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American Academy of Audiology
Clinical Practice Guidelines
Pediatric Amplification
June 2013
www.audiology.org
American Academy of Audiology Clinical Practice Guidelines
Pediatric Amplification
Contents
1. Introduction/Development Process
Explanation of Levels of Evidence
Table 1. Explanation of Levels of Evidence and Grades of Recommendation
Table 2. Sample Recommendations and Summary of Evidence
2. Overview of Pediatric Amplification

References
3. Audiologic Candidacy Criteria

Objective
Recommendations for Determining Candidacy
Summary of Evidence for Audiological Candidacy
References
4. Principles Underlying Effective Amplification

Objective
4.1 Routing of the Signal

Background
Air Conduction Versus Bone Conduction Transmission
Electrical Stimulation
Unilateral Hearing Loss
Recommendations for Selecting Routing of the Signal
Summary of Evidence for Selecting Routing of the Signal
References
4.2 Selection of Hearing Aid Style

Recommendations for Hearing Aid Style
Summary of Evidence for Selecting Hearing Aid Style
American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

4.3 Adequacy of Earmold
Background
Recommendations for Adequacy of Earmold
Summary of Evidence Related to Selection of the Ear Mold
4.4 Safety Considerations

Background
Battery Door
Volume Control
eramplification
Parental Anxiety, Training, and Resulting Device Use
Nonfunctioning Hearing Aids
Ear Impressions and Contact Dermatitis
Recommendations for Safety Considerations
Summary of Evidence for Safety Considerations
References
5. Signal Processing and Features

Objective
Fundamental Requirements for Hearing Aid Audio Signal Processing
Recommendations for Hearing Aid Audio Signal Processing
1. Compression in the Dynamic Range
2. Software Bands
3. Compression Channels
4. Output Limiting
5. Expansion at Low Input Levels
6. Extending High-Frequency Bandwidth
7. Techniques for Frequency Lowering
8. Feedback Suppression
9. Directional Microphones
10. Digital Noise Reduction
Summary of Evidence for Signal Processing
References
6. Fitting/Verification
6.1 Electroacoustic Hearing Aid Fitting

Objective
ecommendations for itting/ erification
1. Prescription Methods
2. erification et ods
3. erification of Ad anced eatures
4. erification est ignal
ummary of idence for itting and erification
References

6.2 Other Verification Tools
Objective
6.2.1 SII/SHARP
Recommendations for SII/SHARP
Summary of Evidence for SII/SHARP
References
6.2.2 Cortical Auditory Evoked Potentials (CAEPS)

Recommendations for CAEPS
Summary of Evidence for CAEPS
References
6.2.3 Aided Thresholds in Sound Field

Recommendations for Measurement of Aided Thresholds in Sound Field
Summary of Evidence for Functional Gain
References
7. Outcomes Assessment
Objective
Recommendations for Outcomes Assessment
Table 3. Outcomes Assessments for Children
Summary of Evidence for Outcomes Assessment
References
8. Management/Follow-Up and Referrals

Objectives
Recommendations for Management, Follow-Up, and Referral
Summary of Evidence for Management, Follow-Up, and Referrral
References
9. Use of Hearing Aids with Other Assistive Technologies
9.1 Remote Microphone Hearing Assistance Technology
9.2 Cochlear Implants

Recommendations for Cochlear Implants
Summary of Evidence for Cochlear Implants
References
10. Complete Reference List

1. INTRODUCTION/DEVELOPMENT PROCESS
is document as prepared y t e American Academy of Audiology as orce on Pediatric Amplification e
specific goal of t is document is to pro ide a set of statements recommendations and strategies for est practices
specific to t e application of amplification as part of a compre ensi e treatment plan for t e audiologic management
of c ildren it earing loss pecific statements and recommendations ere made y initially re ie ing t e e isting
scientific e idence pu lis ed in peer re ie ed and non peer re ie ed ournals en direct e idence as not
available, both indirect evidence (often evidence from adults), and consensus practice were considered in making
recommendations. In some cases recommendations are based on acoustic or physical facts where an empirical
evidence base is not necessary and would not be expected (known as First Principles). This guideline addresses the
tec nical aspects of earing aid selection fitting erification and outcomes assessments is guideline does not
address treatment solely with cochlear implants, but does touch on cochlear implants used in conjunction with a
hearing aid on the contralateral ear.
is guideline is not intended to ser e as a standard to dictate precisely o earing aids s ould e selected erified
or validated. This guideline is meant to provide the evidence base from which the clinician can make individualized
decisions for each patient. In addition, the guideline can help inform physicians, reimbursement agencies, government
agencies, the hearing health-care industry, patients, families, and caregivers about what research evidence
demonstrates are current est practices related to amplification inally alt oug t is guideline addresses t e tec nical
aspects in ol ed in t e fitting of earing aids t e audiologist is reminded t at t e process of fitting earing aids is an
ongoing one requiring joint participation of the audiologist, patient, and family/caregivers. As indicated, input should also
be sought from the Early Intervention provider, the classroom teacher, and other pertinent stakeholders.
The process of developing this guideline was evidence-based when possible. Evidence-based practice integrates
clinical e pertise it t e est a aila le clinical e idence deri ed from systematic researc ere e idence is
am iguous or con icting or ere scientific data are lac ing t e clinical e pertise of t e tas force as used to guide
the development of consensus-based recommendations.
The previous document, Pediatric Amplification Guidelines (2003), comprised eight areas of focus: 1) audiologic
candidacy criteria 2 principles underlying effecti e amplification 3 signal processing and features fitting/ erification
ot er erification tools 6 outcomes assessment management follo up and referrals and use of earing aids
it ot er earing tec nologies n t e literature searc for t e present document tas force mem ers first soug t to
identify studies at t e top of t e ierarc y of study types see a le 1 nce definiti e clinical studies t at pro ided alid
rele ant information ere identified t e searc stopped e searc as e tended to studies/reports of lo er uality
only if there were no higher quality studies. Traditionally, the highest levels of evidence include systematic reviews/
meta-analyses of randomized controlled trials and randomized controlled trials (Levels 1 and 2). The crossover design
is a alua le ariation of t e randomi ed controlled trial u ects are first identified and t en randomi ed into treatment
groups it eac group recei ing a different treatment After e periencing t e treatment for a specified period eac
subject “crosses over” and receives the other treatment for a period of time. In a crossover design, all subjects produce
data from all of the treatments. In this manner, there are no issues related to group equivalence when the treatments are
compared. For these reasons, studies implementing crossover designs were labeled as Level 2 in this document.

Table 1. Explanation of levels of evidence and grades of recommendation
Levels of Evidence
1. Systematic reviews and meta-analyses of randomized controlled trials
2. Randomized controlled trials
3. Non-randomized intervention studies
4. Descriptive studies (cross-sectional surveys, cohort studies, case-control designs)
5. Case studies
6. Expert opinion
Grades of Recommendation
A. Consistent level 1 or 2 studies
B. Consistent level 3 or 4 studies or extrapolations from level 1 or 2 studies
C. Level 5 studies or extrapolations from level 3 and 4 studies
D. Level 6 evidence or troubling inconsistencies or inconclusive studies at any level
Adapted from Co 200 idence ased practice in pro ision of amplification Journal of the American Academy of Audiology, 16(7),419-438.
n addition to grading t e e idence and assigning it a le el see a le 1 it as determined if t e e idence as fficacy

(EF) or Effectiveness (EV). EF is evidence measured under “laboratory or ideal” conditions and EV is evidence measured
in the “real world.” Each section provides relevant background, a list of recommendations, and a table with each
recommendation t e source citation le el of e idence grade indication of support of efficacy and/or effecti eness
and indication of whether the recommendation is being extrapolated from adult data (see Table 2 for an example table).
In some cases recommendations are based on acoustic or physical facts where an empirical evidence base is not
necessary and would not be expected. In cases where the recommendation is based on a physical or acoustic fact (a
First Principle), either “acoustic fact” or “physical fact” is listed under “Source” in the evidence tables (for an example of
the format of an evidence table, see Table 2).
Table 2. Sample Recommendations and Summary of Evidence table
Rec Evidence Source Level Grade EF/EV Adult
Please note: the recommendations made in this document will not be referenced in the traditional manner but all
references will be provided in full at the end of the section, following the Summary of Evidence table. Additionally, a
complete reference list is available at the end of the guideline.

AAA Pediatric Amplification Guidelines 2013 Task Force
Teresa Ching
Jason Galster
Alison Grimes
Cheryl Johnson
Dawna Lewis
Ryan McCreery
Martha Mundy
Catherine Palmer
Todd Ricketts
Hollea Ryan
Susan Scollie
Richard Seewald
Doug Sladen
Anne Marie Tharpe
Christine Yoshinaga-Itano
The committee gratefully acknowledges the contributions of the following people to this document:
Jenifer Fruit, Audiologist, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
aco ul ers Audiologist Central peec and earing Clinic innipeg anito a Canada

2. OVERVIEW OF PEDIATRIC AMPLIFICATION
e purpose of amplification is to pro ide to an infant or c ild it impaired earing t e opportunity to a e access to
as muc of t e auditory en ironment and in particular speec as feasi le Pro ision of appropriate amplified auditory
input to the child with hearing loss maximizes the opportunities for the child to develop age-appropriate receptive and
expressive oral communication, language development, literacy skills, and psychosocial skills.
e primary goal of amplification is to pro ide to t e degree possi le gi en t e earing loss and limitations of earing aid
amplification audi ility across t e long term a erage speec spectrum A it out deli ering any signal t at is of an
intensity t at ould e eit er uncomforta le or unsafe Goals of amplification also include minimal distortion appropriate
signal-processing strategies for the listener, features that maximize audibility of the desired signal and, insofar as
possi le reduction of undesired signals noise e i ility and ease of connection to e ternal de ices and p ysical
comfort such that consistent, daily use is possible.
Audiologists are t e single professional no ledgea le and competent to manage all aspects of amplification
uccessful amplification can only e ased on complete and accurate diagnosis/measurement of earing sensiti ity
The audiologic diagnosis must be conducted using best practices, employing developmentally-appropriate tests, and
result in relia le and alid findings At a minimum t res olds y air and one conduction for a lo fre uency e g 00
Hz) and a high frequency (e.g., 2000 Hz) stimulus must be obtained in each ear separately. These thresholds can be
obtained via behavioral or electrophysiologic measures, preferably both. The Joint Committee on Infant Hearing (2007)
recommends at least one ABR evaluation for all children under the age of 3 who are diagnosed as having a hearing loss.
e earing aid fitting process s ould not e delayed ecause full diagnostic data are not a aila le
An audiologist ser es as case manager in t e audiologic diagnostic and treatment processes ile t e diagnostic
audiologist may not manage the case of a patient who proceeds to hearing aids, the audiologist responsible for the
treatment of t e patient ill ser e as t e case manager or ing colla orati ely it t e early inter ention team ic
may include teachers of the hard of hearing and deaf, speech-language pathologists, psychologists, physicians,
occupational and/or physical therapists, and geneticists, the audiologist ensures that the child and family are connected
with appropriate services. All care is provided in a family-centered environment and in a manner that is culturally and
linguistically appropriate. Materials must be provided in the family’s preferred language and mode of communication, at a
reading-level that is appropriate to the reader. In some cases, information also should be presented in video-format (e.g.,
those with a primary communication mode of American Sign Language) or pictorial rather than written format for families
with low reading levels.
Amplification is pro ided ased on t e contemporary no ledge of a c ild s earing loss and communication needs
Regular, reliable and valid measures of a child’s progress in meeting early intervention goals (e.g., speech, language,
auditory skills, and psychosocial development) are necessary as part of the intervention process to ensure that
amplification outcomes are eing ac ie ed ould t e goals of early inter ention c ange or s ould c ange in earing
sensiti ity occur amplification needs and goals may c ange accordingly ould alternati e amplification system s
e initiated e g coc lear implant earing aid amplification may need to e modified it out regular assessment of
unaided earing as ell as general outcomes opportunities for modification to est meet t e c ild s needs may e
missed.
Children have unique characteristics that require special consideration for assessment and treatment. Some of these
characteristics are discussed below, with emphasis added on key points.
Children and adults have different patterns of hearing thresholds, due at least in part to the different causes of hearing

loss in c ildren ersus adults pecifically t e incidence of asymmetrical progressi e and aried configurations of
audiometric t res olds across fre uencies is ig er in t e pediatric population is creates specific needs for de ice
e i ility in fre uency s aping and in t e fitting range as ell as in de ice matc ing et een ears
imilarly c ild ood earing impairment is more li ely to e comor id it ot er ealt conditions pecial fitting
considerations and different physical features or signal processing may be required.
Infants may be assessed using electrophysiologic estimates of hearing sensitivity. Some techniques for performing and
interpreting these measures require corrections or adjustments to the resulting values prior to their use in conjunction
with hearing aid prescription formulae.
C ildren s relati ely smaller ut gro ing e ternal ears create a uni ue assessment and fitting c allenge t at re uires
individualized measures of ear canal status, made repeatedly throughout the child’s life and incorporated each time
it in t e prescription and earing aid fitting e p ysical si e and s ape of t e instrument directly affects t e comfort
fit and retention of t e de ice e acoustic coupling of t e de ice to t e ear is affected y t e current si e of t e c ild s
ear (and other factors). In many cases, the best measure to make and use to account for the child’s ear is the real-ear to
coupler difference C o e er t e C measure is transducer specific and does not capture sound incoming
through a vent or slit-leak. Therefore, transition to real-ear measurement (“in situ”) or other evidence-based protocol
selection is required.
Children have different requirements of their hearing. Several related but unique adult-child differences emerge from the
literature:
C ildren are learning language and do not a e t e capacity to fill in t e lan s for sounds not audi le in t e ay
that adult listeners have.
Children spend most of their time listening to the speech of other children and women, which has greater high
frequency content than that of adult males. This places greater importance on providing audibility for the high-
frequency cues of speech when providing hearing aids for the pediatric population.
C ildren o use earing aids must de elop t e a ility to use information ac uired ile earing amplified
processed sound C ildren fit it earing aids t at fail to render audi le t e full set of speec cues are at ris of
deficits in speec production and/or learning
Children have more demanding listening requirements than adults for understanding speech, particularly when the
listening situation is difficult lo in le el noisy and/or re er erant n ancement of audi ility is re uired to support
better speech understanding, either through increased level, increased signal-to-noise ratio, or improvement of the
listening environment. Prescriptive targets for children may specify greater outputs in quiet environments than for
adults. Strategies for hearing aid use in the classroom should include strategies or devices to address the effects of
distance and reverberation.
Children’s hearing aid use is typically mediated by a caregiver, at least through the early years of life. For this reason,
issues of device use and monitoring, and caregiver training, are unique challenges in the pediatric population.
Hearing aid manufacturers typically offer custom hearing aid prescriptions that have been developed by and for the
proprietary use of the hearing aid company. Such prescriptions are not standardized nor are they typically subjected to
external scrutiny, and are typically developed for use in the adult population. Use of independently validated pediatric-
focused prescripti e targets as ell as normati e data and fitting met ods is al ays recommended

