All Ears: Part II

All ears! Part II: The how and the why of hearing evaluation

In the first part of this article, we saw how complex and multi layered the process of hearing is. Owing to these multiple stages and levels, it is essential for hearing tests to rule out problems at all of these levels. In an adult, one can often reduce the number of tests to one or two because the adult can verbally describe symptoms in detail, which helps the clinician narrow down to the diagnostic tests required. In a baby, however, this cannot be done. Hearing evaluation for babies would therefore, consist of a battery of tests. Those used most often are listed below.

Hearing evaluation

Behavioral testing /audiometry

The child sits in a sound treated room, and sounds of different frequencies and loudness levels are presented through speakers or headphones. Responses to these are observed and noted.

Very young babies are observed during light sleep or while feeding.

Immitance / impedance testing

This is done to rule out any problems in the middle ear. This test requires the child to sit still, and takes no more than 5-10 minutes.

BERA testing (brainstem Evoked Response Audiometry)

This requires the child to sleep for about an hour. Electrodes are placed on the child’s head at various spots, and sounds are delivered through earphones. The electrodes pick up responses at the level of the brainstem. This test is usually done to confirm or add to behavioural observation findings, and arrive at a diagnosis as to the type of hearing loss (if present).

OAE testing (Oto Acoustic Emissions)

This test is used to detect the presence and function of the outer hair cells in the cochlea. It requires the child to be asleep and takes about 10 minutes. By itself, the test gives very little information, and should be combined with findings of other tests (at least BERA and/or audiometry).

Ideally, hearing should be screened (BERA, OAE) as soon as the baby is born. Based on this performance and other history (e.g. preterm, any complications during pregnancy, syndromes, etc.), the audiologist might call the baby for a re screening every 3-6 months. This is because some hearing losses might surface later, or are progressive. If a child does not pass screening, then the battery of diagnostic tests is done to determine the further course of action.

It is extremely important for a hearing problem to be detected as early as possible. Here’s why.

Importance of early intervention

As listed in the beginning of this article, one of the primary functions of the hearing mechanism is to detect and make sense of sounds around us. Even before a baby is born, it starts detecting sounds coming from outside the womb. After birth, these sounds become more meaningful. They come from somewhere, someone, or something. This marks the beginning of comprehension and learning.

When a baby hears speech, what it actually hears is a sequence of vowels and consonants. Each of these vowels and consonants has a definite frequency and intensity (loudness or strength). If the baby has a hearing loss, even partial, some of these frequencies are not heard at all. E.g. “Give me the shoes” is heard as “_i_   me __e __U.”

Such a child will have a gross delay in learning language and therefore speaking. Worse still, he may babble for a short period and because he can’t hear the sound of his own speech, he may cease to babble. Since he cannot make sense of or reproduce any of the words being said to him, he would start to communicate mostly using gestures or pointing.

Middle ear infections are very common in young children. A child who has a middle ear infection might cry incessantly, rub his ears and refuse to suckle. Even though conductive hearing losses are partial and reversible, they can cause the child to miss out on a lot of speech inputs, if not cured in time.

While the diagnosis of a sensorineural hearing loss might be difficult for parents to come to terms with, early detection and intervention can work wonders for these children. Introduction to hearing aids or cochlear implants before 6 months of age followed by regular auditory training and speech therapy might even allow the child to develop and achieve milestones like any normal hearing child.

It is therefore, extremely important to be as alert to the child’s hearing milestones as they are to their motor and speech milestones. Here’s a useful link:

http://www.asha.org/public/speech/development/chart/

If in doubt, always consult an audiologist and get the child’s hearing tested. Maybe it was a false alarm after all… maybe our baby just did not choose to attend to our incessant banter! Still, testing would only help us be sure, and at ease. And if in case it really is a hearing loss, we would be doing the best thing that we could possibly do as parents… giving our child the gift of sound as early as we can!

 

Written by Pallavi Kelkar, Speech language pathologist and audiologist

 

ALL EARS! How Hearing Works

Since the inception of ECDP, we have found parents reacting very anxiously whenever a hearing evaluation was recommended. We realized that this was not because they were not willing to face a potential problem, or that they were in denial. The reason for these reactions was that hearing has always been an enigma to the lay person, and we all have a fear of the unknown!

