hello and welcome to AG Bell's 2023 Global listening and spoken language virtual Symposium I am Emilio Alonso Mendoza proud to be the CEO of the Alexander Graham Bell Association for the death and heart of hearing I'm very happy to welcome today nearly 700 Professionals in in listening and spoken language from more than 40 countries our focus is to ensure that every child who can benefit from listening and spoken language has a qualified and caring professional to support their advancement you're joining us for two full days of learning connecting and growing and we're very happy to see and hear you we're very pleased to now have 1100 certified professionals around the world that's 1,100 but so many many more un needed and this is what makes our continuing education so vital to our field we are committed to hosting this annual Symposium to provide you with ways to earn many continuing education credits with the most upto-date information in our field throughout this Symposium you'll hear from an array of wonderful and talented listening and spoken language professionals from across the globe our keynote speakers will deliver the latest information on Research in our field and I am really looking forward to the forums on Innovations and Technology from the our key sponsors CER Americas akos and medel and before we get started I would like to thank the many people who made this impos possible agel is grateful for the guidance and supports of the members of our board of directors they're there there for us all the time so uh thank you we also want to thank the 2023 Symposium core committee members they come from six countries and they have a commitment to bring high quality education to all of you a special thank you goes to co-chairs Lilian Flores Beltran from Mexico Terry olette from Indianapolis Indiana and Trudy Smith in Australia they attended many meeting and encourage many of you to participate in the Symposium we're also thankful for the 40 volunteer ambassadors who reach out to encourage Professionals in their countries we will uh name all the countries later on uh in tomorrow maybe and uh you're going to be so pleased uh when uh you see what a turnout we had this year I also want to recognize the Committee of key sponsors of the global Symposium who help to ensure that this event takes place but also contribute their knowledge to the program our Cradle to Career Partners our year-long sponsors who help us bring to life new ideas we um want to thank akos and desel for their support of agel as well as K their Americas who bring the parent support line and parent chats to you be sure to share those Resources with the families you serve I also want to thank medel Capel RIT National Technical Institute for the death desel Therapeutics Hamilton Capel the Paul school for hearing and speech St Joseph's Institute for the de the central Institute for the de Asha Sunshine Cottage and auditory verbal Center they are all have Incorporated their support of this imposium special thanks are also due to the National Institute on deafness and communication disorders for their conference Grant this grant not only supports our keynote speakers but also supports the Symposium proceedings after the event additional nidcd has funded registration scholarships to enable 40 students and agel funded 10 students from several countries to benefit from Symposium education professional scholarships have also been provided through a special fund drive we are grateful for your commitment to supporting high quality education for professionals all over the world thank you to all our volunteers our speakers and supporters I want to thank our staff members who have worked tirelessly to bring this Symposium to you but in particular I'd like to thank somebody that is very special to the staff and I'm sure very special to you and that is Gaya ginar our chief strategy and programs officer who has been inspirational to us all and is inspirational to me every day along with Gayla I would like to thank our 130 Symposium presenters you you are what makes this 2023 Symposium fresh unique informative and inspiring and please now join me in a round of applause a virtual Round of Applause for all of those who have been involved in making the next two days valuable and memorable thank you uh and now without further Ado uh Gayla thank you amelo hello to everyone from AG Bell for me these are the two most exciting days of the year it's when we come together to learn and connect and I could not be more excited I love to see what happens and while AG Bell and our um volunteer committees which have been really involved many people who've put this opposum together are excited and we' we've carefully planned the Symposium what really makes it so wonderful is what the presenters bring to us and then what you as attendees bring to the chat and to the conversation that's happening out there we encourage you to please communicate on social media whether that's Facebook or um any any social media let people know what's happening at the AG Bell [Music] Symposium so I think even better than um being here is what we take away from this experience and and that's because you will take your individual learning and impact the area that you're from in the world whether that is Brazil Canada Mexico Argentina Lebanon or Chile India Japan China Australia Israel Denmark Finland or the United Kingdom South Africa Kenya United States or somewhere else we're thrilled to have you here and we welcome you so again we want to make sure that everyone is able to stay online in learning so it's very important that we acknowledge that you know who our players are um the foundational support we receive um again this year from Blue Sky e-learning is there's nothing better they have been terrific Partners now this is our fourth Symposium working with them their path learning management system is what um we are using and they have their Tech experts with with us in every session and which is just wonderful we also want to thank AI media who is here again this year to provide captioning in amrad first year with them um out of Mexico who are providing oral translation we'll have a terrific Symposium Casey Jud of conference direct is behind the scenes with the whole team along with Dr Jonie alberg who is leading our moderators and our question and answer language facilitators there are a few more things we'll get started in just a moment but there are a few more things to share with you that will help you navigate the Symposium your ability to stay online and to follow what is happening is very much related to your own internet connection in bandwidth the first way to try to improve your connection is always to select your refresh button and sometimes you just have to leave and then come back to the room new this year English captioning you should already be seeing it will run across the bottom of the screen you can use the control panel I call it sort of your driver pod you'll see it on the right side of your screen as you navigate through sessions there is a captions Tab and um you can choose from um all six languages there that we are captioning this year and there is also the farthest tab over a translation an oral translation Tab and we are translating in English and Spanish so if a if a session is being presented in English and you would like to hear it in espanol then you will select the tab that says espanol if you're listening to a presenter um present in Spanish then you'll select the tab when it says English and you'll be able to hear that oral translation I do want you to know sometimes there's a delay in captioning and that often cannot be helped but continue to stay with us we have all done our very best to make sure that communication access is as as good as possible and we just appreciate um the fact that we're able to provide it and that you're here and participating remember what you are