At least five million children aged under 18 live in Australia. Providing hearing care to those children who need it not only helps them and their families but can boost the performance of audiology businesses.
Hearing Australia is the nation’s largest provider of government-funded hearing services for children, providing hearing aids to those with permanent or long-term hearing loss, and caring for youngsters with cochlear implants. But independent audiologists also have a valuable role in the paediatric service landscape.
In fact, it’s an area private clinics are increasingly playing in: helping them become a go-to hearing professional in their communities while bringing a new dimension to their workday and a differentiating factor to their business.
About 300 babies are born in Australia every year with hearing loss, and two in every 1000 school-age children have hearing impairment.
Hearing Australia is funded by the Australian Government’s Hearing Services Program (HSP) to provide hearing services and devices to young Australians. Children with diagnosed hearing loss or a likelihood of needing hearing aids can receive ongoing services through the HSP, provided they meet eligibility requirements.
The organisation says it cares for about 14,000 children up to age 12 who use a hearing aid or cochlear implant and in 2022, its practitioners fitted more than 2,100 children from birth to age 12 with their first hearing aids. Each year 2,600 young Australians receive their first hearing aids before age 18.
For private hearing practitioners, detection and intervention for hearing loss is not the only way to be involved with care of children. Otitis media, auditory processing disorder (APD) and cerumen removal are other services they can successfully provide to this patient cohort.
Hearing screening at schools is another avenue to extend services to children by detecting cases that might have slipped through the net. Educating teachers what to look out for is also a valuable community service audiologists can provide and raises awareness of the clinic’s name in the wider community.
Knox Audiology – a shining example
Knox Audiology in Melbourne has provided paediatric services for about 30 years. Nearly half its patients are children, says chief operating officer, audiologist Ms Jane Louey.
“Paediatric cases make up approximately 40% of our caseload on average across all four clinics,” she says. “Each clinic is different based on demographics. For example, our Doreen clinic has a higher percentage of paediatric cases based on its location in the northern growth corridor which is a popular region for young families.
“This has remained constant during the seven years I’ve worked here. Changing from bulk billing to a private billing model probably offset any increase in demand that may have occurred over the past few years.”
The business provides neonatal assessments for newborns needing follow-up assessment after hearing screening in hospital who are not referred through the Victorian Infant Hearing Screening Program.
Knox Audiology Wantirna does non-invasive testing ideally while the baby is resting or asleep, measuring their hearing ability with auditory brain stem response (ABR) tests and auditory steady-state response (ASSR).
Auditory processing consultations, assessments and therapy for children with APD is another service offered.
Diagnosis and referral for otitis media treatment also occurs. When middle ear complications arise, the team works with five ENT surgeons who support Knox Audiology as well as other referring ENT specialists in the local area. This includes monitoring hearing levels to assess whether treatment with antibiotics or grommet surgery has been effective and hearing is restored.
Early career audiologist Ms Vanessa Zhang has worked at the business since graduating from The University of Melbourne in 2022. She says the course covered a fair amount of paediatric audiology and in the short time she has practised, she’s noticed more independent clinics are taking it up.
“It’s important to offer paediatric audiology because hearing impairment affects children’s learning, speech and language development and their global development, health and wellbeing,” she says.
“If anything is concerning such as an ear infection or long term cold or flu that’s caused a bit of blockage in the ear, nose and throat area, that can impact on how they’re learning. It’s important to have services like this in the suburbs where people live.”
Other benefits of seeing children include building a relationship with their parents and entire family who may then return for hearing issues.
“We’ve had a couple of cases where it was initially the child who was the patient and while I was presenting tones and sounds, the parents or grandparents noticed they didn’t hear them,” she recalls. “I suggested it might be a good idea for them to think about a hearing assessment and they’ve been followed up with hearing tests and are being monitored.
“School and kindergarten teachers seem more aware of conditions such as APD now and often suggest to parents that children are assessed.”
Pre-covid, the clinic’s audiologists often did screening at primary schools and kindergartens and hearing education for teachers, she says. The clinic hopes to do more hearing education for teachers in the future.
The practice also posts blogs on its website about hearing issues from newborns to teens as part of its community education. “If a parent has a child with hearing concerns, having something that’s easy to read, instead of medical jargon, is best,” Zhang says.
“We mainly focus on diagnostic hearing assessments for children (rebatable through Medicare with a GP referral) and babies referred for further assessment after newborn hearing screening. We refer children needing hearing aids to Hearing Australia and do a lot of APD diagnosis and therapy, offering auditory processing assessments for children aged from six years up.”