So the article that follows tries to describe in as simple words as possible, the hearing mechanism, its problems and their possible solutions. The article is in two parts- the first will cover how we hear, and the different types of hearing impairment. The second will go over the process of hearing evaluation, and underline why it is so important to intervene as early as possible.

All Ears! Part I: How we hear, and when we don’t

We wake up to an alarm. We often stumble but don’t fall. We speak clearly. We enjoy the birds chirping, come spring. We slow down at a sharp turn when we know there is a car approaching.

Wondering what these completely unrelated sentences are all about? Well, they have one indispensable factor in common….our sense of hearing.

While vision, taste and touch are easily tangible, hearing is a sense that a lot of us don’t know completely about. Our ears really serve all of the above purposes. First off, they help us hear our own speech and thus act as a feedback mechanism. The next, most obvious function is that of hearing the sounds around us. By virtue of this, ears often act as a signal or warning mechanism, to alert us (alarms) or protect us from danger (fire alarms, car horns). In addition to this, ears also have a parallel sub system for balance, which prevents us from falling, or sometimes makes us sick if it is overstimulated (too much time on an adventure park ride)!

How we hear

The ears that we see on either side of our head are, in fact, only a small part of the hearing mechanism, called the “outer ear”. The hearing mechanism is, in reality, extremely complex. An attempt has been made to simplify the process of hearing. It must be noted however that the descriptions given below are extremely basic, just for the purpose of easy understanding.

Outer ear

The outer ear mainly collects sounds and “funnels” them into the ear canal (the one ENT doctors clean for us). The ear canal ends at the eardrum, a thin membrane which vibrates when sound waves reach it.

Middle ear

The middle ear is beyond the eardrum, and is grossly shaped like a box. Ear cleaning devices cannot (or rather should not!) reach this part of the ear. It consists of three small bones, which form a chain connected to the ear drum at one end and the inner ear at the other. When the eardrum vibrates, so does the chain of bones and conducts the vibrations to the inner ear.

Inner ear

The inner ear has two parts- the cochlea, for hearing; and the vestibule, for balance.

These are both filled with fluids. The cochlea also has specialized cells for hearing, called the hair cells. The vestibule, similarly, has hair cells specialized for balance. These in turn, are connected to nerves.

When vibrations from the middle ear reach the cochlea, the fluids in the cochlea vibrate. This causes the hair cells to move, leading to hearing sensations being produced in the nerves. These then travel to the brain where they are recognized as sounds.

This entire process needs to take place for each and every shred of sound that we hear. No wonder then, that hearing problems are much more common than we think!

Types of hearing loss

While the causes could be as many as the number of steps in our hearing mechanism, hearing losses can broadly be classified into three types.

Conductive hearing loss

When the cause of the damage lies in the outer or middle ears, which “conduct” sound, it results in a conductive hearing loss. This type is often reversible (to some extent at least) through medicines or surgery.

Sensorineural hearing loss

When the cause lies in the inner ear, the loss of hearing is called a sensorineural hearing loss. The cause lies either at the level of the hair cells (sensory) or the auditory nerve (neural). This type is not reversible. However, with the advent of good hearing aids and cochlear implants, timely intervention can greatly minimize repercussions of this hearing loss.

Mixed hearing loss

As is evident from the name, mixed losses are those resulting in a combination of causes, in the outer/ middle and inner ears. Middle ear problems when ignored over a long period might also result in mixed hearing loss.

While all this information might be a bit intimidating for some, it must be mentioned that the ear is a very robust organ. It can protect itself from many causes of hearing loss, like from debris building up in the ear, or from sudden exposure to a loud sound. However there are certain causes of hearing loss which can strike before birth, and are beyond our control. This makes it extremely essential to assess babies’ hearing, and if there is a problem, act in time.

The next part of this article dwells upon what these assessments are, and why we need to get them done, as early as possible.

 

Written by Pallavi Kelkar M.A.S.L.P,  Speech Language Pathologist 

Wisdom Wednesdays: Why dal ka pani is not best to introduce solids?

