Trisha Williams (Host 1): Hi, guys. Welcome to the Advanced Practice Perspectives. I'm Trisha Williams.

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Welcome back to the Advanced Practice Perspectives. Today, we are pleased to have Hilary Schmidt visiting with us. She is an audiologist at Children's Mercy Kansas City in our Hearing and Speech Department. She is also the co-founder and audiologist in the Hearing Loss Multidisciplinary Clinic. Welcome, Hilary.

Hilary Schmidt, AuD: Hi, thanks for having me.

Host 1: You are so welcome. Hilary and I are good friends, so I'm excited to talk with her today. Hilary, we would love for you to tell our guests just a little bit about yourself.

Hilary Schmidt, AuD: Sure, yeah. My name is Hilary Schmidt. I live in the Kansas State area, and I've been with Children's Mercy Hospital for 16 years as a staff audiologist. I do a variety of things with that title, including seeing patients with hearing loss from age of birth to 21. And so, most of our long-term patients that we follow are patients diagnosed with hearing loss in their journey that we followed through adulthood.

I really enjoy my job a lot, and I'm happy to talk more about the importance of early identification of hearing loss and pediatric hearing loss, so I'm looking forward to it.

Host 2: Great. Well, welcome, Hilary. Hilary and I, I think we started right around the same time in the ENT Clinic and you with Hearing and Speech. So, it has been fun to watch you grow and everything that you're doing within the Hearing and Speech Clinic. So, we're excited to talk to you today. Let's start by covering what the Joint Committee of Infant Hearing Screening Recommendations are.

Hilary Schmidt, AuD: Sure. The Joint Committee on Infant Hearing is an organization that provides a position statement. It's made up of otolaryngologists, audiologists, pediatricians. And they kind of collectively decide on the appropriate recommendations for children with hearing loss and on screening children for hearing loss beginning at a young age.

So, their guidelines are for every baby to have a screening done for their hearing by one month of age, a diagnostic assessment by three months of age and then, being enrolled in services and with amplification by six months of age. So, there's a state agency within every state that kind of helps to monitor that and make sure that those recommendations are being followed.

Host 2: So, Hilary, what type of hearing screening do they do at the newborn hearing screen? Like, what type of test is it?

Hilary Schmidt, AuD: So, there's two types of testing that they do for a newborn hearing screening, and it depends a lot on if the baby is born in the well-child nursery, or if a baby is born in the neonatal intensive care unit or NICU. There's two types of screenings. One for that kind of full-term healthy birth is called the otoacoustic emission screening. It's testing the outer hair cells of the cochlea. So, the cochlea is the organ that sends signals to the nerve to let us know that we hear a sound.

The other type of testing that's primarily done in NICUs, and some states have kind of made that transition to even doing this type of screening on all babies is an auditory brainstem response screening, or ABR. And that is testing the auditory nerve. So ,I often tell my families that that's testing sort of the last stop on the chain and saying, "Okay, can that nerve send up the signal as it's supposed to to the brain to let you know that you hear a sound?"

Host 1: Because the acoustic emission test, or the typical newborn hearing screen, doesn't necessarily tell us the severity of hearing, correct? It just tells us that there is a potential hearing loss of some nature.

Hilary Schmidt, AuD: Correct. Yeah, it's not truly a hearing test. The OAE, is what it's referred to as, it's a cochlear function test. So, it's really just saying does that part work the way that it's supposed to, and not any indication of, yeah, a severity of hearing loss or anything like that.

Host 1: So, what if a baby is born and they fail their newborn hearing screen? Like, to me, as a parent or a primary care provider, it'd be like, "Okay, Now what? What does this mean? Does it mean that my child has to live without hearing? What does this mean?" So, could you kind of walk us through what happens when somebody fails their newborn hearing screen?

Hilary Schmidt, AuD: Of course. So, most newborn hearing screening programs within the United States are run where you have a chance to do two screenings while the patient is inpatient, while the baby's inpatient, you get two chances to pass that screening. And then, you can actually go back and have an outpatient screening two to four weeks later is appropriate.

When you don't pass any of those screenings or when you have trouble with that process, it's time to refer to a pediatric audiologist for more thorough assessment to kind of determine exactly what the child's hearing and kind of go forward from there. So for primary care physicians, I think the important thing is just knowing who the pediatric audiology groups are in your area or who would be appropriate to refer to for further testing after you don't pass three screenings.