idence ased independent prescripti e met ods are specific computations designed for use it t e pediatric
population. Validation studies indicate high levels of speech recognition in controlled and real world environments when
earing aids are fit using ot prescripti e targets and indi iduali ed fittings met ods t at employ erification of audi ility
typically completed t roug t e use of specific real ear pro e microp one measures and le el dependent signal
processing.
n creating t is document t e tas force as fully a are of t e difficulty of pro iding a guideline for t e pediatric
population ic is defined as irt to 1 years of age ne mig t li ely suggest pro iding four guidelines is could e
segmented into Infants (birth to two), Pre-school (2.5 to 5), School Age (5.5 to 12), and Young adult/Adult (12.5 to 18). Age
groups could be conceived through auditory development, auditory demands, and/or the child’s developmental stage
in terms of accessing technology. The current guideline does not separate the age groups but is cognizant that in many
cases the evidence base is coming from children 5 years or older. In the future, it may be prudent to produce individual
guidelines or to incorporate the evidence base in a way that illustrates the population under study by age range. As with
any guideline, it is incumbent on the practicing clinician to interpret the evidence base for the individual patient.
References
American Academy of Pediatrics, Joint Committee on Infant Hearing. (2007). Year 2007 position statement: principles
and guidelines for early hearing detection and intervention programs. Pediatrics, 120, 898-921.
Bagatto, M. P., Scollie, S. D., Seewald, R. C., Moodie, K. S., Hoover, B. M., Bagatto, M. P., et al. (2002). Real-ear-to-
coupler difference predictions as a function of age for two coupling procedures. Journal of the American Academy of
Audiology, 13(8), 407-415.
Bagatto, M., Moodie, S., Scollie, S., Seewald, R., Pumford, J., Liu, K. P., et al. (2005). Clinical protocols for hearing
instrument fitting in t e esired ensation e el met od Trends in Amplification, 9(4), 199-226.
C ing illon yrne 2001 C ildren s amplification needs same or different from adults Scandinavian
Audiology, 53(Suppl.), 54-60.
Ching, T.Y.C., Scollie, S.D., Dillon, H., & Seewald, R.C. (2010). A cross-over, double-blind comparison of the NAL-NL1 and
the DSL v4.1 prescriptions for children with mild to moderately severe hearing loss. International Journal of Audiology,
49(Suppl. 1), S4-15.
Ching, T.Y.C., Scollie, S.D., Dillon, H., Seewald, R.C., Britton, L., Steinberg, J., Gilliver, M., & King, K. (2010). Evaluation
of the NAL-NL1 and the DSL v.4.1 prescriptions for children: paired-comparison judgments and functional performance
ratings. International Journal of Audiology, 49(Suppl. 1) S35-48.
oo er telmac o ic PG e is 2000 ffect of earmold fit on predicted real ear P using a real ear
to coupler difference procedure. Ear and Hearing, 21(4), 310-317.
eidser G illon 200 at s ne in prescripti e fittings o n nder n ee ald d Hearing Care for
Adults 2006. (133-142).
Martin, H.C., Munro, K.J., & Langer, D.H. (1997). Real-ear to coupler differences in children with grommets. British
Journal of Audiology, 31(1), 63-69.
artin C est ood G amford 1 6 eal ear to coupler differences in c ildren a ing otitis media it
10

effusion. British Journal of Audiology, 30(2), 71-78.
Moeller, M.P., Tomblin, J.B., Yoshinaga-Itano, C., Connor, C.M., & Jerger, S. (2007). Current State of Knowledge:
Language and Literacy of Children with Hearing Impairment. Ear and Hearing, 28(6), 740-753.
Munro, K. J., & Howlin, E. M. (2010). Comparison of real-ear to coupler difference values in the right and left ear of
hearing aid users. Ear and Hearing, 31(1), 146-150.
Pittman A telmac o ic PG 2003 earing loss in c ildren and adults audiometric configuration asymmetry
and progression. [Research Support, U.S. Gov’t, P.H.S.]. Ear and Hearing, 24(3), 198-205.
Scollie, S.D., Seewald, R.C., Moodie, K.S. & Dekok, K. (2000). Preferred listening levels of children who use hearing aids:
comparison to prescriptive targets. Journal of the American Academy of Audiology, 11(4), 230-238.
Scollie, S., Seewald, R., Cornelisse, L., Moodie, S., Bagatto, M., Laurnagaray, D., et al. (2005). The Desired Sensation
Level multistage input/output algorithm. [Research Support, Non-U.S. Gov’t Review]. Trends in Amplification, 9(4), 159-
197.
Scollie, S.D., Ching, T.Y.C., Seewald, R., Dillon, H., Britton, L., & Steinberg, J. (2010). Evaluation of the NAL-NL1 and DSL
v4.1 prescriptions for children: preference in real world use. International Journal of Audiology, 49(Suppl. 1), S49-63.
Scollie, S.D., Ching, T.Y.C., Seewald, R.C., Dillon, H., Britton, L., Steinberg, J. & King, K. (2010). Children’s speech
perception and loudness ratings en fitted it t e 1 and t e A 1 prescriptions International Journal of
Audiology, 49(Suppl. 1), S26-34.
ee ald ills agatto collie oodie 200 A comparison of manufacturer specific prescripti e
procedures for infants. Hearing Journal, 61(11), 26-34.
ee ald oodie collie agatto 200 e met od for pediatric earing instrument fitting
historical perspective and current issues. Trends in Amplification, 9(4), 145-157.
o lad arrison ous c illiam A 2001 Parents reactions and recommendations after diagnosis
and earing aid fitting American Journal of Audiology, 10(1), 24-31.
arpe A ino ums i ess 2001 ur ey of earing aid fitting practices for c ildren it multiple
impairments. American Journal of Audiology, 10(1), 32-40.
van Grinsven, J.M., & Brokx, J.P. (1995). Hearing ability and use: three cases with multiple handicaps. Scandinavian
Audiology 41(Suppl.), 68-70.
11

3. AUDIOLOGIC CANDIDACY CRITERIA
Objective
e purpose of pro iding amplification for c ildren is to minimi e t e negati e impacts of earing loss on communication
de elopment and academic ac ie ement Amplification systems s ould t erefore e considered for any type or
degree of hearing loss that could possibly interfere with normal developmental processes, including minimal/mild or
unilateral hearing loss or Auditory Neuropathy Spectrum Disorder. Children with severe or profound hearing loss who
may not ac ie e sufficient le els of aided audi ility and speec discrimination a ility it earing aids to support t e
development of auditory skills and speech understanding should be referred for a cochlear implant evaluation, assuming
parent/caregiver preference.
Recommendations for Determining Candidacy

1. C ildren it aida le unilateral earing loss s ould e considered candidates for amplification in t e impaired ear
due to evidence for potential developmental and academic delays. Children with unilateral hearing loss are at greater
ris t an c ildren it normal earing for speec and language delays and academic difficulties or c ildren it
severe or profound unilateral hearing losses and normal hearing in the other ear, Contralateral Routing of Signal
(CROS) or bone conduction devices may be considered depending on the child’s age and ability to control their
environment. Currently there is a paucity of data available to inform these decisions.
2. C ildren it minimal and mild earing loss are at ig ris for e periencing academic difficulty and may e
considered candidates for amplification systems
3. C ildren it Auditory europat y pectrum isorder A s ould a e a trial it amplification as soon as

it can e esta lis ed t at earing sensiti ity is sufficiently poor t at speec at con ersational le els ill not e
easily audible. Because neither the auditory brainstem response (ABR) in children with ANSD, nor the presence
or a sence of otoacoustic emissions pro ides a alid estimate of e a ior t res old amplification s ould only e
provided based on behavioral observations (by the clinician and by parents) until reliable behavioral thresholds can
be established. Children with ANSD may or may not demonstrate improvements in speech understanding with the
pro ision of amplification ased on t e potential for impro ed speec recognition and t e difficulty in predicting
earing aid enefit from audiological c aracteristics a trial it appropriately fit amplification for c ildren it A
is recommended prior to candidacy evaluation for cochlear implantation. Until hearing thresholds can reliably be
established, careful observation of the responsiveness of the child to sounds while wearing hearing aids is essential,
it ad ustments to t e degree of amplification as necessary Alternati ely information a out t e audi ility of speec
with and without hearing aids can be obtained from assessment of cortical responses evoked by speech sounds.
4. C ildren it permanent conducti e earing loss s ould e fit it air conduction earing aids en anatomically
possi le sufficient e ternal ear and canal anatomy to support t e coupling of an earmold and retention of t e
de ice or one conduction earing aids if anatomy is insufficient for coupling atresia c ronically draining ears or
ot er significant anatomical malformations
5. All potential candidates for a coc lear implant s ould recei e a trial it earing aid amplification prior to
implantation to determine if sufficient enefit accrues from appropriately fit earing aids A finding of o esponse
by auditory brainstem response (ABR) does not exclude a child from hearing aid candidacy, as residual hearing may
exist at intensity levels greater than those capable of being elicited using standard ABR. The threshold levels used
12

to prescri e amplification for a no response A s ould e e ual to t e lo est intensity stimulus le el ere no
response is observed for each frequency tested, except in the case of children with ANSD where the absence of an
ABR does not carry any implications about hearing thresholds.
Summary of Evidence for Audiological Candidacy

1 Children with aidable unilateral hearing loss should be 1 4 C EF
considered candidates for amplification due to e idence for
potential developmental and academic delays. 2 4 C EF
10 4 C EF
11 4 C EV
2 Children with mild hearing loss should be considered 2 4 C EF
candidates for amplification
3 4 C EF
4 4 C EV
5 4 C EV
2 Children with minimal hearing loss should be considered for Acoustic
remote microphone technology to improve signal to noise fact
ratio.
3 Children with auditory neuropathy spectrum disorder 6 3 B EF
A s ould a e a trial it amplification unless it can e
established that the child is responsive to speech sounds at 7 3 B EF
conversational levels without hearing aids. The hearing aid
prescription should be altered as further information about 8 3 B EF
hearing thresholds becomes available.
4 C ildren it permanent conducti e earing loss s ould e fit Physical EF/EV
with air conduction hearing aids when anatomically possible, fact
and one conduction earing aids if anatomy is insufficient for
coupling.
5 Children with profound hearing loss by auditory brainstem 9 5 D EF
response should not be excluded from receiving hearing aids
prior to evaluation for a cochlear implant.
References
1. Kenworthy, O.T., Klee, T. & Tharpe, A.M. (1990). Speech recognition ability of children with unilateral sensorineural
earing loss as a function of amplification speec stimuli and listening condition Ear and Hearing, 11(4), 264–270.
2. Tharpe, A.M. (2008). Unilateral and mild bilateral hearing loss in children: Past and current perspectives. Trends in
Amplification, 12(1), 7–15.
13

3. ee e 200 Amplification and family factors for c ildren it mild and unilateral earing impairment n ational
or s op on ild and nilateral earing oss or s op Proceedings rec enridge C Centers for isease
Control and Prevention, 20–21.
4. Bess, F.H., Dodd-Murphy, J. & Parker, R.A. (1998). Children with minimal sensorineural hearing loss: Prevalence,
educational performance, and functional status. Ear and Hearing, 19(5), 339–354.
5. Yoshinaga-Itano, C., DeConde Johnson, C., Carpenter, K. & Stredler Brown, A. (2008). Outcomes of children with
mild bilateral hearing loss and unilateral hearing loss. Seminars in Hearing, 29, 196–211.
6. ance G Cone esson underlic o ell 2002 peec perception and cortical e ent related
potentials in children with auditory neuropathy. Ear and Hearing, 23(3), 239-53.
7. ance G eer Cone esson ep erd o ell C ing A ic ards Clar G

1 Clinical findings for a group of infants and young c ildren it auditory neuropat y Ear and Hearing, 20,
238–252.
8. ous P A ryma r enedi to ang 2011 Audiologic management of auditory neuropat y

spectrum disorder in children: A systematic review of the literature. American Journal of Audiology, 20, 159-170.
9. agatto collie yde ee ald 2010 Protocol for t e pro ision of amplification it in t e
Ontario infant hearing program. International Journal of Audiology, 49(Suppl. 1), S70-9.
10. Kopun, J.G., Stelmachowicz, P.G., Carney, E., Schulte, L. (1992). Coupling of FM systems to individuals with
unilateral hearing loss. Journal of Speech, Language, and Hearing Research, 35(1), 201-207.
11. Shapiro, I. (1977). Children’s use of CROS hearing aids. Archives of Otolaryngology, 103(12), 712-716.
4. PRINCIPLES UNDERLYING EFFECTIVE AMPLIFICATION
Objective
any decisions must e made prior to selecting amplification for a c ild ese decisions are ased on indi iduali ed
needs and abilities, diagnostic information (e.g., degree of hearing loss, physical characteristics, etc.), environment
in which the individual functions, empirical evidence, and/or clinician experience. The overarching goal is to match
t e tec nology/features of t e amplification system to t e needs and a ilities of t e pediatric patient any of t ese
decisions must be revisited on an ongoing basis as the child matures.
4.1 Routing of the Signal

Background
The routing of the signal may include air conduction, bone conduction, electrical stimulation or some combination
of these methods. In addition, the signal may be routed to one ear, both ears or in the case of bone conduction
to ot coc leae it t e etter coc lea utili ing t e signal en t e signal is deli ered to ot ears t e signal
processing may be independent (bilateral) or coordinated at some level as in the case of hearing aids that compare
14

settings in a wireless manner to ensure similar microphone setting, volume control settings, etc. between ears.
ilateral amplification is recommended for most patients it earing loss in ot ears regardless of symmetry
onaural fittings may e arranted ased on specific patient needs or in cases of asymmetry it potential inaural
interference.
Air conduction versus Bone Conduction Transmission

Typically, air conduction hearing aids are the standard treatment for sensorineural hearing loss and conductive
hearing loss assuming the hearing aids can be coupled to the ear (e.g., no malformation of the outer ear or recurrent
drainage). If coupling is not possible, a bone conduction hearing aid may be more appropriate. A bone conduction
hearing aid may be worn as a completely external device with a band creating the pressure needed to transmit the
vibrated signal or it may be coupled with an implanted abutment (i.e., osseointegrated device). The implantation
and support of a bone anchored hearing aid requires collaboration between the audiologist and otolaryngologist/
otologist e A as appro ed t e use of t e one anc ored earing aids for c ildren fi e years and older t oug
one conducted amplification is often used it out implantation ia a soft ead and in c ildren younger t an
Electrical Stimulation
Individuals with severe to profound sensorineural hearing loss in both ears are candidates for cochlear implants. A
cochlear implant provides tonotopic electrical stimulation to the auditory nerve. Some children may use a hearing aid
in one ear and a coc lear implant in t e ot er i modal y rid amplification de ices are a com ination of earing
aids and coc lear implants and pro ide acoustic amplification to t e lo fre uencies and electrical stimulation to t e
higher frequencies. These devices are not currently approved for use in the United States, nor with children.
Unilateral Hearing Loss

