Part 3: Pediatric Impressions

A series of articles on one of the most critical—and problematic—parts of the hearing instrument fitting process.

Chester Pirzanski, BSc, is senior supervisor
for shell manufacturing with Oticon
Canada, Kitchener, Ontario, and also
serves as an adjunct instructor at the
Pennsylvania College of Optometry,
School of Audiology, Philadelphia. For Parts 1 and 2 of this article (April and May HR), visit www.hearingreview.com.

In most cases, a clinician will see a pediatric patient for various tests several times before an impression is taken. This time is used to establish a relationship of trust with the child.

It is understandable that, if you have never done pediatric impressions on a regular basis, it will be a challenge on your first try. Much of your success relies on how you deal and relate with the child. Many find that it helps to remove the lab coat, and approach the child in a non-intimidating friendly manner.

If you are seeing a pediatric patient who had obtained an impression previously, two things can happen: 1) Either they are an “old pro” and let you do the impression without a lot of trouble, or 2) They are scared. You must calm them down to take an impression. In general, children who wear hearing aids are fairly cooperative because they seem to be used to people working around their ears.

Impression Materials and Techniques for Children
The pediatric population of patients wearing hearing aids is different from the adult population. Because children’s ears grow fast, they are commonly fitted with BTE hearing aids instead of custom ear-level hearing aids (eg, ITE styles). When the BTE earmold becomes loose after several weeks or months of service, the cost of ordering a new earmold is considerably less than the cost of manufacturing a new hearing aid.

Choosing the appropriate impression material and technique for a child is often considered a challenge because there is very little information published on this topic. The guidelines for pediatric impressions offered by field consultants and hearing aid manufacturers are typically based on their professional opinion, not research.

Research data obtained from comparing dimensions of impressions taken from children (3 to 12 years old) and adults (20 to 60 years old) showed an interesting pattern.1 The impressions compared were closed-mouth low-viscosity im­pressions and open-mouth higher-viscosity impressions, taken from the same subject’s ear, from a total of 1,314 ears. As shown in Figure 1, ear canals in children were less dynamic and displayed more firmness than those of adults. The firmness of the pediatric ears was a surprise because it is commonly believed that ear canals in children are soft. Still, note that, in each group, there were individuals with remarkably soft and dynamic ears. These ears are circled in the upper right corner.

Special Considerations for Children’s Ears
Because pediatric ears can be soft or firm and because clinicians cannot accurately predict ear canal softness and dynamics during ear examination,1 pediatric impressions should be taken using the same technique as adult ears: Use a higher-viscosity silicone and the open mouth technique. A review of these materials and this technique is offered in Parts 1 and 2 of this article series, respectively.2-3

The “Big Bear Hug” Restraint Method
For active children, instruct the parent to use a “big bear hug” so the child moves less. Use the term “big bear hug” because you don’t want the parent to be too rough or create a traumatic experience for everyone.
For a right ear, have the child sit on the parent’s right thigh with their legs between the parent’s legs. The child’s left arm gets tucked behind parent’s back. In this way the child only has one appendage to flail with. The right ear faces out and the left cheek goes toward the parent’s chest. Consider when an insect is buzzing around one’s ear, the first reaction is to swipe it away, cover the ear, or shove the shoulder up to defend the ear in an automatic response. To prevent the child from acting upon such instincts, have the parent hold their right shoulder down away from the child’s head by using their left hand. The parent then uses their right hand to gently hold the head into their chest. The child is now restrained by the parent while, at the same time, held as if in embrace—hence “the big bear hug.”
This method gives little room for squirming and flailing about, certainly making the job quicker and easier for everyone involved.

If a patient’s ear canal is firm and/or not affected by mandibular movements, the open-mouth higher-viscosity impression will not differ from an impression taken with any other technique. However, if the ear canal is soft and/or active, the open-mouth higher-viscosity impression will most precisely capture the canal dynamics.

If at All Possible, Make It Fun!
When obtaining impressions from the pediatric population, creativity is a big asset. Each child is different, and what works for one may not work for another. With children you sometimes have to let down your professional image and become a child again. Being silly and crazy in this case is not unprofessional, and parents usually enjoy watching you do it, too.

Equipment seems to be what scares the children most. Make it child friendly. Place a cardboard type animal or cartoon on the otoscope. Use an impression syringe with a smiley face on it (eg, Westone’s Kid’s Syringe). If the child has a stuffed animal or doll with them, pretend to examine its ears and let the child look in the toy’s ear with the otoscope.

You may pretend to take impressions from a toy you have in your office. It can be the ear of Curious George, Mickey Mouse, or a cartoon character. It can be a dummy ear, or a doll’s ear. (Small plastic dolls are easy to sterilize between patients.) You can take an impression on the parent to show the child that it is not a big deal.

