Exploring pediatric audiology and advancing development for children with hearing loss

Host: Hello and welcome to Cook Children's Doc Talk. Today we're sitting down with Dr. Lisa Vaughan. Dr. Vaughan is the program manager of audiology at Cook Children's. Dr. Vaughan has devoted a large amount of her professional career to osseointegrated devices in children. Her research in this area has led to numerous articles in peer-reviewed publications. She has also lectured around the world on this topic. Her other interests include pediatric diagnostics and amplification and acquired hearing loss both in children and adults. In addition, she has also been involved with numerous academies and has served on several committees of the American Academy of Audiology as well as serving as president of the Academy. All this while balancing career and family. Welcome, Dr. Vaughan. 00:00:51 Dr. Vaughan: Thank you. It's nice to be here. 00:00:53 Host: And you have recently taken on yet another role? 00:00:57 Dr. Vaughan: I did, as the chair of the American Academy of Audiology foundation, so I get to do some fundraising for my profession now seems to be really exciting. 00:00:61 Host: Fantastic. It does sound exciting. So you've made a lot of strides in pediatric audiology, how did you determine that you wanted to commit your life to helping children with hearing loss? 00:01:07 Dr. Vaughan: You know, my grandfather had hearing loss and it wasn't just the kind of age, you know, hearing loss presbycusis that we work with as audiologists, but he was in an explosion when my mom was a child, and lost most of his hearing. And so he always wore hearing aids, and I always remember seeing his hearing aids on tables, or you know, like being told not to touch them, but looking at them a lot. And so it's kind of a weird childhood thing, but I guess I always knew what hearing loss was. And I always knew that there was someone who managed those hearing aids. So fast forward to, um, when I went to college. I didn't start out as an audiology major, but quickly turned back to that after I had an aunt, um, go through a bout of dizziness and vertigo. And remembering that with my grandfather kind of rounded me back around, but when I was in graduate school, I thought I was going to work with adults. I had a rotation through my clinical work there at the VA, the Veterans Hospital in Shreveport, Louisiana, and I loved it so much. What I loved about it was the ability to give anyone who needed hearing aids the ability to hear and that's what you can do in a VA system, you to kind of cut out some of the sales or the marketing or the pricing of things, and you really just get to help those veterans and I loved that. But my first job, I worked on purpose, from everything from pediatrics to adults, to see where I wanted to go, what I wanted to do, and I fell in love with working with children and their families. And that's kind of what brought me here today. 00:02:51 Host: And so as the mother of a child with hearing loss as well, how does that inform the care you deliver to the children and families you see today? 00:02:59 Dr. Vaughan: I think I swing from one end to the other one, one side of the spectrum to the other on that. So I'm much less likely to tiptoe around issues with those families, I adopted my daughter when she was three, and she had did not have hearing aid use or consistent hearing use for the first three years of her life. And she had a lot of work to catch up on she had a lot to do. There were lots of weekends spent doing reading camps and lots of time with speech therapists. And it's just a lot to do to catch up. And so I don't tiptoe around that with families. So if a family asks me what they need to do, I'm very direct with them. And so that sometimes may be a little scary for them. But I don't want them to miss three years and to have the catch up that we did. So on that side. I'm very strict and very vocal with them. But I'm also really forgiving on lost equipment. And I know it probably drives some people in my department crazy. But we have lost a lot of hearing aids. Even as an audiologist those things are small, and they're really easy to lose. Pets love them. And my daughter one time buried a set of equipment on the playground, when she was in first grade. She just you know, for whatever reason, just took it off and buried it and we never found that and so you just can't predict what kids are going to do. And I will help a family get anything back and I will give them loaner after loaner equipment, after equipment, help them find lots of ways to do things because I know that kids are kids. And so I'm generous with that. I actually found a pair of hearing aids when we moved here under the refrigerators, so they're easy to lose (laughs). 00:04:34 Host: Hearing loss can be present at birth, which is why newborn hearing screening programs have been widely established in the United States. But the link between screening and diagnostic follow up testing remains inconsistent in some places and for specific segments of the population including economically disadvantaged children and their families. Why is that? 00:04:54 Dr. Vaughan: I think there are a host of reasons for that. And first off, hearing loss in children is rare. It is less common than many other birth defects, if you will. Childhood hearing loss is estimated at about one to three per thousand. So it's not common. Kids can go and be in their school with no other children in their whole school that have hearing loss. So it's rare. And so when it's rare to them, it's rare to us, it's rare for other people to see a child with a hearing aid or a cochlear implant, if you sat at the mall you might see a kid, you probably wouldn't. It's rare. Also, when we work with kids, it's a skill set to work with this population. So that leads to few audiologists specializing in pediatrics. And they tend to be at larger facilities like Cook Children's and other pediatric hospitals across the U.S. We may spend a day where we are literally standing on our heads, blowing bubbles, singing songs, and that's all part of the job. I mean, we do what we do to get the test on the kids. And when you work with pediatrics for so long, we feel like it's more of a gift to us to be able to work with these children and their families. So you have to have the heart and the desire to do it. And there's also a