Contralateral routing of t e signal C and ilateral routing of t e signal C fittings are specially designed
for patients having either unilateral hearing loss or bilateral asymmetrical hearing loss where one ear is unaidable,
respecti ely Currently ired and ireless configurations are a aila le or t e c ild it unilateral deafness an
system with the wireless remote microphone receiver portion coupled to the open, good ear may be preferable in
classroom situations to t e C arrangement to gi e t e enefit of increased signal to noise ratio a enefit in a
noisy classroom. The transcranial CROS is an option for individuals who have no auditory response in one ear. In
t is configuration a po erful earing aid is fit to t e non responsi e ear so interaural attenuation is o ercome and
sound is percei ed y t e functioning coc lea is is not a common fitting for c ildren and again an appropriately
fit assisti e listening de ice may e a etter communication solution in t e classroom e osseointegrated earing
de ice descri ed earlier also can e used as an implanted transcranial C e idence supporting enefit of t is
arrangement in children is limited.
f t e unilateral earing loss is aida le t en a monaural fitting ould e considered
Recommendations for Selecting Routing of the Signal

1. ilateral amplification is recommended unless contraindicated.
2. Sound transmission is chosen based on type and severity of the hearing loss and physical features of the outer
ear.
3. Bi-modal sound transmission (CI on one side and hearing aid on the other) is recommended for children
unilaterally implanted unless contraindicated.
15

4. For a child with unilateral deafness, an FM system with the wireless remote microphone receiver coupled to the
open good ear may e prefera le to a C configuration in classroom situations
5. se of a one conducted signal may e an effecti e means of amplification for c ildren it permanent ilateral
conductive hearing loss.
6. Use of a bone conducted signal may be considered an option with children who have unilateral hearing loss.
Summary of Evidence for Selecting Routing of the Signal

1 ilateral amplification is routinely recommended unless 2 3 B EV

contraindicated.
3 3 B EV
2 Sound transmission is chosen based on type and acoustic EF/EV
severity of the hearing loss and physical features of the and
outer ear. physical
fact
3 Bi-Modal sound transmission is recommended for 1 3 B EV
children unilaterally implanted unless contraindicated.
11 3 B EV
4 For a child with unilateral deafness, an FM 4 3 B EV
system with the wireless remote microphone
receiver coupled to the open, good ear may
e prefera le to a C configuration in
classroom situations.
5 Use of bone conducted signal for children with 5 4 C EF
permanent bilateral conductive hearing loss
6 4 C EF
9 4 C EF
10 4 C EV
6 Use of bone conducted signal for children with 7 3 B EF
UHL
8 3 B EV
7 Use of a hearing aid when unilateral loss is 12 3 B EF
aidable.
13 3 B EF
References
1. Ching, T., Hill, M., Brew, J., Incerti, P., Priolo, S., Rushbrook, E. & Forsythe, L. (2005). The effect of auditory
experience on speech perception, localization, and functional performance of children who use a cochlear
implant and a hearing aid in opposite ears. International Journal of Audiology, 44(12), 677-690.
2. Christensen, L., Richter, G. T. & Dornhoffer, J.L. (2010). Update on bone-anchored hearing aids in pediatric
16

patients with profound unilateral sensorineural hearing loss. Archives of Otolaryngology Head and Neck Surgery,
136, 175-177.
3. Hattori, H. (1993). Ear dominance for nonsense-syllable recognition ability in sensorineural hearing-impaired
c ildren onaural ersus inaural amplification Journal of the Academy of Audiology, 4, 319-330.
4. Hawkins, D.B. (1984). Comparisons of speech recognition in noise by mildly-to-moderately hearing-impaired

children using hearing aids and FM systems. Journal of Speech and Hearing Disorders, 49(4), 409-418.
5. Kenworthy, O.T., Klee, T. & Tharpe, A.M. (1990). Speech recognition ability of children with unilateral
sensorineural earing loss as a function of amplification speec stimuli and listening condition Ear and
Hearing, 11, 264-270.
6. Seemann, R., Liu, R. & Di Toppa, J. (2004). Results of pediatric bone anchored hearing aid implantation. Journal
of Otolaryngology, 33, 71-74.
7. Snik, A., Leijendeckers, J., Hol, M., Mylanus, E., & Cremers, C. (2008). The bone anchored hearing aid for
children: recent developments. International Journal of Audiology, 47, 554-559.
8. e man C andridge A od is 200 ongitudinal enefit from and satisfaction it t e

BAHA system for patients with acquired unilateral sensorineural hearing loss. Otology and Neurotology, 29,
1123-1131.
9. Nicholson, N., Christensen, L., Dorhoffer, J., & Martin, P. (2011). Speech spectrum audibility for pediatric BAHA
softband users with craniofacial anomalies. The Cleft Palate-Craniofacial Journal, 48(1), 56-65.
10. Christensen, L., Smith-Olinde, L., Kimberlain, J., Richter, G.T., & Dornhoffer, J.L. (2010). Comparison of traditional
bone-conduction hearing aids with the BAHA system. Journal of the American Academy of Audiology, 21, 267-
273.
11. C ing C an anrooy ill ncerti P 2006 Performance in c ildren it earing aids or coc lear
implants: Bilateral stimulation and binaural hearing. International Journal of Audiology, 45(Suppl. 1), S108-S112.
12. Kiese-Himmel, C. (2002). Unilateral sensorineural hearing impairment in childhood: analysis of 31 consecutive
cases. International Journal of Audiology, 41(1), 57-63.
13. Kiese-Himmel, C. & Ohlwein, S. (2003). Characteristics of children with mild permanent hearing impairment.
Folia Phoniatrica Et Logopaedica, 55, 70-79.
4.2 Selection of Hearing Aid Style

Objective
The choice of hearing aid style should be made based on factors such as gain and output requirements, bandwidth,
ear canal si e and s ape e pected c anges in conc a and ear canal si e s in sensiti ity and need for specific
features (e.g., directional microphone, telecoil, direct auditory input, built-in FM receiver), comfort, occlusion
considerations, and cosmetic concerns. For the pediatric patient, expected changes in ear size generally promotes
the behind-the-ear (BTE) style as the preferred choice due to the need to replace only the relatively inexpensive
ear mold as the child grows. The outer ear may continue to grow well into puberty, thus dictating the BTE style. In
17

addition, for many pediatric patients, features such as directional microphones, telecoils, direct auditory input, and
built-in wireless (e.g. FM) receivers are desirable and are found on the BTE style of hearing aid.
BTE Terminology
The slim tube is a method of coupling a BTE or mini-BTE to the ear. This tubing is often designed to end in a small
dome that can either leave the ear canal open or mostly close it, but can end with a more traditional, closed mold.
A second style of mini-BTE places the receiver in the ear canal, rather than in the hearing aid case. This style of
hearing aid is referred to in different ways, depending on the manufacturer’s preferred nomenclature. It may be
referred to as a Receiver in the Canal (RIC), Receiver in the Ear (RITE) or Canal Receiver Technology (CRT). The
Hearing Industries Association (HIA) uses the term RIC and that term will be used in this document. The Receiver in
t e Aid A is t e traditional configuration and can e coupled to standard or slim tu ing and to an open or closed
ear mold. The RIC removes the receiver from the BTE case with a wire running down the slim tube connecting the
BTE circuitry to the receiver that is now in the ear canal. This style allows for a smaller BTE case while still having
t e amplification po er of a more traditional t also allo s room for a larger attery in a smaller case e
potential disadvantage is consistent with the disadvantages of the ITE, ITC, and CIC styles in that the receiver is now
more exposed to moisture, heat, and cerumen in the ear canal. Many of the mini-BTE options do not offer telecoils,
coupling for FM input or locking battery doors.
Recommendations for Hearing Aid Style

1. BTEs are the style of choice while the child’s ear is still growing.
2. BTEs may provide needed features for the pediatric patient.
3. Standard BTEs may provide appropriate coupling to a variety of assistive listening devices that may assist in
educational and social settings. Not all RIC or mini-BTEs will have the ability to couple to assistive devices.
4. Tubing size, occlusion, and receiver placement are individual choices based on patient communication needs,
ear canal dimensions earing loss se erity and configuration and patient preferences
Summary of Evidence for selecting hearing aid style

BTEs are the style of choice while the child’s ear is still physical
1 growing. fact EF/EV
BTEs may provide needed features for the pediatric acoustic
2 patient. fact EF/EV
BTEs will provide appropriate coupling to a variety of
assistive listening devices that may assist in educational acoustic
3 and social settings. fact EF/EV
Tubing size, occlusion, and receiver placement are acoustic
individual choices based on patient communication and
needs, ear canal dimensions, hearing loss severity and physical
4 configuration and patient preferences fact EF/EV
18

4.3 Adequacy of Earmold
Background
If a behind-the-ear hearing aid is chosen for the pediatric patient, an earmold to couple the device to the ear canal
must be selected. The audiologist should consider the style, material, color, length, and frequency of remakes for
t e earmold e need for ell fitting earmolds as increased it t e ad ent of ide dynamic range ide and
hearing aids, but has also decreased with the increase in effectiveness and use of feedback management
algorithms. The audiologist is able to make a wide range of sounds audible in an automatic way by using amplitude
compression circuitry with no volume control. The use of automatic technology without the need for a volume
control forces the audiologist to be more proactive about regular earmold changes. Feedback suppression may
alleviate this problem temporarily while the new earmold is ordered. Clinicians should use caution with feedback
suppression and remember that it may alter the frequency and gain characteristics of the response. As such, the
feed ac suppression features if used s ould e acti e during t e erification process ee section 6 1 later in t e
guideline for more discussion on this topic. However, feedback management should not be used to extend the life
of poorly fitting earmolds as significant c anges in t e acoustics of t e earmold coupling are li ely to occur as t e
child outgrows their earmolds. For infants, earmold replacement may be as frequent as monthly.
enting in t e earmold may e appropriate for some c ildren depending on t e configuration and degree of earing
loss as well as the status of their outer and middle ear. Venting earmolds for children should be approached
cautiously. Venting alters the hearing aid’s frequency response, and certain placements of venting (i.e. vents that
intersect the sound bore) may create problems in sound channel tubing retention and reduce the bandwidth of the
hearing aid response. For many infants and young children, internal venting will not be possible due to the small
size of the earmold and the gain and output requirements that may produce feedback if venting is used. External
venting (removal of material from the outside surface of the mold) is usually possible from a space perspective, but
t e potential difficulty it feed ac oscillation remains n order to maintain appropriate gain manage t e small
size of the earmold, and minimize the occlusion effect (OE), it may be necessary to 1) separate the microphone and
location of the acoustic output of the hearing aid by using a behind-the-ear style and potentially coupling this with a
remote microphone (hearing assistance technology), 2) use feedback management algorithms, 3) reduce occlusion
y e tending t e canal of t e earmold to t e ony portion of t e ear canal deep fit e long earmold canal as
t e added enefit of reducing t e olume of t e ear canal et een t e end of t e earmold and t e tympanic
membrane, thereby increasing the sound pressure level that is achieved in the ear canal (without increasing the gain
or attery drain of t e earing aid ile increased gain can e a enefit it is essential to account for t is c ange
in sound pressure level by measuring the child’s real-ear-to-coupler difference (RECD) and applying this correction
during t e erification process so as to ensure t at t e output is appropriately limited for t e indi idual c ild n
addition t e output ac ie ed in t e ear canal ill c ange as t e c ild gro s and eac time a ne earmold is fit
requiring repeated real-ear and RECD measures with each new earmold.
The sound channel consists of the ear hook and tube that leads through the earmold and sends sound into the ear
canal. Just as a horn (increased diameter at the end of the sound channel) increases the high frequency response,
a reverse horn will roll off the high frequencies. These are often the frequencies where the child needs the most
amplification A re erse orn is a common concern in an infant or young c ild ecause t e ear canal is so small t at
the sound channel decreases in diameter from the tubing to the sound bore. It is essential that the end of the sound
channel be checked visually for crimping. It may be necessary to not “tube through” an infant’s earmold to avoid
crimping or unnecessarily restricting the diameter of the sound channel. An electroacoustic measure that includes
the earmold or probe microphone measures with the earmold connected to the hearing aid will reveal any roll off in
high frequency response.
19

Manufacturers generally send adult size ear hooks unless otherwise instructed. A pediatric ear hook can be
crucial for ensuring retention of the hearing aid. BTE tubing systems (comprising the receiver tube, earhook, and
earmold tubing) add resonant peaks to the hearing aid response. These peaks can increase the chance of acoustic
feedback and may dictate the maximum output setting of the hearing aid thereby unnecessarily decreasing the
headroom (the difference between the level of speech and the saturation level of the hearing aid) of the instrument.
A filtered damped ear oo ill smoot t e fre uency response C anging from an adult to pediatric ear oo ill
alter the hearing aid response. Any changes to the sound channel require that new real-ear measures are made.
Earmolds and tubing can separate from the hearing aid and can be swallowed. The integrity of the connection
between the earmold, tubing, ear hook, and hearing aid should be checked at the child’s regular visits to the clinic.
Recommendations for adequacy of earmold

1. Be proactive regarding earmold replacement due to the child’s growth.
2. Use automatic feedback suppression in order to resolve feedback issues, either temporarily while awaiting new
earmolds or permanently if needed to achieve the prescribed gains. Use feedback cancellation (which does not
reduce the gain below the value that applies in the absence of feedback oscillation) in preference to feedback
management systems that operate by reducing gain in one or more frequency regions, at one or more input
levels, until feedback oscillation ceases.
3. Approach venting cautiously in pediatric earmolds because of space limitations.
4. For infants, the only way to fully eliminate feedback may be to use an offsite/remote microphone. Caution must
be used when considering this as a full time option because the child may not hear his/her own babbling/
speech sounds if the microphone is not near the child’s mouth.
5. Provide a long, but comfortable earmold canal length to reduce the occlusion effect and to provide increased
output in the ear canal due to decreased volume between the earmold and eardrum.
6. Guard against reverse horns created by crimping the end of the sound channel in small earmolds.
7. Use pediatric ear hooks to promote retention of BTEs.
8. se filtered ear oo s to ensure a smoot fre uency response
Summary of evidence related to selection of the ear mold

Be proactive regarding earmold replacement due to the physical
1 child’s growth fact EF/EV
Consider automatic feedback suppression in order to
resolve feedback issues temporarily while awaiting new acoustic
2 earmolds fact EF/EV
Approach venting cautiously in pediatric earmolds acoustic
3 because of space limitations fact EF/EV
20

