HEARING AID FITTING IN CHILDREN

- Gagana M S
Presentation Number: 07

Contents:
 Introduction
 Difference in fitting hearing aids (HA) between adults and children
 Protocols for hearing aid fitting in children
 Assessment
 Pre selection criterias
 Approaches to the selection and verification of amplification for children
 HA selection considerations
 Electro acoustic characteristics for Verification: probe microphone measures
 Special population
 Follow-up and counselling
 Hearing instrument orientation and training.

Amplification procedures that have been developed for adults can be with a slight
modification be used for infants and younger children. Hearing Aid (HA) fitting: Adult
and child differences:
1. The external ears of infants and young children are smaller and softer than those of adults,
and they grow in rapidly in 1st few years of life. The fastest growth is from period of birth to
2yrs of age (Feigin et al., 1989), continuing until about age 7. During this time, the pinna size
increases in size, density and orientation (Northern and Downs, 1991).
These changes have important implications for amplification fitting:
a) It is important to use soft moulds that can be replaced frequently to confirm to the
child’s ear
b) Average adult external ear canal resonance data should not be used to obtain
prescriptive targets. Kruger and Ruben (1987) have reported that the peak of resonant
frequency of the external ear can be 2 to 3 times higher in newborn than in average
adult and doesn’t approximate adult values until 2yrs of age.
c) The residual volume of ear between the tip of ear mould and ear drum is
significantly reduced in a child as compared to an adult. So, the output of the hearing
aid in a small ear is likely to be higher than in the ear of an adult. Feigin et al., 1989
demonstrated that Real Ear to Coupler Difference (RECD) were larger in children and
the magnitude of that difference varied with age, with larger RECD found in younger
children so 2cc coupler measures may significantly underestimates the SPL in the real
ear. This highlights the importance of probe microphone measures to assess both gain
and SSPL.
2. The small size of ear canal often limits options in terms of hearing instrument style,
increases likelihood of acoustic feedback, creates hearing instrument retention problems;
limit the scope of ear mold modification. Reduced ear canal volume also result in increase in
intensity of sound delivered to the cochlea (Feigin et al, 1989).
3. Children also differ from adults since they use amplification for acquisition of spoken
language. So in fitting amplification it is necessary to account for the important role of self
monitoring in the process of acquiring spoken language. But adults can alter the settings

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precisely according to their listening preferences and they have linguistic and contextual cues
to fill it up.
4. When hearing loss is acquired prelingually, language competency, cognitive abilities,
world language cannot be used to supplement incoming acoustic information as in adults. For
e.g., young children require higher SPLs than adults to achieve equivalent speech recognition.
Stelmachowicz et al., (2000) shows word recognition as a function of audibility index (AI)
for adults and two groups of children with normal hearing. Even at an AI of 0.2 adults are
able to identify in meaningful sentences. In contrast, 5 and 7 year old children achieve scores
of only 2% and 10% respectively.

5. For infants <6 months of age, initial hearing instrument fitting is based on AEP measures
of auditory function. Supra threshold measures of performance such as speech recognition,
loudness growth, and loudness discomfort level cannot be obtained until much later (Kawell,
1988). Factors such as, middle ear disease, developmental delays complicate the precision
and interpretation of audiologic data.
6. Young children have little control over their acoustic environment so in difficult listening
situations; children are unable to position themselves to maximize audibility.
7. Less cooperative during the testing process than adult.
Thus, the noted differences between adults and children highlight the need for a well
designed and systematic approach to the fitting of amplification in children.

PROTOCOLS FOR HEARING AID FITTING IN CHILDREN:

1) Mueller and Hall (1998)
 Assessment.
 Treatment planning.
 Selection.
 Verification.
 Orientation.
 Validation.

2) Beauchaine (2001) provided a more specific procedure:

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  Taking ear impressions/obtaining ear molds.
 Measuring the RECD.
 Using a prescriptive approach to determine the target gain and output.
 Choosing the hearing aid.
 Verifying the chosen hearing aid.
 Fitting the hearing aid and providing a follow-up schedule.

3) Pediatric working group (1996), AAA (2004) recommendations for infant HA fitting:
A. Case history
B. Otoscopic inspection
 1. Outer ear
 2. Ear canal
 3. Tympanic membrane

C. Comprehensive diagnostic audiology evaluation (following the recommended Diagnostic

Audiology Protocol)
D. Actual or estimated thresholds of discomfort (using frequency specific stimuli)
Counselling
 1. Informational (i.e. test results, amplification options, communication options, next
steps, funding options, etc.)
 2. Expectational (i.e. realistic expectations, motivation, etc.)

Thus broadly, the five stages of hearing aid fitting in children are:
 Assessment
 Selection
 Verification.
 Validation.
 Informational counseling and follow up.

ASSESSMENT
The goal of assessment “is to obtain ear and frequency-specific threshold data” as soon as
possible from the child (Pediatric working group, 1996).
 Infants are often fit hearing aids on the basis of only few audiometric thresholds, with
no measures of supra threshold auditory perception (Paediatric working group, 1996).
 Recent advances in infant assessment make it possible to obtain earlier, more
reliable, and ear specific information through the use of frequency specific evoked
responses (Stapells et al, 1995). Whenever possible, other results from the audiologic
test battery, especially behavioural testing and/or observation should be obtained to
cross check ABR results.
 Thus objective measures like frequency specific ABR, ASSR and behavioural
measures like BOA, VRA, play audiometry are used to obtain audiometric thresholds.
 These threshold predictions are useful in amplification fittings (Stelmachowicz et al,
1998), but do not completely replace behavioural audiometry. The paediatric
audiologist will need to rely on threshold estimates until an infant is old enough to
complete a behavioural audiometric assessment, typically after 6mths of age.

HA Pre-selection considerations
 Degree and type of hearing loss and other associated problems
 Availability of hearing aid
 Different listening needs

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  Earmold and hearing aid styles
 Attitude of child, parent or caregiver
 Economic status of the family.