Host 2: Can you talk about if, say, a baby doesn't pass the initial OAEs and then it gets repeated and then they pass? I often have parents that are concerned, "Well, you know, they didn't pass it the first time and they did the second, but I'm kind of nervous they didn't pass it the first." Is there any way to explain that better to families as reassurance? Like, "Oh, sometimes they don't pass." Is there a reason why that happens?

Hilary Schmidt, AuD: It really can be up to the baby's state when they're trying to do the testing. It's best if babies are sleeping and calm while they do the testing. Often what I tell families is it's an appropriate thing for the newborn hearing screening process. It's normal to have that outpatient screen and pass that. It's a normal part of the process. And I feel like that helps them understand. Because it could very much have to do with the state of the baby, or depending on how quickly after they were born, sometimes there can still be kind of stuff in their ears if they haven't had that first bath or anything yet.

And it really depends on how fast that baby is released from the hospital, if they have a chance to have that screening. I have a lot of parents who report they do those first two screenings kind of back to back. And to me as an audiologist, I'm like, "Well, you just screened them once because then you just did the same thing again." So, I often remind families that that's a normal part of the process to have that outpatient screening. It's still considering passing the newborn hearing screening process and that's okay. 

Host 1: Are there any type of family resources that are out there in the community? Maybe by the Joint Committee of Infant Hearing or by the CDC that says, "Your baby might not have passed their newborn hearing screen, now what?"

Hilary Schmidt, AuD: Yeah. The CDC has a great section where it talks about information about early hearing detection and intervention. Those state agencies that I talked about earlier are called EHDI programs for short and it stands for Early Hearing Detection and Intervention. So, the CDC has good information on their website that talks about the EHDI programs, that is a great resource for families and for PCPs and people who are kind of trying to walk families through this process. I think it has great information.

Being from the Kansas City area, we are right on state lines, so of course we have the Kansas EHDI program and the Missouri EHDI program. So, I know that there's other facilities that I'm sure have that same challenge of trying to report to two different states. So, the CDC is a great national website that you can kind of gather some of the information about what that means and kind of the process moving forward.

Host 1: Perfect. It's always like we know the information's out there on the world Wide Web. It's just how to find it and access it quickly to be able to help our families. So, those are very helpful resources.

Host 2: Hilary, can we talk about the different kinds of hearing loss?

Hilary Schmidt, AuD: Yeah. There are three types of hearing loss, and it's really all related to the part of the ear that is affected. The Most common, I would say, is conductive types of hearing loss, so that means that the primary sensory organ for the child works and sends the signal up the way it's supposed to, but there's some problem between the outer and middle ear that is kind of causing that signal to not go up the way that it's supposed to.

So, it's the most common type of hearing loss that's secondary to ear infections and things like that. The ear canal and then the area behind the eardrum called the middle ear should both be filled with air. When the area behind the eardrum is filled with fluid or congestion or things like that, then that can cause that sound to be kind of reduced as it travels through that permanent part of the hearing. So, that's called a conductive type of hearing loss. It is probably most common cause of hearing loss, because it's secondary to a lot of transient things related to ear infections and things like that.

Sensorineural hearing loss is more of a permanent type of hearing loss. So, it's some hearing loss related to either the cochlea or the auditory nerve, where the sound has to be turned up before those organs work the way that they're supposed to to send the signal up. Kids with sensorineural hearing loss can have various degrees of hearing loss, ranging from very mild to moderate to more severe and profound hearing losses. And depending on the degree of hearing loss may also delineate what we do with that for treatment. but sensorineural hearing losses, there's not a surgical option for that. There's no corrective thing that you can do to help with permanent hearing losses like that. It's more about treatment of the hearing loss that is there.

The last kind is a mixed hearing loss where it's kind of components of both of those. So, you have an underlying sensorineural hearing loss in that your cochlea and auditory nerve need the sound turned up to respond, but you also have a conductive type component. So, there is something to do with kind of the structure that is causing a hearing loss in addition to the permanent hearing loss that that child has.

Host 1: That was a perfect explanation of the different types of hearing loss. And I really think that it'll help our listeners kind of wrap their heads around the different types, because I think it gets confusing. And as long as you can think about if conductivist, how does the sound wave get to the cochlea and the cochlear nerve, like that's the conductive part of it. And then, you have your sensorineural, which is your cochlea, your cochlear nerve, and your processing center. And then, a mixed is, of course, a little bit of a component of both. So, I think that was fabulous.

Host 2: So, newborns, if they don't pass their newborn hearing screen, is their hearing loss most often sensorineural, conductive, or mixed?