Consider off site microphones to eliminate feedback
for infants. Children will not be able to monitor speech/ acoustic
4 a le in t is configuration fact EF/EV
In adults, some negative effects of occlusion can be acoustic
5 reduced with a longer ear canal portion to the earmold fact EF/EV
Increased output can be achieved with a longer ear acoustic
5 canal portion to the earmold fact EF/EV
Avoid reverse horns and monitor for crimping at the acoustic
6 earmold sound bore fact EF/EV
physical
7 Pediatric ear hooks may help with retention fact EF/EV
Filtered ear hooks will provide a smooth frequency acoustic
8 response. fact EF/EV
4.4 Safety Considerations

Background
Several categories of potential hearing aid-related adverse effects emerged from the literature. These may be related
to either physical or acoustic features of the hearing aid.
Battery door: pecific ris s of attery ingestion include to icity and asp y iation C ildren under age 6 are at
greater risk for battery ingestion. The audiologist should recommend tamper-resistant battery doors for younger
children and parents should be supplied with the poison control center number should a battery be ingested.
Battery recycling or other safe disposal of hearing aid batteries is recommended.
Volume Control: A volume control may come in the form of a wheel, toggle, touch sensor or button. The need for
a volume control is dictated by the signal processing scheme that is used in the hearing aid and the user’s previous
experience (if any). Adjustment of a volume control can provide a short-term solution to feedback caused by poorly
fitting earmolds ut reductions in olume to minimi e feed ac ill reduce t e o erall audi ility of t e earing
aid fitting f a olume control is present t e clinician must decide if t e c ild s ould a e access to manipulating
the control or if a locking volume control is preferred (access is then limited to the clinician and perhaps a parent/
caregiver). Most hearing aids are equipped with the ability to activate and de-activate certain features on the hearing
aid including the volume control and memory button. The audiologist may want to de-activate the volume control for
a young child but have the option to activate the feature as the child matures over the life of the hearing aid.
Overamplification: The gain-frequency response and maximum output of the hearing aid should be set
according to pu lis ed independent prescripti e fitting formulae in con unction it t e measured real ear to
coupler difference see section 6 1 for additional details regarding t e C Gain settings significantly in e cess
of prescriptive targets may result in further damage to residual hearing. Excessive output may be especially
damaging for children with severe to profound hearing loss (i.e., thresholds of approximately 90 dB HL or higher).
f o eramplification is suspected monitoring of emporary res old ift y measuring audiometric
thresholds before and after a day of device use is recommended. Threshold-shift in excess of 5 dB may indicate
o eramplification ceeding t e safety limit is unli ely en earing aids are fit to independent prescripti e
formulae, when nonlinear signal processing is used, and when the user has hearing levels below the severe to
profound range (lower gains are necessary). Prescriptive targets have a degree of caution built in to the suggested
21

outputs so fitting a earing aid it less t an t e prescri ed ma imum output is not ad ised since t is may lead to
reduced headroom, thereby increasing the compression ratio needed.
Parental anxiety, training, and resulting device use: Effective counseling and coaching are required to ensure
that parents are prepared, technically and emotionally, to provide hearing aid use support for infants and young
children. Support in various forms (e.g. device retention, coaching/counseling regarding developmentally appropriate
expectations) is required to work with families to promote appropriate use across environments and developmental
stages Parents of c ildren it earing loss may e i it concerns at t e time of earing aid fitting regarding earing
aid maintenance appearance and potential enefit Parents may e perience an iety resulting from t e earing
aid fitting apart from an iety specific to t e identification of earing loss Consistency of de ice use aries across
families, environments, degree of hearing loss and developmental stages.
Nonfunctioning hearing aids: An overall loss (i.e., the combination of loss of open ear canal resonance and
earmold attenuation) of a nonfunctioning hearing aid can range from 25-30 dB. This is equivalent to that of noise
attenuation de ices and represents a significant loss of sound compared to eit er t e unaided or aided listening
condition. Regular checks by caregivers are needed to ensure that hearing aids are functional.
Care should be taken to ensure that parents are skilled at monitoring device function and troubleshooting. The
specific mec anism for ac ie ing t ese goals ill ary it t e c ild s caregi ers en ironments and a ilities o er
time Caregi er listening c ec s it out furt er support ia ritten materials may e insufficient to ensure daily
functioning of hearing aids. Parents may require/prefer written materials to supplement in-person training regarding
daily check procedures.
Ear impressions and contact dermatitis: Ear impression taking carries several risks, including impaction of
cerumen, injury to the ear canal or tympanic membrane, injection of material into the middle ear space, or contact
dermatitis arising from the type of ear impression material used. In addition, some earmold or earshell materials
carry risk of contact dermatitis. Case history of prior skin reactions should precede ear impression taking to avoid
re-exposure to allergenic materials. Selection of materials with lower allergenic properties can assist in avoiding
most, but not all, skin reactions. Patients with pre-existing ear abnormalities are at greater risk of complications
arising from ear impression procedures. Contact dermatitis is also a risk of ear impression taking and/or earpiece
use. Risk is dependent on both material type and patient susceptibility.
The unique combination of the above decisions will lead to the selection of particular hearing aids for a particular
child. Some decisions exclude other choices and a compromise may have to be reached by prioritizing these
choices.
Recommendations for safety considerations

1. Utilize tamper resistant battery doors to decrease the likelihood of battery ingestion.
2. De-activate or lock volume controls, or utilize wide dynamic range compression thereby eliminating the need for
volume control manipulation for audibility and comfort.
3. Use a validated, pediatric-focused prescriptive formula and account for the real-ear to coupler difference (RECD)
en prescri ing gain or output for a c ild in order to a oid o eramplification
4. onitor temporary t res old s ift if o eramplification is suspected
5. Attempt to reduce parental/caregiver anxiety through counseling and instruction.
22

6. Provide parents/caregivers with tools and instructions to ensure functioning hearing aids.
7. Identify prior skin reactions in order to minimize incidence of contact dermatitis with earmold impression and/or
earmolds.
Summary of evidence for safety considerations

1 Use tamper resistant battery doors physical EF/EV
fact
2 De-activate or lock volume control acoustic EF/EV
fact
3 Use an independent prescriptive formula that accounts 1 4 D EF
for the real-ear to coupler difference (RECD) when
prescribing gain or output for a child in order to avoid 2 4 D EF
o eramplification
3 4 D EV
4 4 D EV
5 5 D EV
6 3 B EF
7 3 B EF
8 3 B EV
9 4 C EV
4 onitor if o eramplification is suspected 7 3 B EV
5 Attempt to reduce parental/caregiver anxiety through 10 4 C EV

counseling and instruction.
11 4 C EV
12 4 C EV
6 Provide parents/caregivers with tools and instructions to 13 4 C EV
ensure functioning hearing aids.
14 6 D EV
7 Identify prior skin reactions in order to minimize incidence 15 3 B EV
of contact dermatitis with earmold impression and/or
earmolds.
References
1. Darbyshire, J.O. (1976). A study of the use of high power hearing aids by children with marked degrees of
deafness and the possibility of deteriorations in auditory activity. British Journal of Audiology, 10, 74-82.
2. ittel G A mann 1 1 eterioration in earing caused y earing aids in c ildren Advances in Oto.-
Rhino.-Laryngology, 27, 130-1377.
23

3. Newton, V.E. & Rowson, V.J. (1988). Progressive sensorineural hearing loss in childhood. British Journal of
Audiology, 22, 287-295.
4. Podoshin, L., Kremer, M., Fradis, M. & Feiglin, H. (1984). Effect of hearing aids on hearing. Laryngoscope, 94,
113-117.
5. Heffernan, H.P. & Simons, M.R. (1979). Temporary increase in sensorineural hearing loss with hearing aid use.
Annals of Otology, Rhinology & Laryngology, 88(1 Pt.1), 86-91.
6. Macrae, J.H. (1991). Prediction of deterioration in hearing due to hearing aid use. Journal of Speech & Hearing
Research, 34, 661-70.
7. Macrae, J.H. (1994). An investigation of temporary threshold shift caused by hearing aid use. Journal of Speech
& Hearing Research, 37, 227-37.
8. acrae 1 afety aspects of amplification for se ere/profound earing loss Australian Journal of
Audiology, 17, 27-37.
9. Reilly, K.M., Owens, E., Uken, D., McClatchie, A.C. & Clarke, R. (1981). Progressive hearing loss in children:
Hearing aids and other factors. Journal of Speech & Hearing Disorders, 46, 328-34.
10. cCrac en oung A attersall 200 ni ersal e orn earing creening Parental e ections
on Very Early Audiological Management. Ear and Hearing, 29(1), 54-64.
11. Moeller, M.P., Hoover, B., Peterson, B. & Stelmachowicz, P. (2009). Consistency of hearing aid use in infants with
early identified earing loss American Journal of Audiology, 18(1), 14-22.
12. o lad arrison ous c illiam A 2001 Parents reactions and recommendations after
diagnosis and earing aid fitting American Journal of Audiology, 10, 24-31.
13. Smedley, T. & Plapinger, D. (1988). The nonfunctioning hearing aid: A case of double jeopardy. Volta Review, 90,
77-84.
14. Elfenbein, J. (2000). Batteries required: Instructing families on the use of hearing instruments. Chapter 11 in R.
Seewald (Ed.) A Sound Foundation Through Early Amplification: Proceedings of an International Conference.
Phonak: Stafa Switzerland. Pp. 141-149.15 .
15. aco A orris elling 2006 ea ing a lasting impression ear mold impressions as middle ear
foreign bodies. Annals of Otology Rhinology and Laryngology. 115(12), 912-916.
5. SIGNAL PROCESSING AND FEATURES
Objective
For the child with hearing loss the audiologist often begins a rehabilitative treatment plan with the selection of appropriate
amplification is process includes matc ing appropriate signal processing features to t e c ild s listening needs
efining t e listening needs of any c ild ill e ased on t e degree configuration and type of earing impairment as
24

well as consideration of environmental, familial and economic factors. The choice of appropriately validated features and
related signal processing for each individual is paramount.
Fundamental Requirements for Hearing Aid Audio Signal Processing

1. The system should avoid unnecessary distortion.
2. e system s ould allo sufficient fre uency s aping to meet t e prescripti e re uirements of t e earing loss
configuration
3. e system s ould employ amplitude compression t at offers t e e i ility to restore audi ility for lo le el inputs
while maintaining comfort for high level inputs.
4. utput limiting must e sufficient to a oid e posure to loud sounds ile minimi ing electroacoustic distortion
Recommendations for Hearing Aid Audio Signal Processing

ntil sufficient data are a aila le to e clude t e follo ing processing tec ni ues eac s ould e considered ia le and
prefera le for t e pediatric fitting of earing aids
1. Compression in the dynamic range: The system should employ an amplitude compression strategy. As with the
adult patient t e prescription of amplification gain for t e pediatric patient s ould ensure t at a range of input le els
are compressed sufficiently to accommodate sensiti ity to loud sounds ile restoring lo le el speec audi ility
In meeting these requirements, selection of compression characteristics should also minimize alteration of speech
cues. The generation of pediatric- focused target gains should be done with an independent prescriptive procedure
that accommodates the considerations discussed above.
2. Software bands: A minimum of four to seven software adjustment bands (i.e., handles) should be selected for the
digitally programmed hearing aid. t is e pected t at t is ill allo for sufficient fre uency s aping to meet t e needs
of most audiometric configurations ere s ould not e a disad antage to increasing t e num er of ands eyond
se en e system also s ould allo sufficient e i ility to accommodate t e c ild s gro t any progression or
uctuation in earing t res olds and any related c anges to fre uency s aping e g larger ear canals or increased
vent diameter may require an increase in prescribed gains).
3. Compression channels: Multi-channel compression should be selected for the management of frequency
specific audi ility ncreasing t e num er of c annels eyond one may increase audi ility as s o n y predicti e
models of audibility), particularly for sloping audiograms, but may also reduce the discrimination of sounds on the
basis of their spectral shapes. The disadvantages associated with a high number of channels increase with the size
of the compression ratio used.
4. Output limiting: Output limiting will constrain the maximum output of any hearing aid. This constraint will assist
in avoidance of discomfort, as well as avoidance of possible sound-induced threshold-shift, for loud inputs.
Compression output limiting will provide superior sound quality as compared to hearing aids that limit maximum
output through peak clipping. Inaccurate prescription of output limiting (unnecessarily low or high) has been shown
to decrease speech recognition in adults.
5. Expansion at low input levels: Expansion at low input levels is expected to improve comfort by reducing audibility
of low level environmental sounds. There is evidence to suggest that expansion also will decrease audibility of low
25

level speech if the expansion threshold is set too high. Thus the prescription of expansion in children should be done
with the understanding that prioritizing comfort in quiet environments also may have a negative effect on audibility of
low level speech inputs.
6. Extending high-frequency bandwidth: Extended high-frequency bandwidth (up to 9000 Hz) will improve
audibility for sounds such as /s/ that represent an essential cue for the recognition of plural or possessive
statements in the English language. The clinician should not conclude that a lack of increased performance from
ig fre uency amplification implies a decrease in performance
7. Techniques for frequency lowering: Individual techniques for frequency lowering have markedly different
effects on t e amplified speec spectrum t e clinical implications of t ese differences are not understood ere is
evidence to suggest that frequency lowering may improve detection and recognition of high-frequency consonants
for children with high-frequency hearing loss ranging from moderate to profound. There also are data that suggest
acclimati ation to fre uency lo ered amplification may increase ot acceptance of and performance it a gi en
frequency lowering technique. Fitting of any frequency lowering algorithm should be accompanied by behavioral
alidation re uency lo ering s ould e treated as a form of distortion purposefully introduced to t e amplified
pat ay ine tuning and t e accompanying erification and outcome assessment s ould a e t e goal of pro iding
the least possible effect (distortion) that allows access to high frequency sound. Frequency lowering should not be
prescri ed until electroacoustic erification as re ealed t at ig fre uency speec audi ility cannot e restored
through conventional means.
8. Feedback suppression: It is an acoustic fact that feedback suppression will decrease the occurrence of feedback
oscillation (i.e., whistling). The reduction of feedback will allow for larger vents and increase the time period between
earmold rema es All erification s ould e performed after t e acti ation of any modern feed ac suppression
algorithm as it is a common process for manufacturers to limit accessible gains during the initialization process of
the feedback suppression algorithm.
9. Directional microphones: Full-time directional processing is not recommended. This feature may be
recommended for children, although there are common listening environments in which directional technology is not
desirable. The directional mode may reduce audibility of off-axis talkers, limiting overhearing and related incidental
learning mall ut significant additional directional enefits may e associated it adapti e directional microp one
tec nology and no significant negati e conse uences are associated it adapti e directional processing in adult
listeners.
10. Hearing aids that automatically switch between directional and omnidirectional modes depending on which
mode produces the signal with the greater apparent signal-to-noise ratio should be considered. However, it is
the responsibility of the audiologist to understand the switching parameters of the automatic program as well as
the acoustic conditions of the educational setting in order to establish appropriate expectations for any automatic
switching behavior.
11. In some cases full-time omnidirectional mode may be preferred to an automatic directional mode. All children with
earing loss s ould e considered candidates for use en appropriately prescri ed systems ill pro ide
improvements in signal-to-noise ratio that are similar or superior to directional microphones.
12. Digital noise reduction: Adult listeners are expected to experience reduced annoyance and increased
acceptance of background noise when listening with digital noise reduction. On average, digital noise reduction is
not expected to negatively impact speech recognition ability in children. The prescription of digital noise reduction
26

should be done with the understanding that different implementations of this technology vary in their electroacoustic
behavior and that prioritizing comfort or the acceptance of background noise may negatively impact speech
audibility.
Summary of Evidence for Signal Processing