APPROACHES TO THE SELECTION AND VERIFICATION OF AMPLIFICATION

FOR CHILDREN
Deciding about that a child is a hearing aid candidate, the first step in the process is selection
of hearing aid characteristics for the child. Two approaches for this task are:-
1. Traditional / Empirical / Experimental approach
2. Theoretical / Prescriptive approach.
The first step for both approaches involves obtaining a reliable and accurate picture of the
child’s hearing impairment either by behavioral assessment or electrophysiological
approaches.
Beyond this, the two approaches in the selection and verification of amplification for
children differ significantly in their conceptualization and execution.
I. TRADITIONAL APPROACHES:
It has considerable face validity. The procedure is as follows:
1. Assess the child’s hearing thresholds
2. Preselect hearing aids based upon clinical experience and range of hearing aids
available
3. Manufacture custom made ear mold
4. Child returns to clinic for HA fitting
5. Evaluate and compare pre- selected HA with child based on
a. Sound field aided thresholds
b. Speech reception thresholds
c. Speech perception test scores
6. Aid yielded the best results is selected and fitted to the child
7. Gather the feedback from parents, child and teachers to fine tune the hearing aid
fitting
Sound field thresholds have limited test retest reliability and the limited attention span
of small children dictates that only a few frequencies can be tested in any single test session.
Testing at main octave frequencies often masks the inter octave peaks and troughs in the HA
frequency response. Sound field aided threshold assessment is also sensitive to environmental
background noise and the internal noise of the hearing aid which may mask true thresholds at
low intensity levels. Macra’s (1982) investigations of the impact of ambient noise at internal
noise levels upon aided thresholds results concluded that it was not possible to obtain valid
aided thresholds for hearing impairments less than 30dBHL.
Repeated aided threshold or speech perception testing can be a very slow process.
Children become easily fatigued and distracted. Although traditional approaches have been
popular in the past (Bess 1996), their general appeal to be in decline (Seewald.1998).

II .Theoretical approaches to hearing aid selection

It aims to optimize the audibility of speech according to the degree and configuration of
hearing Impairment (HI). A step by step guide to hearing aid selection using a theoretical
approach is as follows:-
1. Assess unaided hearing
2. Manufacture Custom made ear mold

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3. Pre-select HA in 2cc coupler based upon theoretical set of criteria, i.e., set of prescriptive
targets
4. Fit the aid to child and verify HA fitting with a measure of real ear gain. Adjust HA to fit
performance criteria (e.g. Sound field threshold, insertion gain, and real ear aided response).
5. Evaluation of HA fitting and fine tuning of HA fitting based upon feedback from parents
and teachers.
The advantages associated with theoretical approach are:
1. The theory or model for optimizing the child’s reception of speech is clearly stated
2. It is a systematic procedure that clearly specifies the criteria for pre-selection of HA and
verification following fitting.
3. Can be implemented with some confidence by both experienced and inexperienced
audiologists
4. Time efficient, usually one HA is preselected for the child on the basis of 2cc coupler
measures and then modified to fit the targets of prescriptive procedure during the real ear
verification process.
5. It has eliminated problems of reliability and fatigue associated with sound field and speech
perception testing.
Several well documented prescriptive approaches have been developed including
POGO II (Schwartz, Lyregard and Lundh, 1988), DSL (Seewald, 1992, 1993) and National
Acoustic Laboratory’s Revised Procedure (NAL-RP) (Byrne and Dillon, 1986; Byrne,
Parkinson and Newall, 1990). Selection of a specific procedure is important because each
procedure will prescribe a different amount of gain and power for the hearing impaired
individual.

HA SELECTION CONSIDERATIONS:

A. Physical characteristics
1. Earmold material (soft material recommended for children)
2. Hearing aid type (behind-the-ear, bone conduction, etc.)
3. Binaural fitting is optimal unless contraindicated (i.e. unilateral hearing loss)
4. Compatibility with assistive listening devices (i.e. FM system)
5. Safety features (i.e. tamper resistant battery compartment, volume control covers, etc.)

B. Prescriptive approach
Use paediatric specific prescriptive approach (i.e. Desired Sensation Level {DSL}, National
Acoustic Laboratory – Revised Procedure {NAL-RP}).

C. Other HA selection characteristics

Other hearing aid characteristics selection: (flexible electro acoustics, changing electro
acoustics like AGC, Volume control, memories, temporal cues, feedback management, SNR
requirements and multiple channels)

A. Physical characteristics
Earmolds: EAR MOLD SELECTION
Good impression taking technique and the manufacture of a well fitting custom made ear
mold is a critical component in pediatric HA fitting process. All the acoustic modifications to
a child’s ear mold will affect the gain, frequency response and the SSPL of HA. Three main
options available are venting, damping, and acoustic horns.

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 Soft molds are used more commonly than hard molds, because soft molds are less
likely to cause discomfort, feedback oscillation, or injury to the ear if they are broken.

HA TYPE
In general, binaural fitting of BTE with flexible electro-acoustic characteristics are the
standard. BTE are always favourable with infants and children because:
1. Reduced risk of injury
2. Reduced risk of component damage from drainage from middle ear
3. FM compatible
4. The BTE also requires fewer repairs than custom devices
5. Less occurrence of feedback because of separation between microphone and
receiver
6. Earmold remakes are less costly than new shell, considering frequent
remakes/recasing
7. Child does not need to give up hearing aids during earmold remake.
8. High FOG up to 80dB and 125-140dB OSPL 90 ( wide fitting range)
9. Doesn’t amplify clothing noise
10. More natural hearing reception in head
11. Cosmetic appearance
12. Flexibility.

Disadvantages of BTE: If children have additional difficulties that require head support then
BTE would
- Muffle sound pick up by the BTE hearing aid.
- Frequently bump the hearing aid
- Feedback oscillation
Other ear level devices:
 There are many practical disadvantages :
- Most young children have ears that are simply not large enough to accommodate ITE,
ITC, CIC
- Frequently replacing of the case as ear grows and it’s expensive
- It is not common for ITE HA’s to have necessary audio input, telecoil or FM systems
- Breakage of hard plastic shell can lacerate ear canal wall
- Difficult to visibly identify by the parents (to check on/off or Volume control {VC}).
Binaural fitting:
The critical need for optimal hearing by infants, toddlers and children demands the
use of binaural HA’s. The binaural HA’s should be fit for all hearing impaired children unless
there is contraindication (such as total deafness in one ear).