not able to participate in this year or sorry these two days the lives Symposium we have 19 hours but what you're not able to to participate in you can come back during the on demand portion of the conference you have registered for the Symposium that's a two for one experience you get to come to the Live two-day conference today and tomorrow and then come back from July 25th all the way to September 15th that's eight weeks for the ond demand Symposium and listen to all 52 hours of the um continuing education so you can even watch sessions over and over again as attendees you will not be able to use your microphone to communicate with the presenter or other attendees that's why we have a chat and I can already see that the audience has learned that the chat is there it's open we encourage you to please connect with others greet and meet others in the chat throughout the Symposium you'll have access to the chat you'll also have access to your presenters by answering or asking questions in our Q&A pod it's called slido we have added some special sessions this year they're called conversations and you can ACC access those sessions through path as well all sessions will be recorded however the audience will only be viewable your faces and names will only be viewable during those conversation chats those are happening at midday today and tomorrow and towards the end of this day there will be 15minute breaks in between every session and there will be video content with announcements during those breaks as you enter the next session please keep an eye out for um that content and also QR codes that will help you find all the information you need about agbell programs such as our new Young leaders program for individuals post High School up to about age 40 you'll also see information about the AG Bell Academy and LS LS certification last we're almost there we're almost ready to start but last I must say a few words about CEUs continuing education those are available to individuals who have registered as Professionals for the Symposium and to be awarded continuing education units or any credit for hours connected to the Symposium you must participate in the entire session we'll give you a few minutes to be late and if you have to leave a few minutes early certainly don't worry about that but essentially you will need to be at most of the session in order to um gain credit and we we are aware of who is on um and in the Symposium at all times also you will need to complete the continuing education grid um it's a very um easy process so I am not able to do a screen share right now but what you'll see is on the land page you'll see an icon that says ceu grid and that's how you open it up you need to complete just one cuu grid um I wish I could do a screen share that's not going to work out but here's what you do open one up be sure to fill in your name and other required information as you attend the Symposium and you can save the ceu grid as you go jot form which is where we have that CU grid stored we email you an edit link whenever you save or submit each time you want to reopen your ceu grid go to your email and just update the form it's very very easy if you use jot form in some other way in your work be sure to log out of it before you open and use our form it's very important to fill up that form completely and be sure to indicate the types of cus you wish to earn at the top of each day on the grid here's the great thing about the cuu form if you end up submitting it it's no big deal you just open it up again in your email and edited C the final form the final submission must happen no later than July 7th and when it is time for the um on demand from July 25th y on demand Symposium July 25th through September 15th you'll fill out a new ceu form and you'll just do one at that time as well a certificate of attendance will be downloadable at the end of the Symposium and and the same is also true of being able to download um an evaluation form and we certainly hope that you will evaluate the Symposium we look at every response and we do our planning according to the the um feedback we receive a certificate of learning with ceu amounts will be emailed to you at the email you've provided approximately 30 to 45 days following the Symposium now let's transition to the Symposium and our first keynote presentation i' taken a minute of her time enjoy your Symposium turn it over to the [Music] [Music] moderators [Music] [Music] [Music] hello and good morning everyone and welcome to the AG Bell imposium over these next two days my name is Peter stiger and I am at the beluchi translational hearing Research Center at Craton University and it is my distinct pleasure to introduce today our first keynote speaker for this Symposium and her name is Dr Lisa Hunter and she is a highly experienced audiologist at Cincinnati Children's Hospital and at the University of Cincinnati she's a renowned pediatric hearing researcher with interest in collaborations in speech and language development psychology neonatology and neuroimaging and I am particularly fortunate to be one of her collaborators her NIH funded research focuses is on the effects of prematurity on hearing and language delay and that is the focus of her presentation today Dr Hunter also has a passion for addressing the systemic effects of poor access to hearing health care and early intervention the title of her presentation today is the early detection of hearing loss and language delay in infants born prematurely and the mic is all yours now Lisa I'm really looking forward to this thank you so much Peter it's um it's a special honor having you um give such a kind introduction and I was I had the privilege of visiting with Peter and um participating in the recent beluchi Symposium at kraton University and they're doing just fantastic work there so it's really nice to to have that that connection here today and I'm I'm especially thrilled to be asked to present um to all of you today at this virtual Symposium um I know it can feel a little bit different I can't see your faces and I regret that but I do think it's wonderful that so many people from across the world are able to participate this way without flying millions of miles and burning up carbon and all of those things so there there's a upside to it as well but I do regret not being able to meet you in person and and have those individual chats but hopefully in another Forum um normally as Peter mentioned I'm working at Cincinnati Children's Hospital which is shown uh right here in the second panel and I'm very lucky to actually work in this building um this hospital is so dedicated not only to clinical care but to research that they've you know they've really um they've invested enormous amounts of their foundation in these not only physical structures but in people um the more important part who I get to work with and um and in facil ities like this MRI suite that's shown here over on the right which is so key to the research that I'm going to be talking with you um about today so um I would not uh want to miss um acknowledging the whole team that I'm lucky to work with because this is really team science that we're going to talk about today and um the interdisciplinary collaboration that I have with Dr Jennifer vanest who's a speech language researcher at uh children's and also at the University of Cincinnati uh Dr Nal Peri um who originally started with the first the older Co cohort that I'm going to talk with you about today and his special interest has been in predicting Motor problems especially cerebral py and cognitive problems and he just jumped at the chance to expand this into hearing and speech language so he's really thinking about the whole child and family in his research program uh Dr David Moore who um I am fortunate enough to not only collaborate with but be married to and he's actually here listening today um and