APD testing and therapy
The clinic offers nine different tests for APD depending on the child’s age and attention. If the diagnostic assessment is long, audiologists split consultations and continue later that day or on another day. Initial treatment of in-person therapy extends to using iPad apps for brain training video games that can be done several times a week at home.
Knox Audiology audiologists have undergone training with the Auditory Processing Institute to enable diagnosis and treatment.
Assistive listening devices such as wireless technology and FM systems for children struggling to hear in class are also provided. These wireless amplification systems ensure the teacher’s voice is picked up by a small microphone worn by the teacher and transferred directly to the child so they can hear clearly and understand accordingly, or via a speaker which benefits the whole classroom.
“The teacher’s voice is streamed directly into the child’s earpiece to reduce background noise and distraction,” Zhang adds. “We allow the child to trial the system in class first before deciding.”
National Disability Insurance Scheme (NDIS) funding can sometimes be used for APD assessment and therapy, and assistive listening devices at school, but this depends on circumstances, she adds.
Otitis media and grommets
“We do a lot of middle ear testing and tympanometry to tell us what’s happening with the eardrum and if there’s congestion or fluid buildup consistent with otitis media,” Zhang says. “If we see a child maybe twice and both times there’s fluid and congestion, we recommend they return to their GP for an ENT referral.
“Pre-grommet testing helps medical professionals decide whether the child could benefit from grommets or whether otitis media can just naturally resolve. Post surgery, we do checkups every six months until the grommet comes out and after that regular checkups to monitor hearing and the middle ear in case fluid returns.”
Gold standard tests for subjective audiometry including VRA, play audiometry, speech audiometry and pure tone audiometry are done. APD screening and assessments provide additional information for children whose listening difficulties cannot be explained by audiometry alone.
Zhang says paediatric cases provide variety. “It breaks up the day, I enjoy it as it’s rewarding to see parents’ faces before and after treatment seeing their child can hear better.”
Working with children can be challenging though and practitioners must be patient and resilient, she cautions. “Even though you have high standards and try to get every single result and threshold, it’s OK to sometimes take a step back and say, you may not get it all this time because the child’s unwell or won’t sleep. It’s OK to get it next time.”
The room also requires a different configuration for paediatric testing of young children, she adds. Children aged over seven can have the same set-up as adults but younger children, aged three or four, need a small table to play with cards, toys and pegboards so they can hold on to something, rest their elbows and focus.
From around age three, children can wear headphones and have hearing assessed with play audiometry which teaches response to a test tone by putting a peg into a board. For those aged one or two, the room must be calibrated to where they’re sitting, on their parents’ lap, for example. Visual reinforcement audiometry featuring a puppet is used to gauge hearing. Speakers are also required.
Many clinics also perform otoacoustic emission testing on babies and older children which involves placing a small probe into the ear canal for a minute or so and presenting a tonal or click stimulus.
Hospital care
Ms Tamara Veselinović is a paediatric audiologist who works at Perth Children’s Hospital and the Djaalinj Waakinj Centre for Ear and Hearing Health, a centre which improves access to ear care for Aboriginal children in the metropolitan area.
She is also a PhD student with the Ear Health team at The Kids Research Institute Australia (formerly known as Telethon Kids Institute) and the University of Western Australia where she is an adjunct clinical lecturer.
Working in a research setting, with Aboriginal families and with a multi-disciplinary team in hospital, she had to learn extra skills.
“The patients aren’t just ours, we’re trying to make a plan for them, so we work with Aboriginal Health Workers, ENT surgeons and speech pathologists to devise a plan for the child’s developmental needs as well,” Veselinović says.
“In the hospital we see any child referred, which can include referrals from GPs, ENTs and speech pathologists in the community, as well as general paediatrics, rehabilitation, neurology and oncology departments in the hospital. As there are many reasons a child may be born with or acquire ear and hearing problems, there is wide case variety within the paediatric audiology setting.
“We see children referred for syndromes, those with genetic risks of developing hearing loss and children who fail their newborn hearing test but then pass who we monitor to ensure it isn’t something that we didn’t pick up.”
The hospital audiologists monitor children with certain viral infections early in life such as meningitis as they potentially could develop permanent hearing loss. Additionally, they monitor children who sustain injuries, specifically head injuries, head knocks or concussion which can damage the cochlea.
