Effect of age at intervention on language outcomes at age 5 years for children with mild hearing loss in the LOCHI study

Dr Teresa YC Ching1, Dr Harvey Dillon, Mr Mark Seeto, Ms Patricia Van Buynder, Ms Laura Button, Ms Vivienne Marnane (National Acoustic Laboratories, Sydney, Australia)

Background: Universal newborn hearing screening has been implemented to detect permanent childhood hearing loss early, with the ultimate goal of improving outcomes through early treatment. Despite previous literature showing an association between early treatment and superior language outcomes, there is disagreement between studies on the size of this benefit, and in some cases whether it is significantly different from zero. No study of sufficient size had determined reliably whether the effect varies with degree of hearing loss.

Aim: In a population-based prospective study, the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study, we aimed to explore how intervention timing influences 5-year language in children with hearing loss. This paper describes the effect of age at intervention on outcomes of children with mild hearing loss.

Method: We collected demographic information and measured language outcomes of the LOCHI cohort at several intervals after detection. The outcomes measured at 5 years were analysed using multiple regression analyses. The effect of age at intervention was quantified, after allowing for the effects of nonverbal IQ, severity of hearing loss, sex, birthweight, maternal education, socio-economic status, and communication mode.

Results: The benefit of early intervention for language development increased as hearing loss increased. Factors influencing outcomes will be discussed.

Conclusion: The evidence arising from the LOCHI study can be used to guide management of children with different degrees of hearing loss.


Dr Teresa Y.C. Ching, PhD is Head of Communication Sciences Department and Pediatric Hearing Impairment research at the National Acoustic Laboratories in Australia. Her current research focuses on investigating the efficacy of early hearing aid fitting or cochlear implantation for populations of children with hearing loss and determining factors influencing outcomes; evaluation of sound detection and discrimination in infants with hearing loss or auditory neuropathy spectrum disorder using cortical measurements and parental reports; and prescription of hearing aids and electric-acoustic stimulation (bimodal fitting) for children and adults. Teresa is leading longitudinal, population-based studies that examine the outcomes of children with bilateral or unilateral hearing loss. She has published more than 120 peer-reviewed manuscripts. She is regularly invited to deliver keynote presentations at international conferences. She serves on the editorial boards of international journals.

Her research interest and experience encompass many aspects of hearing rehabilitation for children and adults with hearing loss: bimodal hearing, electric-acoustic stimulation, cochlear implantation candidacy and outcomes, amplification requirements, speech intelligibility, psychoacoustic abilities, and evaluation methods for children. Her current research focuses on evaluating the efficacy of early intervention for improving outcomes of children with bilateral or unilateral hearing loss.

What does the Australian Hearing national data-base tell us about children who have received amplification for mild or unilateral hearing loss?

Alison King, Principal Audiologist, Paediatric Services, Australian Hearing

The number of children who receive amplification for mild hearing loss has increased over time, due to improvements in diagnostic test techniques, improvements in hearing aid technology and growing awareness of the possible impacts of such loss on children’s development.

The optimal management of mild hearing loss remains controversial, which poses significant challenges for many families, professionals and for those involved in policy and funding decisions.  Australian Hearing’s data showed that at 31 December, 2018 almost 60% of aided Australian children under 7 years of age have better ear hearing levels of 0-40dBHL.

This presentation will draw on Australian Hearing’s historical demographic data to report upon changes in fitting trends for children with hearing levels of normal hearing to mild hearing loss in at least one ear.  It will also present data about hearing aid usage and benefit for this group of children.



After graduating from the University of Melbourne, Alison joined Australian Hearing in 1985 and has specialised in paediatric audiology for 30 years.  During this time she has provided clinical services to children with complex needs and to clients through outreach services to Aboriginal & Torres Strait Islander communities, as well as participating in clinical research and staff training. In her current role as the Principal Audiologist for Paediatric Services at Australian Hearing, Alison is responsible for the development and management of Australian Hearing’s paediatric clinical protocols and quality measures. She also provides lectures in paediatric audiology for the University of Melbourne Masters in Audiology program and serves on the Australian Hearing Human Research Ethics Committee.