interested in in what we have to say and he does he comes from a neuroscience perspective um and then Dr Maria Barnes Davis who is also an neologist and has excellent expertise in EEG uh research which we are using in this study Chelsea Blankenship is an outstanding post doctoral research associate you'll be hearing a lot more about her in years to come and she's been doing most of the EG and ABR recordings that I'm lucky enough to talk about today and then Lauren Prather and S seissan quero are both uh PhD students in speech language who have been working with us and doing some of their doctoral research with us and actually Lauren in addition to the um wonderful funding that we've been able to receive from nidcd Lauren received a supplement diversity Grant um to do some work um in Black children's language and then jod cwal Cur man who is actually the heart of it all she's our senior research coordinator and she makes it possible because she connects with all these families um that we have a really really high retention rate over a five-year longitudinal study so far so um to continue on so prematurity um you see in your work a lot of children who were premature um a lot of them who are doing so much better now um because of all of the efforts of the neonatologists who have managed to allow them to survive this very very challenging time when they're so fragile and we see babies that are born as young as 23 weeks these days who are surviving but of course the younger they are when they're born the more likely they'll have these multiple adverse developmental outcomes that include both hearing speech language and lots of other problems that we'll talk about and it's a really common problem 10% of of all births in the US are premature and unfortunately for developed countries we have one of the highest rates of prematurity in the developed world and so it's something that really needs a lot of effort and attention to improve um and of course developmental disabilities are really common especially in the babies who are born very or extremely pre-term and that's um that is defined as less than 32 weeks gestational AE at the time that they're born so speech language and hearing of course cognition vision and motor disorders are quite common any of these can occur and they can occur in combination so we may see children many of the children we see who we talk as being deaf Plus or heart of hearing Plus have these other problems um there's also an increased risk for autism and cerebal paly as well as ADHD with pre-term birth but we can't really predict which babies are going to have which problems and so when they're born don't know exactly what kind of therapy they're going to need and that includes hearing loss fortunately for us we have Universal newborn hearing screening and that started actually my career started um the very first job that I had um was doing hearing screening in the neon Intensive Care Unit and I've just had I've just been drawn to that ever since I keep finding that that's an area that I really love to work in um but these are in invisible disabilities we know that hearing loss and speech language delay are often coexisting they're often not picked up until the child is is older fortunately as I said with hearing loss we can pick it up sooner but vary to extremely pre-term babies have a three to tenfold increase in the risk for these problems another issue that we want to bring up is noise in the NICU and auditory development because of course this can play a role in um excess noise and potentially damage not only medically because babies have higher risk for increased blood pressure and other problems and it could intersect with things like aminoglycosides um because there's an inflammatory process that may be worse when we have noise especially in excess of 45db these babies are born weeks earlier than they should have been they would have been in a very different acous environment than they are in the niku most ncu have done a lot to try to bring down these noise levels in fact some are so successful that now we're worried about it being too quiet and so it can vary dramatically um in the ncu that haven't been treated acoustically the average noises are 70 to 80 DB but can exceed 120 so that's clearly risky um not only for the baby's Health but also for their hearing um but if we make it super quiet and they're not having the normal language and acoustic stimulation that they should from their caregivers from their parents that can be problematic for their development as well another um thing that I want to highlight is that we're probably only seeing the tip of the iceberg with newborn hearing screening we do a really good job at picking up moderate to profound hearing loss sort of okay with mild hearing loss but we're likely missing most slight hearing loss and that's because we have our criteria set at a level where we're not over um detecting babies that have just temporary fluid in the ears when they're born but we may be under detecting slight to mild sensory neural hearing losses and of course those can go on and progress if they're present so that's something that we're really looking at with this study so what is slight to mild hearing loss well it's beyond the green area in this audiogram familar sounds audiogram so above 15 DB on average and you can see our much beloved speech banana Falls below that so the idea is that if we pick up hearing of at least 15 DB or greater hearing losses of 15 DB or greater that we'd be able to amplify and bring in sounds across the entire speech Spectrum but we know that if we're skating at 15 to 25 or even 30 DB we may not have picked that hearing loss up and those children may miss especially the softer sounds and the higher frequency sounds and especially at a distance right or especially when there's noise or any other type of difficult acoustic environment so slight to mild hearing loss technically it's 15 to 40 dbhl we know that it affects speech language development and academic progress but currently we have a really hard time picking it up and infants cared for in the ncu are definitely a great greater risk for all degrees of of hearing loss so rates of hearing loss that we find really depend on the definition and age this is a really interesting figure it's pulled from a couple of different sources from the CDC Ed data from enhan survey and also um reviewed by nidcd and you can see that at Birth the rates of moderate to profound hearing loss are about 1.7 overall per thousand three per thousand if we include slight to mild hearing loss um but we think we're not always detecting it because as you can see if we go way over here to the right six to 19 years of age we have 30 times the prevalence of slight to mild hearing loss at school age than we have at Birth and we've got this like missing Gap in here around three years of age where moderate to profound hasn't really increased but we don't know anything about slight to mild loss because those kids are the most difficult to test and there's not a good way to screen at that at that time and there's no Universal screening around that age so somewhere these hearing losses increased but were they there all along or have they really increased that much from birth you know to to school age um this is um a nice study that was actually done by my collaborator David Moore here in the UK where we are right now um and this is looking at slight to mild loss that's undetected in primary school children so you can see that's up to 35 DB in these kids most of them have very normal hearing but we've got this tail of kids that have some hearing loss and this was detected um in a large sample of of school children um using automated audiometry so um we should have more of them down below zero but it didn't go down that low so probably you know this part should be higher but nevertheless if we look up at these slight to