See the child in a room that is not intimidating or scary. Try to avoid using the soundbooth or the office where hearing aid programming is done, so they don’t make a connection between the impression room and the room where they will often need to be for follow-up fittings and adjustments.

If you can, take impressions in the classroom. Even 3 year olds don’t want to look like they are afraid in front of their peers. The same child who would cry and arch their back trying to get off their parent’s lap will sit bravely like a little soldier in front of their classmates. Give lots of praise and compliments to the child (“Good job! Brave girl!”).

Describe the otoblock as an “ear pillow.” Tickle the child’s ear with the cotton block and tell them it will tickle again when you will be inserting it. When you do insert it, ask them if it tickles. Most children will laugh. Some children get a little scared and worried when they feel the otoblock going further. To pass the otoblock past the second bend without hurting, use a cotton block and apply a drop of Otoease on it. This will lubricate the ear and make the block slide in easier.

If taking the impression is like going into battle, using a pistol injector with a low-viscosity silicone can be messy. You may get the silicone all over the child’s ear and hair. Using a higher-viscosity silicone with a syringe helps if the child moves around, and the silicone will not droop out of the ear.

Use treats or a sticker as a reward for good behavior. Many professionals are rewarding children with non-foods, preferring small inexpensive toys like rubber balls, toy cars, etc. Be cautious about offering a lollipop or candy, as children may have food and dye allergies. Always ask the parent first. If food treats work for you, keep a supply of candies that are not manufactured in the same place as nuts and are Kosher.

Involving the Parents
A lot also depends on the parents you are dealing with, not just the child. Parents can make or break the situation. Parents are often able to bargain or bribe the child to endure an impression-taking procedure. However, at the same time, parents of children are sometimes dealing with a million questions of their own relative to the child’s hearing health and are not always completely cognizant of the fact that one of your goals is to get a good impression—and that you need their help. In some cases, if you realize that you cannot count on the parent, enlisting the help of a coworker is advisable. A second set of hands can prove extremely useful.

Impression-Taking Strategies for Infants and Small Children
For infants and small children, schedule the appointment around nap-time or feeding time. Advise mom or dad to bring the baby in hungry and sleepy. Ask them to feed the baby in the waiting room so that, by the time you see them, the baby is content and asleep. Leave the children in their car seat if they are sleeping or buckle the child in their stroller and have the parent hold down their head with one ear up.

Small children are usually calmer with the parent holding them. Have the parent bring the child’s favorite toy, blanket, doll, or food to make them feel safe and keep them occupied. The parent should give the child a hug close so you will have the security of knowing the child is being restrained adequately. This works out better for the child, parent, and clinician. Carefully insert the block with your hand against the baby’s face so you can move quickly with the head if you need to.

Toddlers and younger children can be challenging because they are afraid of the unfamiliar. Small children sometimes have panic attacks about getting ear impressions taken. The tough ages are between 2 and 5 years old, especially if the child had a lot of ear infections and medical treatment; they appear worried that there will be pain associated with the process. You may play music in your office during the visit or, if you have a hard time with a child, you and/or a person who is helping you may sing a nursery rhyme, hamming it up a bit. In most cases, the child will smile and become calmer.

For rowdier children that respond to “time out,” use a kitchen timer and let them watch a video (with sound off). For toddlers that are active and tend to grab their ears, use a puppet on their hands to keep their hands occupied. For some of the children, the impressions make everything so quiet they just take a nap.

Some children need to be restrained by another person or with a papoose, and you may end up taking the impression on a crying child. At times, this can be avoided if you take the impression under sedation for ABR or for PE tubes (if medical clearance is signed).

Impressions for Children 5 and Up
Impressions for most children ages 5 years and older are usually straightforward. Involve the child in the whole process, since in most cases this is just the beginning of a lifetime of earmold impressions. Always have the child in full view of what you are doing so there are no surprises. Let them feel like they are in control.

Use a friendly tone and talk to the child at his/her level. Look them in the eye and have them do the same. Most children can relate to you when you are on their level, but at the same time know you mean business. Show the child your equipment and tell (or sign to) them what you are doing. Even toddlers understand a lot more than people give them credit for. Keep your voice low but excited, like this is the best thing that has ever happened to them. Do not mention the word pain. Don’t say “This won’t hurt.” It only may get their little minds thinking that they have heard that before, and translate it into “this is going to be painful.”

Shine the light speculum in their hand, so that they see how non-threatening it is, and tell them it helps you to see in their ear. Practice with them plugging their ears so they can have some idea of what to expect—that everything will be quiet for awhile. Make a big deal about how cool it is to see how the inside of their ear is shaped, etc.

The “Crocodile Game” and open-mouth impressions. In order to obtain an open-mouth impression for a small child, you will need to hold their mouth open by inserting your gloved fingers in their mouth. While working on the right ear, you will have to use the fingers of your right hand. Your thumb holds up the upper jaw. Cross your index and middle finger and have your index finger hold down the lower jaw. With your left hand syringe the impression material. If a parent or another person is present, ask them to put their fingers into the child’s mouth.

