Early identification of hearing loss through universal newborn screening is important. Screening should involve testing all infants with otoacoustic emissions (OAEs) no later than 1 month of age. Any infants who do not pass should receive auditory brainstem response (ABR) testing no later than 3 months of age to confirm a diagnosis. Early intervention is crucial for infants diagnosed with hearing loss, as those identified by 6 months of age develop normal speech and language skills, while those identified later face delays. Screening protocols may differ between well baby nurseries using primarily OAEs and neonatal intensive care units using ABR from birth due to risk of neural hearing loss.

1. Ali Ravanbod
(Medical student)

2. Early identification and intervention can prevent severe
psychosocial, educational, and linguistic repercussions. Infants
who are not identified before 6 months of age have delays in
speech and language development. Intervention at or before 6
months of age allows a child with impaired hearing to develop
normal speech and language.

3. Hearing loss is one of the most common congenital
anomalies, occurring in approximately 2-4 infants per
1000. Prior to implementation of universal newborn
screening, testing was conducted only on infants who
met the criteria of the high-risk register (HRR). It was
found that the HRR was not enough, given that as many
as 50% of infants born with hearing loss have no known
risk factors.

4. Misconception Clinical Fact
Parents will know if their child has a hearing
loss by the time their child is 2-3 months of
age.
Prior to the universal screening, the average
age at which children were found to have a
hearing loss is 2-3 years. Children with mild-
to-moderate hearing loss were often not
identified until 4 years of age.
Parents can identify a hearing loss by clapping
their hands behind the child's head.
Children can compensate for a hearing loss.
They use visual clues, such as shadows or
parental expressions and reactions, or they
may feel the breeze caused by the motion of
the hands.
The HRR is all that is needed to identify
children with hearing loss.
The HRR misses approximately 50% of all
children with hearing loss.
Hearing loss does not occur often enough to
justify the use of universal screening
programs.
Hearing loss affects approximately 2-4 per
1000 live births, and it has been estimated to
be one of the most common congenital
anomalies.
There is no rush to identify a hearing loss.
The loss does not need to be identified until a
child is aged 2-3 years.
Children identified when they are older than
6 months can have speech and language
delays. Children identified when they are
younger than 6 months do not have these
delays and are equal to their hearing peers in
terms of speech and language.
Children younger than 12 months cannot be
fitted with hearing aids.
Children as young as 1 month of age can be
fit with and benefit from hearing aids.

5. All infants will access hearing
screening
 no later than 1 month of age
All infants not passing initial
screening and subsequent
rescreening should have
confirmatory audiological and
medical evaluations
 no later than 3 months of age
All infants with confirmed
permanent hearing loss should
receive early intervention as
soon as possible

6. children identified as early as age 7-12 months had
lower receptive and expressive language quotients than
those of children identified by age 6 months. No
significant difference was found between children
identified at age 7-12 months and those identified at
age 25-30 months.

7. •Family history of permanent childhood sensorineural hearing loss
•In utero infection such as cytomegalovirus, rubella toxoplasmosis, or
herpes
•Craniofacial anomalies, including those with morphological
abnormalities of ear
•Hyperbilirubinemia at a serum level requiring exchange transfusion
•Bacterial meningitis
•Syndromes associated with progressive hearing loss such as
neurofibromatosis, osteopetrosis
•Head trauma
•Premature infants in the neonatal intensive care unit.

8.  Otoacoustic emissions (OAEs).
 Auditory brainstem response
(ABR) .

9. OAEs are used to assess cochlear integrity and are physiologic
measurements of the response of the outer hair cells to acoustic
stimuli.
Sounds are presented to the ear canal and a small microphone
measures the response in the ear canal
Fast objective screening test to evaluate the function of the
peripheral auditory system, primarily the cochlea, which is the
area most often involved in sensorineural hearing loss.
Quicker to perform than ABR.

10. There are two types of otoacoustic emissions
tests which are used clinically.
These are:
1. Transient (TEOAEs): These are evoked
responses from stimulating the cochlea with a
transient signal such as a click or tone burst
acoustic signal. TEOAEs are a wide frequency
response in the 500 to 4,000 Hz range. They
typically do not occur when hearing loss is about
30 Dbhl or greater.
2. Distortion Product (DPOAEs): These are evoked
response OAEs from stimulating the cochlea with
two simultaneously presented pure tones of
different frequency. This type of OAE may be
recorded in individuals with a greater degree of
hearing loss at higher frequencies. DPOAEs are
typically measured in the frequency range of 750

13. Auditory brainstem response (ABR) is a neurologic test of
auditory brainstem function in response to auditory (click)
stimuli.
AABR measurements are generally obtained by placing
disposable surface electrodes high on the forehead, on the
mastoid, and on the nape of the neck . The click stimulus
(usually set at 35 dB hearing level [HL]) is delivered to the
infant's ear via small disposable earphones designed to
attenuate background noise.
ABR is reliable after 34 wks postnatal age.
ABR is the preferred screening method to evaluate hearing
loss in NICU graduate.

14. AUDITORY BRAINSTEM
RESPONSE
 Sounds are
presented
and surface
electrodes
measure
brainstem
activity
 Average test
time 30-45
min/baby

15. Auditory Structure OAEs ABRs/AABRs
Outer ear Yes Yes
Middle ear Yes Yes
Inner ear Yes Yes
Auditory nerve No Yes
Auditory brainstem No Yes
Although OAE screening continues to be cost effective in the
well-baby nursery, OAE screening followed by AABR is a reliable
protocol .

16. NICU
 >5 days in NICU
 ABR should be
included to screen
for neural loss
 Rescreen BOTH
ears, even if only
one ear fails
 Non pass – refer to
Audiologist
 Readmission –
rescreen before
discharge
Well baby
nursery
 Screen with OAE or
ABR
 Repeat screen
when necessary
before discharge
 When using 2 step
protocol test order
should be OAE then
ABR
 Rescreen BOTH
ears, even if only
one ear fails