huge stigma attached to hearing loss still, all of those things that we have for ourselves, whether it's glasses, or whatever, hearing loss or wearing hearing aids is a huge stigma, especially with older adults. And one day, we were at a basketball game for my son and my daughter was sitting beside me. And as you can imagine, as the daughter of an audiologist, she has every color of hearing aids, so you know, purple, green, blue, red, pink, so she has all of them. And a man behind us, you know, kind of caught my eye, and he looked at us and he said, "Oh, she's got the same problem as I do." And she like, shot him this dirty look. And I was like, I'm so embarrassed that she looked at him so mean that I turned around, and I really looked at him. And I was like, "Oh, I was like honey, he's wearing hearing aids just like you," and she was like, "Oh." And in her mind, it's not an issue but in his, it is. She got the feeling of him, you know, having a little bit of pity or a stigma, that being something bad. And so that that still exists that was, you know, just a few years ago. And it's. it's hard to be a kid and be different. It's also getting the knowledge out to everyone. So families don't follow up many times because they don't know that we can test an infant in the first few hours of life. We can do a screening quickly. We can fit babies with hearing aids very early in life. The goal is to screen every baby that is born from the hospital, with a newborn hearing screening to check their hearing, it's a pass fail, or some people say a pass or a refer to or refer to a diagnostic evaluation. But we can test those babies generally within the first 24 to 48 hours. If they're in a normal delivery hospital. Here at the NICU at Cook Children's, we wait until those babies are medically stable. But knowing that we can go in very quickly and test. And so that's still a myth that we don't get an accurate test. But we follow guidelines that are set up through the whole U.S. We have state chapters that work on things that are early hearing intervention and detection. And the rules that we try to follow in the guidelines are that we screen a baby by one month of age. That we do a diagnostic test by three months of age. And that by six months of age, we have intervention in place. Meaning, if they need hearing aids, it's in place. If they need speech, it's in place. If they need OT or PT or anything else, that's ready to go at six months. And what we have found is that when we make that happen, those babies grow up to compete with their normally hearing peers. So they don't see the delays. We don't have the educational problems and the speech delays when all of that rolls into place. But unfortunately, there is that missed step between the diet, the screening at birth and getting back in. At least once a month, if not more, we still have families that come and say, well, we didn't think you could test, or our PCP didn't think you could test. So we waited until they were a year old where you could really get a good test on them. And unfortunately, that's just still out there in the world that we can't test or fit that young. But we can. We test babies diagnostically all the time here. 00:09:10 Host: And what about families that are economically disadvantaged? 00:09:14 Dr. Vaughan: You know, that's a hard one. Because of one of those things that I said in the beginning. One of those points is that it's rare and so that kind of centers pediatric audiology in big facilities like this. We have families who drive for hours. We have, I have a family that lives in El Paso that comes to see me. We have families in San Angelo. We have families all through West Texas, and we have families in Texarkana, Tyler, they drive hours to get here to see us because there's not a specialist in their area. It's hard for them if it's a day off of work. It could be missed pay for the day. It's finding someone else to take care of other children or having to bring other children out of school. It's an all day thing. And when you look at that when you're living paycheck to paycheck, and every day counts, it's hard hard to get to a big center to do that. And unfortunately, because of hearing loss being so rare and there being few specialists, that's where we end up. 00:10:08 Host: It seems like reducing the number of children who fail their newborn hearing screening is following up on failed newborn screens being mandated. And how do you see that as far as compliance with this? 00:10:21 Dr. Vaughan: Yeah, absolutely. So this same state facility, we call ours TEHDI, which is the Texas Early Hearing Detection and Intervention Program. And it's state mandated and it's here in our state and there are chapters in other states, but they don't, they're not TEHDI they're EHDI programs, um, we are special here. So what we find with those programs is they do monitor every baby born, or every baby that's turned in that has failed a screening or not failed a screening. And we do track those babies. So depending on the state you live in the law to have a newborn hearing screening is slightly different. Some states say if you are a facility that births babies, and you have less than 50 babies born a year, you don't have to have someone dedicated to a newborn hearing screening. So it just depends on what state you're in and what the legislation is. But basically, at this point, every hospital that is the birthing center has a newborn hearing screening program. The problem that we run into now is that there are babies born in birthing centers and home births are a little more popular than they have been in the past. And those babies are not followed. So that's the first loophole that we fall into. Even though we have state laws that make newborn hearing screening mandated or mandate newborn hearing screening, we have a couple of loopholes that babies can fall through. And then as you said, once they are screened, then they have to come back. So if they fail, we have to get those babies back in. And they are monitored through the state. But follow up is difficult at times. Names change. Some babies go home without a first name or last name, or they don't report it when they leave. And phone numbers change, addresses change, the education to remind their families sometimes gets missed. Sometimes there's a hardship for distance, like we talked about before to get a baby into a