1 Independent prescriptive formulas provide a starting point for 8 3 C EV Adult
target gains at multiple input levels.
11 4 C EF Adult
27 2 A EF
1 Compression applied across the dynamic range may improve 9 3 B EF
low level speech audibility while maintaining comfort
10 3 C EF
2 e en ands ill pro ide sufficient fre uency s aping to 1 3 C EF Adult
address most audiometric configurations
3 Speech recognition differences have been associated with 33 4 C EF
increased number of compression channels, but some
experiments have shown no increase in speech recognition
with increased number of compression channels.
4 Compression output limiting maintains sound quality when 37 4 C EF Adult
compared to peak clipping.
5 Expansion may reduce low level speech audibility and 4 3 B EF Adult
recognition of low level speech segments.
32 3 C EF Adult
6 Audibility of extended high-frequencies positively impacts 12 3 B EF
recognition of high-frequency consonants for children.
28 3 B EF
29 3 B EF
7 Frequency lowering is a form of acoustic distortion that, when 2 3 B EF Adult
properly prescribed, may provide access to high frequency
cues for the child with unaidable high frequency hearing loss. 6 3 B EF
23 3 C EF
34 2 A EF
35 3 B EV
27

7 Frequency lowering improves consonant recognition for some 2 3 B EF Adult
listeners with hearing loss ranging from moderate to profound
for children and adults. 6 3 B EF
23 3 C EF
35 3 B EV
7 Consonant recognition ability with frequency lowering will 2 3 B EF Adult
improve with listening experience and training both in children
and adults 23 3 C EF
35 3 B EV
8 Gain limitations introduced during the initialization process of Acoustic EF/EV
feed ac suppression algorit ms may limit t e fitting range of fact
that device
9 Directional hearing aids provide speech understanding in 3 1 A EF Adult
noise enefits to adults in many noisy en ironments o e er
decrements also may be present in some environments. 13 3 C EF Adult
15 3 C EF Adult
22 3 C EF Adult
23 4 C EF Adult
24 3 C EF Adult
31 3 C EV Adult
36 3 C EF Adult
Acoustic
fact
9 Children as young as 4 months of age can and do orient 5 4 B EV
their heads towards sound sources of interest in home
environments 40% of the time. Children in the study were not
earing amplification
9 C ildren in simulated sc ool en ironments e i it significant 7 3 B EV
directional enefit en t ey are facing t e signal of interest
easured and self reported increased difficulties it speec 20 3 B EF
recognition can occur in the directional mode when the
signal of interest is e ind t e listener ese difficulties are of 21 3 B EF
considerable concern if the hearing aid does not automatically
switch to omnidirectional processing in such situations, given
evidence that children can and do learn through overhearing
speech that is presented off-axis, even when distracted.
28

9 or c ildren speec recognition enefits e perienced it 19 3 B EF
directional microphones are generally smaller than those
observed when using FM technology.
9 mall ut significant additional directional enefits may e 13 3 C EF Adult
associated with adaptive directional microphone technology
and to date no significant negati e conse uences are
associated with adaptive directional processing in adult
listeners.
10 Adults experience reduced annoyance and listening effort 16 3 C EF Adult
when using digital noise reduction.
17 3 C EF Adult
25 3 C EV Adult
26 3 C EF Adult
10 On average digital noise reduction does not negatively impact 18 3 B EF Adult
speech recognition ability.
30 3 B EF
References
1. Aahz, H. & Moore, B. (2007). The value of routine real ear measurement of the gain of digital hearing aids. Journal of
the American Academy of Audiology, 18, 653-664.
2. Auriemmo, J., Kuk, F., Lau, C., et al. (2009). Effect of linear frequency transposition on speech recognition and
production of school-aged children. Journal of the American Academy of Audiology, 20(5), 289-305.
3. Bentler, R.A. (2005). Effectiveness of directional microphones and noise reduction schemes in hearing aids: a
systematic review of the evidence. Journal of the American Academy of Audiology, 16(7), 473-484.
4. Brennan, M. & Souza, P. (2009). Effects of expansion on consonant recognition and consonant audibility. Journal of
the American Academy of Audiology, 20, 119-127.
5. Ching, T.Y.C., O’Brien, A., Dillon, H., Chalupper, J., Hartley, L., Raicevich, G. & Hain, J. (2009). Directional effects
on infants and young c ildren in real life mplications for amplification Journal of Speech Language and Hearing
Research, 52, 1241-1254.
6. Glista, D., Scollie, S., Bagatto, M., Seewald, R., Parsa, V. & Johnson, A. (2009). Evaluation of nonlinear frequency
compression: Clinical outcomes. International Journal of Audiology, 48(9), 632-644.
7. Gravel, J.S., Fausel, N., Liskow, C. & Chobot, J. (1999). Children’s speech recognition in noise using omni-directional
and dual-microphone hearing aid technology. Ear and Hearing, 20(1), 1-11.
8. ogan C A urner C 1 ig fre uency audi ility enefits for earing impaired listeners Journal of the
Acoustical Society of America, 104, 432-441.
9. enstad ee ald Cornelisse ant 1 Comparison of linear gain and C earing aid circuits
Aided speech perception measures. Ear and Hearing, 20, 117-126.
29

10. enstad Pumford ee ald Cornelisse 2000 Comparison of linear gain and C earing aid
circuits II: Aided loudness measures. Ear and Hearing, 21, 32-44.
11. Keidser, G., Dillon, H., Flax, M., Ching, T. & Brewer. (2011). The NAL-NL2 prescription procedure. Audiology
Research, 1(24), 88-90.
12. orte aas telmac o ic PG 2000 and idt effects on c ildren s perception of t e in ectional
morpheme /s/: Acoustical measurements, auditory detection, and clarity rating. Journal of Speech, Language and
Hearing Research, 43, 645-660.
13. Kuk, F., Keenan, D., Lau C.C. & Ludvigsen, C. (2005). Performance of a fully adaptive directional microphone to
signals presented from various azimuths. Journal of the American Academy of Audiology, 16(6), 333-347.
14. u eenan or onen P au C 200 fficacy of linear fre uency transposition on consonant
identification in uiet and noise Journal of the American Academy of Audiology, 20, 465-479.
15. Mackenzie, E. & Lutman, M.E. (2005). Speech recognition and comfort using hearing instruments with adaptive
directional characteristics in asymmetric listening conditions. Ear and Hearing, 26(6), 669-679.
16. ueller G e er orns y 2006 e effects of digital noise reduction on t e acceptance of

background noise. Trends in Amplification, 10(2), 83-93.
17. Palmer C entler ueller G 2006 Amplification it digital noise reduction and t e perception of
annoying and aversive sounds. Trends in Amplification, 10(2), 95-104.
18. Pittman, A. (2011). Children’s performance in complex listening conditions: Effects of hearing loss and digital noise
reduction. Journal of Speech Language and Hearing Research, 54(4), 1224-1239.
19. Pittman, A.L., Lewis, D.E., Hoover, B.M., & Stelmachowicz, P.G. (1999). Recognition performance for four
combinations of FM system and hearing aid microphone signals in adverse listening conditions. Ear and Hearing,
20(4), 279-289.
20. ic etts A Galster A arpe A 200 irectional enefit in simulated classroom en ironments
American Journal of Audiology, 16(2), 130-144.
21. Ricketts, T.A. & Galster, J. (2008). Head angle and elevation in classroom environments: implications for
amplification Journal of Speech Language and Hearing Research, 51(2), 516-525.
22. Ricketts, T.A., Henry, P. & Gnewikow, D. (2003) Full time directional versus user selectable microphone modes in
hearing aids. Ear and Hearing, 24(5), 424-39.
23. ic etts A enry P P orns y 200 Application of fre uency importance functions to directi ity for
prediction of enefit in uniform fields Ear and Hearing, 26(5), 473-486.
24. ic etts A orns y 2006 irectional earing aid enefit in listeners it se ere earing loss
International Journal of Audiology, 45(3), 190-197.
25. ic etts A orns y 200 ound uality measures for speec in noise t roug a commercial earing
aid implementing digital noise reduction. Journal of the American Academy of Audiology, 16(5), 270-277.
26. Sarampalis, A., Kalluri, S., Edwards, B., & Hafter, E. (2009). Objective measures of listening effort: Effects of
30

background noise and noise reduction. Journal of Speech Language and Hearing Research, 52, 1230-1240.
27. Scollie, S.D., Ching, T.Y.C., Seewald, R., Dillon, H., Britton, L., & Steinberg, J. (2010). Evaluation of the NAL-NL1 and
DSL v4.1 prescriptions for children: preference in real world use. International Journal of Audiology, 49(Suppl. 1),
S49-63.
28. Stelmachowicz, P.G., Lewis, D.E., Choi, S., & Hoover, B. (2007). Effect of stimulus bandwidth on auditory skills in
normal-hearing and hearing-impaired children. Ear and Hearing, 28(4), 483-494.
29. Stelmachowicz, P.G., Pittman, A.L., Hoover, B.M. & Lewis, D.E. (2001). Effect of stimulus bandwidth on the
perception of /s/ in normal- and hearing-impaired children and adults. Journal of the Acoustical Society of America,
110(4), 2183-2190.
30. Stelmachowicz, P., Lewis, D., Hoover, B., et al. (2010). Effects of digital noise reduction on speech perception for
children with hearing loss. Ear and Hearing, 31(3), 345-355.
31. alden urr Cord et al 200 e ro ustness of earing aid microp one preferences in e eryday
listening environments. Journal of the American Academy of Audiology, 18(5), 358-379.
32. ise C a is A 200 ffects of e pansion algorit ms on speec reception t res olds Journal of the
American Academy of Audiology, 19, 147-157.
33. oods an asell ic ert rine 2006 and fit to target analysis of compression system
performance as a function of number of compression channels. International Journal of Audiology, 45, 630-644.
34. olfe o n A c afer et al 2010 aluation of nonlinear fre uency compression for sc ool age c ildren
with moderate to moderately severe hearing loss. Journal of the American Academy of Audiology, 21, 618-628.
35. olfe o n A c afer et al 2011 ong term effects of non linear fre uency compression for c ildren it
moderate hearing loss. International Journal of Audiology, 50(6), 396-404.
36. Yuen, K.C., Kam, A.C. & Lau, P.S. (2006). Comparative performance of an adaptive directional microphone system
and a multichannel noise reduction system. Journal of the American Academy of Audiology, 17(4), 241-252.
37. Hawkins, D.B. & Naidoo, S.V. (1993). Comparison of sound quality and clarity with asymmetrical peak clipping and
output limiting compression. Journal of the American Academy of Audiology, 4(4), 221-228.
6. FITTING/VERIFICATION
6.1 Electroacoustic Hearing Aid Fitting

Objective
e o ecti e of t is segment of t e fitting process is to assure t at t e fitting and erification procedure is ie ed
as a process rat er t an an e ent ic culminates in t e optimal fitting for t e c ild erification procedures also
serve as a benchmark against which future hearing aid changes can be compared.
31

Recommendations for Fitting/Verification
1. Prescription methods: Independent pediatric-focused and pediatric-validated prescriptive targets,
normati e data and fitting met ods t at ta e into account t e uni ue de elopmental and auditory needs of
c ildren s ould e used for pediatric earing aid erification instead of manufacturer s proprietary prescripti e
approac es Pediatric and adult populations differ significantly in areas t at directly affect t e prescription
of appropriate hearing aid gain, output, and signal processing. Hearing aid manufacturers typically offer
custom hearing aid prescriptions that have been developed for proprietary use with their hearing aids. Such
prescriptions are not standardized or subjected to external scrutiny and are typically developed for use in
the adult population. As such, their incorporation of important pediatric considerations is both unknown and
unli ely ignificant ariance in gain and output among manufacturer dri en fittings as een demonstrated
even for the same audiogram. Validation studies indicate high levels of speech recognition in controlled and real
orld en ironments en earing aids are fit using prescripti e targets generated y independently de eloped
formulae such as the Desired Sensation Level (DSL) or National Acoustics Laboratories (NAL) prescriptions and
en t e indi iduali ed fitting is erified t roug real ear pro e microp one measurements
2. Verification methods: The response of the hearing aid should be measured for a variety of input levels to
estimate the audibility of speech and ensure that the maximum output does not exceed prescribed levels.
or c ildren t ere are t o options for earing aid erification
1. Real-ear aided response (REAR) probe microphone measurements – The output of the hearing aid is
measured in the child’s ear (in situ) using a probe microphone. This option is a better choice for highly
ented fittings and for c ildren it earmold tu ing t at is longer t an 3 mm t an simulated real ear aided
response measurements. The response of the hearing aid should be measured for a variety of input levels,
minimally for average level speech input and maximum power output of the hearing aid.
2. Simulated real-ear aided response measurements in the coupler using measured or age-appropriate real-
ear to coupler difference (RECD). The output of the hearing aid is measured in a 2cc coupler. The RECD
is used to convert coupler measures to estimates of SPL in the child’s ear and to accurately display target
fitting data against ic to compare t e estimated output in t e ear canal is option is a etter c oice
for un ented fittings fittings t at cannot e erified on t e ear it out feed ac and for infants and young
children who cannot sit for real-ear measurements.
Clinicians s ould consider multiple factors en determining ic met od ill e used for erification
Simulated real-ear aided measurements using a previously measured RECD to estimate the output in the
individual child’s ear canal may be more practical than direct real-ear aided response measurements with
children because it is a single measurement, requires less cooperative time from the child, and is not affected by
head movement. Because the signals used to verify maximum output are loud and may startle young children,
simulated, coupler measurements of maximum output using RECD may be preferable over real-ear maximum
output measurements. Correct use of the RECD in clinical practice relies upon appropriate clinical decision-
ma ing and consideration of fi e e idence ased points
1. The RECD is measurable in most cases, as long as it is attempted routinely. One common practice is to
measure t e C for at least one ear and apply it to t e fitting of ot ears eac time ne earmolds
are obtained. An RECD from one ear may be a good predictor of the RECD in the other ear. If this is not
possible on a case by case basis, age-appropriate predicted RECDs or recently measured RECDs from the
same child may be used in lieu of newly measured RECDs. These substitute RECDs are likely less accurate
32

