Babies who do not pass newborn hearing screening tests require immediate diagnosis and intervention, but that can be a challenge for families living in the vast expanse of rural Northern California, where a dearth of pediatric hearing specialists, geographic isolation and the topography all conspire to create obstacles.
Those obstacles meant that in 2007, 40 percent of rural Northern California newborns who needed additional testing for a potential hearing loss did not receive it and were "lost to follow-up" care -- giving Northern California the poorest lost-to-follow-up rate in the state, where the overall average was 8 percent.
"Bringing these babies back for testing is imperative to optimize their development, especially the speech development critical to acquiring language and learning," said Anne Simon, senior pediatric audiologist in the UC Davis Department of Otolaryngology.
But Simon also said she understands that there are substantial barriers that discourage families in rural communities from making the trek to the audiologist so that their infant can receive additional testing.
"Making the three- or four-hour-long trip to a big city medical center with a four-week-old baby and may not be possible for many families," Simon said.
To meet those families' needs and improve the numbers of Northern California infants receiving follow-up care for hearing loss, UC Davis has entered into a unique new partnership with the State of California and Mercy Medical Center, Redding. It will allow infants located throughout Northern California to be seen by a pediatric audiologist at UC Davis -- via telemedicine.
Among the first of its kind in the nation, the new pilot program is funded by a three-year, $354,242 grant from the U.S. Health Resources and Services Administration Maternal and Child Health Bureau through the state Department of Health Care Services (DHCS), Children's Medical Services.
"We are thrilled to be implementing this innovative approach to more quickly identify infants with hearing loss in Northern California," said DHCS Director Toby Douglas. "UC Davis is a leader in telehealth and pediatric audiology, and we are fortunate to have them as partners in this endeavor."
Early identification of deaf and hard-of-hearing infants before 3 months of age and starting early intervention services before 6 months of age are the most important factors in developing age-appropriate language skills, whether families communicate using sign language or spoken language.
The program focuses primarily on infants living inland in the far northern counties in California adjacent to Shasta County where Redding is located, such as Glenn, Butte, Trinity, Tehama, Lassen, Modoc and Siskiyou counties. Participation in the program is by referral from the state Hearing Coordination Center.
The teleaudiology program is unique because, rather than consulting with audiologists or other clinicians at the remote location, who then diagnose and treat the patient, the UC Davis audiologists actually perform the hearing screening and make the diagnosis.
"We are very, very excited about providing this program, because central Northern California has the highest lost-to-follow-up rate in the state for newborn hearing screening," said James Marcin, professor of pediatric critical-care medicine and director of the UC Davis Pediatric Telemedicine Program.
"But with this model, and with Redding being a very central location for families in Northern California, we hope to eventually eliminate the lost-to-follow-up rate and provide the excellent care that these infants and their families deserve," Marcin said.
Through the program, an electroencephalogram (EEG) technician in Redding, such as Dawn Deines or Debbie Nickell, places electrodes on an infant's head and earpieces in his or her ears. Then audiologist Simon controls the screening equipment remotely from Sacramento.
The telemedicine connection also allows Simon to switch camera views in order to see the infant and their parent, as well as the technician and the screening room, and to view the child's ear canal and eardrum with the information being recorded by the device during the two- to four-hour-long testing period.
Simon administers three tests to determine whether a child does indeed have hearing loss, and if so, its source.
In the auditory brainstem response (ABR) test, an electrical signal is evoked from the brainstem as a response to an auditory stimulus. It tests whether the child may have a conductive hearing loss, which may be caused by obstruction of the middle ear, a sensory loss in the cochlea, or neurological issues. The second test, otoacoustic emissions (OAEs), tests inner-ear health and can indicate the site of a lesion for hearing loss in infants. Typanometry tests the health of the middle ear and the mobility of the ear drum.
Simon and Marcin said that the goal is to have children return for diagnostic testing and follow-up care by the time they reach 3 months old, at the latest.
"The sooner the better," Simon said. "We find that about 6 months of age is when we start to see developmental differences between infants who have not had diagnostic testing and intervention and those who have," adding that she has fitted infants as young as 2 months with hearing aids.
"If we intervene by 6 months we find that children have a much better chance of acquiring age-appropriate language," she said. "So we want to get hearing aids on them by 6 months."