center if they live far away. And so those are all big issues to get in, they are tracked, but sometimes it's not so seamlessly tracked. And that's one of the reasons that we think it's really important that that's brought up and some of those first well-baby checkups, because they come in and you've got a captive audience at that point to ask, "Hey, did your baby pass their newborn hearing screening?" If they did pass, great, let's check through some risk factors to make sure you don't need to be followed up again. Or if they did not pass, let us help you find a way to get that baby in for a diagnostic test. 00:12:43 Host: Extensive research, clinical experiences and feedback from families have established that children who are hard of hearing have different amplification needs than adults with hearing loss. How do they differ? And why? 00:12:55 Dr. Vaughan: I love this question, because it starts with the testing. And that's one of the reasons that pediatric audiologists are so specialized in so many areas, because, you know, infants don't raise their hand when they hear the beep. Strangely enough, they don't tell us, "Oh, I just heard that." So starting with the testing, we do tests that babies don't have to respond to they sleep through the test. And one of those, the most commonly used, is called an auditory brainstem response or an ABR. We can do those in a natural sleep or a sedated sleep. And that's where it starts. It starts with those highly specialized tests to get the hearing loss. So when we start at that level, and we have a baby who is three months old, and we're putting hearing aids on we have a great hearing test through that ABR. But then how do we make sure the hearing aids are not too loud or not too soft, and that they're set appropriately. And so because children are not like adults in that aspect, we are putting pieces of a puzzle together sometimes. So we have specialized equipment that we use to fit hearing aids for infants. And the best way I like to describe the difference here is if you are at Dickies arena or AT and T Stadium and you are watching your favorite band there. It's pretty loud, right? 00:14:09 Host: Absolutely. 00:14:11 Dr. Vaughan: What if you put that band in your living room at home. And that's kind of what it's like to fit a baby with a hearing aid. You have an adult ear, which is a larger ear, ear canal volume is bigger, the tiny microphone that's placed down in the ear and it's only got a certain amount of space in there. And adult ears are small enough, but a baby's ear, think how tiny that is? So it's like moving that concert from the big adult ear to a baby ear and so it's already too loud. So we have specialized equipment that take real-life measurements of the baby's ear. Or if a baby is too fussy and won't do it, it will simulate based on age and it gives us the actual reading of the size of the ear so that it will mathematically compute that and make sure that we are not over amplifying or under amplifying. It gives us targets to reach, and so, those two pieces of equipment right there, that really are equipment, is housed in a lot of adult based clinics. But it's not as critical for some of them to go through that process. But you look at that piece, and we've already had two big pieces of complicated big equipment that have big price tags on them, and now you'll see a little bit of why we don't have so many pediatric audiologists in every little town. And it's just, it's the way that works, you wouldn't buy all of that to test a handful of kids. So those are big differences, just the size of the ear alone is a huge difference. 00:15:31 Host: So does that mean that when you place a hearing aid for a child, a baby say, as they grow how often do they have to be like refitted? 00:15:40 Dr. Vaughan: That's a great question. It depends on their age, kind of a rule of thumb that we follow is if they are under three years of age, we see them about every three months. We do that for a couple of reasons. All children due to the growth of just, again, just their ear canal, we have to redo the ear molds, the part that fits down in the ear, on average, about every three months because of growth. So you think of how much your baby grows between the time they're born until the time they're three. And so that's the first piece of it. All babies wear what we call behind the ear hearing aid, and for most of the kids too, until they're a certain age, so it's the part that goes behind your ear, and then the mold that goes inside. The reason we do that is because the ear grows rapidly. And we have to take different impressions of their ears. So we take those every three months and make new air molds because of growth. Once they're about three to five, we can pull back to about every six months. And once they're in school, and good reporters, usually it's an every year hearing test to make sure hearing is changed. It hasn't fluctuated that the hearing aids are still working. And all of that is great. And then earmolds can kind of back off a little bit. So we don't have to do those as often unless we have children that are in puberty, and that happens. And they have some rapid growth. And so we redo at that point as well, as much as we need to. 00:17:02 Host: So children also need more access to acoustic information in the speech signal to reach the same level of understanding as adults. How does your program approach this? 00:17:13 Dr. Vaughan: So first off, we use that real ear equipment that I mentioned before, we combine that with behavioral testing on every patient that we fit. And so that gives us the science on how to size the child to get the exact amount of amplification that's needed based on their hearing loss, the size of their ears, and the actual hearing aid that we're putting on them. So that gives us the science part of the calculation. But we also need to know what they do with that sound. Not everyone understands and interprets sound and speech and language the same way. So we also do behavioral testing. And we can get, using those two methods, we can get children very young all the way up to teenage kids within a normal to near normal range of hearing with hearing aids, or cochlear implants or osseointegrated implants. And that's very important when learning to listen and use spoken language. We need to make sure they can hear subtle sounds like the S on the end