mild losses um what I'm going to show you in the next slide is if you look at a range of developmental issues um from speech and noise ability to language skills to memory non-verbal IQ shown here word reading pseudo or non-word reading General communication ability and then the chaps which is a questionnaire you see that there are some of these that interestingly start to take off with a higher Pro probability of low performance once we exceed 10 DB threshold on average and you can see this sort of accelerating risk of low performance so that by the time we get to 25db hearing level we've got a three times greater risk of low performance or about 15% on language skills memory pseudo word reading in particular and so we see that there there's a real relationship between slight to mild hearing loss and some of the most important skills for academic progress I should say I sorry I didn't say it at the beginning but please do put anything in the chat that you're interested in or want to hear more about um or questions that you have but we'll take questions at the end and then I want to make sure I allow time for that um now if we look at pre maturity the developmental trajectories that we see are that there's kind of three groups of children shown here the green are children who will have normal speech language abilities um over time a group that's resilient that starts out with some delays but either through therapy or through better developmental you know or um um a lot of um work I'm sure by their parents they are resilient and they catch up that's the blue line and then we have other children in Orange who early on May show a slight delay but that increases over time and so these are the kids that we really in this study are trying to pick up and try to figure out earlier that they're at risk for increasing problems over time because they can really benefit from therapy so um the study I'll talk about with you uh today is a five-year longitudinal study that started in March of 2020 right as Co became a new word in our vocabulary we were lucky to find that we got funding so it's probably the world's worst time to start a longitudinal study um but nevertheless through the work of that big team that I showed you at the beginning and especially our research coordinators and all the nurses who helped us babies were still coming in they were still being born during that time they were still coming into the NICU and these parents are really you know they really want to know that their child is doing okay they've been through such a traumatic period so actually despite CO as soon as we were able to open back up we were able to start enrolling and we we've really had a lot of success during this time enrolling these children and following them so far so our long-term goals are to improve predictions of speech language and literacy deficits and to try to do that so we can facilitate identification and intervention during what we know is the peak neuroplasticity window in infants or earlier than two and those of you who work with children um know that the earlier they get hearing aids better the earlier they get better and it's exactly the same idea here the problem with speech language deficits is that we take more of a wait to fail approach where we wait until the child is very delayed before they're offered therapy and that's what we want to change we want to facilitate earlier and more effective intervention by finding them sooner and you can see that on this graph that if we have early detection and add to that Intervention which you all are experts in that's where we will get the better outcomes we are sure about that so the way that this study is working is that we enroll children when they're pre-term so they have to be 32 weeks or less they have to not have really major brain anomalies or syndromes that we know are associated with speech language problems like cleff pallet or down syndrome we're not enrolling those children so we're enrolling children where there's you know it's gray we don't know if they're going to do really really well like these little pumpkins up here on the right side these are children who have come in and they just look spectacular their development looks really good we don't know you know when they're first in the NICU how their course is going to look um so we enroll them then they get um an MRI scan at term equivalent birth as part of the study but this is sort of a super duper what we call resting state functional MRI where we're really trying to look at areas of the brain that will be important for speech and language development they also get an anatomic type AB or um MRI so that if there are problems we're able to find out and the parents get that information um and that's one of the reasons they want to be in the study is to get that extra information they wouldn't get otherwise that includes an extra ab and we're doing a threshold AB all the way down to the lowest levels we can um at both one and 8 kilohertz so we're interested in the higher frequency region so we're doing that higher frequency ABR we're also doing a speech evoked EEG with syllables ba and da where we're looking um for speech contrasts and the brain's ability to pick those up and we do that with a high density electrode cap that has 124 four channels that we're able to then analyze later on in between we get caregiver questionnaires on the home environment are they're reading to the child do they have educational toys you know things like that um and then we do our speech language and hearing assessments at age two and three years of age the behavioral hearing assessment as shown here and then a speech language assessment um and I'll tell you more about those what they consist of so um we have the older cohort where we didn't have the EEG and ABR measures early on but we're doing everything at the two and threeyear age range and they had MRI as well and in addition to that we have 149 new babies that we enrolled in this postco period so the first cohort was pre-co second cohort was postco it might be interesting to just look at that in respect to their speech language and social skills um but that's not the reason for the study but it's it's it's going to be possible um but we have 149 and the new cohort who we enrolled and scanned with MRI of those 74% were very pre-term 26% extremely you can see we have um some nice diversity with 25% who are black 5% other and 8% Hispanic or Latino um and then you can see the risk factors over here of course all of them spent more than five days in the ncu but we also have a fair number who had Amino aides I know Peter wants to know more about this um and also 177% because this was prevaccine 177% of the birth moms had a covid-19 diagnosis while they were pregnant and we know that's a high risk factor for prematurity um not so far for hearing but we're certainly going to be looking at that um and then only 5% failed their newborn hearing screen and 5% had a family history of hearing loss so um the MRI that I described earlier is done in natural sleep we don't sedate any of the babies for the MRI and so that's where this wonderful lady down here has made this study possible because she became like a baby Whisperer um she would swaddle the babies and you know the MRI techs are extremely good at doing this in natural sleep um so we were able to get um on 149 babies full MRIs if they didn't get them they weren't able to continue in study and that was about 20% so we actually enrolled more babies but not all of them had a full MRI of those if we use something called the keto Coro brain abnormality scoring system you can see that only 28% of these babies are classified as having completely normal brain scans at Birth 45% have mild abnormalities and then 16% moderate 11% severe so this is really quite a wide range already at Birth but we also know that because of neuroplasticity despite these