Mueller and Hawking (1990) presented 3 main advantages of Binaural HA’s

 binaural summation: they demonstrated that person with bilateral SNHL have a 6-
10dB of binaural summation
 elimination of head shadow
 binaural squelch

As Pasco has observed, HA should be chosen to help restore binaural hearing. The
advantages associated with binaural HA fitting include improved sound quality, improved
speech discrimination in noise, reduction of head shadow effect, loudness summation, sound
localization and spatial balance.
FM systems

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  “The assistive listening device will be the best solution for listening in noise and/or
listening at a distance”.
 Recommendation: BTE hearing aid in order to permit coupling of FM system via
direct audio input.
Safety features:
Huggie aids and volume control covers can be used as safety measures.

B. Prescriptive approach
Two theoretical procedures frequently used with children are: -
DSL and NAL RP
THE DSL APPROACH TO HA SELECTION FOR CHILDREN
The earliest versions of this approach appeared during 1980s. Its stated goals are to
provide children with amplified speech that is audible, comfortable and undistorted across the
broadest frequency range possible(Seewald et al,1987).It justifies the importance of adequate
amplification during the early language learning years and the differences between young
children and adult’s speech perception skills.
Gain and frequency response selection originates from a set of DSL across the
frequency range for the long term speech spectrum. These DSLs are dependent upon
frequency and degree of HI. From these DSLs, targets for real ear aided gain, real ear
insertion gain and sound field thresholds have been generated. The DSL approach uses a
probe microphone measurement so that all measurements are specified in the ear canal. So no
conversions or corrections are required and child’ resulting HA fitting can be clearly
presented as his dynamic range for speech showing unaided thresholds, amplified speech
spectrum and real ear saturation response of the HA, all as if measured in the ear canal. The
innovation in DSL approach has been the use of RECD procedure, whereby the only real ear
measurement performed with the child is to establish their individual RECD (Seewald.1994).
The single real ear measurements may only take a few seconds. This information of 2cc
couplers can be used to predict real ear aided response and real ear saturated response.
Stelmachowicz, 2000 shows three 3 displays of aided audibility for average conversational
speech for a moderate to severe SNHL.

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The left panel shows the amplified spectrum using the manufacturer’s algorithm for an adult
who is a new user. Using the same HA, the middle and right panel shows amplified spectra
for a 5 yr. old child using the manufacturer’s algorithm and DSL [I/O] respectively. The AAI
values for 3 conditions range from 0.35 to 0.87. The transfer function can be used to estimate
speech recognition scores from these AAI values. For adults, when the input is meaningful
sentences, the relatively low AAI value of 0.35 corresponds to approx. 92% performance.
This probably explains why many adults with HL do not seem to require much gain. Using
the transfer function for 5 years old child, the manufacturer’s algorithm would result in 68%
and DSL [I/O] fitting would correspond to 97% performance.

THE NAL APPROACH TO HEARING AID FITTING

This approach aims to amplify the long term speech spectrum, so that it is comfortable and
equally loud across the frequency range. Byrne and Tonnison(1976) based their estimate of
the overall required real ear gain on research by Byrne and Fifield (1974) that had shown that
moderate to severely HI children preferred to use on average, 4.6dB of gain each 10dB of
hearing loss. In 1986, Byrne and Dillon revised the procedure as NAL-RP following
extensive evaluation with HA user’s fitted using original NAL procedure. They added an X
factor to take into account the slope of the audiogram and modified the formula used to
calculate the required gain. In 1990 the profound correction factor was added for individuals
with severe and profound HI prescribing more gain overall for 60 dB + losses.

C. Other HA selection characteristics

OUTPUT LIMITING
All the HA protect the hearing and comfort levels of HI listeners by implementing a
type of output limiting, usually either peak clipping or compression limiting.

PEAK CLIPPING

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 With peak clipping amplifiers, the sound coming into the aid and output of the aid,
input output ratio remains constant until the limiting level is reached. As the saturation is
reached, peak of the amplified signal are clipped result in squaring of waveform and adds
harmonic and IMD to signal. The distortion added to the signal impacts upon sound quality
and also affects speech intelligibility so , peak clipping is of rare choice.

FIG: original signal Vs peak clipped signal.

Signal processing and advanced technology

COMPRESSION LIMITING
AGC or compression is a way of controlling the gain and output of HA. It uses an electronic
feedback system to monitor either the level of input signal (input controlled compression) or
the output of the signal (output controlled compression) to prevent the signal from reaching
saturation when confronted with high input levels. Output limiting compression system
reduces distortion added to speech system at saturation and improved sound quality. They are
superior to peak clipping and is system of choice.
NON-LINEAR PROCESSING
Literature suggests better speech performance with non-linear processing than with
linear processing (Marriage & Moore, 2003) & (Gou, Valero, & Marcoux, 2002)
 Hearing aids should utilize different levels of compression and should be chosen
carefully depending on the age and language skills of the child.
 Pre-verbal
 Post-verbal

Compression range: Recommendations:

 Pre-verbal child: EDRC (expanded DRC) or WDRC
 Post-verbal children: WDRC or HLC (high level compression)

EDRC: Low compression threshold in hearing aids (EDRC) will optimize the audibility
of soft sounds which are capable of enhancing speech and language abilities in children.
Compression thresholds:
 EDRC: approx 20 depending on configuration of hearing loss
 WDRC: approx 35dB HL(low), 50dB HL(high) (variable)
 HLC: approx 40dB HL(low), 55dB HL(high) (variable)

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Studies on compression:
WDRC HA uses a low compression knee point so that compression occurs over a
range of inputs and portion of dynamic range of speech is in compression. Such systems aim
to increase the listener’s comfort and increase audibility of soft phonemes.
Based on data from adolescents and young adults with HL , (Jenstad, 1999, 2000)
found that , relative to linear circuitry , WDRC processing improves the perception of low-
level speech in quiet and results in aided growth of loudness functions that approximate NH
individuals. Improved audibility for low- level speech can only be when low compression
threshold (< or = 40dBSPL) are used. For some children with greater degree of HL, a low
level compression threshold may increase likelihood of acoustic feedback.
Christensen, 1999 compared the performance of WDRC circuitry to linear peak clipping
(LPC), and linear compression limiting (LCL) in 9 to 14 yr old children with mild to
moderate HL. In general, speech perception across a range of listening conditions was highest
with the WDRC processor. LPC resulted in the poorest performance for most listening
conditions.
Marriage, 2005 compared speech scores for children of 7 to 15 yrs with severe to profound
HL who were fitted with LPC, LCL or WDRC HA. They also found significant benefit for
the WDRC condition. There is indirect evidence to support the use of WDRC processing in
infants or young children.

