The better to hear you with

A visiting expert tells Judy Siegel-Itzkovich that fitting hearing-disabled babies with hearing aids can ensure normal functioning.

By JUDY SIEGEL-ITZKOVICH
hearing aid 88 (photo credit: )
hearing aid 88
(photo credit: )
Six out of 1,000 newborns are at risk of a hearing impairment or total deafness, and the earlier they are identified and provided with hearing aids or cochlear implants, the more normal their lives will be. Yet such screening, which takes a few minutes but requires hi-tech equipment and a professional interpreter, are not included in the basket of health services, although some hospitals provide the service at their own expense or thanks to contributions. Earlier this month, Prof. Shane Moodie - a clinical supervisor in audiology at the University of Western Ontario in Canada - came here for the fourth time to advise audiologists about setting up newborn screening programs. As the state has not taken responsibility for the service, his visit was sponsored by a voluntary self-help parents' organization called A.V.-Israel (www.avisrael.org.il) and the Steiner company (that imports advanced hearing aids). The Jerusalem-based organization was founded 12 years ago by Elaine Matlow Tal-El, mother of twin daughters diagnosed as profoundly deaf at the age of two. Moodie, whose research focuses on diagnostic and amplification strategies for children and adults, was interviewed by The Jerusalem Post at Jerusalem's Shaare Zedek Medical Center where he was meeting with audiologists about its new screening service. Lobbying by A.V.-Israel has been credited with persuading the government to include cochlear implants in the basket of health services. It also runs a clinic in Ra'anana for testing and fitting of children, named the Dr. Daniel Ling Speech and Hearing Center. "AT ONE time, we had a fairly large number of referrals from Israel, England, Mexico and from all over the US and Canada, but things have changed because services have improved in other places," said Moodie. "Testing babies on the day after their birth and fitting with hearing aids before the age of six months of age is the best policy," he added. Infants who would not be helped by hearing aids are referred for cochlear implants. Most of the US states and Canadian provinces, as well as the United Kingdom, have made such testing mandatory, unlike Israel. Among the Israeli hospitals that have set up their own programs are the Hadassah University Medical Centers, Sheba Medical Center, Bnai Zion, Schneider, Soroka and Shaare Zedek. MOODIE INITIALLY knew nothing about the subject. "I studied sciences, chemistry and physics, but then ventured into audiology as I was looking for a caring profession and a physiotherapist friend got me into it." Moodie started off in a children's development center. "I was frustrated by our inability to assess hearing problems precisely, and not knowing when to fit children for hearing aids 25 years ago. The technology today is entirely different. If you had asked me 25 years ago what we'd be doing now, I would never have guessed," said Moodie, whose wife is a research audiologist. "At first, we could test using only pure tone signals, but now there is digital processing, and we can analyze what a hearing aid is doing, how it amplifies speech in a baby's ear. We developed techniques for fitting adults as well, but children came first. An adult can tell you what's bothering him, but a baby can't." LING, THE man for whom the A.V.-Israel Ra'anana clinic is named, was then dean of the University of Western Ontario's applied health sciences, and came to assist with the auditory verbal therapy needed to fit children with hearing aids. He brought Dr. Richard Seewald, then the world's leading expert. Under their tutelage, Moodie became an authority and made his university one of the world's leading institutions in the field. Newborns are tested not only using evoked potential audiometry, but by physiological risk factors assessed from family histories. About 8-10% fail, but that doesn't mean they will all have hearing problems, said Moodie. "Many are normal. Accuracy depends on the sensitivity of devices, and to make it 99% sensitive, the cost would be very high." There are more newborns at risk of hearing disabilities today, Moodie explained, as "we have more kids surviving trauma at birth who in previous years wouldn't have survived. Most of them were premature and have a fragile neurological condition. "Due to the plasticity of the young brain and its need for stimulation by sound, early diagnosis and treatment is key, as such children grow to achieve much more academically, socially and vocationally," noted Moodie. "This saves a huge amount of money on social services; early screening and diagnosis are very cost effective." During the first few months, infants can't put on hearing aids, and their hands can't find their ears. Later, wearing them becomes second nature. "Parents must be diligent, as they are delicate, expensive devices. I have never heard of a child swallowing a hearing aid, but some may throw them into the toilet or washing machine, or a family dog may chew it," Moodie said with a smile. Hearing aids cost about $900 in Canada or the US, but in Israel the cheapest model is NIS 8,000, and others run as high as NIS 15,000. This is without the constant cost of batteries. Health funds partially subsidize aids once in three years, but this doesn't cover the real expense. RICKI SALOMON, a young audiologist at Shaare Zedek and part of the team setting up screening for babies, said the hospital's otolaryngology (ear-nose-and-throat) department started performing cochlear implants and has an audiology clinic for adults. Hearing tests are performed at tipat halav (well-baby) clinics in a much simpler manner (noises are made with cellophane behind the baby's back), but testing in the hospital is much more accurate. A cochlear implant is an electronic device - essentially a bionic ear - with an external segment that attaches by magnet to an internal segment surgically implanted in the inner ear. The external section contains a microphone and sound processor that collects sound data and turns it into electrical pulses, sending them via a wire to an external transmitter. This in turn transmits them through the skin to the internal receiver, which transmits them to 24-channel electrodes inside the cochlea (the snail-shaped structure in the inner ear) to stimulate the auditory nerve along a whole range of frequencies. Candidates for implants have a severe-to-profound hearing loss (cannot discriminate words) and don't benefit from high-powered hearing aids. Studies have shown that implanting these devices is among the most cost-effective medical procedures, ranking above interventions such as coronary artery bypass. THE EAR normally translates sound waves into electrical impulses, which the brain perceives as sound. Implants bypass the dysfunctional inner ear and mirror the natural mechanical-to-electrical translation - unlike hearing aids, which merely amplify sounds. Cochlear implantation is aimed at people of any age - from one-year-olds to octogenarians, born deaf, and those who became deaf with age or from injury, toxic reactions or noise. The implants work best for people who lost their hearing after they acquired speech, and are even more effective in those with recent hearing loss, but also work wonders for those born deaf, especially before the age of seven. "In some children," said Salomon, "low-frequency hearing is good, but not at high-frequency levels. When problems are picked up at an older age, they are much harder to cope with." Jozie Eisner, who lives with her family in Ginot Shomron and came to the meeting with Moodie, has a 31-year-old daughter with a cochlear implant in one ear and a hearing aid in the other. Today a mother of four, the daughter was diagnosed at two and a half in Toronto, before the family came on aliya 18 years ago. Eisner's son, 28, who also suffers from an inherited hearing disorder, used to wear hearing aids but has just undergone a cochlear implant. An older son has normal hearing. Her hearing-disabled children were all mainstreamed in school. "Today, the sky's the limit. My daughter did national service, and my son is doing well. Now implants are provided through the basket of health services for adults as well; if parents had to buy them, they would cost $27,000 without the batteries," she says. "My job is to decide whether we can provide effective treatment with a hearing aid," Moodie said, "and what are the limits of a hearing aid's performance. If I think it isn't enough, we advise an implant. Some children may not benefit from an amplification device. There may be problems of neural integration so that the sound is understandable. Sometimes assessment takes months or years. Not all hearing losses are stable; some fluctuate. With babies, I see them every three months over a period of three to five years." Moodie advises the Israeli government to finance screening, and provide support for parents and the devices. Coordination is needed here. "I was brought as a consultant because I was trained in evidence-based skills. I have also seen some of the more difficult child cases, but that has not been my primary responsibility because I can't provide them with continuity of service. But I can share my experience with local pediatric audiologists," he said.