It is a common practice to start weaning a baby with liquid foods like dal pani, chawal pani, vegetable soups, runny porridges, fruit juices, milky kheers and others. Sometimes these liquids are given even to a baby under 6 months old, because most mothers think that “I don’t have enough milk”.

However, this is a dangerous practice and it is best to avoid giving such liquids to a baby.

There are two main reasons why babies should not have liquid or very runny foods:

1. Liquid foods have very little nutrition. Liquid or very runny semi solid foods will simply fill up the baby and replace breast milk or formula and provide no nutrition to compensate. One of the main reasons why solids are started at 6 months is to get an additional source of iron in baby’s diet. There is no iron in dal pani, it is better to give thick dal instead.

2. Liquid foods do not contribute in any way to baby learning about different textures of food. When babies start eating food, they must learn to manipulate foods of various textures in their mouth. If babies are given liquids or purees for too long, they do not get enough practice with normal textures of food and may be reluctant to eat normal food.

Keeping both of the above reasons in mind, please do not give your baby any liquid foods at 6 months. Give thick purees that do not pour off from a spoon easily (if you are doing traditional weaning) or normal food that you eat (if starting with baby led weaning). 

To know more about do’s and don’ts while starting solids, do purchase our webinar on starting solids. The following topics are included in the webinar:

1. What are the signs of readiness for solids
2. What is baby led weaning
3. What is traditional weaning
4. How to progress texture of foods in traditional weaning so that baby is self-feeding normal family food by 8 to 9 months old
5. Why you should let your baby play and make a mess while eating
6. How much water to give your baby
7. What is gagging and what is choking
8. What to do if your baby is choking
9. How much quantity of food to give your baby

Email us at theyearlinghouse@gmail.com to purchase the webinar. Look at our video on what is a webinar and how to access our webinar here.

Happy Parenting

12/9/2015

Aparna

 

Sitting up: made to sit or come to sit?

Often parents wonder if their baby has achieved the milestone of sitting if the baby can sit well when made to sit but doesn’t come up to sit up.  Lets take an in depth look at sitting. The topic is too big for one post, so this is Part 1. Parts 2 and 3 are linked below.

When babies turn 6 months old, parents start thinking about the sitting milestone as it is synonymous with starting solids.  In earlier days, babies would be already coming to sitting at 6 months before the advent of the back to sleep campaign, bed and other equipment which has taken the focus off tummy and floor time.  These days, the number of babies are not coming to sit by 6 months is on a rapid rise.

So now we have a classic catch 22 situation. Solids need to start by 6 months for various reasons. If the baby hasn’t learnt to come into sitting by themselves, the only solution is to make the babies sit up because the recommendation for feeding is upright posture, not reclined. If your baby cannot come to sitting independently at 6 months, read our guidelines about making your baby sit up for solids here

In that case, we have 2 different ideas here: 1) Coming to sit from the floor by themselves and 2) Maintaining sitting posture and balance.

Both these ideas are different simply because the act of coming into sitting requires more strength, coordination and overall higher activation of brain while maintaining sitting balance is easier. Think of stacking blocks vs. looking at a tower. While you are stacking blocks, you need more precision and concentration etc, while once the tower is ready; all it needs is not be to be disturbed.

Let’s look at both these two ideas separately.  You can read about progression of sitting balance, once the baby is either made to sit or comes to sit in Part 2 of this series.

How do babies come up to sitting by themselves?

 Let’s look at the ideal way of coming to sit.

When a baby is placed on tummy since birth, they start to use their hands to push their head, chest and elbows off the ground by 4-5 months. The baby learns that they can move their bodies in various ways like pivoting, rolling and creeping. Enough practice (which differs for each child) of these movements automatically triggers the need to come to sit.

Check this video of a baby sitting up as described.

Ideal way of a baby to sit up on their own

As each part of the body from head to hip becomes stronger by pushing up on the floor from tummy, the next milestone automatically triggers. There is a range for each milestone to account for each child’s personality and environment. Some additional time is also allowed in case the exposure to floor was not sufficient.

When the parent makes a baby sit up before they can do it themselves, some of the pre-sitting steps automatically get less time to be practiced. Often times, this could lead to less use of hands for protection while losing balance, poor strength in shoulder which will have a huge impact in school and poor eye-hand coordination.