Preserving temporal cues:

 Children use cues to identify different speech signals.
 Temporal cues (change in loudness over time) help individuals recognize and identify
speech sounds.
 Hearing-impaired individuals rely on temporal contrasts to a greater extent in order to
achieve discrimination (Van Tassell et al., 1987)
 Children may require larger temporal contrasts than adults in order to identify speech
signals (Nozza et al., 1991).
 Preservation of temporal cues is imperative following speech processing from the
child’s hearing aid.
 Temporal compression characteristics of speech processing shape/affect the speech
input.
 Slow vs. fast-acting compression will affect speech inputs differently.
 AAA has no recommendation with respect to temporal compression characteristics.

Recommendations:

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  Slow-acting compression preserve important temporal cues of speech inputs for the
hearing-impaired (especially pre-verbal) child up to severe hearing loss.
 Fast-acting compression may be more suitable for children with a residual range of
hearing that is of lower magnitude than the dynamic range of speech (i.e. profound
loss).

Volume control
Adjustment of a volume control can provide a short-term solution to feedback caused by
poorly fitted earmolds. No volume control recommended for young children (Kuk &
Marcoux, 2002).

HA Bandwidth (BW)
Stelmachowicz, 2001, investigated the effects of stimulus BW on the perception of /s/ (in
both CV and VC context with the vowel /i/) produced by 3 talkers (adult male, adult female,
and child). Stimuli were low pass filtered at seven frequencies from 2 to 9 kHz, and the data
were collected from normal and HI adults and children (5 to 8yrs).

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The figure shows the lowest cutoff frequency at which maximum performance was achieved
as a function of talker for the 4 groups. For the male talker, the cut off frequency of only 4 to
5 kHz was adequate for all the groups. For the female and the child talkers, a much wider BW
(6 to 9 kHz) was needed for the maximum performance. Majority of BTE have an upper limit
in the 5 to 6 kHz range. Because the young children tend to spend most of their day with
adult female caregivers and / or other children, the limited BW of current HA may have
negative impact on the early language development.

Frequency transposition and frequency compression

Many of the early attempts at frequency transposition met with limited success largely due to
complication such as shifts in voice pitch, alterations in the time course of acoustic events,
and unnatural sound quality.
The subsequent use of the proportional frequency compression ( FC) (using a fixed ratio)
helped to preserve the normal frequency relations between the spectral components of
speech, thus minimizing the problems described above. With proportional frequency
compression, the entire BW of speech is compressed to lower frequencies, and the spectrum
is narrowed.
MacArdle, 2001, studied the effects of FC for 36 children (2 to 15 yrs old). After 4 yrs, only
11 of the 36 children continued to wear the devices. All of these children demonstrated
significant improvements on a 10 word list of monosyllabic words. The children in this
subgroup were fitted at a younger age than the other subjects.

Multiple Memories
Christensen, 1999 investigated the ability of 9 to 14 yrs old children to use multiple memory
devices. Results indicated that these children were willing and able to switch memories and
that they reported subjective befits from being able to do so.
Disadvantage
 Young child cannot operate program switch and therefore should not be given
memory option: disabling of program switch.
 Young children could accidentally switch program (program switch/M-MT-T switch)
and decrease audibility of speech
 Therefore, memory switch not seen as primary method to address changing listening
environments, especially in very young children. (Kuk & Marcoux, 2002).

Optimizing the signal-to-noise ratio:

 Directional microphone systems
 Noise reduction/Speech intensification algorithms
 FM systems

Directional Microphones
Gravel, 1999, studied the performance of omni directional versus dual microphone
HA technology in both preschool and school age children. Objective benefit of directional
microphone technology was demonstrated in children as young as 4 to 6 years of age, but the
magnitude of benefit was smaller ( 3 to 5dB) than that typically observed with adults ( 5 to
7dB). In addition, the youngest children required a more advantageous S/N to achieve the
same speech perception performance as older children.
Kuk, 1999, assessed speech recognition in noise and subjective listener preferences in
20 school aged children wearing digital directional HA versus their own analog omni

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directional HA. Results showed improved speech recognition scores at multiple presentation
levels with the directional HA as well as subjective preference.
Directional microphone may pose a safety risk if environmental sounds cannot be
detected and localized. They also limit the ability to “overhear” the conversation of others (a
rich source of language input). Adults solve these problems by selecting a directional
microphone only when listening in noise: young children may not be able to make these
decisions reliably. Recently, adaptive directional microphone has been developed. These
systems are designed to determine the azimuth of the noise source and automatically modify
the null point in the polar pattern to optimize S/N. Ricketts, 2002 have demonstrated the
benefit of adaptive directional microphone.

Single Microphone noise reduction

Studies with adults have shown significant improvements in speech perception when
the noise is restricted to a narrow frequency region (Rankovic, 1992). When the long term
spectra of the target signal and noise are similar, most studies have failed to show
improvement in speech perception despite improvement in the physical S/N (Levitt, 1990).
Jamieson, 1995 reported that Noise reduction (NR) resulted in a reduction in test performance
when stimuli were non sense syllables. These results suggest that certain types of NR may
actually degrade the speech signal. Because of the inherent redundancy of conversational
speech, such alterations may have little influence on speech perception for adults with
acquired HL but may be detrimental to infants and young children who are developing speech
and language skills.