of a word. Because when you think about reading and language, an S on the end of the word can change the whole concept. And so those soft sounds need to be there. They also need to be there so that the child can hear them and then reproduce them in their own speech. The other thing with that I think that we try to ensure here is that we always have a tech or a second audiologist in the booth with the child. If you can imagine sometimes we have really fun days where kids come in and they love to play the games with us. One of the things that we do when babies are about six months to about two years of age is they sit in the middle of the sound booth and they will wear headphones or little insert earphones. And we will play sounds to them out of one ear or the other. And when they hear it, they'll turn and look to the sound so they localize to it. And then they see like a video screen that pops up with a cartoon. And so that will engage them. But if you've sat and tried to have an 18 month old sit in your lap for an extended period of time, it's often helpful to have another set of hands in the room. And so that's one of the things that we do with every patient that's at least five years or younger. We have a tech or another audiologist that comes in to do a two person audiogram. And we have referrals from all over the state even from other people who may see a good amount of children but they'll send referrals to us here at Cook Children's because we always have that second person. I like to tell them their crowd control because they're like they're entertaining, blowing bubbles bringing toys out we have a lighted ones doing anything to keep the child engaged, but not too engaged, so that they can respond and do the test. 00:19:44 Host: One of the more challenging conditions in children is auditory neuropathy spectrum disorder ANSD. What are those challenges and why? 00:19:53 Dr. Vaughan: Yeah, you know, we love acronyms in audiology, so we will say ANSD, um, ABR, we have a whole alphabet soup of things. And that's fine. The words are kind of lengthy and hard. So the challenges with that is ANSD is not just a typical hearing loss, as you can get from the actual term, auditory neuropathy or auditory dyssynchrony. And so the actual eighth nerve, the auditory nerve can be dyssynchroness, it cannot transmit the sound as needed. And that's what makes it difficult. So I always like to describe that to parents as it's sometimes like a radio station, we've had adults that have ANSD that have been able to say these analogies, but it's like a radio station where, you know, it's a song that you know, but it's just not quite tuned in for you to get every detail of it. And that, unfortunately, varies. Every child is different. What works for one child may not work for another, a lot of times hearing aids work well. Sometimes they don't. Sometimes they need a manual communication, like sign language to help bridge some of these gaps. But the hardest part about it, I think, is knowing that there are great treatment choices, but sometimes it's hard to pinpoint which one is right for that child. And so many times it's hard for families to keep hearing aids on and very hard for the family to be patient when things don't always work quickly. And progress is many times slow. So those are the challenges there that it's not a one stop shop, everything works well. It takes time takes some trial and error sometimes to get what's best for the child. 00:21:29 Host: So are cochlear implantations or auditory brainstem implantations a solution for these kids? 00:21:35 Dr. Vaughan: Absolutely. For some of those kids cochlear implants are definitely a good solution. We actually do lots of those here every year for children with ANSD. We're not a brainstem implant center here at Cook Children's. So we do refer to those different facilities when needed, but we actually do find some great success with cochlear implants for kids with auditory neuropathy. 00:21:57 Host: So what is the connection between hearing cognition and brain development in children, and what impact can hearing aids or implants have. 00:22:05 Dr. Vaughan: So without access to auditory language, or stimuli, there are certain parts of the brain that will not develop. Your brain is wired for sound. When you look at a child's maturation, and we look at their language and their learning, there's actually what we know from research, is a window of time. And that window of time, we cannot go back and get the brain development back. So if the brain does not develop those auditory pathways, in that right amount of time, there's a good chance we cannot get listening and spoken language skills from that child. So if you think of hearing, it is like auditory brain development having the access and the input to that sound. Generally children with hearing loss require three times more exposure to new words and concepts due to that acoustic bandwidth that's caused by the hearing loss or reduction in the bandwidth. And what we know is that if a child does not wear technology consistently, it will require them a longer time to acquire speech and language, if at all, if we go past that kind of window of time. And I can give you an example, if you have a child that only wears their hearing aids four hours a day, it's going to take six years for that child to hear what a typically hearing child hears in one year, they have a thing that we borrowed here from our friends at Parts for Hearing in Oklahoma, when your eyes are open, your ears are on, meaning that we want your child to wear their hearing aids every second of the day that they're awake. 00:23:27 Host: Wow, that is fascinating. Once a child has been fitted with a hearing aid, another hurdle to overcome is ensuring consistency in using the hearing aid. So what role do parents play? What are their challenges? And how can our team help and can primary care doctors play a role in encouraging parents to ensure the child has the best possible developmental outcomes? 