Quality and improvement: How well are we doing in the diagnostic process?

Ms Florencia Montes1

 1Sydney Children’s Hospital, Randwick, Artarmon, Australia



To share our Peer review system for quality monitoring and improvement.


In 2009 the NSW Department of Health conducted an evaluation of the SWISH program. The evaluation was an audit of screening only and did not include diagnostics at that stage. The outcome was very positive, with high levels of satisfaction. The screening rate has consistently been >99%.

So, how well are the diagnosticians doing and how are we ensuring quality?

The JCH position statement outlines that appropriate audiological and medical evaluations to confirm the presence of hearing loss should occur at no later than 3 months. Quality involves correct and timely diagnosis, obtaining enough information for appropriate management and referrals for further management and investigations, and parent’s satisfaction.

A systematic internal and external peer review system has been implemented at The Children’s Hospital Network, with the aim of reviewing most patient’s diagnostic results to ensure accurate diagnosis and also as a learning and improvement tool. This is in addition to sign off of waveforms at the time of diagnosis prior to providing families with results. We aim at including JPAC and John Hunter, and Canberra Hospital to have a state wide peer review system.

There are well established peer review programs internationally, a good example is the Welsh program. The system we have in place has some differences with other peer review systems, mainly the review is conducted by all audiologists in both clinics, locally in a fortnightly meeting and network monthly.


The benefits have been consistency across both sites, improvement in quality of traces and test efficiency, well received by participating audiologists, consensus in protocols. In addition, the knowledge that others will be perusing waveform results in detail has led to a more careful and considered approach to testing.


I’m a clinical diagnostic audiologist with 12 years experience in the diagnostic assessments of babies. I’m currently working at Sydney Children’s Hospital in Randwick

Testing hearing in newborns “early” – does it make a difference to audiology process and outcome?

Ms Melanie Jarvis2, Dr Peter Carew2, Dr Melinda Barker1,2, Ms Alison Jagger1, Dr Zeffie Poulakis1,2,3

 1Royal Children’s Hospital , Melbourne, Australia,

2The University of Melbourne, Melbourne, Australia, 3Murdoch Children’s Research Institute, Melbourne, Australia


Background: There is limited evidence regarding the earliest optimal age for audiological testing following a positive result on a newborn hearing screen. Earlier scheduling may alleviate stress on families awaiting diagnostic clarification, however later scheduling may allow the infant auditory system to mature, resulting in fewer required appointments.

Aims: To examine the relationship between age at first audiology appointment and the:

  1. i) number of appointments required to reach a diagnosis, and
  2. ii) likelihood of being diagnosed with not-normal hearing.

Results: Of the 2191 infants born between 2015 and 2017 who returned a positive result on their Victorian Infant Hearing Screening Program newborn hearing screen, 2117 (96.6%) had valid diagnostic audiology results available. Age at initial audiology appointment was categorised based on post menstrual age, with 1313 (62%) being aged less than 44 weeks.

For those infants with results and a final diagnosis (n=2112 (99.8%)) there was no difference between those aged <44 weeks versus ≥44 weeks at first audiology appointment in the number of appointments attended (mean 1.65 and 1.59 respectively (p=0.077) or the rate of diagnosis of normal hearing (58.0% and 55.6% respectively p=0.277).

For infants diagnosed with not-normal hearing, the proportion of infants with target hearing loss did not differ between the groups (9.6% in those aged <44 weeks and 10.2% in those aged ≥44 weeks (p=0.651)).

Implications: Infant age at first diagnostic testing does not impact the number of audiological appointments required to determine diagnosis, or the likelihood of normal hearing being diagnosed. These findings support the minimisation of time between newborn screening-referral and diagnostic audiology testing to reduce parental anxiety and facilitate timely access to early intervention services for those infants diagnosed with permanent hearing loss.

Future research could compare infant age at first diagnostic testing with changes to hearing status during the newborn period.