When should parents worry?

In terms of its timeline, babies should be coming to sit, from their tummy between 6-9 months. If there is no sitting by 11-12 month, then help is needed immediately. This is a big red flag. The baby will need intensive therapy to catch up if we wait till 12 months. If baby is trying to come to sitting from their back, please consult a PT right away. Do not “help” or “encourage” baby to do this movement.

So what is your baby is little over 9 months and still not sitting?  In  my opinion, if your baby is not coming to sit by themselves by 9 months, it is better to have a consult with a pediatric physical therapist to make sure all the pre-requisites for the movement are in place.

For example, if the baby is not even pushing up on palms at 9 months, it doesn’t seem likely that the baby will sit up soon. So it’s better to get some easy handling strategies to work on such pre-sitting skills so the baby does not need regular therapy sessions at 12 months. If you would like to consult us, we can be contacted at theyearlinghouse@gmail.com

Read the guidelines for making your baby sit for for solids in Part 3 here.

Happy Parenting

11/28/2015

Puja.

WHY MONITOR DEVELOPMENT IN PREEMIES?

Having worked with preemies babies straight out of the NICU, I can endorse the facts that there is so much more complexity to preemie development than any other. In many countries around the world, preemie babies are given special status, which means that they are automatically eligible for monitoring of development till they are at least 2 years old.

As an early intervention therapist and service coordinator in the US, I have followed many babies as soon as they come home from the NICU. Support for families include discussing how to take care of the baby within the home and family environment, how to inform other family members about the many do’s and dont’s associated with a preemie baby, how to create a development friendly environment and what to expect from preemie babies.

All families were followed by a service coordinator once a month and all five areas are tracked using parent questionnaires. As soon as a concern is noted or observed, simple environment changes are suggested to see if the baby will respond differently. If there is further need for intensive hands-on strategies, then services are provided accordingly. This system is put in place so we can monitor and track all at-risk babies and prevent any long term delays.

Families who are diligent from the beginning had higher chances of not needing any additional support after 3 years.  A lovely family I worked with had twin preemie boys. As usual, both babies were regularly screened and we picked up a delay in one of twins at the 3 months screen. There was a distinct lag in head control and we started with regular therapy sessions. At the 9 month check, this baby was at par with his peers. In fact, I remember that he walked 2 weeks before his brother did!

On the other end of the spectrum, I distinctly remember a child we were following right from the time she came home from the NICU. The family, for various reasons, decided not to pursue regular services after 6 months. At 2 years, when the child needed help with speech and problem solving skills, they came back to the program. If they would have remained within the regular monitoring system, there is a good chance that we would have picked this up sooner and the child would have shown some progress.

There are many possible outcomes of development in a preemie baby and it is impossible to make a guess of what will happen unless development is tracked closely. There could be multiple outcomes ranging from all perfectly okay to a diagnosable condition in a few years.  Since there is no way of predicting it, all we can do is keep a close watch and try prevention.

If there is one thing parents can take away from all of this, please remember to track your preemies development, not only growth. Growth is measured by height and weight while development is measured using milestones and skills.

While there is a general lack of awareness to track development in India, families with premature babies are hit the hardest! During NICU stay, families are overwhelmed by the medical aspects and bringing your preemie baby home in itself feels like a huge victory.

Please do remember that this is just the beginning to their beautiful lives. Track their milestones based on adjusted age and know that premature birth come with certain developmental risks that are visible later in life. Be aware and educated so IF there is need, you know what to do and where to go.

Happy Parenting

Puja

11/20/2015

Get Talking: Normal Speech Development

 Mom A: My child is two but still not talking!

Mom B: Oh don’t you worry… I know this child who didn’t utter a word till he was three and now he refuses to stop talking!

A conversation we hear only too frequently. So who do we listen to? How long do we wait? Is there any way we can help our child speak?

Before we launch into all these questions let’s try and understand the difference between “speech” and “language”.  Imagine a little boy who can’t hear since birth. He would not get any exposure to what we say and therefore would not know what to say. Another case is that of a girl who asks for a  “tate” instead of “cake” on her fifth birthday. The difference is that this child knows what to say, but is unable to execute it correctly.  The first case was that of delayed language, the second, of a speech disorder. It follows then, that speech is the output. Language on the other hand, is within us.