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Electro acoustic characteristics for Verification: Probe microphone measures
In early 1980s, the validity of the aided audiogram was questioned by several
investigators (Macrae, 1980). It was noted that the interpretation of aided threshold can be
complicated by noise floor problems in regions of normal and near normal hearing. In such
cases, amplified room noise will impose a lower limit on aided sound field thresholds.
Stelmachowicz and Lewis, 1988 reported that aided sound field thresholds cannot be used to
estimate the degree of hearing aid gain for supra threshold signals such as speech. This is
particularly true for non linear hearing aids where gain varies as a function of input level.
Other criticism of functional gain method is poor test -retest reliability, limited frequency
resolution, inability to provide information about real ear maximum output level (Hawkins,
1993).
The 2cc coupler measure of hearing aid output do not adequately reflect individual
differences in factors that are known to affect hearing aid performance(Larson,1997).These
include acoustic impedance of the ear, ear mold acoustics, ear canal size, leakage of sound
from ear canal, head diffraction effects, microphone location effects. Discrepancies between
real ear and coupler measures may be particularly large for infants and young children

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(Nelson- Barlow et al, 1988). The results of these studies support the use of individualized
real-ear measures in both children and adults in order to optimize the hearing instrument fit.
Fortunately, an approach for obtaining individual real-ear measures (probe-tube
microphone technology) was introduced into clinical practice in the early 1980s. Placement
of small flexible probe tube microphone in ear- canal allows individualized measures of
REAG and maximum output for test signals presented in the sound field. Studies have shown
good test – retest reliability for probe microphone measures in 3-15 year old children
(Nelson, 1988). Advantages of individualized probe tube microphone measures over
functional gain include a detailed representation of gain across frequencies, improved
reliability, efficiency, direct measurement of real ear maximum output, avoidance of noise-
floor effect, valid representation of hearing aid performance for non-linear circuits (Hawkins,
1987).

RECD (Real-Ear-to-Coupler Difference)

What is it?
Formal Definition: Difference in decibels, as a function of frequency, between the SPL at a
specified measurement point in the ear canal and the SPL in a 2cc coupler, for a specified
input signal. Note: ANSI S3.46-1997 does not define RECD.

Informal Definition: Difference in dB across frequencies, between the SPL measured in the
real-ear and in a 2cc coupler, produced by a transducer generating the same input signal.

Given the differences in volume and impedance between the ear and the coupler, RECD
values are generally greater than or equal to 0 dB (i.e., greater output in ear than coupler for
same input signal level). As can be expected, RECD values can vary substantially across age
groups (with children typically having larger RECDs than adults) and even within age groups
(Feigin et al., 1989). A negative RECD value may indicate an inadequate seal of the
transducer to the ear (e.g., foam ear tip), a larger than average ear, a perforated eardrum or a
myringotomy tube in place (Martin et al., 1997).

How is it done? (RECD)

A number of real-ear equipment manufacturers have incorporated automated RECD

measurement procedures into their software. Check with the manufacturer for specific
instructions on how to conduct this measurement with the equipment you are using (see
Moodie et al., 1994 for further information). The typical steps, with an emphasis on the
Audioscan RM500 implementation, are outlined below:

1. Coupler Measure:
Attach the transducer used to generate the signal to the speaker jack if necessary.

Attach the 2cc coupler (i.e., HA-2 coupler) to the coupler microphone.

Couple the transducer to the coupler.

Introduce the signal.

Store the coupler measurement (most equipment will store this coupler response
automatically).

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2. Real-Ear Measure:
Conduct otoscopic examination.

Place probe tube in the ear canal, with end of the tube at appropriate distance from the
intertragal notch (i.e., within 5 mm of the eardrum)

Couple transducer to the standard foam ear tip (or earmold tubing).

Insert foam ear tip (or custom earmold) into the ear, being careful not to move the inserted
probe tube.

Introduce the same signal as used with the coupler measurement.

Store the real-ear measurement.

Subtract the stored coupler response from the real-ear measurement to produce the RECD.
(Most equipment will calculate the real-ear-to-coupler difference).

Seminar in Rehabilitative Audiology (2012)Page 16

Why should you do it? (RECD)

The RECD is a powerful tool that can assist the clinician throughout the various stages of the
amplification process. RECD values can also be used to convert real-ear targets to 2cc
coupler targets to assist with selection of hearing instruments via manufacturers' specification
sheets.

Arguably the most useful application of the RECD is in the prediction of real-ear output
when measuring hearing instruments in the 2cc coupler. Given that the RECD allows us to
know the difference between output in the real-ear and the 2cc coupler, real-ear hearing aid
output (e.g., REAR, RESR) can be accurately predicted to within approximately 2 dB
(Seewald et al, 1999).

The ability to predict hearing instrument output offers a number of advantages, which, as
described by Seewald (1997) include the following:

1. The audiologist will know the levels of amplified sound delivered into the patient's ear
canal.

2. The unique acoustic properties of the ear and earmold coupling (if the RECD is conducted
with the earmold) will be accounted for. This helps avoid errors that can occur when using
average values in the fitting process.

3. All hearing instrument response shaping can be performed in the hearing aid test chamber,
under highly controlled acoustic conditions.

4. The degree of cooperation and amount of time required from the patient in the fitting
process is greatly reduced.

To estimate the real ear amplified speech spectrum, this level independent RECD values are
added to coupler measures of hearing aid output for different input levels. To predict REAR,
the formula is
REAR= 2cc coupler response+ RECD +HD+ML
Where HD and ML represent head diffraction and microphone location effects as function of
frequency.

ADVANTAGES OF REAR
It is advantageous over traditional over probe tube microphone measures with young
children.
1. Requires passive cooperation
2. As stimulus is presented via insert head and body movements will have
minimal effects on results.
3. Stimulus presentation is brief (2-5secs.), so multiple attempts to obtain
RECD can be made.
4. Clinician can obtain RECD measures in approx. 5 mins.
5. After RECD is obtained subsequent measures of hearing aid performance
are obtained by adding RECD to 2cc coupler measures and do not require
the child’s presence.

