuck") would often try to show me something or explain a clinical or experimental standard that might or might not be easy to comprehend. If teaching this concept with his hands didn't do the trick (Have you seen Chuck's demo of hair-cell function or how low and high frequencies relate to mass and stiffness?), then Chuck would espouse "Do the experiment!"

Hey, remember trying to learn masking? One simple example of this was Chuck suggesting to experiment with how much narrow-band masking it really took to mask a warble tone in my own ear. Then Chuck would walk away while I 'did the experiment'.

So, even years later, when insert earphones started to become the standard for testing (sure hope you use them E-A-R Tones), there were graphs published by Etymotic about the minimum and maximum inter-aural attenuation they provided for each frequency, i.e., when to mask - much less often it turns out, of course. Did I check it out and do the experiment with a patient with a dead ear on one side and normal hearing on other? Ya, you betchya!

And when we needed a velcro head-band for attaching the bone conductor to young children, of course I had to know how tight to put on the headband to match thresholds with the standard, metal, spring-loaded, bone conduction head-band. We used a few willing adults to determine that.

Taken together, Marion's teaching by example of
going with your clinical intuition
and Chuck's teaching of doing the experiment, are great models for learning and improving the way we do pediatric audiology every day.

One more thing, after you've tried something that works and/or done the experiment, please share it here for all of us to learn by. Thanks!!

Counseling: What parents understood? Mary Ruth Sizer taught me this parent question

Want to know what has gotten through to a parent or caregiver on previous visits to you or elsewhere; what they remember; what they understood?

In the beginning of a visit ask them this open-ended question Mary Ruth Sizer taught me when I was the Director of the BEGINNINGS (Program) for Parents of Children Who are Deaf or Hard of Hearing:

"What have you been told about your child's hearing?"

Counseling Parents: 2 simple questions David Luterman taught me

When we ask a parent these questions as often proposed by David Luterman:

"How are you feeling?"
"What do you need to know?"
and deal with that, no more and no less, parents stay with us and come back when they need more.

Father, mother, grandparents, other significant care-givers will not likely be on the same schedule of processing their feelings nor will they have the same questions . Be mindful of all family members.

Of course, ask only one of these questions at a time - not rapid-fire and wait calmly/silently for them to open up and reply.

Use bubbles+ other distractions while testing OAE's

Most little children love bubbles

Slowly blowing bubbles with one hand, not in child's eyes, while holding OAE probe transducer* in other hand to 'chase' or follow child's head movements works wonders. Child can quietly pop the bubbles with their finger or you can with your nose . . . use your imagination. Let the child show you what they need, i.e, pay attention to their interests . . .

click on photo above for some entertaining,

expert bubble-blowing tips

*Don't hold the OAE probe itself in ear - that makes too much noise and ties you down, making it hard to pay attention to the child or blow bubbles in a controlled fashion. After all, who else has such a cool job where they get paid to blow bubbles?

The large dome-type bubble holders that don't spill can be held with your legs during this.Sparkly wands, other visual quiet distractions or toys work well for other children.

When I run out of 'children' things, I'll often just grab something nearby from my desk. Some children will be so distracted by the unusual, like holding my hole puncher, unusual pen, sticky note pad, wooden egg my son carved for me . . . anything different that provides an experience to hold their attention.

Some children could care less about purely visual distractions; they need to do something physically with their hands. A fairly quiet toy that they have to push on or slide things to make it do something, colored pegs or rings . . . can do the trick.

One child's mother suggested I turn the lights down and let him nurse under a blanket - it worked like a charm!

Some are content to look at a picture book; others a (silent) video on my computer monitor.

In my work setting we only see children up to age 3. Some of the older children (almost 3) like to hit the buttons to turn on the OAE unit or 'enter' key on my computer and watch the screen as "their ear connects the dots. . ."

All of the above also goes for tympanometry and please, please don't forget to try and get acoustic reflexes!! Two ipsi-acoustic reflexes per ear (2 frequencies), rules out auditory dys-synchrony (auditory neuropathy).

My OAE unit is next to a small couch in my small office, with a stuffed animal, a few select children's books and good view of the outside. There are plants on the window-sill. This does not look like a doctor's office.

VRA - first stimulus - Barney Music!

First VRA stimulus - Barney Music calibrated through Audiometer!

I learned this from another pediatric audiologist - Thanks Meg Gunther! (Meg learned this from someone else, but I do not recall) - and have used this for years with nearly 100% success. Others who have tried this are always amazed, wishing they had been doing this longer.