Let’s visualize now, a tiny baby, about a month old. He is armed with neither language nor speech, but he still manages to make us do what he wants. He does this through the third and most important skill, communication. This is the first among the three skills to develop, and stays with the child for life. Language and speech skills join in later, as the child proceeds through development from 0 to 3 years.

What follows is a list of things we can expect our child to do at different stages of development.

0-3 months

• Listening intently, stopping activity in response to sound
• Watching your lips and eyes as you speak
• Developing different ways of crying
• Cooing, smiling in response to speech

3-6 months

• Localizes sounds with accuracy
• Can understand emotions like anger, warning, happiness through the voice
• Can produce different vocal patterns for anger, displeasure
• Babbling alone and for communication
• Beginning to respond to their own name

What we as parents could do to help our child along, is use our face, eyes and voice to the fullest. Looking at the child and smiling, singing, making funny sounds, using our voice to stress on key words, playing games like peek- a boo, help the child develop the first and most important of the three skills- communication.

6-9 months

(The child has now started sitting)

• Responds with the appropriate action for “bye”, “give”, “come”, etc.
• Understands names of family members, some common objects
• Vocalizes in sentence- like tones
• Expresses denial
• Shows some basic imitation

9-12 months

(The child is constantly on the move)

• Lots of verbal imitation
• Understands simple commands like “put it down” or “give me the ball”
• Responds with the appropriate action/ pointing/ vocalizing
• Uses some meaningful single words

This is the stage where language has begun to emerge. The parents’ job here is to continuously expose the child to language, speaking about whatever the child is attending to. The language used should be simple, using a lot of voice modulation, and  accompanied by gestures. This not only helps the child understand better; but eventually the child even learns to use the gestures or signs to communicate, before the third skill, speech, begins to develop.

12-18 months

• Indulges in more structured activities like “feeding the doll biscuits”
• Starts imitating actions for rhymes, etc. with greater accuracy
• Learns more and more words everyday
• Consistently uses verbal requests

18-24 months

• Beginnings of co operative play
• Can bring an object even if it is not in immediate sight
• Begins to follow a sequence of two simple commands
• As auditory memory increases, so does the length of utterances! (e.g. mummy come / dolly, eat apple)

24-30 months

• Understands the meaning of different language structures like adjectives (colors, sizes, taste), prepositions (in, on), possessives (mine, mummy’s)
• Consistently uses a basic sentence structure (subject- verb- object)
• Relies only on speech to express wants, needs and feelings.

30-36 months

• Follows a picture story, answering simple questions related to it
• Begins to understand causal relationships
• Uses negatives, tense and gender markers
• Counts till three (meaningfully)
• Clear articulation (at least the sounds p, b, t, d, k, g, f, v)
• Engages in a conversation, asking “where”, “how” and “when” questions
• Uses speech to form new relationships, to be a part of a group

As is evident in the 12 to 18 months list, the child starts being verbal at this stage. In other words, speech begins to emerge. The parents’ role from here onwards is even more important, since the child is ever so willing to absorb whatever comes their way. Parents should be engaging in the following activities, usually in that order.

• Modelling the correct utterance
• Prompting the child to produce it once they know the utterance
• Extension and expansion of whatever the child says

E.g.: Child: “birdie”

Parent: Yes, that’s right! That’s a little bird! It flies high up in the sky! (with actions)

Many parents are quite well informed about milestones, and are also trying their best to teach the child language. However, they often forget three basic rules:

• Create opportunities for communication.

If the child does not feel the need to communicate, he would know whatever there is to know, but never try!

• Encourage trying (use verbal, behavioral, tangible reinforcements).

Let your child know that trying to speak, whether they are successful or not, would always make you happy.

• Keep raising the bar gradually.

Follow a speech and language checklist and set your goals accordingly. A child who speaks single words and gets the job done would not bother to say three word sentences unless you indicate that you need more information!

The chart below would help recall how the three skills- communication, language and speech emerge. As the chart shows, they initially overlap and then develop together.