than a newly measured RECD. Audiologists who routinely measure the RECD report excessive cerumen or
child non-compliance with probe insertion in less than 30% of cases.
2. The RECD differs by age (smaller ears generate larger RECDs). The RECD also differs based upon whether
coupling to the ear is done with foam tips or earmolds during RECD measurement. Age- and coupling-
appropriate predicted RECDs are available in the independently developed pediatric prescription software
packages.
3. e C is used in t o places during t e earing aid fitting process
i. The RECD is used to convert thresholds to SPL or equivalent adult HL and therefore impact the
calculated targets. This is done only for insert phone audiograms. These calculations are performed
automatically by the independently developed pediatric prescription software packages.
ii. The RECD is used to convert measures or prescriptive targets to and from the coupler and the ear
canal. These conversions also include other factors such as the microphone location effects and
are included in the independently developed pediatric prescription software packages and real-ear
measurement systems.
4. se of t e C measure in earing aid fitting does not capture t e acoustic effects of unamplified sound
entering the ear canal via the vent.
5. e C is transducer specific ome differences in C s et een t e earing aid an insert p one

and system specific C transducers a e een noted ese differences are slig t en t e ear is ery
small and/or en filtered ear oo s are incorporated into t e fitting
a ing all of t ese into consideration erification systems employ prescriptions A t at use t e C
when it is appropriate to do so, and automatically substitute age- and coupling-appropriate RECDs when
necessary. Audiologists can support the accuracy of this process by providing measured RECDs when
possible. Accurate incorporation of the RECD, when measured using the same transducer coupling (earmold
or foam tip) as is used in threshold measurement, is expected to produce a more accurate transformation
from HL to SPL thresholds which in turn produces more accurate output targets which are based on the SPL
thresholds. This allows for an accurate estimate of the hearing aid output that will be achieved at the individual
c ild s eardrum ese transforms are automatically performed y pediatric earing aid fitting soft are systems
that employ either DSL v5 or NAL-NL1 or NL2.
3. High Frequency Audibility: Children use their hearing to develop communication and to support learning.
Children typically spend most of their time listening to the speech of other children, and women, which has
greater high-frequency content than speech of male talkers. The importance of providing audibility for the high
frequency cues of speech is greater for the pediatric population. Children who use hearing aids require more
ig fre uency audi ility and deri e more enefit from audi ility of ig fre uency cues en t ey are pro ided
C ildren o are fit it earing aids t at fail to render audi le t e full set of speec cues are at ris of deficits
in speech production and/or learning. Children have different listening requirements for understanding speech,
particularly en t e listening situation is difficult lo in le el noisy and/or re er erant
4. Verification of advanced features: The impact of hearing aid signal processing and features such as
directional microphones, digital noise reduction, feedback suppression and frequency lowering on audibility
s ould e erified if t ese features are determined to e appropriate earing aid features suc as directional
33

microphones, digital noise reduction, feedback suppression, and frequency-lowering signal processing are
widely available and are being used with children. If utilized with children, the impact of these features on
audi ility of speec s ould e e aluated during t e erification process f t e signal processing strategy
includes automatic acti ation of any features erification of feature acti ation s ould e included tandardi ed
met ods for erification of t ese features a e not een e aluated in peer re ie ed studies o e er
recommendations are available.
5. Verification Test Signal: A standard real speech or a speech-like signal should be used when attempting
erification of prescripti e met ods for ic t e targets are ased on speec inputs at is t e preferred
earing aid erification met od s ould include a test signal t at produces an output similar to t e output for a
speech signal of the same input level. This would require that the test signal adequately represent the frequency,
intensity and temporal aspects of speec e clinician must select signals ensuring accurate erification
Various features and signal processing (compression, noise reduction, feedback suppression, etc.) interact with
the test signal and the most accurate representation of the hearing aid’s response will be through the use of a
speech-like signal or by turning off signal processing during tests that attempt to reduce output that it considers
noise ile no direct e idence e ists it is an acoustic fact t at disa ling specific signal processing features
may obscure potential interactions between signal processing schemes in the same hearing aid.
Summary of Evidence for Fitting and Verification

1 Independent prescriptive methods that take into 2 4 B EF
account the unique developmental and auditory
needs of children should be used for pediatric hearing 3 3 B EF
aid erification instead of manufacturer s proprietary
prescriptive approaches. 4 2 A EF/EV
5 2 A EF/EV
11 4 B EF
12 4 B EV
2 The response of the hearing aid should be measured 1 4 B EF
for a variety of input levels to estimate the audibility
of speech and ensure that the maximum output 2 4 B EF
does not exceed prescribed levels. Real-ear output
response measurements with the use of real-ear to 3 3 B EF
coupler difference (RECD) to correct threshold and
resulting target data in the child’s ear or 2 cc coupler 6 4 B EF
measurements with measured or average RECD should
e used for erification 7 4 B EF
8 4 B EF
9 4 B EF
16 3 B EF
34

3 Children who use hearing aids require more high 10 4 B EV
fre uency audi ility and deri e more enefit from
audibility of high frequency cues when they are 12 2 A EV
provided. Children have different listening requirements
for understanding speech, particularly when the 13 4 B EF
listening situation is difficult lo in le el noisy and/or
reverberant). 14 4 B EF
15 4 B EF
4 The impact of hearing aid signal processing and Acoustic EF/EV
features s ould e erified if t ese features are fact
determined to be appropriate for an individual child.
5 Some signal processing can interact with the test 11 2 A EF

signal. A test signal that is similar to speech in spectral
and temporal content is preferable. Failing this, it is
necessary to disable features that react differently to
speech versus non-speech sounds, and the resulting
measurement may then not be indicative of the hearing
aid’s performance when the features are re-enabled.
References
1. Bagatto, M. P., Scollie, S. D., Seewald, R. C., Moodie, K. S., Hoover, B. M., Bagatto, M. P., et al. (2002). Real-
ear-to-coupler difference predictions as a function of age for two coupling procedures. Journal of the American
Academy of Audiology, 13(8), 407-415.
2. Bagatto, M., Moodie, S., Scollie, S., Seewald, R., Pumford, J., Liu, K. P., et al. (2005). Clinical protocols for
earing instrument fitting in t e esired ensation e el met od Trends in Amplification, 9(4), 199-226.
3. Bagatto, M.P., Moodie, S.T., Malandrino, A.C., Richert, F.M., Clench, D.A., Scollie, S.D. (2011). The University of
estern ntario Pediatric Audiological onitoring Protocol Trends in Amplification, 15, 57-76.
4. Ching, T.Y.C., Scollie, S.D., Dillon, H., Seewald, R.C., Britton, L., Steinberg, J., Gilliver, M. & King, K. (2010).
Evaluation of the NAL-NL1 and the DSL v.4.1 prescriptions for children: paired-comparison judgments and
functional performance ratings. International Journal of Audiology. 49(Suppl. 1) S35-48.
5. Ching, T.Y.C., Scollie, S.D., Dillon, H. & Seewald, R.C. (2010). A cross-over, double-blind comparison of the
NAL-NL1 and the DSL v4.1 prescriptions for children with mild to moderately severe hearing loss. International
Journal of Audiology, 49(Suppl. 1), S4-15.
6. oo er telmac o ic PG e is 2000 ffect of earmold fit on predicted real ear P using a

real ear to coupler difference procedure. Ear and Hearing, 21(4), 310-317.
7. Martin, H.C., Munro, K.J. & Langer, D.H. (1997). Real-ear to coupler differences in children with grommets.
British Journal of Audiology, 31(1), 63-69.
8. artin C est ood G amford 1 6 eal ear to coupler differences in c ildren a ing otitis
35

media with effusion. British Journal of Audiology, 30(2), 71-78.
9. Munro, K.J., Howlin, EM., Comparison of real-ear to coupler difference values in the right and left ear of hearing
aid users. Ear and Hearing, 31(1), 146-50.
10. Pittman A telmac o ic PG 2003 earing oss in C ildren and Adults Audiometric Configuration
Asymmetry, and Progression, Ear and Hearing, 24(3), 198-205.
11. Scollie, S., Ching, T.Y.C., Seewald, R., Dillon, H., Britton, L., Steinberg, J. & King, K. (2010). Children’s
speec perception and loudness ratings en fitted it earing aids using t e 1 and t e A 1
prescriptions. International Journal of Audiology, 49(s1), S26-S34
12. Scollie, S.D., Ching, T.Y.C., Seewald, R., Dillon, H., Britton, L. & Steinberg, J. (2010). Evaluation of the NAL-NL1
and DSL v4.1 prescriptions for children: preference in real world use. International Journal of Audiology,
49(Suppl. 1), S49-63.
13. collie ee ald 2002 aluation of electroacoustic signals comparison it amplified speec Ear
and Hearing, 23(5), 477-487.
14. Scollie, S.D., Seewald, R.C., Moodie, K.S. & Dekok, K. (2000). Preferred listening levels of children who use
hearing aids: comparison to prescriptive targets. [Research Support, Non-U.S. Gov’t]. Journal of the American
15. Scollie, S.D., Steinberg, M. & Seewald, R.C. (2002) Evaluation of electroacoustic signals II: development and
cross-validation of correction factors. Ear and Hearing, 23(5), 488-498.
16. Stelmachowicz, P.G., Lewis, D.E., Choi, S., & Hoover, B. (2007). Effect of stimulus bandwidth on auditory skills in
normal-hearing and hearing-impaired children. Ear and Hearing, 28(4), 483-494.
6.2 Other verification tools

Objective
nce primary earing aid erification as een completed audiologists may perform additional erification
procedures to quantify the acoustic characteristics of the device under listening conditions where the speech
spectrum may differ from the standard signal used during assessment of gain and output.
6.2.1 Recommendations for SII/SHARP

1. Estimates of speech audibility using the Speech Intelligibility Index (SII) can be used to evaluate speech
audi ility for earing aid fittings once primary erification as een completed t roug t e erification soft are
or computer programs i e ituational earing Aid esponse Profile A P e peec ntelligi ility nde
(SII) is a standardized method of calculating the audibility of a speech signal that can be applied to hearing-aid
erification results ormati e data for t e e pected a e recently een pu lis ed se of alternati e speec
spectra allows the audiologist to estimate speech audibility for situations, such as when a child is held on the
parent of caregiver’s hip or in the cradle position, where the level and spectrum of the speech signal may differ
from t at used during primary erification e ituational earing Aid esponse Profile A P is a computer
program that allows calculation of Aided Audibility Index (AAI) using a variety of different speech spectra that
estimate various listening conditions that may be encountered by children. These data may be helpful when
36

providing guidance to the speech-language pathologist about how well the child actually can monitor his/
her vocalizations, discussing the impact of distance on audibility when discussing the need for a personal FM
system in the classroom, etc. (Please note: An updated version of SHARP is expected to be released in 2013).
2. SII predictions will overestimate speech recognition scores for children, which should be taken into account
en t ese estimates are used ile alues can e used to predict speec recognition scores for adults
with hearing loss no more than moderate at any frequency, SII values tend to overestimate speech recognition
scores for c ildren for any degree of earing loss ile t e can e used to compare t e audi ility of speec
spectra across listening conditions, clinicians should recognize that the SII does not have similar predictive
validity for speech recognition for children as it does for adults. The SII may be of limited value in cases where
the speech spectrum is altered using frequency-lowering signal processing, because current SII methods do
not account for changes in the distribution of the speech spectrum in the hearing-aid output. Research has
not been conducted to predict the effects of frequency-lowering on SII estimates of audibility. Because of the
different assumptions inherent to SHARP and Desired Sensation Level (DSL) prescriptive formula, such as the
input speech level, differences may exist between the two programs in the predicted hearing aid output.
Summary of Evidence for SII/SHARP

1,2 SII can be used to quantify audibility for hearing-aid 1 4 C EF Adult
erification
2 3 B EF
3 4 B EF
1,2 SII-based predictions of audibility will overestimate 1 4 C EF
speech recognition because as hearing loss increases,
people of all ages are progressively less able to extract 2 3 B EF
information from speech even when it is made audible
and children, relative to adults, need a greater SII for
the same speech intelligibility. These data should be
applied with caution.
References
1. C ing illon atsc yrne 2001 a imi ing effecti e audi ility in earing aid fitting ar and
Hearing, 22(3), 212-224.
2. collie 200 C ildren s speec recognition scores e speec intelligi ility inde and proficiency factors
for age and hearing level. Ear and Hearing, 29(4), 543-556.
3. Bagatto, M. P., Moodie, S. T., Malandrino, A. C., Richert, F. M., Clench, D. a, & Scollie, S. D. (2011). The
ni ersity of estern ntario Pediatric Audiological onitoring Protocol PedA P rends in
Amplification 1 1 6
6.2.2 Cortical Auditory Evoked Potentials
Objective
nce primary earing aid erification as een completed audiologists may perform measurement of cortical
37

responses e o ed y speec sounds to confirm t at speec at con ersational le els is in o ing acti ity in t e
auditory cortex. These measurements are most valuable for children who are unable to give feedback as to the
audibility of speech, either because they are too young for reliable behavioral testing or because of the presence
of other disabilities that restrict communication ability. They are extremely valuable for children for whom there is
any uncertainty over hearing thresholds, particularly those with auditory neuropathy spectrum disorder.
Recommendations for Cortical Auditory Evoked Potentials (CAEPs)

CAEPs can provide information about the audibility of sounds (including speech sounds) and about the maturity
of t e auditory system CA Ps in response to sounds presented in t e sound field can e measured it and/or
it out amplification C ildren s ould e in t e same state t at is desira le for e a ioral testing calm a a e
and quiet. CAEPs provide three types of information:
1. Presence or absence of a CAEP: The presence of a CAEP in response to a speech sound indicates that
t e sound eliciting t e CA P is e o ing acti ity in t e auditory corte is pro ides confirmation t at
t e earing aid settings are sufficient to ac ie e audi ility of speec at t e sound le el used for testing
The absence of a cortical response does not, however, necessarily indicate that a sound is inaudible, as
different c ildren re uire different sensation le els efore cortical acti ity is sufficiently strong for it to e
detected on the scalp. Determining presence or absence of a cortical response is facilitated by objective
metrics. Some detection metrics have been shown to be at least as accurate as expert human clinicians
in differentiating true cortical responses from random electrical activity on the scalp. Children for whom it
is possible to detect CAEPs to a greater proportion of speech sounds presented are more likely to display
greater functional hearing ability, so the presence of CAEPs is an indicator of the child’s likely functional
hearing ability. CAEPs do not, however, directly indicate the ability of a child to discriminate one sound from
another. The absence of CAEPs unaided combined with the presence of CAEPs aided can be a valuable
aid to counseling parents of babies whose hearing loss was detected at birth. This pattern of responses
reinforces both the likely impact on the child if hearing aids are not worn, and provides reassurance that the
child is detecting sounds when aided.
2. Latency of a CAEP: In children with normal hearing, the latency of the major positive peak in a CAEP
decreases from around 250 ms at birth down to around 100 ms at age 5 years. Children deprived of
audi ility for t e first mont s or years of life a e CA Ps it a latency near t at of a ne orn a y en
t ey first ear audi le sounds Pro ided sounds are made audi le to t em y age 3 years t e latency
decreases to age-appropriate values over the ensuing months. The latency of a CAEP in a young child is
therefore a marker of the extent to which the central auditory nervous system has been able to mature in
response to auditory stimulation.
3. a eform morp ology of a CA P ere is not yet sufficient no ledge a aila le for any inference to e
drawn when CAEPs are reliably present but display a waveform morphology markedly different from that
expected for children of the age being testing.
38