Seminar in Rehabilitative Audiology (2012)Page 17

RECD procedure can provide valid and reliable alternative to traditional probe tube
microphone measures (Westwood and Bamford.1995; Sinclair, 1996; Seewald, 1999).
Adults HA verification protocols often define prescriptive targets in terms of Real Ear
Insertion gain (REIG), which is calculated by subtracting REUR from REAR. When testing
children, it is preferable to evaluate HA performance in terms of REAR for several reasons.
1) This approach capitalizes on the accuracy of real ear measures while minimizing test
time and amount of child’s cooperation since only one probe microphone measure is
needed.
2) When test stimuli are speech shaped noise or signals designed to mimic the spectral
and temporal characteristics of speech, REAR will provide a more valid
representation of amplified speech for HA with complex DSP than when swept pure
tones or steady state noise is used. (Stelmachowicz, 1990; Scollie, 2000).
REAR to visualize the audibility of speech
Although the relative differences in aided audibility provide necessary information for
comparison across different listening conditions and/ or HA setting, the Aided Audibility
Index (AAI) alone cannot provide an estimate of speech recognition. The relationship
between AAI and speech recognition will depend on both the speech material used and
characteristics of the listener. Stelmachowicz, 2000 shows the average transfer functions for 4
word meaningful sentences in adults and 5 year old children. Because young children cannot
take full advantage of semantic context, their function is shifted to the right.

ENSURING AN ACCURATE HA FITTING, Marcoux & Hansen, 2003

Hearing levels (ie, hearing thresholds expressed in dB HL) are defined as the difference in
sound pressure level at threshold between an individual and an average group of normal-
hearing adults.The advantage of the dB HL scale lies in its independence from the point of
measurement. That is, the same value is repeated whether it is obtained in the free field or
with insert earphones. This is not fulfilled for the dB SPL scale, which only makes sense if

Seminar in Rehabilitative Audiology (2012)Page 18

the place of measurement is mentioned (eg, in free field, or at the eardrum) or at the place of
the hearing aid microphone.
For accurate documentation of children’s thresholds, it is recommended that measurement
conventions be revised in order to avoid confusion during the hearing assessment. In order to
reach this objective, it is important to refer to dB readings from an audiometer as dial level or
dB DL.
DL: Dial level (Unit: dB). The dial reading on the audiometer. . 0 dB DL typically does not
indicate normal hearing for a child. The mismatch between 0 dB DL and the DL at the
threshold of the normal hearing threshold in children is age-, frequency- and transducer-
dependent.The conversion of a child’s hearing thresholds (eg, from dB DL to dB SPL or to
dB HL) makes use of some well-known acoustic transforms. These transforms include
• REUG
• REDD
• RECD
Error sources originate from the probe-tube depth, position, azimuth, stability, and location of
the sound source during measurements with children and adults . Average transforms are
available for various age recording the difference in real-ear measures (RECD, REDD,
REUG) between the child and adult (Kruger, 1987, Kruger and Ruben, 1987). For these
reasons, in the absence of an effective and reliable technique, average age and transducer-
dependent corrections are available.
The authors have introduced the following terminology:
∆RECD, ∆REDD, ∆REUG: Difference of real-ear differences between child and adult (Unit:
dB), ie,

∆RECD = RECD (child) – RECD (adult)

and correspondingly for ∆REDD and ∆REUG.
At the child’s eardrum , the sound level will be different by an amount equal to ∆RECD, or
∆REDD or ∆REUG relative to the sound level at the average adult eardrum for the same
equipment and setting (same hearing aid + coupler, or headphones, or free field, etc.). As an
example, if
∆RECD=5 dB at a certain frequency, the same hearing aid will produce a sound of x dB SPL
at the eardrum of an adult and of (x+∆RECD) = (x+5) dB SPL at the eardrum of the child, ie,
5 dB higher compared to the average adult.

Ensuring an Accurate Documentation of Hearing Thresholds in Children

There are two established methods to accomplish the task of expressing a child’s hearing
threshold in a well-defined way.

1)The first method is to express hearing threshold information in dB SPL at the eardrum
instead of dB HL. The SPLogram, such as used with the desired sensation level prescriptive
formula (DSL [i/o]) (Seewald, 1995).

2)The second method also accounts for the properties of the child’s ear; however, it achieves
a representation of the child’s threshold information by providing an equivalent adult
threshold (EAT) expressed in dB HL.

EAT: Equivalent adult threshold (Unit: dB HL). The EAT is defined as the hearing
threshold level that an average adult would have if the adult had the same threshold in dB

Seminar in Rehabilitative Audiology (2012)Page 19

SPL at the eardrum as the child. For the purpose of this definition it is assumed that the
threshold measured in dB SPL at the eardrum is the same in a normal hearing adult and in a
normal hearing child.

An EAT of 0 dB HL indicates normal hearing regardless of the age of the child and
independent from the frequency or transducer chosen. The EAT for a child cannot be directly
read from audiometric equipment, it can be
calculated in a variety of ways,
EAT = DL + RETSPL2 cc + RECD2 cc(child) – REDD(adult)
where DL is the dial level dB and RETSPL2 cc is defined as the reference equivalent
threshold in a 2 cc coupler, expressed in dB SPL (ANSI S3.6, 1996). The above equation can
also be written as:

EAT = DL + RETSPL2 cc + RECD2 cc(child) – MAP

EAT = DL + RECD2 cc(child) – (MAP – RETSPL2 cc)
EAT = DL + RECD2 cc(child) – RECD2 cc(adult)
which finally leads to:
EAT = DL + ∆RECD2 cc
If thresholds were measured in free field instead of with insert phones, a similar calculation
for the EAT can be expressed as:
EAT = DL + ∆REUG …………… (2)
An EAT-based method is used by the NAL-NL1 procedure. The main advantage of the EAT
is that it provides a direct comparison between the hearing thresholds of the child and that of
a normal hearing adult (0 dB HL in both cases).