00:23:49 Dr. Vaughan: Absolutely, it's a team approach. It takes everyone to support these families sometimes and I will tell you the earlier we get this the better and not just for that auditory maturation and not for the access to sound, but a baby will wear a hearing aid much easier than a two year old. It is also much easier to put hearing aid on a baby, as, as scary as that may sound, than it is to chase a two year old around a room. And we do that sometimes because we all know what toddlers are like. They have their own ideas about the world and sometimes it takes little bribery to get the hearing aids on them. So consistency is the key. Basically, the more they have them on the more it becomes part of their routine at some point. And that's hard to walk parents through, especially if maybe we didn't know about the hearing loss until the baby was older, until they were two or three. It's a hard job to get that in there and distraction, I tell parents, distraction is king. Find a favorite video, find a favorite snack, do what you can and once you get them busy, they do actually forget they're on and they will move through their day. But I can tell you with my daughter getting consistent hearing aid use at three, when she wasn't used to that, I would put the hearing aids on her, and I'm pretty skilled at putting a hearing aid on so it didn't take me but a second, and she would hold her breath until she passed out. Because it was against what she wanted to do. It was hard. And I will tell parents that and they're like, oh, yeah, it's not that bad in my house. I'm like, "Oh, well, she's pretty strong willed." She still is. But it's hard. And if you have a really strong willed child, it's even harder. So anything that we can do is helpful. We can set goals to actively talk about with the family, what's the goal for that family? What do they want for their child? Is it that child learning to speak and have an auditory listening and a verbal language? Then we've got to make this a goal, we have to find ways to get them on. We have a family support group here at Cook Children's. And that's always helpful to have other people to say, "Hey, when my child was 10 months old, and we put the hearing aids on and they immediately went into their mouth, because they were teething," which also happens. Then other families will say, "Hey, this is what I use, and this was helpful to me." They have a Facebook group as well that we manage for them so they can get on and talk to each other without professionals, but just parent-to-parent and it's a really good place for them all to connect. 00:26:09 Host: So do you also have opportunity to work with a family's primary care doctor or pediatrician? 00:26:15 Dr. Vaughan: We do. A lot of our audiologists gladly reach out. A lot of our physicians reach out to us as well. And many of them pick up on things like that. They're like, "Hey, so we see that this baby has hearing aids, but you know what? They came in for their two year well -child today without the hearing aids on. Tell me what's happening." You know, and that's so insightful to us. Because many times, especially in the past, we had to go on when a family said, you know, yeah, so, "Of course we had them on every day." Now we have some information within the hearing aids called data logging. And we can actually tell how long the hearing aids were on every day, we can tell what listening environments they were in, and that all pulls from the hearing aid software. And so we can have those conversations both with the families and their physicians to say, "Hey, this is, you know, an 18 month old and they are only wearing their hearing aids three hours a day. What can we do as a team to help?" How do we talk to this family? Can we get them back in? Or a lot of times? What is the absolute most helpful way with our physicians here in the Cook system is that we can reach out to them and say, "Hey, we haven't seen this kid in over a year and we're really worried about them, will you reinforce their need to come in when you see them again." They're also great at doing that for us. 00:27:27 Host: So as we touched on a little earlier, obviously, a family's finances can impact a child's access to hearing aids and corresponding speech and auditory therapies, how costly is their care? 00:27:38 Dr. Vaughan: You know, depending on the technology, the cost differs a little bit. Hearing aids can run from $4,000 to $8,000 dollars, depending on if it's one hearing aid, two hearing aids, the technology needed, are Osseointegrated devices that are made for a permanent conductive loss. And the cochlear implants, also, they're more of a medical device, if you will, or insurance qualifies them more as a medical device. And they are more often covered by insurance. But many times there's deductibles, there's some out of pocket money. So it's a lot to have. And many times we find kids who still don't have any access to an insurance or any sort of funding. And so that, that's really hard. We're fortunate that we have some very generous donors that donate to just the audiology program here to help us provide hearing aids to children for FM systems for the classroom, just sometimes to help with batteries. Sometimes families can get insurance coverage for the hearing aids, but they use a lot of batteries. And so sometimes that's all they need is to get batteries every few months through our donors. And so that's been a huge help to have these donors help us make sure that these kids are able to use the equipment. We've actually even had our donors fund a cochlear implant for a baby who was implanted prior to being six months of age. And they actually paid for that because the insurance wouldn't pick it up because it wasn't FDA approved. But this baby had meningitis, and with our kids and infants that have meningitis, it will ossify or harden the cochlea. And when it does that our great ENT surgeons cannot insert the electrode array into the cochlea. And so we're on a timeframe where we've got a timeframe to get this done. And it's a very costly surgery, you know, from $20,000 to $50,000 for these families, and to have a one shot at this for a baby who's six months old, we're about to decide their destiny the rest of their life at this point, they're not going to have listening and spoken language she had no hearing. And so it's hard for families to come up with that and insurance dug their heels in even though as much as we tried to appeal it based on the diagnosis. We were lucky enough to have some donors come in and help us and lucky enough to have some of our surgeons who will help donate their time as well to these kinds of causes. So money's hard with this 00:29:59 Host: It's incredible that we have such fantastic donors. Of