Hilary Schmidt, AuD: I think it's important to refer to a pediatric audiologist for further testing to determine that. So, I still find that kids who fail their newborn hearing screening and end up coming to me for more diagnostic testing, about 60% of them still end up having normal hearing. So, for whatever reason, they didn't pass that screening process, but once we test everything, it ends up being fine. For us as pediatric audiologists, we're trying to capture, you know, those who do have hearing loss, and then kind of get them enrolled in the services they need, provide them with amplification so that they can be the most successful.

There's a lot of research that surrounds the importance of early detection and intervention of hearing loss to help kids stay caught up on their speech and language milestones, and their cognitive abilities and their academic abilities and things like that. So, I think it's hard to really say what percentage is which. I think the most important thing is just making sure you're referring to somebody who's equipped provide the appropriate testing to determine that.

Host 2: Okay. Yes, that makes sense. So, how does hearing loss affects kids' development and learning?

Hilary Schmidt, AuD: The simplest answer, and what I often tell families, is we learn to talk the way that we hear. So, there's been a lot of research through the years in literature that talks about the sooner we know about hearing losses and provide the treatment that they need, the more successful these patients can be with their outcomes. Because basically, we're closing that gap of when they don't hear normally by providing them the services that they need in order to get all of that good information so that they can develop their speech and language skills appropriately, and things like that.

There is also a very high percentage of kids who have other factors secondary to their hearing loss. About 50-60% of hearing losses in developed countries are thought to be genetically linked. Oftentimes, they're autosomal recessive, meaning that they have no outward phenotypes that you can really tell. And so, identifying those early and often are just going to help those kids be more successful.

Host 1: The way that I like to phrase it, too, is that we're just helping put their puzzle pieces together and to provide them with the tools that they need to be successful. So, that is fantastic.

I think it's really important to also address the fact that not all kiddos find out that they have hearing loss in the newborn period, right? They can pass their newborn hearing screen and then develop hearing loss later in life. So, sometimes they're getting screened at their primary care offices or they're getting their screenings at school. So, can you talk a little bit about that and what families can do or what primary care providers can do if they fail a screen at school or they fail it in their primary care office?

Hilary Schmidt, AuD: I think the challenge that we have as pediatric audiologists is that we have newborn hearing screenings that are fantastic and that process works for the most part. But you're absolutely right, most school-based screenings don't happen until a child is in kindergarten, right? Until they're five or six years old. So, there's very much a period of time in there where kids' hearing isn't necessarily being screened or regulated or monitored regularly.

I think it's important for primary care providers to screen a child, ask parents about speech and language milestones. "Do you feel like they talk like other kids their age? Are other adults outside the home able to understand them?" I think that's a question that doesn't often get asked. We have parents who can always find a way to communicate with their child, but sometimes it's asking that outside perspective. Can someone outside the home hear and understand their speech and be able to hear it? Can that child communicate their needs? Those can all be signs. Whenever there's a concern for a speech and language delay, you should always check a child's hearing just to make sure that it's not a contributing factor. Even patients who get referred to our facility for a speech evaluation are always scheduled for a hearing test in conjunction with that. And sometimes that's how we have found those patients who either never completed the newborn hearing screening process, which does still happen, or those who passed their newborn hearing screening and then are found to have hearing losses later in life.

Screening programs are screening programs. So, they're not made to catch everything. They can't be so specific that everyone refers, because then it would be a challenging process for everybody involved. So, I think there is always a possibility of missing more mild hearing losses, can certainly be missed in the newborn hearing screening process, or I've had families diagnosed later who've said, "Oh, well, they passed, but it took forever" or they said they barely passed, those sorts of things. So if primary care providers can watch for that too, I think that would be helpful to just kind of help monitor their hearing through that process.

And of course, monitoring for things like chronic ear infections and eustachian tube dysfunction and all of that, which can really have a detrimental effect in those critical years when kids aren't having their hearing screening performed as regularly.

Host 1: And that's when their speech develops so rapidly when we're not monitoring their hearing, like in that one to two to three years of age, it's like rapid development of speech. So, we're missing a good opportunity to screen for their hearing loss.

Host 2: Another thing that I thought I would mention, though it's rare, there are those kids potentially school age that have been previously hearing just fine and might report to a parent, "I can't hear." And so, it's like a sudden onset. So, could you maybe just like briefly cover that and how important it is for PCPs to refer over to get a hearing test during those times?