Is earlier always possible? A review of infants diagnosed with Unilateral ANSD

Ms Inge Kaltenbrunn1, Dr Robyn Cantle Moore2 

1Royal Institute For Deaf And Blind Children, North Rocks, Australia,

2RIDBC Renwick Centre/Macquarie University , North Rocks, Australia


Auditory Neuropathy Spectrum Disorder (ANSD) is a complex auditory condition. In the presence of unilateral ANSD, the audiological and medical assessment results critical to informing clinical management and hearing device options are often obtained at later stages than is possible for infants with bilateral ANSD. This delay is primarily due to the need to obtain additional audiological results to inform hearing device fitting and waiting lists for an MRI appointment to identify the integrity of the cochlear nerve. The incidence of cochlear nerve deficiency/aplasia is reported to be a significant cause of unilateral ANSD (Lui et al., 2012; Nakano, Arimoto & Matsunaga, 2013). Recommendations regarding hearing device options/cochlear implantation are therefore typically deferred until further audiological and MRI results are available. Electronic and archived records (2011-2018) were reviewed for 15 children with unilateral ANSD who receive services at the Royal Institute for Deaf and Blind Children (RIDBC). The data was examined in terms of age at diagnosis; age at enrolment in early intervention; age at completion of additional audiological assessments; age at MRI; integrity of the cochlear nerve; parent decision-making regarding hearing device fitting; range of RIDBC service accessed, and longitudinal speech and language outcomes.    The results are discussed in terms of the strengths and challenges of current practice. Recommendations are made to better inform future management pathways and enhance support for parents and families.


Inge Kaltenbrunn, BSp&Aud, MCommunication Pathology, LSLS Cert.AVT, is the Best Practice Lead: Early Intervention (Deaf/Hard of Hearing Children) at RIDBC in Sydney, Australia. She is a qualified speech pathologist, audiologist and LSLS Certified Auditory-Verbal Therapist with 23 years of experience in the field of hearing loss and cochlear implants. She has worked in early intervention programs and cochlear implant clinics for children with hearing loss in South Africa and Australia. She has significant experience in delivering family centred early intervention, cochlear implant (re)habilitation, program development, mentoring and professional training in the area of paediatric hearing loss.

Optimal Management of Infants and Young Children with Conductive Hearing Loss associated with Cleft Palate

Ms Kylie Bolland1

 1Hutt Valley District Health Board, Lower Hutt, New Zealand


Management of children with conductive hearing loss is highly variable in terms of the age at which they may be fitted with a hearing instrument, and the instrument of choice. For example, babies identified as having a cleft palate or Down’s syndrome require close management to ensure appropriate access to sound for speech and language development, despite fluctuating hearing loss. The timing of surgical intervention varies and children can be left with sub-optimal aiding prior to surgical intervention taking place.

Conventional BTE hearing aids are not appropriate in these children due to the possible fluctuating nature of the conductive hearing loss component, and the outcome with different bone conduction devices is variable. Recently an audit was completed reviewing the hearing and speech and language outcomes for children born with cleft palate in the Wellington region.  Management of these children has been a focus at Hutt Hospital, with the introduction of a new protocol and testing regime to reveal the optimum fitting solution. The results will be discussed.

The study aims to review changes to the management strategies and compare the objective and subjective outcomes of the Ponto Bone Anchored Hearing Solution.

Review audit results of clinical findings and audiology management of babies with cleft palate in the Hutt Valley DHB area.  Describe how this audit formed the basis of a new protocol in use at Hutt Hospital for babies with cleft palate

Review of aided speech detection thresholds and speech in noise testing in children with Ponto devices

Results and conclusions:

Children performed well using the Ponto device. Implications for timely management and choice of device will be discussed and recommendations for management of conductive loss in this population group will be given


Kylie Bolland is a NZ trained Audiologist who has been the professional leader for Audiology at Hutt Hospital for the past 10yrs.  Prior to that Kylie worked as a paediatric Audiologist at the Nuffield Hearing and Speech Centre in London.