Summary of Evidence for CAEPs
1 Some detection metrics are at least as accurate as 1 4 B EF Adult
expert human clinicians in differentiating true cortical
responses from random electrical activity on the 2 4 B EF
scalp.
2 CAEPs present for a greater proportion of speech 3 4 B EF
sounds is associated with greater functional hearing
a ility and speec identification a ility 4 4 B EF
3 The latency of a CAEP in a young child is a marker 5 4 C EF
of the extent to which the central auditory nervous
system has been able to mature as a result of 6 5 C EF
receiving auditory stimulation.
7 5 C EF
References
1. Carter, L., Golding. M., Dillon, H. & Seymour, J. (2010) The detection of infant cortical auditory evoked
potentials (CAEPs) using statistical and visual detection techniques. Journal of the American Academy of
Audiology, 21(5), 347-356.
2. Golding, M., Dillon, H., Seymour, J. & Carter, L. (2009) The detection of adult cortical auditory evoked
potentials (CAEPs) using an automated statistic and visual detection. International Journal of Audiology,
48(12), 833-842.
3. Golding Pearce eymour Cooper A C ing illon 200 e relations ip et een

obligatory cortical auditory evoked potentials (CAEPs) and functional measures in young infants. Journal of
the American Academy of Audiology, 18(2), 117-125.
4. ance G Cone esson underlic o ell 2002 peec perception and cortical e ent
related potentials in children with auditory neuropathy. Ear and Hearing, 23(3), 239-253.
5. Sharma, A., Cardon, G., Henion, K. & Roland, P. (2011) Cortical maturation and behavioral outcomes in
children with auditory neuropathy spectrum disorder. International Journal of Audiology, 50(2), 98-106.
6. auer P arma A artin orman 2006 Central auditory de elopment in c ildren it

bilateral cochlear implants. Archives of Otolaryngology Head & Neck Surgery, 132(10), 1133-1136.
7. Sharma, A., Martin, K., Roland, P., Bauer, P., Sweeney, M.H., Gilley, P. & Dorman, M. (2005) P1 latency as
a biomarker for central auditory development in children with hearing impairment. Journal of the American
6.2.3 Aided Thresholds in the Sound Field

ecommendations for measurement of aided t res olds in t e sound field
1. easurement of aided sound field t res olds s ould not e used as a met od of earing aid erification
A commonly used measurement is the “aided audiogram” or “functional gain”. These two terms are not
synonymous, but are related: “aided audiogram” simply implies that thresholds are determined in sound
39

field ile t e c ild is earing t eir earing aids e aided audiogram may e o tained in eac ear
separately (with the contralateral ear masked if necessary), or obtained binaurally. “Functional gain” implies
a comparison of t e unaided t res olds soundfield eit er ilaterally or eac ear separately it appropriate
contralateral masking) with the aided thresholds in the comparable condition. This permits, theoretically, a
determination of the insertion gain provided by the hearing aid(s). Both measures, while having appealing
face validity, are fraught with potential error sources. These error sources are related to a) the patient; b) the
interaction of t e input stimulus it t e earing aid signal processing c t e noise oor in t e test oot
and d) the underlying principles involved in making assumptions based on these measures. Further, aided
testing only samples hearing aid characteristics at widely-spaced intervals (octave/half-octave) and does
not indicate the presence of peaks or troughs in the hearing aid response characteristics.
pecifically test retest relia ility commonly referred to as / d in t e adult population may e
significantly greater in t e pediatric patient epending on t e c ild s de elopmental le el interest in t e
test procedures, and other variables, test reliability may be large enough to obscure meaningful test
results. Additionally, children are likely to move (both head position and possibly body position) during
testing ic may result in significant increase or decrease in t e test signal intensity at t e ear or earing
aid microphone. The input stimulus, depending on its intensity, may interact with the hearing aid signal
processing in a manner such as to over- or under-estimate the aided response. In children with normal or
near-normal hearing in any portion of the frequency spectrum, but in particular the low-frequency region,
t e noise oor of t e test oot may o scure lessen t e apparent gain pro ided y t e earing aid in t at
frequency region.
2. In cases of bone conduction hearing aids, real-ear probe microphone measures cannot be conducted
(when there is no acoustic signal in an ear canal), and the aided audiogram may be the most readily
a aila le erification option n spite of its limitations t e aided audiogram can pro ide information and in
the case of bone conduction and frequency transposition/compression hearing aids, may be the most valid
way to quantify the aided response with currently available technologies.
Summary of Evidence for Functional Gain

1 Functional gain audiograms should not be used as 1 4 B EF
t e primary met od of earing aid erification
Acoustic
fact
2 one conduction does not allo for erification 2 6 D EF
through probe microphone measurements
Acoustic
fact
References
1. a ins ontgomery A Prose alden 1 amination of t o issues concerning
functional gain measurements. Journal of Speech and Hearing Disorders, 52, 56-63.
2. Kuk, F. & Ludvigsen, C. (2003). Reconsidering the concept of the aided threshold for nonlinear hearing aids.
Trends in Amplification, 7(3) 77-97.
40

7. OUTCOMES ASSESSMENT
Objective
utcomes assessment is an integral part of e idence ased clinical practice is section identifies a range of ualitati e
and uantitati e measures t at are effecti e in documenting t e successful use of and enefit from earing aid use y
children.
Recommendations for Outcomes Assessment
n order to alidate enefits and/or assist it fine tuning e ery c ild s ould recei e an outcomes assessment after
amplification is pro ided ereas erification ser es to ascertain t at prescripti ely appropriate amplification is
pro ided outcome assessment c ec s t at amplification needs of indi idual c ildren are met Assessment tools
available for children include subjective and objective measures as outlined in the following table (see Table 3). As
new measures are continually being developed, this is not intended to be an exhaustive list. Even though laboratory-
based assessments are useful, assessments of performance in real life are crucial to determining the effectiveness of
amplification pecific recommendations include t e follo ing
1. Parental reports provide a reliable and sensitive method for evaluating alternative gain-frequency responses in hearing
aids for children.
2. Outcome assessment should be carried out after introduction of new features in hearing aids. The need to
e aluate amplification is supported y e idence s o ing t at c ildren s performance is affected y ariations in gain
frequency response slope of >3 dB/octave; directionality of microphones; presence or absence of noise reduction; and
applications of frequency compression or transposition in hearing aids.
3. For children older than about 6 years of age, paired-comparisons judgments may be used reliably to identify the
optimal frequency response among a small set of alternatives. This assessment method may be more sensitive than
speec perception testing and is useful in identifying t e ay in ic gain fre uency responses may e modified to
meet individual needs.
Table 3. Outcomes assessments for children
Clinic/Laboratory eal orld

Children Aided audiogram* Parents’ Report:
AL. Developmental Index of Audition and Listening (DIAL9)

<3 years old
AM. Functional Auditory Performance Indicators (FAPI10)
AN. Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS11)
AO. LittlEARS16,38
AP. Parents’ Evaluation of Aural/oral Performance of Children (PEACH12)
Teachers’ Report:
AQ. Teachers’ Evaluation of Aural/oral Performance of Children

(TEACH13)
41

Children Speech perception: Parents’ report:
AR. Video Speech Pattern AX. Auditory Behavior in Everyday Life (ABEL14)
3-6 years Contrast Test (VIDSPAC1) AY. C ildren s ome n entory of istening ifficulties C 15
)
AS.Northwestern University-Chil- A Meaningful Auditory Integration Scale (MAIS17)
dren’s Perception of Speech
(NU-CHIPS2) BA. Meaningful Use of Speech Scale (MUSS18)
AT. ord dentification y Picture BB. Parents’ Evaluation of Aural/oral Performance of Children
n entory P (PEACH12)
AU. Phonetically Balanced Teachers’ report:
Kindergarten (PBK3)
AV. Aided Audiogram* BC. Screening Instrument For Targeting Educational Risk (Preschool
SIFTER19)
A Ling 6 Sounds Test40
BD. Teachers’ Evaluation of Aural/oral Performance of Children
(TEACH13)
Children Speech perception: Parents’ report:
BE.standard adult word lists BL. C ildren s A re iated Profile of earing Aid enefit CA P A 20)
>6 years
BF. Banford-Kowal-Bench Sen- BM. Parents’ Evaluation of Aural/oral Performance of Children
tences (BKB5,39) (PEACH12)
BG. Hearing In Noise Test–
Children(HINT-C6) Teachers’ report:
BH. etection of ord final BN. Screening Instrument For Targeting Educational Risk (SIFTER21)
plurality Plurals est 35
BO. Teachers’ Evaluation of Aural/oral Performance of Children
BI. Loudness rating7: (TEACH13)
BJ. Paired-comparison judgment8
Self report:
BK. Ling 6 Sounds Test40
BP. C ildren s A re iated Profile of earing Aid enefit CA P A 20)
BQ. Client Oriented Scale of Improvement for Children (COSI-C22)
BR. Hearing Performance Inventory for Children (HPIC23)
BS. Listening Inventory for Education (LIFE24)
BT. Self-Evaluation of Listening Function (SELF13)
*Please see Section 6.2.3 for a full description of potential error sources that are associated with aided audiograms.
Reported tools that have published information on normative data and critical differences include the ABEL14,
CA-PHAB20, MAIS17, PEACH12, TEACH13, and LittlEARS36,37.
Summary of Evidence for Outcomes Assessment

1 Parental reports are sensitive to differences in frequency 13 3 B EV
response in hearing aids for infants and young children with
severe and profound hearing loss.
1 Self-reports are sensitive to differences in hearing aid gains 26 2 A EV
for school-aged children.
29 2 A EF
28 3 B
42

2 Difference in hearing aid gain of more than 3 dB results in 26 2 A EF
a difference in loudness comfort, intelligibility judgment and
everyday functioning. 28 3 B EV
2 Difference in hearing aid frequency response of more than 3 28 3 B EV
dB/octave results in a difference in everyday functioning.
3 Paired-comparison judgments can be used reliably to 13 3 B EF
evaluate differences in gain-frequency response, but not
output compression characteristics in hearing aids for school- 30 3 B EV
aged children.
26 2 A
29 2 A
References
1. Boothroyd, A. (1991) Speech perception measures and their role in the evaluation of hearing aid performance. In:
eigin telmac o ic P eds Proceedings of t e 1 1 ational Conference of Pediatric Amplification oys o n
National Research Hospital, Omaha, NE, pp 77-91.
2. Elliott, L.L. & Katz, D.R. (1980) Development of a new children’s test of speech discrimination. St Louis: Auditec.
3. Haskins, H.A. (1949). A phonetically balanced test of speech discrimination for children. [Master’s Thesis], Evanston,
IL: Northwestern University.
4. Pittman, A.L., Lewis, D.E., Hoover, B.M. & Stelmachowicz, P.G. (2005) Rapid word-learning in normal-hearing and
earing impaired c ildren effects of age recepti e oca ulary and ig fre uency amplification Ear and Hearing,
26(6), 619-629.
5. Bench, J. & Bamford, J. (1979) Speech-hearing Tests and the Spoken Language of Hearing Impaired Children.
London UK: Academic Press.
6. Nilsson, M.J., Soli, S.D. & Gelnett D.J. Development of the hearing in noise test for children (HINT-C). House Ear
Institute: 1996.
7. Kawell, M., Kopun, J. & Stelmachowicz, P. (1988). Loudness discomfort levels in Children, Ear and Hearing, 9(3),
133-136.
8. C ing C e all P igney 1 Audio isual and auditory paired comparison udgments y se erely
and profoundly hearing impaired children: reliability and frequency response preferences. Australian Journal of
Audiology, 16(2), 99-106.
9. Palmer C ormer A 1 Goals and e pectations of t e earing aid fitting Trends in Amplification, 4(2),
61-71.
10. Stredler-Brown, A. & DeConde, J.C. (2003). Functional Auditory Performance Indicators: an integrated approach to
auditory development. Boulder, CO: Marion Downs National Center.
11. immerman P illips s erger o ins A 1 nfant oddler eaningful Auditory ntegration cale
A n asta roo s ed Cochlear Implants for Kids. as ington C AG ell Association for t e eaf
43

12. Ching, T.Y.C. & Hill, M. (2007). The Parents’ Evaluation of Aural/oral Performance of Children (PEACH) scale:
normative data. Journal of the American Academy of Audiology, 18, 220-235.
13. Ching, T.Y.C., Hill, M. & Dillon, H. (2008). Effects of variations in hearing-aid frequency response on real-life functional
performance of children with severe or profound hearing loss. International Journal of Audiology, 47, 461-475.
14. Purdy, S.C., Rarrington, D.R., Moran, C.A., Chard, L.L. & Hodgson, S.A. (2002). A parental questionnaire to evaluate
children’s auditory behavior in everyday life (ABEL). American Journal of Audiology, 11, 72-82.
15. Anderson maldino 2000 C ildren s ome in entory of listening difficulties C edaud org
16. u n nac er eic old sia pini Conin aese P 2003 ittl A auditory uestionnaire
parents questionnaire to assess auditory behavior. Innsbruck, Austria: MED-EL.
17. Robbins, A.M., Renshaw, J. & Berry, S. (1991). Evaluating meaningful auditory integration in profoundly hearing-
impaired children. American Journal of Otology, 12 (Suppl.), 144-150.
18. Robbins, A.M., Svirsky, M., Osberger, M.J. & Pisoni, D.B. (1998). Beyond the audiogram: the role of functional
assessments. In: Bess F. ed. Children with Hearing Impairment: contemporary trends. Nashville: Vanderbilt Bill
il erson Center Press 10 12
19. Anderson, K. & Matkin, N. (1996) Screening Instrument for Targeting Educational Risk in Pre-school Children (Age
3 – Kindergarten) (Pre-school SIFTER). Tampa, FL: Educational Audiology Association.
20. opun G telmac o ic PG 1 Percei ed communication difficulties of c ildren it earing loss