The distinction between EAT and DL is necessary to retain the original intent of the
definitions of hearing level (HL) and hearing threshold level (HTL). This distinction is
illustrated in Figure 4. By directly plotting the audiometer’s dial level at threshold on the
skewed audiogram and by extrapolating to the dB HL axis of the standard audiogram, the
EAT is provided. Consider the example where a child under the age of 1 year is assessed with
insert earphones. Threshold at 4000 Hz reveals a dial level of 40 dB DL. By placing this
value on the skewed audiogram in Figure 4 (top panel), and extrapolating to the standard
audiogram, an EAT of approximately 50 dB HL is revealed. Now consider the same child
assessed in the free field. Threshold at 4000 Hz is now obtained at 65 dB DL. By placing this
value on the skewed audiogram in Figure 4 (bottom panel), and extrapolating to the standard
audiogram, the same EAT of
50 dB HL is revealed.

Seminar in Rehabilitative Audiology (2012)Page 20

Figure 4. Illustration of DL and HL audiograms for a child under the age of 1 year assessed
with
insert earphones (top panel) or in the free field (bottom panel). The calculations of DL values
are based on average RECD and REUG values taken from Seewald et al., 1993, and Dillon,
2001.

Prescription of Hearing Aid Gain and Output

Once the EAT has been determined, the following gain can be calculated:

EAIG: Equivalent adult insertion gain (Unit: dB)

The EAIG is a function of a set of EATs. The EAIG is the insertion gain that a prescriptive
fitting rule will calculate for an adult with a hearing loss as specified by the EAT values of a
child. The EAIG is thus identical for all individuals independently of their age and individual
characteristics of the ear canal.
IGRO: Insertion gain for restored output, Unit: dB
The IGRO is the insertion gain which the hearing aid needs to produce for a child in
order to give the same “restored” output sound pressure level at the eardrum of the child as
would be measured at the eardrum of an average adult with the hearing aid set to the
corresponding EAIG prescribed to the adult.
The IGRO can be calculated from the EAIG as:
IGRO = EAIG – ΔREUG
Using the real-ear unaided response REUR and real-ear aided response REAR, the expression
for IGRO can be deduced as follows:

Seminar in Rehabilitative Audiology (2012)Page 21

IG(child) = REAR(child) – REUR(child)
IG(child) = REAR(adult) – REUR(child)
and since REAR(child) and REAR(adult) are equal:
IG(child) = REAR(adult) – (REUR(adult) + ΔREUG)
IG(child) = REAR(adult) – (REUR(adult) – ΔREUG)
IG(child) = IG(adult) – ΔREUG

Transformation of Prescribed Insertion Gain to Coupler Gain

The previous section proposes that amount of gain equal to IGRO should be prescribed to a
child. This value of IGRO should also be measured on the child, eg, during verification with
real-ear measurement equipment. In the event where verification takes place with the hearing
aid mounted to a coupler rather than to the real-ear, an appropriate coupler gain target should
be determined CGRO: Coupler gain for restored output, Unit: dB
The CGRO is the coupler gain which the hearing aid needs to produce in order to give the
same “restored” output sound pressure level at the eardrum of the child as would be
prescribed and measured at the eardrum of an average adult with the hearing aid set to the
corresponding EAIG prescribed to the adult. The CGRO can be calculated either from the
EAIG or from the adult’s coupler gain2 cc(adult) corresponding to that EAIG by:
• CGRO = gain2 cc(adult) – ΔRECD ……. (9)
• CGRO = EAIG – RECD(child) + REUG(adult) …… (10)
Using the output level in the coupler, p2 cc, and the input level in the free field, pFF,
the expression for CGRO (Eq 9 & 10) can be deduced as follows
• gain2 cc(child) = p2 cc(child) – pFF
• gain2 cc(child) = REAR(child) – RECD(child) – pFF
• gain2 cc(child) = REAR(adult) – RECD(child) - pFF
• gain2 cc(child) = REAR(adult) – (RECD(adult) + ΔRECD) – pFF
• gain2 cc(child) = p2 cc(adult) – ΔRECD – pFF
• gain2 cc(child) = gain2 cc(adult) – ΔRECD …… (11)
• gain2 cc(child) = IG(adult) – RECD(adult) + REUG(adult) – ΔRECD
• gain2 cc(child) = IG(adult) – RECD(child) + REUG(adult) ….. (12)
Ensuring an Accurate Verification-Based Fine-Tuning Process

The insertion gain can then be obtained by measuring the REAR and subtracting the child’s
REUR. The resulting insertion gain would then be compared to the prescribed insertion gain
in order to determine whether the amount of available gain is adequate for the child’s hearing
loss.
At this point, it is vital for the verification process to actually compare the measured IG in the
child’s ear with the correct IG prescribed for the child: IG(child) = IG(adult) – ∆REUG

Adjusting an Internal Gain Parameter of the Hearing Aid

Internal hearing aid gain handle Gint is the setting of a hypothetical internal gain handle of
the hearing aid (Unit: dB), indicating the insertion gain of the hearing aid for an average
adult. Such a handle might be provided in the fitting software if it assumes an average adult

Seminar in Rehabilitative Audiology (2012)Page 22

value for REUG and RECD. In an average adult, the amount of insertion gain that the hearing
aid actually provides will equal the value of Gint., which is also equal to EAIG, while a
mismatch between the two values will be observed in a child.
If the aim of the fitting is to prescribe the same hearing aid output as for an adult, and if no
specific pediatric fitting mode is available, the Gint. needs to be corrected by the value
ΔGRO:
ΔGRO: Difference in internal gain parameter for restored output (Unit: dB). In the case
where the hearing aid offers a handle for Gint. and if no pediatric fitting mode is available,
that hearing aid gain handle needs to be set to the value Gint. = EAIG + ΔGRO in order to
produce the same output at the eardrum of the child that the hearing aid produces for an
average adult with the hearing aid set to Gint. = EIAG. The difference equals ΔGRO =
ΔRECD, ie, the internal gain handle needs to be set to Gint. = EAIG – ΔRECD. This can be
seen as follows:
Gint. = REAR(adult) – REUR(adult)
Gint. = REAR(child) – ΔRECD – (REUR(child)– ΔREUG)
Gint.= REAR(child) – REUR(child) – ΔRECD + ΔREUG
Gint.= IG(child) – ΔRECD + ΔREUG …… (13)
Gint.= GRO – ΔRECD + ΔREUG
Gint.= EAIG – ΔREUG – ΔRECD + ΔREUG
Gint.= EAIG – ΔRECD ……………. (14)