course, there's more to access than financial hurdles. There is also physical access for families who live near major cities and suburbs finding care is a lot easier. I think you mentioned that earlier. Then for those who live in small towns and rural areas, what is being done here to alleviate this? 00:30:22 Dr. Vaughan: Ourself, we are Texas Medicaid providers, and that unfortunately, due to the reimbursement from the state, is hard to find in other than your large medical centers. And so even some of those large medical centers around the state do not take Texas Medicaid as it is very costly to the provider. And so we are lucky enough that Cook Children's supports us in our endeavors to fit these kids. And we continue to see these kids. So that's a huge thing that we still take Texas Medicaid. Cook Children's also has a financial assistance program that we put families in touch with. So there's the issue of distance. There's, you know, travel and things that we can help them with. But we also, again, have very generous donors to help us get these kids where they need. But the other thing is that we actually are helping families through a little bit of telehealth at this point. We can do some troubleshooting and some counseling to families who are at a distance from us here at the medical center. 00:31:22 Host: That's awesome. So I recently read some interesting articles on genomics and hearing. One focused on ototoxicity and pregnancy. Another was in regard to genomic testing in newborn hearing screens. Can you talk a little about each of these and how they could impact early intervention and long term care for children? 00:31:43 Dr. Vaughan: Absolutely. So taking those ototoxic drugs in pregnancy, we've known about this for a while, there's several antibiotics, gentamicin pops into my mind as one right now, that cause hearing loss, and they can be passed on to a baby in utero. So these babies can develop or start to develop hearing loss prior to birth. Those are one of the things that we do look at as Cook Children's being not a birthing center, but a NICU only, we have a newborn hearing screening tech that has a literal laundry list of things that can cause hearing loss in utero, and after, given what treatments we've done here that were medically necessary. And so we keep a running tab on all of those things. And so if any of those red flags come up in any of the medical history, we are ready to jump in. So there are many, many things that cause that. So that brings us to like genetic testing and things that we do when a child has hearing loss. So there's one slight disadvantage to a newborn hearing screening, especially newborn hearing screening that's done with a ABR or screening ABR, that sometimes can miss a very mild hearing loss. And it sure will miss a hearing loss that's progressive in nature. So a hearing loss that, for whatever reason happens when the baby's six, nine, two, three, four, or five years old, happens over time. And so the newborn hearing screening can't check those. But what we can do is when we do notice a newborn hearing screening, we always have a medical workup, we have a great team of ENTs, here at Cook Children's, and they see all of our kids for a medical workup prior to us fitting hearing aids to make sure there's not any medical concerns that we need to know about. And when they do that a lot of times they order a genetic panel and imaging so that we can figure out a little bit of why they have the hearing loss. Was it genetic? Is there some sort of a malformation that we found on imaging that will let us know that the hearing loss would be progressive over time, or a little bit more about the loss of that we can fit that better with the hearing aids or progress to an implant? So all of those things are fascinating at this point, it's fascinating to know that we can look and find out that, you know, there are several genetic markers for hearing loss at this point, as well as a whole Host: of syndromes that are genetically based that have hearing loss with them as well. So we do dive into that with every kit 00:34:00 Host: So, there are also certain diseases and or their treatments which can cause hearing loss in children. So let's start with cancer. At what point are parents and the child told about the risk that the treatment may have on hearing and how soon is audiology brought into the treatment process? 00:34:17 Dr. Vaughan: That is another favorite group of amazing physicians that work with our cancer patients and the nurses here at Cook Children's. And basically it's certain treatments that they have for their cancer treatments, certain chemotherapies such as cisplatin, that are ototoxic. And so those drugs that they give them will cause hearing loss, and they sit down with the families prior to even seeing us to discuss that with them to tell them this is the option they need. And this is going to more than likely cause some hearing loss. We'll try for it not to but obviously medical concerns take up hearing loss so they see those families and tell them about us pretty quickly. And then we get all of those kids in for a baseline hearing test prior to treatment. So we know exactly what their hearing was before treatments start. And then we follow them through the whole process to make sure that if there is hearing loss, we report that right back to the physicians, if there's something they can do to reduce the medications or to change things to prevent further hearing loss, they will. But sometimes it, like I said, takes some medical priority. And then we watch it, monitor it, fit the hearing aids and change things as needed through that pathway. Those are often at some of the harder patients we see. To be honest, they've already gone through so much. And then we throw one last little thing on them. Oh, and by the way, here's another reminder that you're going to spend the rest of your life with hearing aids and it's hard to pin on there. But we see so many kids that work through our program here that come out happy and healthy, and we love seeing them back for all their audiology appointments to see how far they've come. 00:35:52 Host: That's really amazing. So another issue is ear infections. They're are one of the most frequent childhood conditions. So how serious a problem is this? And what role can primary care doctors play in addressing this before it becomes like a major issue? 