If a look at the chart rings alarm bells, the next logical step would be to confirm with a checklist. If the checklist confirms your doubts, see a speech therapist.

NEVER ignore the feeling that your child could be lagging behind. Remember, it’s always better to be sure. And then there is the additional benefit of being proved wrong – it makes you a relaxed and happy parent!

Pallavi Kelkar

Speech Language Pathologist

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We would like thank Pallavi for this wonderful article and covering most of parent concerns in such a practical manner. Pallavi is a mother of a precious toddler and a speech and language pathologist. She is currently pursuing her PhD along with working in a local hospital in Pune, India.

Milestones: What is all the fuss about?

Heard this before?

“My child walked at 10 months, isn’t it amazing?”, “Oh no! My child is 14 months and taking a few wobbly steps. I am so concerned!”

Often, our concern about our child’s development is overwhelming. At such times, having something to measure against is reassuring. A developmental checklist provides parents a good way of keeping track of their child’s development. Typically this checklist is made of certain skills that should be visible at each age. These are called milestones. Lets understand why these are important for parents.

Development has been intricately linked with milestones from centuries.  A quick Google search revealed that the first formal assessments were used in the western world to test larger number of school kids at the same time after schooling became compulsory. However the first formal standardized test developed was the Stanford-Binet IQ test in 1905. The earliest developmental tests were developed by Giselle in 1911, based on observations of infants.  As standardization become more common, developmental milestones were observed in larger cohorts to formalize these ranges as well.

Development of skill is extremely individualistic. Just like two individuals following the same recipe will not be able to replicate the exact taste, no two children can grow in the same exact manner. Several studies, with twins and siblings, have shown that growing up with the same set of parents and environment does not mean the rate of development or even the qualities within the children would be the same. Holistic development of a child is a delicate balancing act of parent personality, child personality and the environment around them.

So exactly what are milestones?

1) Milestones are skills laid down at certain intervals along the path of development. But development is not linear and two dimensional like a roadway. Therefore, developmental milestones cannot be thought as one fixed point on this continuum.

2) Milestones are categorized in five distinct areas.

All these five areas are development simultaneously and are inter-linked with each other. For example: skill in the adaptive area like brushing teeth requires motor skill of upright balance and hand movements to have developed beforehand. A skill in the speech area like responding to a question requires cognitive and social skills to be in place as well.

3) Milestones are ordered in sequence from easy to complex. In the initial months, milestones in the five areas seem easy and obvious. These early skills are the foundation for later skills. Simplest example is learning the alphabet around 2 years builds to reading and language skills in pre-school years.

 4) Milestones are points fixed as the average age for that skill. So basically a large sample of children was observed and the age of achievement of a skill was noted. Then the average age was taken to be the fixed point for that skill milestone. So if there were 100 infants who were observed for sitting milestone and the earliest age was 6 months while the latest was 10 months, on the milestone checklist, sitting would be placed at 8 months.  Parents should be aware of this aspect

 5) Milestones should not be used in isolation while tracking your child’s development.  As we have discussed above, developmental areas are not independently demarcated. Skills are inter-linked. There is a cause for concern when you see a whole bunch of skills missing or lagging on one or more areas.

Why are milestones important?

1) Reassurance: Parents, especially first timers, are always concerned about raising a healthy, happy child. Following a developmental milestone checklist is the easiest and simplest way to get that reassurance.

2) Early detection:  Following the milestone checklist also gives parents an early inclination of any red flags in developmental pathways. Early detection is the key to getting the right help to prevent and intervention in case of any delays.

3) Holistic development: Tracking with milestones will allow parents to focus on holistic development of their children rather than focus only on certain socially or culturally acceptable skills.

Where can you find a good milestone checklist?

Pathways.org is an organization dedicated to creating free resources for parents to understand their child’s development. Their resources are evidence based and renowned world wide for easy of use for parents.

Here is the link to their developmental checklist.

We hope that parents are able to look at milestones with a slightly more open perspective rather than focusing on them as a rigid entity. The most important aspect of development is progress- adding something new in learning various skills by exploring their environment and limits of their movements.

Till then,

Happy Parenting!

Puja

4/12/2015