Hilary Schmidt, AuD: Yeah. I think it's important, especially when kids do become more self-aware, if they're reporting any kind of deficit. It's always worth having their hearing checked by a professional who specializes in children. Those things can begin happen. You can have viral attacks on your auditory system. You can have congenital issues that present later where they might have passed their hearing loss screening during that newborn process, but then have developed hearing loss later because either it's been a progressive type of hearing loss or they have other co-morbidities that have turned up in that kind of early childhood time as well that I think it's important to monitor, because it certainly can happen that there are kids who pass the newborn hearing screening process and then end up presenting with hearing loss.

The most common, I think, is probably unilateral. So, kids who pass the newborn hearing screening process, but then end up having hearing loss in one ear. Those can take a while to present, and it can be for various reasons.

Host 1: The sudden onset hearing loss would be a kid's like, "Oh my gosh, I can't hear out of my right ear." That's something that the primary care needs to really listen to, correct, and make a referral to Audiology in a pretty timely manner, correct?

Hilary Schmidt, AuD: Correct. And what I would like primary care providers to know is that pediatric audiologists can test any child at any age with any abilities. And that may mean that we have to determine the best way and most appropriate way to test that child. But we are capable of doing that and finding a way to determine a child's hearing at any age and with any ability.

Host 1: You got lots of tools in your toolkit to be able to get those accomplished. That's a good plug.

Host 2: You guys work some miracles, that's for sure.

Hilary Schmidt, AuD: Well, thank you.

Host 1: So, let's pivot a little bit to hearing aid use. If we have a patient that would benefit from amplification for their hearing, what are the recommendations for using hearing aids? And how can a primary care provider or even a provider in another specialty clinic help support families and support patients with their hearing aid use?

Hilary Schmidt, AuD: There's a study that is ongoing that began in 2008 that is looking at the outcomes of children with hearing loss over a long period of time. It's across multiple facilities, and it's all about learning the impact on newborn hearing screening and early intervention and technologies and if that works.

And the research that has come from that is called the OCHL study, has shown us that kids should really be wearing their hearing aids all waking hours. That's the goal, right? I always say I have normal hearing. I never turn my ears off. And I think that's important and I hope that all primary care providers can help encourage families to be successful.

It's a normal process for families to go through a grieving process related to a child diagnosed with hearing loss. And I think it's important to accept that and realize that hearing loss is an invisible handicap. We can't see it. There's no outward expression of it. And so, it can be sometimes really hard for families to struggle with that diagnosis. So, I think it's important for families to feel supported, feel like they're being successful, and just encouraged to try to get that daily hearing aid use, because that's really when those patients are the most successful.

I often tell my families too the newborn hearing screening is great in a lot of ways because we identify these hearing losses at a very young age. And we get them in the services and amplification that they need to be successful, and it's before they're toddlers, right? They're babies. So if they're wearing hearing aids, it's really up to a parent and that family member support for them to be the most successful. My families that are the most successful are the ones that really establish those daily hearing aid use goals at a very young age before the child is really aware.

And so, I think whatever providers can do to help families feel supported in that journey is really valuable.

Host 2: So to receive a diagnosis of hearing loss, whether it be from their newborn hearing screen or even toddler through elementary school can be really overwhelming to the patient and to the families. So, what can Children's Mercy, like what do we have in place that we can offer to families to kind of help guide them through this diagnosis and working up like why there's hearing loss?

Hilary Schmidt, AuD: We have a multidisciplinary clinic available through Children's Mercy for patients newly identified with hearing loss. And that can be kids of various ages. So, some kids are going to be found through that newborn hearing screening process and be babies. And then, that also helps that those kids who are later identified for whatever reason.

The goal of multidisciplinary clinic is to get families enrolled in services that can be helpful for them. They get the opportunity to meet with them, and Ear, Nose, and Throat nurse practitioner, for a medical evaluation for their hearing loss based on JCIH's recommendations. So, the Joint Committee on Infant Hearing also has recommendations for what children with hearing loss should receive, what services they should receive, what kind of testing should be ordered, and things like that. So, our ENT nurse practitioner is very valuable in providing that medical evaluation and workup. I staff that clinic as the audiologist. And a lot of times I'm just there to help families hear it in a different way. So, they've already been seen and managed by their audiologist who's diagnosed their hearing loss, but I'm just sort of a secondary opinion, so to speak, but not really, just kind of making sure that families understand their hearing loss diagnosis, what it means. We have a bunch of documentation that we've gone through our Health Literacy Department to provide to families about types of hearing loss, degrees of hearing loss, what that means for their child moving forward. And so, that's kind of my role.