Special population
Unilateral HL
In cases where poorer is unaidable due to anacusis, poor speech recognition, and/ or
loudness intolerance, amplification options are limited. A Contralateral routing of signals
(CROS) fitting is usually considered.
A better option might be a personal FM system fitted to the better ear with a non
occluding EM to improve listening in selected environments (Kopun, 1992). For school age
children, a classroom sound field FM system is another option.
Minimal-mild hearing loss
Current evidence suggests that children with minimal and mild hearing losses are at
high risk for experiencing academic difficulty (Bess, Dodd-Murphy, and Parker, 1998; Bess
and Tharpe, 1984). As such, children with minimal and mild hearing loss should be
considered candidates for amplification and/or personal FM system or sound field systems for
use in school.
Conductive and Mixed HL
In these cases, it may be necessary to deliver sound via BC using either an externally
worn BC transducer (either at ear level or body level device) or a surgically implanted
transducer BAHA. BAHA is not approved by FDA until 5 yrs of age. So, an external
transducer is kept in place using a headband that has been designed to accommodate the
transducer and BTE HA. To minimize distortion of the skull, the placement of the transducer
should be moved frequently during the first yr. of life. Several reports comparing the BAHA
to conventional BC HA have shown improved subjective rating in children (Granstrom,
1997).
Profound hearing loss
A finding of no response by ABR should not exclude a child from hearing aid
candidacy, as residual hearing may exist at intensity levels greater than those capable of
eliciting a standard ABR response. Children with confirmed profound hearing loss still may

Seminar in Rehabilitative Audiology (2012)Page 23

experience benefit from hearing aid amplification. An infant or child with severe to profound
hearing loss is a cochlear implant candidate.
Normal peripheral hearing sensitivity
In some cases, children with normal peripheral hearing sensitivity may benefit from
amplification (Matkin, 1996). These cases may include children with auditory processing
disorders (APD), auditory neuropathy (AN) or dysynchrony, and children with unilateral
hearing impairment when an FM system is coupled to the normal-hearing ear. In such cases,
close audiologic monitoring of hearing sensitivity, and careful control of the output of the
amplification is required.
Progressive or Fluctuating HL
Etiologies like cytomegalovirus, hyperbilirubenemia, persistent pulmonary
hypertension, neurofibromatosis, Pendred syndrome, usher syndrome, meningitis etc. is
associated with progressive and/ or fluctuating HL. Close monitoring of auditory thresholds
is essential. Current HA are flexible enough from electro acoustic perspective to
accommodate substantial changes in threshold over time. When fluctuations are frequent,
multi- memory devices may be useful.
Follow-up
A. Schedule
• Birth to 3 years: follow-up every 3 months (more frequently if necessary and some of
these follow-up visits may be only for hearing aid/earmold check)
• 3-6 years: follow-up every 6 months (more frequently if necessary)
• 6 years and older: follow-up annually (more frequently if necessary)

B. Counselling of family members in the process of accepting the hearing loss; important for
carry-over into the social-familial and educational environments.

Hearing Instrument Orientation and Training.

Orientation and training should include family members, caregivers, and the child.
This information also must be communicated to the child’s educators through interactions
with the educational audiologist, deaf and hard-of-hearing specialist, or other qualified
personnel. Orientation and training should be discussed, demonstrated, and sent home in a
written or video format. Orientation and training may take place over several appointments
based on the family’s and child’s ability to perform tasks.

Orientation and training will include:

a) care of the hearing aids, including cleaning and moisture concerns
b) suggested wearing schedule and retention
c) insertion
d) removal
e) overnight storage (including the mechanism for turning off the hearing aids)
f) insertion and removal of the batteries
g) battery life, storage, disposal, toxicity
h) basic troubleshooting (batteries, feedback, plugged earmold and/or receiver)
i) telephone coupling and use
j) assistive device coupling and use
k) moisture solutions (e.g., dehumidifying systems and covers)
l) tools for maintenance and care (e.g., battery tester, listening stethoscope, earmold
air blower)
m) issues of retention/compliance/loss (including spare hearing aids and any loaner
program)

Seminar in Rehabilitative Audiology (2012)Page 24

 n) recommended follow-up appointments to monitor use and effectiveness

References:
 Alpiner, J (1993), rehabilitative Audiology: Children and Adults
 Beauchine, K.L (2001), An amplification Protocol for infants: a sound foundation
through early amplification (105-112). In R.C.Seewald and J.S. Gravel (Edns).
 Cunningham (2007). Protocols for fitting infants and young children. Hearing Journal.
 David B. Hawkins (2004), Limitation and uses of aided audiogram. Seminars in
hearing, vol 25, No 5.
 Dillon (2000), Hearing Aids.
 Katz (2005), edition V, chapter 36 Hearing aid fitting and verification in children.
 Madell, Pediatric Audiology: Diagnosis, Treatment and Management
 McCormick, B. (2004). Pediatric Audiology (0-5 years) 3rd edition.
 Newton, E. (2002). Pediatric Audiological Medicine
 Northern and Downs, Pediatric audiology.
 Pollack M.C, Amplification for the hearing impaired.
 Sanford E. Gerber (1996); Handbook of pediatric audiology.
 Scollie et al. (2000). Preferred listening levels of children who use HA: Comparison
to prescriptive targets. JAAA, 11(4), 230-238.
 Stelmachowicz, P.G. (2000). The relationship between stimulus context, speech
audibility, and speech perception for HI children, JSHR, 43, 902-914.
 Marcoux, A. & Hansen, M. (2003). Ensuring accuracy of pediatric hearing aid fitting.
Trends in amplification, 7(1), 11-28.
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