“We also seen children with tinnitus, which is often challenging as it is difficult to explain to a child why they have ringing in their ears but when you do you can ease those nerves in the parents as well as the child,” she adds.
“We work closely with the ENT department as we’re next to each other so we bounce cases off each other to figure out the best plans.”
The cartoon character Bluey is a popular aid on an iPad as a visual reinforcer during paediatric hearing tests.
“I love the work. It’s complementary to my personality and it’s fast paced; you have to think quickly because if you lose the attention of a child, you’re not going to get anything,” Veselinović says.
“It’s challenging but equally rewarding; you get the opportunity to work with different disciplines and learn from each other, which maybe isn’t always the case working independently in adult audiology practice.
“You don’t always get a ‘thank you’ from the patient – they might be screaming and crying but the hospital is associated sometimes with bad things so we have lots of toys and our clinic is colourful. Every audiology booth is a different theme and colour and the kids enjoy that.
“While alot of the basic equipment is the same as in independent audiology clinics, we also have more advanced and comprehensive pieces at the hospital to perform diagnostic testing. For example, we do electrophysiological testing of the Auditory Brainstem Response in infants and balance testing using vestibular testing equipment.”
Encouraging more into paediatrics
Veselinović personally believes that every audiologist should be equipped clinically to see children.
“We have that skillset but it’s whether you enjoy paediatrics because it can be challenging,” she adds. “We probably need more paediatric audiologists.
“In WA, most paediatric audiology is done in the public healthcare system although there are a few private paediatric audiologists with their own clinics but compared to private adult clinics, there’s a huge difference.”
The Perth Children’s Hospital audiologists work closely with Hearing Australia and refer children with hearing loss to the organisation for hearing aids and cochlear implants.
Veselinović believes that in future, the scope of practice will extend more for paediatric audiologists to manage grommet cases post-surgery because of the volume of cases,
“Having audiologists manage grommet cases post-surgery will alleviate the burden on the public health care system because it will free up time for surgeons to do surgery,” she says. “Audiologists have enough experience and are well trained to know when the patient’s’ ears are good and when they need to see a doctor.”
Research she was recently involved in found that 75% of children who were followed up by an audiology-led clinic did not need an ENT to review them post grommet surgery.
Only 25% had to be escalated for an ENT to check.
“In paediatric audiology, we still have quite a few challenges and barriers because we work with a diverse range of kids, particularly in hospital settings, kids who are difficult to test so if we find better ways to do that, that would be amazing,” she says.
“When babies have to be tested, if they have severe, profound hearing loss, they have to be asleep and for other tests they need to be quiet but kids often cry so we have logistical behavioural things that we need to consider.
“Sometimes it makes it difficult to get results. You have to be extremely patient but we’re constrained with our time because we have patients booked in. If you don’t get anything, you bring them back in and sometimes the journey is very long to get a confirmed diagnosis because we have a small child who doesn’t want to be there.”
EarGenie aims to revolutionise assessments
This is where Professor Colette McKay, the Bionics Institute’s principal scientist and leader of its translational hearing program, comes in. Prof McKay is developing better paediatric hearing tests and innovative ways to fast-track early intervention for babies, infants and young children with hearing loss.
The EarGenie® system, developed by her team and NIRGenie, a spin-off company funded by the Bionics Institute and The University of Melbourne, could revolutionise hearing assessments for these youngsters.
Prof McKay hopes it will gain FDA approval in the next two years and be available in audiology practices soon after.
She says it may eventually allow audiologists to tune hearing aids and cochlear implants accurately from the start, allowing babies, infants and young children to hear vital sounds giving them the best start in life.
The non-invasive and harmless brain imaging system for detecting auditory responses uses light – a technique called functional near-infrared spectroscopy (fNIRS) – to measure the brain’s response to sounds.
It started as a research ‘bonnet’ with lots of cables connected to computers and has developed into a prototype headband containing light sources and detectors.
The Velcro headband wraps around the child’s head and connects to a laptop via Bluetooth. When the brain responds to a sound, there is a change in oxygen level in the brain detected by EarGenie.
These changes indicate whether the child has heard the sound and if they can differentiate between different sounds, known as discrimination.
“It’s similar to the blood pulse oximeter clipped on your finger in hospital to measure oxygen levels but this is like a pulse oximeter for the head,” Prof McKay says. “When a child hears a sound or distinguishes between two sounds, that oxygen level changes, and we can detect that in the signal.”
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