American Journal of Audiology, 7(1), 30-38.
21. Anderson, K. (1989) Screening Instrument for Targeting Educational Risk (SIFTER). Austin, TX: Pro-Ed.
22. Lovelock, K. (personal communication)
23. Kessler, A.R., Giolas, T.G. & Maxon, A.B. (1990). The Hearing Performance Inventory for Children (HPIC): reliability
and validity. Poster presented at American Speech-Language-Hearing Association Convention, Seattle.
24. Anderson, K. & Smaldino, J. (1999) Listening inventories for education: a classroom measurement tool. Hearing
Journal, 52, 74-76.
25. Scollie, S., Ching, T.Y.C., Seewald, R., Dillon, H., Britton, L., Steinberg, J. & King, K. (2010). Children’s speech
perception and loudness ratings en fitted it earing aids using t e 1 and t e A 1 prescriptions
International Journal of Audiology, 49(s1), S26-S34.
26. Ching, T.Y.C., Scollie, S., Dillon, H., Seewald, R., Britton, L., Steinberg, J., Gilliver, M. & King, K. (2010). Evaluation of
the NAL-NL1 and DSL v4.1 prescriptions for children: paired-comparison judgments and functional performance
ratings. International Journal of Audiology, 49(s1), S35-S48.
27. Scollie, S.D., Ching, T.Y.C., Seewald, R. & Dillon, H. (2010). Evaluation of the NAL-NL1 and the DSL v.4.1 prescriptions
for children: preference in real-world use. International Journal of Audiology, 49(s1), S49-S63.
28. Ching, T.Y.C., Hill, M., Birtles, G. & Beecham, L. (1999) Clinical use of paired comparisons to evaluate hearing aid
fitting of se erely/profoundly earing impaired c ildren Australian and New Zealand Journal of Audiology, 21(2),
51-63.
44

29. Ching, T.Y.C., Scollie, S., Dillon, H. & Seewald, R. (2010). A cross-over, double-blind comparison of the NAL-NL1 and
DSL v4.1 prescriptions for children with mild to moderately severe hearing loss. International Journal of Audiology,
49(s1), S4-S15.
30. Stelmachowicz, P.G., Lewis, D.E., Hoover, B. & Keefe, D. (1999). Objective and subjective effects of peak clipping
vs compression limiting in normal and hearing-impaired children. Journal of the Acoustical Society of America, 105,
412-422.
31. Golding Pearce eymour Cooper A C ing C illon 200 e relations ip et een
obligatory cortical auditory evoked potentials (CAEPs) and functional measures in young infants. Journal of the
32. Carter, L., Golding, M., Dillon, H. & Seymore, J. (2010). The detection of infant cortical auditory evoked potentials
(CAEPs) using statistical and visual detection techniques. Journal of the American Academy of Audiology, 21(5), 347-
356.
33. ance G Cone esson underlic o ell 2002 peec perception and cortical e ent related
potentials in children with auditory neuropathy. Ear and Hearing 23, 239-253.
34. Kurtzberg, D. (1989). Cortical event-related potential assessment of auditory system function. Seminars in Hearing,
10, 252-261.
35. Glista collie 2012 e elopment and e aluation of an nglis language measure of detection of ord final
plurality mar ers e ni ersity of estern ntario Plurals est American Journal of Audiology, 21, 76-81.
36. Conin eic old sia pini Autri ue escond G amas et al 200 alidation of t e ittl A
Auditory Questionnaire in children with normal hearing. International Journal of Pediatric Otorhinolaryngology, 73,
1761-1768.
37. Bagatto, MP., Brown, C., Moodie, ST., Scollie, S. (2011). External validation of the LittlEARS Auditory Questionnaire
with English-Speaking families of Canadian children with normal hearing. International Journal of Pediatric
Otorhinolaryngology, 76(6), 815-817.
38. agatto P oodie alandrino AC ic ert Clenc A collie 2011 e ni ersity of estern
Ontario Pediatric Audiological Monitoring Protocol. Trends in Amplification, 15, 57-76.
39. Ng, S., Meston, C., Scollie, S., Seewald, R. (2011). Adaptation of the BKB-SIN Test for use as a pediatric aided
outcome measure. Journal of the American Academy of Audiology, 22, 375-386.
40. Scollie, S., Glista, D., Tenhaaf, J., Dunn, A., Malandrino, A., Keene, K., Folkeard, P. (2012). Stimuli and normative data
for detection of Ling-6 sounds in hearing level. American Journal of Audiology, 21, 232-241.
8. MANAGEMENT/FOLLOW-UP AND REFERRALS
Objectives
The prescription of hearing aids for children is an on-going, interdisciplinary process. Following the initial diagnosis
45

and earing aid fitting continued audiologic e aluation and ad ustment of amplification settings ased on t e updated
audiologic data should be prioritized. Audiologists should continue to provide informational and adjustment counseling
to support consistent hearing aid use and facilitate understanding of hearing aid care and maintenance. Additional
objectives as part of the on-going management process include diagnostic medical evaluations, connection with
education and early inter ention resources and financial support resources
Recommendations for Management, Follow-up and Referral

n going audiologic e aluation and ad ustment of amplification are necessary to ensure consistent audi ility o er time
earing aid fittings for infants and young c ildren are often ased on limited electrop ysiological or e a ioral data
C ildren are more li ely t an adults to e perience uctuation or progression of earing loss o er time in addition to
normal p ysical gro t t at can in uence t e acoustics of t e earing aid fitting and earmold ade uacy
Patient/family education and adjustment counseling (social and emotional support) should be provided as part of routine
audiologic follow-up to ensure children and their parents and caregivers have the knowledge and assistance necessary
to support consistent use of intervention strategies, including but not limited to hearing aid and other technology use and
communication strategies as well as healthy psychosocial development.
Referral for medical evaluations is important for identifying potential medical conditions related to the hearing loss, as
well as the likelihood for progression or precautions that could minimize likelihood of progressive hearing loss (i.e. limiting
participation in contact sports for children with enlarged vestibular aqueduct). Referral to otolaryngology, ophthalmology
and medical genetics should be provided for all children who are hard of hearing.
Support for accessing early intervention and academic support should be facilitated, including timely referral to early
intervention for infants and young children who are hard of hearing. Educational and academic support also include
supporting Individualized Family Service Plans/Individualized Education Plans (IEP/IFSP) and performing periodic
assessments of the child’s listening situations and needs to determine candidacy for hearing assistance technology and
to optimize use of the technology.
esources for financial support and funding to offset t e cost of earing aids s ould e pro ided as concern for t e
cost of de ices is often cited y parents as delaying t e initiation of amplification
Parent-to-parent support should be offered to families and caregivers of children with hearing loss. Special consideration
should be given to matching families based on support needs, hearing loss characteristics and other factors.
Summary of Evidence for Management, Follow-up, and Referral

1 ngoing audiologic assessment and earing aid erification 1 4 C EV
are necessary to maintain audibility with the potential for
uctuation or progression of earing loss in addition to 2 EF
normal ear canal growth.
2 Informational and adjustment counseling should be 3 4 C EF/EV
provided on an on-going basis to support consistent use of
amplification
46

3 Referral for medical evaluations, including otolaryngology, 4 5 D
ophthalmology and medical genetics should occur for
children with hearing loss.
4 Referral for early intervention and educational services should 4 5 D
occur in a timely manner in compliance with local, state and
federal regulations.
5 eferral for financial programs and funding resources s ould 5 4 C EF/EV
e pro ided to a oid delays in t e initiation of amplification
6 Parent-to-parent support should be offered to families and 6 4 C EV
caregivers of children with hearing loss.
7 EV
References
1. Pittman A telmac o ic PG 2003 earing oss in C ildren and Adults Audiometric Configuration
Asymmetry, and Progression. Ear and Hearing, 24(3), 198-205.
2. Bagatto, M. P., Scollie, S. D., Seewald, R. C., Moodie, K. S., Hoover, B. M., Bagatto, M. P., et al. (2002). Real-ear-to-
coupler difference predictions as a function of age for two coupling procedures. Journal of the American Academy
of Audiology, 13(8), 407-415.
3. Moeller, M. P., Hoover, B., Peterson, B., & Stelmachowicz, P. (2009). Consistency of hearing aid use in infants with
early identified earing loss American Journal of Audiology, 18(1), 14-23.
4. American Academy of Pediatrics, Joint Committee on Infant Hearing. (2007). Year 2007 position statement:
principles and guidelines for early hearing detection and intervention programs. Pediatrics, 120, 898-921.
5. arrison ous allace 2003 rends in age of identification and inter ention in infants it earing
loss. Ear and Hearing, 24(1), 89-95.
6. Ain inder G lanc ard inger G ulli an Po ers ar uis G antelli 1

A ualitati e tudy of Parent to Parent upport for Parents of C ildren it pecial eeds Journal of Pediatric
Psychology, 23(2), 99-109.
7. aidman ait A 200 Parenting a c ild it a coc lear implant a critical incident study Journal of Deaf studies
and Deaf Education, 12(2), 221-41.
9. USE OF HEARING AIDS WITH OTHER ASSISTIVE TECHNOLOGIES
9.1 Remote Microphone Hearing Assistance Technology

e American Academy of Audiology as pu lis ed clinical practice guidelines CPG and erification supplements
for remote microphone hearing assistance technology. Available for download at http://www.audiology.org/resources/
documentlibrary/Documents/HAT_Guidelines_Supplement_A.pdf and http://www.audiology.org/resources/
documentlibrary/Documents/20110926_HAT_GuidelinesSupp_B.pdf
47

e CPG descri es in detail issues surrounding candidacy personnel erification orientation training and alidation
procedures and rele ant recommendations on t ese su ects ile all c ildren earing earing aids or eing
considered for amplification are descri ed as candidates for remote microp one tec nologies t e clinical practice
guidelines recognize that the utilization of these technologies increases at school age. Although hearing assistance
technology is commonly considered in school age children it is appropriate to employ an off-site microphone in
cases where feedback is an issue in infant ears, and communication is happening at a distance or under unfavorable
conditions i e during car tra el in a daycare en ironment etc e output deli ered to t e ear must e erified en
signals are deli ered ia a remote microp one ee supplements A and for erification guidelines upplement C is
forthcoming.
9.2 Cochlear Implants

Recommendations for Cochlear Implants
ac c ild o recei es a coc lear implant in one ear and o as residual earing in t e ot er ear s ould e fit
with a hearing aid in that ear for providing bilateral stimulation. Children with bilateral hearing impairment require
stimulation in both ears for encouraging auditory development and for performing binaural hearing functions. These
functions arise from the effects of head shadow, binaural summation and redundancy, and binaural squelch. The
enefits of inaural earing range from impro ed speec perception in noise and sound locali ation to impro ed
functional performance in real life and percei ed uality of life ere are inaural enefits en a earing aid is used
it a coc lear implant imodal fitting in t e opposite ear e enefits can e largely attri uted to ead s ado
effects and binaural redundancy, as well as complementary low-frequency cues such as prosody cues, word-
oundary identification and music appreciation
imodal fitting s ould e pro ided e en en residual earing in t e non implanted ear is limited to fre uencies
elo 00 en a earing aid is com ined it a coc lear implant oice pitc information con eyed y
acoustic earing accounts for t e ma ority of t e speec perceptual enefit and language de elopment enefit
for c ildren en en earing t res olds at fre uencies 00 are et een 0 to 100 d some c ildren
s o enefits in speec perception en acoustic stimulation is added to electric stimulation idence from adults
s o enefits e en en t e acoustic stimulation as restricted to t e and idt elo 1 0 is supports t e
pro ision of imodal fitting to c ildren it limited residual earing in t e non implanted ear ere is currently no
direct comparison of t e relati e efficacy of imodal fitting and ilateral implantation for c ildren
The hearing aid should be optimized with the cochlear implant by balancing loudness of sounds between ears.
n order to ac ie e ma imal inaural enefits it imodal earing it is important t at loudness of sounds eard
48

simultaneously through each device should be similar.
Summary of Evidence for Cochlear Implants

1 enefits in speec perception and locali ation ere 1 3 B EF
o tained y c ildren en acoustic amplification
was used with electric stimulation (bimodal hearing), 2 3 B EF
consistently across different languages and different test
set-ups. 8 3 B EF/EV
9 3 B EF
10 3 B EF
11 3 B EF
2 Children with hearing thresholds of >80 dB HL in low 8 3 B EF/EV
fre uencies o tained enefit from imodal earing
9 3 B EF
2 Acoustic information below 150 Hz improved speech 6 4 B EF Adult
perception with cochlear implants for adults.
7 4 B EF
2 Acoustic information about voice pitch improved 5 3 B EF Adult
consonant perception for adults with cochlear implants
2 Acoustic information about voice pitch improved 4 3 B EF
consonant perception for children with cochlear implants
3 Loudness balance between ears improved performance 3 4 B EF Adult
for adults
3 Loudness balance and optimized hearing aid frequency 9 3 B EF/EV
response led to increased enefit it imodal earing
in children
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American Academy of Audiology

Clinical Practice Guidelines

2. Overview of Pediatric Amplification

3. Audiologic Candidacy Criteria

4. Principles Underlying Effective Amplification

4.1 Routing of the Signal

4.2 Selection of Hearing Aid Style

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

4.4 Safety Considerations

5. Signal Processing and Features

6.1 Electroacoustic Hearing Aid Fitting

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

6.2.2 Cortical Auditory Evoked Potentials (CAEPS)

6.2.3 Aided Thresholds in Sound Field

8. Management/Follow-Up and Referrals

9. Use of Hearing Aids with Other Assistive Technologies

9.1 Remote Microphone Hearing Assistance Technology

9.2 Cochlear Implants

10. Complete Reference List

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

n addition to grading t e e idence and assigning it a le el see a le 1 it as determined if t e e idence as fficacy

Table 2. Sample Recommendations and Summary of Evidence table

Rec Evidence Source Level Grade EF/EV Adult

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

Anne Marie Tharpe

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

Recommendations for Determining Candidacy

3. C ildren it Auditory europat y pectrum isorder A s ould a e a trial it amplification as soon as

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

Summary of Evidence for Audiological Candidacy

Rec Evidence Source Level Grade EF/EV Adult

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

7. ance G eer Cone esson ep erd o ell C ing A ic ards Clar G

8. ous P A ryma r enedi to ang 2011 Audiologic management of auditory neuropat y

4. PRINCIPLES UNDERLYING EFFECTIVE AMPLIFICATION

4.1 Routing of the Signal

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

Air conduction versus Bone Conduction Transmission

Unilateral Hearing Loss

f t e unilateral earing loss is aida le t en a monaural fitting ould e considered

Recommendations for Selecting Routing of the Signal

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

Summary of Evidence for Selecting Routing of the Signal

1 ilateral amplification is routinely recommended unless 2 3 B EV

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

4. Hawkins, D.B. (1984). Comparisons of speech recognition in noise by mildly-to-moderately hearing-impaired

8. e man C andridge A od is 200 ongitudinal enefit from and satisfaction it t e

4.2 Selection of Hearing Aid Style

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

Recommendations for Hearing Aid Style

2. BTEs may provide needed features for the pediatric patient.

Summary of Evidence for selecting hearing aid style

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013

American Academy of Audiology Clinical Practice Guidelines on Pediatric Amplification 06/2013