00:36:08 Dr. Vaughan: Absolutely. So our primary care doctors, most of them with our system, once there's a few ear infections, they make a referral to our ENT team. And we now have audiology services at every ENT location. So our ENT location and another one here on the main campus, as well as Alliance and South Lake, we have boots and audiology equipment, and we test kids prior to tubes or any kind of treatment that the ENT may feel is necessary to make sure how much hearing loss they have based on the ear infection. Ear infections most often cause a temporary hearing loss, most often mild, but it can be more moderate. And remember earlier, we kind of talked about auditory deprivation and the brain's way to learn, that auditory brain maturation can still be affected. If it's temporary, if you're fluctuating in and out, it's especially hard for even school aged children because they're missing a lot of their teacher at school. They're missing education. So we test all of the kids through the ENT clinics. So when they refer on for ear infections, they are managed by both of us when they leave the primary care. 00:37:14 Host: Of course, we can't leave out high levels of noise, especially in today's headphones, earbuds world. All at decibels well above the norm. This can do enormous damage. So should primary care doctors be screening patients for this on a regular basis? When should they recognize the red flags? And what should they do? 00:37:34 Dr. Vaughan: They can be our first line of defense by just simply asking how much time they spend using headphones or earbuds daily. That's the first step. Just asking those questions. We do that when kids come in if they failed a hearing screening at school, or something else, we ask about that for sure. And we ask about that at younger and younger ages. And I think COVID has been one of those issues. And and one of the things that's made us all be on earbuds and headphones more because we've all been on so many zoom meetings, whether it's adults for work, or kids for school, and so actually did a piece for The New York Times about noisy households, because that when you think about being in the height of the pandemic and the height of COVID, you might have had a parent or two parents working from home, one or two kids on Zoom. We have these huge open floor plans in our homes, you turn on the dishwasher, turn on laundry, you have a pet barking, what do we do? We all start turning up our own headphones. And just to overcome the background noise. And so headphone use, earbud use, all of those things are so heightened right now. So the first step is just finding out why and how much they're listening. The second step to that is a little harder. It's asking if they have tinnitus or ringing in their ears, because if they have that, unfortunately, that's the warning sign. And the warning sign is almost too late at that point. There's already damage there. And so we do take those kids, though, um, we've had a lot of kids that have come in with complaints of tinnitus, and it's new for us and pediatric audiology. We don't always have those complaints. It's usually a lot of adults who have noise complaints or work in noisy situations that come in with those complaints. But a lot more often we're seeing kids with it because of a noise induced hearing loss. And we do take those kids, I primarily see a lot of those kids right now and we determine how bad it is. If there's intervention needed. Talk to them about what's too loud, how to protect their hearing how to turn things down and educate the family to about the home if everyone's going to be on Zoom, save that load of dishes for the evening, save the laundry for the weekend. Pull those things back so everyone in the house isn't turning up the volume, that those are all kind of great things to kind of look for and we definitely rely on our on our physicians out there to help us know what kid needs to be brought in and tested for all of this. 00:40:00 Host: What are some of the things you and your team are doing to help educate the medical community and the community at large on the prevention and treatment of hearing loss in children? 00:40:21 Dr. Vaughan: You know, I have to brag a little bit. I think that we have the absolute most amazing team of pediatric audiologists here at Cook Children's. The skill level and their involvement and their passion for our profession, I think is unmatched. And I tell them this all the time, I would pit them against any group of pediatric audiologists in the world. They are, bar none, the best. And many of them, like me, their "no" button stopped a long time ago, and they have lots of volunteer positions. We have audiologists who volunteer for the American Academy of Audiology, we have them that volunteer for the Texas Academy of Audiology. They do presentations, and all sorts of volunteer work around, we have lots of interaction with our Listen Up parents support group that they volunteer for. We do Neighborhood Clinics, we've gone out and done lunch learns here at Cook with some of the physicians, and we will honestly talk to anyone about childhood hearing loss who will listen and that is pun intended there. 00:40:42 Host: A good pun, indeed. You've been so instrumental in helping patients, families and health providers overcome multiple challenges. But there are still many ahead. So I'd like to wrap up with this. When you completed your year as president of the American Academy of Audiology, you were quoted as saying, "Our challenges will always exist. It is how we accept the challenges that will change audiology. It is an amazing time to be an audiologist, there are so many things that will shape our profession over the next few years. Let us all remember to be present and thoughtful in how we take any challenge and turn it into an improvement for Audiology." That quote is amazing. So how do you see the future of audiology here at Cook Children's, and in health care as we move forward? 