We also have a speech-language pathologist that participates in that clinic who does speech assessments on these kids. And I'm always surprised at how young she can do those assessments on kids to see how they're doing. And I think that helps to answer that family's question about, well, what does this mean for my child's ability to talk? Because that's often one of the first questions we get asked.

And then, the other person they get to meet with at that clinic is a genetics counselor. As I stated before, a lot of these hearing losses that we're diagnosing often don't have any outward phenotype or any other way of knowing why they have hearing loss, the etiology. And so, genetics is such a wonderful component to kind of help open those answers and provide answers for the family about why their child has hearing loss. There's oftentimes a grieving process, as I mentioned, for families. So, I think a lot of them want to be informed. "Okay, well, why did this happen?" And so, that allows us to provide that comprehensive information for them.

We also, in establishing and founding that clinic, worked with a parent of a child who has hearing loss to obtain a lot of resources to help these families. So, part of what we also provide in that clinic is a bunch of resources of your child has hearing loss. Now what? What does that mean for their education? Who can help me with this? Who can help me with that? And we've got what's called a Parent Seal of Collaboration with our work with that parent to just kind of show that we want families to feel supported in this journey. 

Host 2: I love it. Trisha is the nurse practitioner who co-founded it with Hilary, so I'm so proud of both of these girls. They've worked really hard. And it's such a nice option we have to offer families now and hopefully avoid multiple visits with multiple different types of providers. I just think it consolidates everything, and it really helps families to be able to have like a one-stop shop kind of thing, especially when they travel far. And it's just such an overwhelming thing to have to kind of walk through and navigate. So, you guys are great. Thank you for doing that and working so hard on this.

Host 1: I don't like to toot my own horn on the podcast. It's all about our guests and them kind of giving the knowledge, but it is something that Hilary and I are extremely proud of, and the work that we've done and that the opportunities that we're being able to provide for our parents and our patients and the investigative work that we're able to do. So, there's great things to come. I think it's important that our primary care providers know that it's out there. That right now, we are in a growing phase in kind of a pilot program with hopes to be in an overarching umbrella with a Hearing and Ear Institute, put together by one of our Otology physicians. So, it's pretty exciting work that we're doing and lots and lots of room for growth to service our patients in the metro area.

Host 2: Well, thank you guys so much. I know this has been really helpful and hopefully all of our listeners will find it really helpful as they are assisting babies or any kids going through this, I'm sure it will be beneficial to them. As we close, Hilary, we end each episode with the same question. So, this season's question is, what is filling your cup in this season of your life?

Hilary Schmidt, AuD: I think professionally the thing that often fills my cup is I love being an audiologist. I do. I know. I love ears and it's good that I'm an audiologist. But even more than that, I love being a pediatric audiologist. And a lot of times, I present to one of the local doctoral programs for Audiology. I present to their pediatric class and what I often tell them that is still true for me is I think the importance of Pediatric Audiology is the ability to change a life. So, Audiology is important for all ages. Most people are most familiar with Audiology in adult life. They all have parents or grandparents who have lost their hearing later in life, and that is an important aspect of Audiology. And it's all about extending life and quality of life, and that is very important and valuable.

I think the thing that jumps out to me that I love about Pediatric Audiology is my ability to change a life. By diagnosing and treating at a young age, we have the ability to really change a life for that child for the better. And I think that's what really fills my cup professionally. And personally, I'm a busy mom with three kids. And so, running around and chasing tiny humans is my other job.

Host 1: Right? I was going to say your personal cup is overflowing. Your cup overfloweth with the love of your children and your life, so...

Hilary Schmidt, AuD: Yes, I do. I'm very blessed to have a wonderful husband and three amazing kids. And even an extended family that's close by that really fills my cup in a lot of ways.

Host 1: That's awesome. Well, Hilary, thank you so much for sharing all your knowledge about pediatric hearing loss and being able to provide our listeners with some good, helpful information. We really enjoyed our time with you today.

Hilary Schmidt, AuD: Thank you so much. I appreciate the opportunity to talk about it. It's a very strong passion of mine.

Host 1: It shows. Thank you.

Host 2: If you have a topic that you would like to hear about or you are interested in being a guest, you can email us at tdobrien@cmh.edu or twilliams@cmh.edu. As a reminder, to complete your evaluation and ensure that you get the credit for listening, visit childrensmercy.org/appeval. That's childrensmercy.org/A-P-P-E-V-A-L. Once again, thanks so much for listening to the Advanced Practice Perspectives podcast.