problems with the brain If the child has enough stimulation and things go well from there they can still do very well this doesn't necessarily mean that they're going to have problems and in fact um we have so far not found this brain abnormality scoring to be that predictive for language some other things though that may be present and are frequently present is something called diffus white matter abnormalities or more subtle types of brain problems and this is a particular interest of Dr pek um who's been working on this and has found that if they use Advanced MRI techniques you can do a good job at predicting motor outcomes so they've been able to get to where they can predict with better than 95% confidence children who will later on be diagnosed with cerebral py but unfortunately we haven't gotten there yet with language scores um on the Advanced MRI so there's a need for more sensitive early biomarkers to identify pre-term infants at risk for language impairment so this is something that we're continuing to work on and to look at using machine learning techniques our hearing assessment methods we have tried to use the most advanced methods that we could that are clinically feasible at this age so we use Distortion product AO acoustic emissions or oaes to measure inner ear function and we're measuring that out to 10 khz to get the higher frequency information we're using something called wideband tonometry which is um just as it sounds it's a wide frequency way to look at middle ear function so it goes beyond the typical temp panogram that can only measure at one frequency and then and that's at Birth and then again we do that um earlier or later at age two to three years we use those same techniques but then in addition to that at three months we're doing a complete ABR and we're using some special stimula that allow us to go really high in frequency um and then at age two to three years we're doing visual reinforced audiometry or condition play and we're including 8 kilohertz so a lot of times audiologists sort of stop at 4 kohtz and we don't go higher but we really should because these children um are at risk for higher frequency hearing loss with a lot of the problems that they've had um with the pre-term birth okay so finally I have some data to show you um so this is and I'm highlighting Dr blinkin ship who's done a lot of this work and this analysis um so the ABR thresholds that we did and just to cue you in on the ABR you can see that over here on the right side so we have a series of waveforms which when we're at higher intensities like 70 DB you can see them very clearly but when we go down down down down and level they eventually disappear and we call that the ABR threshold and we know that that correlates very strongly with the actual hearing threshold even though this doesn't tell us how the baby's hearing it tells us at what level the auditory system is capable of responding okay so if we look at the thresholds over here for 1 kilohertz we we know what normal is there and so we have this group of normal and so that's how we're classifying them as normal is based on their 1 KZ threshold which is well um well um understood and you can see we have this whole group of children that apparently have hearing loss at one kilohertz even though very few of them didn't pass newborn screening so there's something going on with hearing with these these children at 1 Kilz and then if we look at 8 kerz so classified on their 1 Kilz threshold you can see here's their 8 ktz threshold so these are probably in the normal range and the these we can see a big difference at 8 KZ so we've got children with both a one and 8 KZ threshold and when we looked at the correlation they actually correlate quite well so most of the hearing losses that we're looking at are probably flat not just high frequency but adding in this high frequency information is really helpful okay and then so if we go ahead and we kind of uh group that down into type of hearing loss and then degree of hearing loss you can see that and this is based on the ABR at three months you can see that overall only 68% were completely normal we had 18% that were classified as sensory neural and we used their bone conduction ABR to help classify that as well as the wideband reflectance tonometry and then we've got 12% that were conductive okay you can understand that might not have been picked up with newborn screening because maybe it wasn't present at birth but came on later because this is at 3 months so they can start you know having otitis media or maybe they had fluid because um babies in the Nicor at higher risk for otitis media as well and then 2% we weren't able to determine because we didn't have good bone conduction on them so we're not sure if that's conductive or sensory neural um so pretty high rates of of hearing loss and if we look at the degree of loss you can see these are the ones that I was talking about like that iceberg that under under the radar you know this 19% slight hearing loss newborn screening isn't designed to pick that up um but nevertheless it is a hearing loss mild hearing loss in 10% again some of those may not have not been picked up the moderate to severe we would expect those to be picked up with newborn screening so that actually correlates pretty well with the 5% who didn't pass newborn screening okay I had me mentioned earlier that we're doing this EEG to speech syllable so I want to tell you a little bit about how that works we're using ba and da stimuli and we're getting an overall cortical response to each of those syllables so for BA and for da and you can see the sound spectrogram for them here they differ only of course in place of articulation so the vowel is the same um and they also differ in voice onset time um but they're both you know voice consonants um and then we have what's called a mismatch response this has been studied and it has been shown in some studies but not all to be predictive of later L language outcomes so because it's not always predictive we didn't want to hang our hat just on the mismatch response but we're doing that in addition to an overall cortical response what the mismatch response shows us is the difference between the ba syllable and the da syllable is right here here and you get this in infants you get a positivity that the brain has recognized oh I'm hearing something different I'm going to respond to that differently and so that's what we're really looking for with this mismatch response as part of that we did a very simple analysis first this is our first set of results um we're not done analyzing the mismatch response yet so I don't have those results to show you yet but we did something simpler which is looking at what's called resting state EEG so this is before we give any um stimulus so before we do the syllables but we're looking at different frequency bands in terms of how the brain overall is responding or is you know sort of wired and the lower frequencies are Delta and then as we Step Up Theta Alpha and beta are different bands in that overall EEG energy that we're getting from all those electrodes and we look at something called relative power and what we find is that um we found a correlation with the degree of hearing level by AB so this is at three months of age so basically the poor the hearing the higher was the Delta energy which is an abnormal signature of brain energy and we see that more often in babies who were born preterm where the Delta energy is increased the high frequencies were actually decreased so it went the opposite way when there was hearing loss and this has been shown in kids with more severe hearing losses but to our knowledge it hasn't been shown before in these really mild degrees of hearing loss now it's it's not a huge correlation but it is significant even in a relatively small sample size and we're seeing it across all of the Bands um but