00:41:56 Dr. Vaughan: Thank you, that was probably the highlight of my career thus far, is being able to serve and for president for the Academy for all of the audiologists in the U.S. It was an amazing experience. And you know, audiology is a is a fairly new profession, it's fairly new practicing profession. We didn't really get a lot of traction until the end of World War Two when veterans came home with hearing loss. So when you kind of think about in the grand scheme of other, you know, professions, nursing, physicians and things like that, we're fairly new in the playing field. And so just like how your cell phone changes, there's almost all these updates. Hearing aids do that too now. And so I think it's so exciting. They're smaller, they're sleeker, they all have Bluetooth capability. So you don't even have to pull out your phone to your ear anymore. Many audiologists have hearing aids just for this point without any amplification. But it's so neat, the technology is so great, the batteries are become rechargeable and rechargeable is now in a phase where when it came out a few years ago, it wouldn't last you the whole day, but they last all day, plus some, and you can just plug them in at night when you plug your phone in. So I think it's incredibly exciting with the technology. And when we look at challenges, right now, some of you may have seen the presidential executive order about bringing the cost of hearing aids down and providing over-the-counter-aids, much like reading glasses. So kind of wrap your mind around an optometrist and an audiologist have a lot of similarities in that fact where you can walk into Walgreens, CVS, or any of those places, pick up a set of reading glasses. You know, the idea is to be able to provide a little bit more of an amplifier for people who maybe can't afford more or maybe who don't honestly need more. So that's on the horizon right now. And President Biden asked that that move along. That actually went through the FDA for FDA approval, and it's been approved, but the logistics of it are still being worked out. And that honestly was probably the highlight of my time as President, as I spend a lot of time at the FDA and in DC and talked about hearing loss and how it impacts not just children, but adults and getting access to hearing for certain populations that need it. And I think that the over-the-counter push will help with that. So if you think of a elderly person who just needs to volume up their TV up a little bit, but they can't turn it up because they're in assisted living. So they just need a little bit of a sound generator, they need something they can put in their ear, that's going to give them a little bit more volume, over the counter things are going to be great in that aspect. Or you know my thought is, is it's exciting because maybe it has like reading glasses, maybe you go in and you pick up a pair of reading glasses and then you realize everything you've missed out on, so you go to the optometrist and you get your eyes checked and you go with something a little bit better. Maybe you realize you need more than reading glasses. I think that over-the-counter will be the same way. I think it's going to put audiology in a place we haven't been before, which is in a very consumer-related place. So when you walk into CVS, you'll be like, Oh, wow, look at that. Yeah, you know, you're right. I don't hear as well as I think I might. Maybe I'll pick that up and try it. I pick it up and try it, maybe it works great. You go on with your life or you know what, maybe you realize you need something more and you go and you get your hearing tested. And you, you know, have more access to sound, more access to hearing your family, more access to your job, and whatever you may need. And while those FDA pieces, and all of that doesn't really revolve around children, so to speak, since adult based, children should be excluded from over-the-counter aids, as we don't often know what they hear, as we've talked about before. However, over the counter hearing aids, what we're calling them, they've been around for a little while. You probably have seen some things like on the end of the aisle at Walmart or other places that are sound amplifiers. So we've been able to sell some things like that, and not call them hearing aids for a while. And we actually have seen kids come in wearing those devices. And it's hard, it's hard to educate a family, that that's probably not the best thing. We don't know what they're getting. We don't know what they're not getting, but maybe that was all the family had at that point. So we have already seen this coming in. There's also one other kind of exciting piece that I think is exciting. We have legislation out right now, it's another thing that I had the pleasure of working on as president that it looks at Medicare, because right now Medicare, which is where the majority of people who need access to hearing are on Medicare. Medicare excludes hearing aids. It excludes hearing tests if the reason for a hearing test is hearing loss. So our most vulnerable population of adults don't have access to audiology. They can't even go to an audiologist without a referral just for a simple hearing test when they can go to a multitude of other providers. And so there's legislation out on that right now to try to help get audiology services and access to our Medicare recipients. So I think that's also very, very exciting. And I just think the future's bright. Really, there never has been a better time to be an audiologist. There's never been a better time to have a child with hearing loss. Technology's amazing. I said Bluetooth earlier, that's been a game changer with our teenagers. Our teenagers walk around streaming music all day long from their hearing aids, which is a blessing and a curse. It is good that they're wearing their aids more and not stopping to wear them because of peer pressure and things like that and bullying but my teenagers love their hearing aids again, they like to be able to string music and to have similar devices to their friends who walk around with Bluetooth. So that's been a big impact. Babies are identified early and we truly have the ability to change a child's life right now. 00:47:35 Host: That is so fantastic. Dr. Vaughan, thank you so much for your time today all your insights and sharing all of your vast knowledge about audiology. We're so glad you could join us. 00:47:47 Dr. Vaughan: Thank you. 00:47:48 Host: If you'd like to learn more about this program, or any program at Cook Children's please visit Cook Children's dot org. Want more Doc Talk? Get our latest episodes delivered directly to your inbox when you subscribe to our Cook Children's Doc Talk podcast from your favorite podcast provider. And thank you for listening.