After making a connection with the child 1st, and then parents in our play waiting room (thank you Dr. Charles Berlin for literally doing your magic with children in the waiting room on their arrival!), instructing parent on VRA protocol (not cluing child), the first stimulus the child hears in the booth is 20 dBHL of Barney Theme music (rather than the old style live voice - "Look here baby!" or "Baa, baa, baa!"). It is best if the music starts almost immediately after the child is seated and the booth door closed quickly before the child gets restless. That is why I give any parental instructions and take history before we even get to the booth door. If a child is crying turn up the music to about 35 - 40dBHL - this will usually get the child's attention and quiet her/him so you can reduce the stimulus and proceed with testing.

Most young children who are cognitively 6 mos of age and up to about 3 years (especially children who appear to be on the autism spectrum), love this, respond immediately, and quickly learn the VRA task this way. In fact, if you have calibrated the music via the VU meter on your diagnostic audiometer, many children will even respond down to 5 or 10dBHL. Typically I do this sound-field initially and yes, our annual calibration includes sound-field calibration.

Not only have you made a child happy with their 1st booth experience, you have also just obtained an SAT (to music instead of live voice), and young children will then typically generalize to the next stimulus. I quickly go from the music to 6000Hz narrow band noise and move on from there . . . .

One other caveat: don't make your VRA animals dance - turn that off - and only use the lighted part of the reinforcement at 1st. I can't tell you how many parents over the years have told me their child freaked out over the clapping/dancing animals 'at the other place' their child was tested. So, if a child has established that he/she is already very happy with the lighted-only component of the animal reinforcers and is getting bored, perhaps you can then consider turning on the dancing component a few milli-seconds soon after the light reinforcement is already turned on. Even this still may startle a previously happy child - wouldn't it be best to choose the few children with whom you use the moving/dancing/noisy VRA animal component carefully, after you've seen their response to the quiet, visual-only reinforcers?

Hopefully you will eventually get more than one or two reinforcement boxes, including a box or two that allows for different lighting arrangements. I.E., the more variety you have in your array, the longer you are likely to keep the child interested and responding.

This tip, using an stacked array of visual reinforcers, I gleaned from Judy Gravel's publications, talks and video demonstrations. Judy passed away in December 2008 and is dearly missed. I trust we all will continue to honor her inspirations by example, her enthusiasm and willingness to widely share her knowledge and clinical expertise, as well as her advocacy for high standards in pediatric care.

Here's what you will need or some similar arrangement to set up the music stimuli:

• I bought the Barney's Favorites theme music CD
• Have used various standard CD-players at different locations with no problem
  
• A Radio Shack splitter cable that goes from the earphone output of the CD player to the A & B input on the diagnostic audiometer (one jack on the CD-player end, two on the audiometer end)
  
• Turn on the CD and music, adjust the volume on the CD-player and the A and/or B channel you use with the audiometer's VU meter so that the VU centers around 0 (not much over 0) when the music is playing
  
• Turn up the audiometer output to 45 or 50dBHL and go listen in the booth to make sure the music is not distorted (a mismatch between the volume on the CD-player and audiometer). If there is a mismatch, the music will sound distorted or spiky. The solution is to turn down the volume on the CD-player and turn up the output adjust on the audiometer again until it centers around 0 on the audiometers VU. Remember these volume settings on the CD-player and your VU adjust, so it stays that way each day or check them each morning. Some CD-players need to warm up a good bit before the music will be heard, so once turned on, leave the CD-player on or pause it. (tip: if our power goes out in a storm, the volume on one of my CD-players is no longer set like it was.)
  

Stay tuned - I am working on some norms with another colleague, David Pillsbury, so that you maybe able to use narrow-band/filtered music stimuli for those children who do not generalize from the 'full-banana' of the Barney music to narrow-band noise or warble tones. Think about it, in the old days, my understanding is that narrow-band noise was created by filtering white noise - now we create it digitally. So why not filter music centered around 500Hz, 1000Hz, 2000Hz, 3000Hz, 4000Hz and create a "narrow-band/filtered music" audiogram? It actually works, we just want to make sure we have some good norms so when we share this with you, all you will have to do is zero a cal-tone on the 1st band of the CD or digital file, so that you will know that each of the narrow bands of music are calibrated as well. As busy clinicians this is taking us some time to get to. In addition, the filtered 3000Hz and 4000Hz does not seem as identifiable to some children as music . . . again, will let you know when this is ready to share.

Baby steps first: in the meantime, as my wife says, "Go play!", see if we are right, go get a CD-player, set some Barney music up with your audiometer, try it and enjoy your success with music as the 1st stimuli young children condition to.