especially the beta the very high frequency band and the Delta the very low frequency band so that it's this inverted sort of response so what that tells us is that already at three months of age the brain is reacting differently when hearing loss is present um so in summary at three months of age what we found was that 27% of these babies who were born preterm had moderate um to severe brain abnormality 32% had conductive or sensory neural hearing loss but most of these hearing losses were slight to mild in degree so they wouldn't normally probably come to your attention they wouldn't be fit with hearing aids um even children that have mild hearing loss often are not receiving amplification even though we really feel they should be 89% of these hearing losses were not detected by newborn hearing screening and we found that this hearing loss even though you know we've talked about it previously as being minimal hearing loss it is related to um to neural um activity at the same age we don't know how it's going to look later or if it's going to be predictive of those later language outcomes but that's what we're intending to look at so so far these results reinforce the jci recommendations to followup babies who were cared for in the ncu for more than five days even if they past newborn hearing screening so that's that's not new but but it certainly reinforces that um okay so then at two and three years of age I'm going to talk with you about the older cohort um who we weren't able to do ab on at Birth but we're now doing behavioral on and we finished up all of our results at two and three years of age so I have a complete set of data to tell you about here and we also have language so that's exciting so I'll show you how we do um testing um using condition play audiometry I am it's saying my internet connection is unstable so I hope my voice is okay um someone please tell me if it's not um so we we have the a child in the high chair usually if they need to be in Mom's lap we'll do that but we really like to have them in the high chair so that we can kind of control the situation and have the child just focused on that so the parents not having to to do both um and I'm a big believer in always getting ear specific results whenever we can but if if we have children who won't tolerate ear phones of course we'll do soundfield usually then by three years of age we're able to get ear specific results but we go through this training and I'll just show you what that looks like here and I want to make sure that I am sharing my sound before I do that so that you will be sure to hear it well and let's just do a little sound check and maybe Peter or someone can tell me if it's okay listening for the birdies in terms of the sound do a little bit more listen for birdies not yet there's the birdies did you hear them good job a chy let's Okay let's listen for the birdies again can you hear the birdies can you hear the birds put it in Yay good job and pink and yellow Okay pink and yellow so that's the basic technique that we use and this little one she's pretty sassy but she's really good at doing the job even at this age at two years of age with condition play so we will use V if we need to if the child isn't as developmentally able or we'll use addition play and then we do this in between one which is where we'll still use V but we'll use the motor tasks to reward them because a lot of times the two-year-olds are hard to test because they just want to get in there and do it they want to play the game and so we'll use the game as the reward rather than expecting them to do it if they're not quite developmentally ready like this little one was we can use that in between if that makes sense like a combination of v and condition play and I know all the Pediatric audiologists in the audience say yeah that's what I do too okay L for the bir a lot of adaptations for different developmental needs because a lot of these children have different needs a lot of them have visual loss or they have Motor problems um or some of them have autism spectrum disorder and other issues that make it more difficult to find a good way for them to respond and so one of the things you can do is a picture exchange system or PCS to help for communication if the child is developmentally delayed or delayed in speech and language for those children who have a lot of anxiety or who have autism spectrum disorder a social story book can help prepare them for the clinic visits and help decrease their anxiety and improve the results so those are all techniques that we we can use I am a big fan now of condition play audiometry on a tablet this is something that was developed by Children's Mercy um and they've done a wonderful job at putting together not only the ability to test spides or different words as shown here but all kinds of other condition play audiometry scenes and if you're working with kids who have hear um hearing aids or Coke implants and you need something more engaging and you know that they can do over and over and over again you can use this because they the child can select the scene they want and then when they respond they get a different part of the scene that comes through each time and so it's really motivating and rewarding where works really well from about age three and up um and I think it'd be a great therapy tool too because there's lots of different naming that would go on in different categories like for the farm or for the fish and so forth so it's great for that use as well and a lot of kids love it here's an example of using that tablet with a little boy who's three who has cerebal py so because he doesn't have great trunk or head support he needs the wheelchair that he's in so we will test the child in the way that works best for them and we're doing again here the insert earphones and this is Veronica or research coordinator working with this little guy oh where's that one popcorn no she didn't say popcorn we're going to listen again and see what word Miss Lisa says yeah you heard her go ahead and tap it popcorn oh there you go great job he's still able to do that and he found this really rewarding and he uses a communication board a lot so kids are often familiar with it and it works well for them to to do that when we're testing okay so here are some results from our two to three year olds um for 128 children where we were able to get results um and we were able to get results on 95% by the age of three um so using you know these techniques and just having enough time to work with them bringing them back for an extra visit if needed was really successful for us um and what you can see over here for the audiogram um children that have normal hearing classified as better than 15 DB they have really normal hearing like you can get very good thresholds on these children even at Age 2 to three it's a little bit elevated at 1 ktz but gets better with higher frequencies and this exactly matches up what we've seen developmentally from older studies that have looked at hearing thresholds for young kids um the ones that have hearing loss obviously a lot more variable these are very slight to mild hearing losses overall um and then if we look at how that correlates with oo acoustic emissions as a cross check you can see what we would expect to see that the ones with um normal hearing have much better AO acoustic emissions as shown here in blue so higher is better here the opposite of the audiogram um and the ones that have hearing loss have much lower oo acoustic emissions and especially in these high frequencies around 8 kilohertz and so forth so we're going to be interested in looking at these oae results related to some of the risk factors that they've had and then um the wide band abs absorbance technique that I talked about for detecting conductive hearing loss what that shows is that it's a very broad frequency range where conductive hearing