Hearing and structural preservation in paediatric cochlear implantation: considerations for future developments in hearing restoration therapies

Dr Kirsty Gardner-berry1, Associate Professor Catherine Birman1, Dr Halit Sanli1, Dr WaiKong Lai1

1Sydney Cochlear Implant Centre, Gladesville, Australia


The introduction of universal newborn hearing screening has lead to a significant decrease in the age at cochlear implantation, and infants born today have an average life expectancy of over 80 years.  Advances in regenerative therapies in the field of medicine have accelerated over recent years, which has resulted in the need to take into consideration the possibility of hearing impaired infants being able to have their hearing restored within their lifetime.  This presentation describes the techniques currently in use to maximise preservation of residual hearing and structures during cochlear implant surgery.

There are currently four strategies in place at the Sydney Cochlear Implant Centre to optimize the opportunity to preserve residual hearing, and structures of the cochlea during cochlear implant surgery.  The first strategy relates to the choice of implant array, with a preference for a thinner design.  Second, is the surgical approach and angle of insertion to minimize structural damage during the drilling and insertion process.  Third, is the speed of insertion, with a preference for a very slow insertion.  Fourth, is the use of steroids to reduce inflammation associated with surgical entry into the cochlea, and the introduction of the implant array into the cochlear space.

Pre and post-operative pure-tone thresholds were measured on a series of adults to evaluate the success of utilizing the residual hearing and structural preservation approaches.  Mixed results were obtained, with some adults demonstrating successful preservation; some initially demonstrating preservation but losing hearing over subsequent months; and some demonstrating a near total loss of hearing during the surgical period.

The mixed results in adults indicate more research is needed to better understand the factors that optimize hearing and structural preservation in cochlear implant surgery.  Nevertheless, the use of soft surgery techniques should still be considered for paediatric cochlear implantation.


Kirsty is a diagnostic audiologist at the Sydney Cochlear Implant Centre, and clinical consultant audiologist at Scanmedics in the area of newborn hearing screening.  Kirsty has a Bachelor of Science, Masters in Audiology, and PhD.  Kirsty specializes in electrophysiological testing and early identification through newborn hearing screening.

Improving accuracy in classifying neonatal hearing losses

Mr Andrew Geyl1

1Sydney Children’s Hospital Randwick, NSW, Australia

When assessing neonates using the evoked Auditory Brainstem Response (ABR) determining the nature of a hearing loss — conductive, sensorineural/retrocochlear or mixed — is of utmost importance. In most cases, clinicians need to determine only if a hearing loss is sensorineural or conductive. Tympanometry is useful, but bone conduction thresholds are generally thought to be the gold standard.
However, for the neonatal population ABR bone conduction thresholds can be difficult to obtain. Babies tend to be “non-compliant”, and the vibrator itself causes significant electrical interference. Often, the bone conduction thresholds obtained for neonatal ABRs are quite limited – both due to limited time available before the baby starts to protest, and the limited gain before interference is too great.
Further, we show that, in our experience, the relationship between neonatal air and bone conduction thresholds is not necessarily 1:1. This means that first normalising air conduction thresholds and bone conduction thresholds and then applying a correction factor will not always produce an accurate estimation of the air conduction – bone conduction gap (ABG), especially at higher intensities.
Instead, using historical data neonatal ABR data we can significantly improve both accuracy and range by using a combined approach:
• At intensities less than or equal to 45 dBHL, the normal (ie non-conductive) ABG can linearly modelled as a function of air conduction threshold.
• At intensities greater than or equal to 45 dBHL, we use logistic regression to create a hearing loss classifier model as a function of wave V latencies (sensitivity and specificity both ~ 0.95)
The combined approach not only improves a clinician’s accuracy but can also provide statistical confidence intervals for the diagnosis.


Andrew Geyl is an audiologist with more than twelve years experience in assessing neonatal ABR, with an interest in data analysis.

