School education has undergone a drastic change in recent times due to the COVID-19 pandemic. The global choice today is delivering remote virtual learning -- thanks to the availability of internet technology. Both teachers and students are slowly adapting to the art of online education and are finding ways to engage in learning activity akin to the erstwhile schooling.
However, there is an overall lifestyle change among children in this lockdown period. They tend to be more engaged with electronic devices playing games and watching streaming videos, since they do not have any outdoor activities to engage in and cannot physically meet with their friends. This, in addition to online classes, leads to cumulative harm to their sensory organs and mental health and leads to the premise of this article.
Sensory influences of online classes
The World Health Organization (WHO) estimates that around a billion young people across the globe could be at the risk of hearing loss because of unsafe listening habits using earphones. There have always been medical issues connected with excessive gadget use and now, after about 3-4 months of lockdown, ENT doctors are beginning to see a rising trend in ailments among children who have been exposed to numerous hours of screen time. Children now report ear discomfort and pain due to ill-fitting ear phones with the risk of hearing loss; and ringing noise in the ears, due to prolonged exposure to electronic noise. There is the added risk of ear canal infections like 'Otomycosis' due to fungal mould found in ear phones.
In addition to their vision and hearing, their higher mental functions like cognition and behaviour are also vulnerable. ENT specialists are nowadays meeting anxious parents with their children complaining of episodic headaches, photophobia (aversion to bright light), eye and ear strain, tinnitus (noises in the ear), vertigo, imbalance, stress, fatigue and insomnia. Parents also mention cognitive and behavioral changes including lack of interest and distraction during online classes. Such a phenomenon was largely unheard of in the past and seems like an emerging issue related to the current trend of virtual learning and gadget use
Poor quality headphones and over-exposure to bright screens can trigger visual flares, aura, photophobia, nausea and headaches. Clinically, these symptoms may be diagnosed as pediatric migraine, and there is no clear-cut remedy to offer apart from alleviating the trigger factors. In such situations, it is imperative for us to investigate the gadget-use habits of the child and other down-time activities. Treatment primarily involves lifestyle changes for both parents and children with a need to develop gadget etiquette for limiting exposure over the long term.
Excessive use of gadgets such as mobile phones, tablets and computer desktops has been known to cause physical and mental damage to children. Children are likely to become sedentary and overweight, have vision problems and may even become susceptible to seizures when they spend too much time on gadgets. Noise and music-induced hearing loss have been a well known entity among children exposed to prolonged electronic signals. The sensory trauma to the organ of hearing is similar to the risk of mobile phone over-exposure and manifests with temporary threshold shifts in hearing, which can later on cumulatively become permanent hearing loss.
By nature, our ears have the capacity to augment and attenuate sounds. Therefore, in comparison to natural noise, sounds delivered through headphones can be augmented by 40dB than the source. Ear phones are even worse as they can augment sounds up to 70dB higher than the source. In this scenario the natural protective mechanisms of the inner ear are lost and the risk of damage to the end organ of hearing is very high with cumulative usage. This is more so in the tender ears of children.
Occupational Safety and Health Administration and Centre for Disease Control, USA have stringent guidelines to noise exposure as below:
OSHA Guidelines, 2019 (cdc.gov)
Unfortunately, earphones / headphones do not have a set calibration for exposure time with loudness, since it is user-based and levels vary over time. In general earphones deliver about 90 to 120 dB sounds into the ears when the device is set at maximum volume, which is known to damage hearing when used for more than 45 minutes. For instance, classic iPod earbuds at 100% volume on an iPhone can hit noise levels of 112dB for the wearer, leading to hearing damage in minutes. The same ear buds at 60% volume measure approximately 80 dB, which makes them safe to listen to for several hours. Cheaper quality devices can harm the ear even at lower decibels due to poor signal-noise attenuation. As a rule of thumb if parents can hear their child's earphone from 3 feet away, then their children are at risk of hearing damage and should take remedial action.
ENT specialists advocate the use of certified good quality (CE marked) head phones with anti-noise filters to offer a pleasing listening experience for learning. Sound levels should not exceed the prescribed limits on these phones and adequate breaks away from noise exposure is crucial to allow time for the ears to recuperate and rejuvenate. Similarly ophthalmologists drive home the point on using radiation filtered screens and maintaining a comfortable distance while online, which is more pleasing to the eye. It is essential to make children understand the risks of hearing and visual impairment and restrict their exposure time while adhering to good gadget etiquette.
Safe hearing practices for online learning:
- Headphones are safer than ear-insert phones
- External speakers of good quality are even safer if the volume is kept around 80 db
- There are many free apps which can be downloaded from the net which can be used to monitor the noise level in the room used by the child for e-learning.
- Purchase good quality gadgets for your child's use
- Dirty earphones can increase the possibility of an ear infection
- Check the sound levels on yourself before fitting it on your child
- Be mindful of the environment you are in when your child is wearing headphones - avoid noisy surroundings
- Limit the volume on your device to not exceed recommended levels (<85dB)
- Follow the 60/60 rule: listen at 60 percent of the max volume for no more than 60 minutes at a time
- Encourage frequent breaks from noise exposure - atleast 15mins / hour of use to allow the hair cells in the inner ear to rest
- Do not allow your child to indulge in gadgets apart from the time of their classes
- Encourage rejuvenating lifestyle measures for your child like yoga, exercise, meditation, art and dance
Safe practices to be adapted by schools while engaging in virtual teaching
- Try not to exceed 4 hrs of online teaching per day
- Give breaks of at least 15 min after each 1 hour session
- Mix didactic teaching with ‘fun activities’ like yoga, physical exercise etc. This will give time for recovery of their sense organs and attention
Conclusion
Parents need to identify early signs of sensory disturbances in children while they are online, and seek timely medical help. Health workers need to create parental awareness regarding the health issues related to virtual learning and emphasize the importance of implementing gadget etiquette early among their children.
(The authors are senior Consultant ENT surgeons, Madras ENT Research Foundation, Chennai. They can be reached at Email: merfmk30@yahoo.com)