loss has an impact and similar to when we look at hearing we're finding that the low frequencies and the higher frequencies are the most affected at this age with relatively less of a difference between the conductive ears which are in orange and the normal hearing ears which are in blue and the really cool thing is that if we compare that to bone conduction what we find is better than 95% um performance for detecting conductive hearing loss with this technique and that's really important because it can be very hard at this age or in the younger age to especially with these really slight hearing losses to differentiate between conductive and sensory neural loss I really think we should be doing this at the time of newborn screening it's a technique that could be incorporated along with an oae so that we would have less of that limbo less of that uncertainty about whether we were dealing with a a permanent hearing loss that needs immediate intervention or whether we're dealing with a conductive loss that might be temporary and needs medical treatment first before we go forward so for the two to threeyear olds this is the summary of hearing loss we actually have a pretty similar proportion that have some degree of hearing loss compared to that thre Monon time window but there's an important difference more of the kids at two to three years of age had conductive loss then did sensory neural we had 4% sensory neural losses which is still pretty high um but most of the losses that we found were conductive so why is this different from what we found at three years of age we're not sure this is what we're trying to delve into and find out about um and you can see the degree of loss over here is kind of similar most of them sorry most of them are slight to mild um a few are moderate um no severe ones um and then some that were un unknown um see let me get this window out of the way oh undetected hearing or unknown degree of hearing loss in 2% because we couldn't get full results um so pretty similar in terms of the percent that have hearing loss pretty similar in terms of degree but kind of an open question about the sensory neural versus conductive loss now these are two different cohorts so one was again was enrolled pre-co one was postco I'm not trying to say this is anything to do with covid we don't know that yet um but there could be differences in the in the cohorts that we'll be looking at um it's a different technique ABR versus behavioral um it could be that some of these kids had um hearing loss that was just skating on the on the The Edge and then maybe over time medically they improved that seems unlikely with with a sensory neural loss but all of those questions are something that we'll be looking into further um and the really important thing that we're trying to detect is our language outcomes so at two years of age it's a very hard time to get a really thorough language sample but what we're doing is something called the communication and symbolic Behavior scales or csps this is a direct standardized assessment but it's really geared to young children and especially the pre-term population because it's very naturalistic so you can see this little boy over here that's sitting down it's the child just thinks they're playing a game they have no idea they're being tested for language um this little one is being given to zoo what we want to know is do they understand how to use toys can they follow directions and then any verbal language that they have it's all recorded so it takes about an hour um we record every word every syllable that they say takes two to three hours to score it so we have this whole big group of graduate students who's helping us with that um but it's a very in-depth sort of assessment that looks at non-verbal as well as verbal communication so it it allows for a range of language performance in children who are delayed in using words and one really cool thing that we have found and this is Lauren's doctoral thesis is that our preliminary results so far when we compare white and black children we find exactly the same performance um no difference based on race and this is I think the only scale that we've seen where we didn't find a difference based on race so some of the other language measures that may have more racial bias in them may show more of a racial difference but in terms of language and communication abilities at this two-year age we did not find a difference between the children in our study who are white or black and then but we what we did find is um a real relationship between hearing level and language scores using the teld or the test of early language um um development at age three years so we've got our twoyear and our three-year language and when we look at our three-year language so longer term compared to the hearing levels at two to three years um what we're showing here is the hearing levels for both years averaged um from you know Z up through 50 DB compared to their receptive language and compared to their expressive language and these little graphs up here show you the hearing levels you know kind of that bell-shaped curve and then the language scores and what we're finding is a significant relationship between degree of hearing and language scores but what's interesting is that we have these cluster of kids down here who despite having normal hearing have really poor language so obviously hearing isn't the reason but there's something else going on so this is going to require looking at multiple factors to find out what's predicting these language abilities um and we did find that even when we controlled for um what we call social risk score so that's parents education um their um their U zip code where they live um and so forth that these um relationships between hearing and language held firm term so um it was not explained by social risk factors so in summary for the two to three year olds um we found 20% of cases had conductive or sensory neural hearing loss um 5% were incomplete so the rate could be higher than that um and the mild hearing loss was related to language outcomes at three years so again reinforcing the need to continue hearing followup longterm for these high-risk kids and also to look for conductive loss because that seems to be common out to age three years in this pre-term population so I want to talk a little bit about management strategies in the time that I have remaining um so this is one I came up with this silly acronym called here um so I'll take credit for that for that um but um this is management of infants with mild hearing loss so the first thing that's important is for parents to understand this hearing bubble I know you talk a lot about that with kids with more you know higher degrees of hearing loss but whenever they can communicate with a baby at close range that's so much better so spending onetoone time with a baby like is shown here with this Dad um and maximizing language and repetition while they reduce background noise so turning off TV turning off radi radio or other machines getting into a quiet room to have that that story time is so important enhancing the speech environment so this is a very family centered kind of approach um there's good evidence for what's called parentes so the way that we talk to young babies is very very helpful for them um in terms of learning language teaching parents about dialogic reading which is the conversational more storytelling approach as opposed to just reading the book as it is expanding on it bringing in more vocabulary watching for the child's interest what they want to focus on um and this you know in a therapy approach could be monitored for synchrony with a Lena device where we're looking for how much are the parents talking to the kids and help them to understand the more they talk to their children the better their language is going to be um amplifications should certainly be