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Chapter 54 ■ Neonatal Hearing Screening 387

NICU (5). This specific population is at high risk for

having auditory neuropathy, which is detected by AABR

but not by OAE (9,10). Immediate and direct referral

should be made to an audiologist if an infant does not

pass AABR in the NICU.

2. For well-nursery infants: Although OAE is more often

used than AABR, both methods are widely used in many

hospitals, as there is no standardization of newborn hearing screening protocols for well infants. Some hospital

programs screen neonatal hearing with OAE first. If

infant does not pass OAE, AABR will be used to rescreen.

There are advantages and disadvantages to using OAE as

the first newborn hearing screen. Please refer to H for an

explanation. For infants who do not pass AABR as the first

screening test, a direct referral to an audiologist should be

made as the infant might have a neuro auditory disorder,

and OAE should not be used to rescreen (5).

3. For infants readmitted to hospitals: A repeat hearing

screen is recommended for infants <1 month old, who

were readmitted to hospital, if the medical condition

is associated with increased risk of hearing loss (e.g.,

meningitis or hyperbilirubinemia requiring exchange

transfusion) (5).

4. The following timeline is a goal objective in Healthy

People 2020 (5,9,11)

a. By 1 month old: All newborns to have hearing

screened

b. By 3 months old: Those that do not pass initial

screening need to have a comprehensive evaluation

by an audiologist.

c. By 6 months old: Infants with confirmed hearing loss

should receive appropriate interventions.

H. Limitations

1. Infant hearing screening can be compromised by environmental noise (such as a busy intensive care unit) or

infant movement. OAE screening, more so than

AABR, is particularly affected by vernix occluding the

ear canal, or middle ear pathology such as effusion

(12).

2. OAE screening, although less time-consuming to set up

and conduct, has a higher “refer” (fail) rate than AABR.

The refer rates for OAE screening alone have been

cited in the literature as being between 5.8% and 6.5%,

with refer rates using AABR screening around 3.2%

(13,14). In particular, infants who are <48 hours old are

more likely to have a “refer” result if screened with

OAE, as the presence of vernix and debris in the ear

canal can be a significant factor (15).

3. Some infants who pass newborn screening will later

demonstrate permanent hearing loss. Although this loss

may reflect delayed hearing loss, both ABR and OAE

screening technology will miss some hearing loss (mild

or isolated frequency losses) (5).

I. Contraindications

1. Patient has significantly atretic or total lack of external

ear canal: Refer directly to pediatric audiologist.

2. Although it is certainly fair to rescreen an infant who

has potentially failed screening because of excessive

background noise, vernix in ear canal, etc., multiple

rescreening attempts in hopes of eventually obtaining a

“pass” are not recommended and can contribute to

delayed identification of congenital hearing loss.

J. Special Circumstances

1. Hearing parents whose infant does not pass a hearing

screening: Parents are often quite concerned to learn

their infant has not passed a hearing screening. The

result can be especially stress provoking for parents

whose infant may have spent a good deal of time in a

NICU and may be facing additional medical concerns

upon discharge. It is extremely important to remember

that a failed hearing screening is not a definitive diagnosis of hearing loss. It is an important indicator that the

infant needs immediate referral to an audiologist for

further detailed evaluation, which may or may not

result in a formal diagnosis of hearing loss.

2. Deaf parents whose infant does not pass a hearing screen:

Deaf parents, especially culturally deaf individuals who

use American Sign Language and identify strongly with

being members of the deaf community, are often thrilled

to find out that their infant may have hearing loss. This

is a cultural identification: These parents are rejoicing

in the fact that their infant is like them and will have a

cultural place of significance in their social world. This

is often in direct opposition to the traditional medical

perspective on hearing loss. The parental reaction can

be frankly surprising for involved health care professionals. It is very important to realize that these infants of

culturally deaf parents are not facing the immediate crisis

of delayed language development referred to earlier.

American Sign Language is a well-researched, intact

language (16,17) that is immediately accessible to an

infant of deaf parents. Although it is still extremely

important to establish audiologic follow-up for these

infants of deaf parents who fail a hearing screen, it is also

critical to respect the potential cultural implication for

such families. These parents may be celebrating in a

manner very similar to hearing parents who are happy

that their infant has passed the hearing screening.

K. Complications

OAE and AABR are considered to be noninvasive and safe

procedures. Like any procedure that involves the application of electrode pads, mild superficial skin abrasions could

possibly occur with the removal of the electrode pads after

AABR testing.