For toddlers, if a mouth prop cannot be used, the “alligator game” may be more appropriate. To play the game, face the child with your face close to theirs, as you will be playing along with them. Tell the child to open their mouth a little bit and make it wider and wider like an alligator, each time repeating the words “wider… wider… wider…” Once you reach the point where the mouth is sufficiently open wide, perform the impression taking procedure. Remind the child that they cannot close their mouth until the impression is taken out. When you are finished you may reward the child with a treat. You would be amazed how children love this game. Most do this playfully, happily, and voluntarily!

For older children, take an open-mouth impression using a mouth prop, as shown in Figure 2.

More Pediatric Impression-Taking Tips
Unless the child is really comfortable, do one ear at a time. With little ones, it lessens the chance of them touching or smashing it on mom’s shoulder. With older children, it lessens their stress since they can still hear and talk with their parents.

One key to success is that all materials and supplies need to be ready, and you need to move as fast and effortlessly as possible. Children are great at perceiving panic or haste, so work quickly but deliberately. You may not take an impression of a child’s ear if there is occluding wax—there is so little room to begin with—so make sure this is taken care of beforehand.

Keep the child busy so they do not have much time to think about what is happening. If you use powder-liquid, let the child pour the mixture into the cup and make your “secret potion” that they will now also be privy to. If you use silicone, mix it in front of them. Talk to the child through the process.

Blowing no-spill bubbles is effective to distract the child. Better yet, if you have an automatic bubble machine, it will blow bubbles for you while you take the impression. TVs are also good for distracting attention. Use a DVD/video that does not feature a soundtrack. With the volume off, even when you put the impression in, the child is less likely to notice the difference of the voices, and they will not panic.

If TV is not capturing the child’s attention, have the person helping you entertain the child. They can play with a puppet, making it eat the bubbles. You may use a picture slide on your computer or create some pictures with funny faces. A hand-held computer can mesmerize the child for the duration of the procedure. Many young patients do not have to know how to play the games; pushing the buttons keeps them happy. Another useful item is a mirror for the child to watch what is going on. A mirror prevents a lot of turning. But sometimes it backfires and they cry at the sight of the impression material in their ears.

When the first impression is done, give the child a sticker before starting the next ear.

Post-Impressionism
You’ve accomplished your objective. Now, make sure that the silicone syringed into the child’s ear will cure there undisturbed for several minutes. Here are more ideas on how to keep the child’s little hands busy and get their mind’s off their ears.

Children 2 to 5 years old love the idea of getting to pick the colors for their earmolds and swimming plugs. Try to get them focused on their “very important job” of picking good colors. Show them charts or colorful posters in your office so that both the parents and children can look at different colors to see what they want.

Let them watch cartoons, videos, or play with Mr. Potato Head. Blow more bubbles, let them draw on your computer, or have them work on a puzzle or a picture, or read a book.

Squeeze the extra material from the syringe into a fun shape like a snake, turtle, or ball into their hands. Tell them once it is hard enough to bounce, it is ready to come out of their ear. Children like to play with the material and see it as a great reward. Feeling the material harden will also make them feel in charge and excited to tell you when it is time to take out the impression. Advise children not to put the hardened impression material into their mouths, and collect it before they go home so they will not get the idea of tearing it into pieces and putting it back into their ears (or the ears of their little brothers/sisters, or friends)!

Sending them for a walk after the impression is a good technique too. If you have an aquarium with fish, frogs and snails, they will love seeing them.

Children are usually interested in the look of the impression once it is removed. If you make swimming earmolds for them which you will send to them, tell them they are going to get mail in the mailbox with their name on it. This will make them even more excited.

If you are a good entertainer, the only problem you may face by the end of the visit is that the child may not want to leave!

Acknowledgements
The ideas for taking ear impressions from children presented in this article have been gathered from chats and threaded discussions with audiologists enrolled in the AuD program at the PCO School of Audiology, 2000-2006.4

References
1. Pirzanski C, Berge B. Ear canal dynamics: Facts versus perception. Hear Jour. 2005;58(10):50-58.

2. Pirzanski C. Earmolds and hearing aid shells: A tutorial, Part 1: The external ear canal and impression-making materials. The Hearing Review. 2006;13(4):10-20.

3. Pirzanski C. Earmolds and hearing aid shells: A tutorial. Part 2: Impression-taking techniques that result in fewer remakes. The Hearing Review. 2006;13(5):39-46.

4. Pirzanski C, Berge B. Earmold acoustics and technology. AuD course offered at: PCO School of Audiology. Available at: http://audonline.org.

Correspondence can be addressed to HR or Chester Pirzanski, Oticon Canada, 500 Trillium Dr, Unit 15, Kitchener, ON N2R 1A7; e-mail: [email protected]