considered it doesn't have to be hearing aids especially for slight to mild loss we could try sound field or body warn speakers these were more simple more inexpensive especially for parents that may be reticent to use hearing aids for these children that have slight to mild loss um could consider personal hearing hearing aids especially if there's hearing loss across the board flat you know flat hearing loss across frequencies we should also consider remote microphones worn by caregivers whether that's FM Bluetooth or other means this is especially suited for infants with mild hearing loss who don't need lots of amplification and there's good evidence for efficacy even for children who have normal hearing but have language learning problems so I want to show you um a program that's in niku at at Cincinnati Children's Hospital um I'd like to do a little Shameless plug because just this last week um in the US News and World Report we made it to number one in children's hospitals in the US so we jumped over Boston and Philadelphia right to number one and we couldn't be more thrilled about that of course um and I'm even more thrilled for my neonatology colleagues because the neonatology department was also ranked number one in the nation in this last US News and World Report so with that I want to show you this little video that was put together by some of our uh reading and Pediatrics colleagues do you like Green Eggs in H with every word I do not like them Sami am and every touch parents at the newborn intensive care unit at Cincinnati Children's are helping their babies in a number of ways I like to watch his reactions even though I know he's Young but it just seemed like he reacts to the things that I say when I read sometimes sometimes he jumps when he's awake a new literacy initiative called The niku Bookworm program recently launched to help parents learn about the importance of reading to their babies soon after birth the current Trend in in brain sciences that is to really go younger and younger you know we're learning that the most rapid stage of brain development is in the first 5 years and and even in the first couple years I mean that's when the brain pretty much doubles in size you know there's there's really really robust connections going on so all these things are responsive to stimulation whether it's from being held or or hearing language and you know as far as books I mean that stimulates um the brain in all kinds of ways it makes it feel like home I'm sorry yeah it just makes me feel like a little more home like Al it takes you away from all the medical stuff and the fact that I can sit here on the little Hospital couch and have it feel not like aital hospital for 5 minutes is great there's the red bird you love Cyrus red bird Redbird what do you see I feel like we're really making a difference I love to read I'm an Avid Reader and wanted to pass it on the girl I choose is just as sweet as a delicious reading and sharing books also creates a bonding experience during what can be a difficult an emotional time getting that Comfort level is really important part of it is the reading development but part of is the interaction between the parent and child and and for many families that's 15 minutes of special one-on-one interaction a book once a day can be a very powerful thing you give the best hugs in the whole wide world we Crown you nail with ribbons and berries and name you the princess of all the fairies p in all right so with that I just want to say thank you with my favorite type of dog a golden retriever um and I hope we have a little bit of time for questions thank you Lisa that that was uh fabulous and we do have a few questions in the chat and um I'm going to read them out for you um if you have your chat up you may be able to read along but uh the first one I would like to uh refer to to read out is what auditory intervention in those with mild hearing loss and would you recommend for children with mild hearing loss and how do we get the pediatricians and parents on board probably because most parents would not understand the importance when they don't see that hearing loss in their child yes that's um that's sort of what I was alluding to earlier when I I talked about those different ideas for intervention so I think you know the H the hearing bubble the enhanced speech environment that should be done with every child you know actually whether they have hearing loss or not this is the best way to parent children but especially for those that have hearing loss if they don't do anything else if they would do this type of and really focus on it and make sure that they're spending time every day one to one with that child in that close environment quiet turning off everything else and if they understand that the more that they do that and the more language they get in at close range the better it's going to be for that child so some parents don't want to use personal amplification um when it's I think it should always be offered um when there's there's mild hearing loss but some parents aren't aren't ready for it but they can do these other things um and this idea about you know soundfield there's some things where it's sort of like a little speaker and if they would have that on when they're reading the CH to the child and that's you know a type of remote microphone that they can wear even if they're not using personal hearing aids they can they can use that type of amplification device and those are relatively inexpensive and so talking with an audiologist about trying some of those things and the audiologist and the audience you know please think about it you know what can you do that will help parents to accept amplification more readily to use it with these more slight to mild hearing losses when they are detected especially when there's you know conductive loss you know the we had we didn't have children in our study who had like down syndrome or cleft pallet but of course they're going to be having hearing loss over and over and over again so using something like a soundfield sort of system can be can address that without you know the problems that happen when you're using personal hearing aids especially when there are PE tubes and drainage and that kind of thing thank you Lisa that that's really important and U thank you for emphasizing that and and again it's another example of how interventions or activities that we can do with infant that help children with hearing loss in fact help every every child of that age um to to grow and develop to their maximum potential so so that's really good another question that came up is can you clarify if the assessment dates uh that you use in your study particularly for the earlier age points like three months are they for with gestational age or are they for corrected age yeah I'm sorry I didn't make that clear um they are corrected for gestational age even all the way out to three um and that's based on you know um recommendation by our neonatologists that children continue to have that correction for gestational age through at least age three okay great super we have time for a couple more questions that are in the chat and one of them is did you um control for any participants that are born with congenital DMV infection so um I am not aware that we have um children that were diagnosed with congenital CMV but we know that they must be there um and so that's information that we're collecting is whether there's any intra intrauterine infection including CMV that was detected we haven't yet analyzed for that um we have looked at um whether they had oot toxic medications whether what type of ventilation okay I'm sorry Lis but we we have to end here everyone please thank Lisa that was a fabulous talk and presentation to the Symposium to kick it off and uh so great and I will be catching up with you later Lisa okay have a great suppos everyone thank you