Using an Information Management System to Inform Practice in Paediatric Audiology Settings

Ms Kelly Nicholls1

1Healthy Hearing Program, Queensland Health, Nundah, Australia

The Healthy Hearing Program in Queensland was established in 2004, with universal roll-out completed by 2006.  More than 99% of babies are screened each year, and referred babies are seen in one of 13 paediatric diagnostic Audiology sites around the state.  The program uses direct referral pathways to audiology, with bilateral refers to be seen for their first audiology appointment within 2 weeks, and unilateral refers within 6 weeks, of screening.  Queensland has established audiology protocols for the diagnosis of babies referred from screening, and clinical audit processes that monitor the quality of audiology services delivered to this cohort.  In addition, all audiology sites report back to Queensland’s state-wide Healthy Hearing database, QChild.

QChild holds 12 years’ worth of audiology records, of which the potential is only now starting to be realised.  The Healthy Hearing Program has commenced analysis of audiology data from newborns who did not pass their AABR screening, looking specifically at hearing loss hit rates based on type of refer and risk factors in combination.  Preliminary analysis of data indicates that there are significant differences in terms of patient outcomes, dependent upon type of referral and risk factors present.  The findings have significant potential use in clinical decision making, parent and audiologist preparation for appointments, preparedness for counselling, and more practical operational matters such as appointment scheduling and staff allocation to caseloads.  This presentation will outline the findings to date, including how the data can be used meaningfully in terms of service planning, provision and management.


Kelly Nicholls is a paediatric / neonatal diagnostic audiologist in Queensland, and has worked for the Queensland Healthy Hearing Program since 2014.  In this role, she is responsible for protocol development, quality and safety for the audiology component of the newborn hearing program.  Prior to 2014, Kelly worked at the Royal Children’s Hospital in Brisbane, with considerable experience in neonatal and infant diagnostic audiology and paediatric cochlear implantation.

Speech perception outcomes of 5-year-old children using hearing aids or cochlear implants: findings of the LOCHI study (Outcomes Symposium paper 3)

Dr Teresa YC Ching1,2, Dr Vicky ZHANG1,2, Patricia Van Buynder1, the LOCHI team1,2

1National Acoustic Laboratories, Macquarie University, Australia,

2HEARing CRC, Australia

We propose a series of 4 papers to feature in a Symposium on Improving outcomes for children through early detection and intervention. All papers draw on data from the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study to shed light on children’s abilities and parents’ perspectives.

Objective: The aims of this study were to report on the speech perception in noise in 5-year-old with hearing loss; and to determine the factors associated with the speech perception outcomes, separately for children using hearing aids (HAs) and cochlear implants (CI).

Methods: Participants were 224 children enrolled in the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study. All children received their first HAs or CIs before 3 years of age. Speech reception thresholds (SRTs) for 50% correct perception of words or sentences were measured by presenting speech from a loudspeaker positioned at 0° azimuth, and babble from either the same loudspeaker (S0N0) or from two loudspeakers positioned at the sides (S0N±90). The difference in SRTs between the two test conditions gives a measure of spatial release from masking (SRM).

Results:  On average, the mean SRTs in the S0N0 and S0N±90 conditions were 6.9 dB (SD 3.8) and 3.6 dB (SD 4.2) for children using CIs; and 4.0 dB (SD 3.2) and 1.4 dB (SD 3.8) for children using HAs respectively. Compared to normal-hearing children, children with hearing loss required a better signal-to-noise ratio to achieve a similar level of performance. The SRM was around 3 dB for both groups, comparable to that for normal-hearing children. Regression analyses showed that better speech perception was associated with better language ability for both groups. In children using CIs, earlier age at implantation was associated with better outcomes.

Conclusions: Early intervention was effective in improving speech perception for children using CIs.


Trish is a Research Audiologist who commenced work with the National Acoustic Laboratories in 2004. Prior to this Trish worked clinically as a paediatric audiologist with Australian Hearing performing diagnosis, hearing assessment and rehabilitation.

Trish works as part of NAL’s rehabilitation procedures team. Her main areas of work include amplification and outcomes in children with hearing loss and the impact of unilateral hearing loss in children.



The Australasian Newborn Hearing Screening Committee aims to foster the establishment, maintenance and evaluation of high quality screening programs for the early detection of permanent childhood hearing impairment throughout Australia and New Zealand.

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