When is an auditory brainstem response (ABR) indicated and how should it be performed?

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Auditory Brainstem Response (ABR) Testing

When ABR is Indicated

ABR testing is indicated for infants and children who cannot cooperate with behavioral audiometry, including all NICU infants admitted >5 days, infants who fail newborn hearing screening, children with developmental delays/autism, and any child requiring definitive hearing assessment when behavioral testing is unreliable. 1, 2

Specific Indications:

Screening Context:

  • NICU infants: Must include ABR (not just OAE) to detect auditory neuropathy/dyssynchrony 2
  • Failed newborn screening: Direct referral to audiologist for diagnostic ABR after automated ABR screening failure 2
  • Risk factors present: Infants with CMV, syndromes with progressive hearing loss, neurodegenerative disorders, ECMO, chemotherapy, culture-positive postnatal infections, family history of hearing loss, or caregiver concern 2

Diagnostic Context:

  • Children unable to complete behavioral audiometry due to age (<6 months), developmental delay, autism, or behavioral problems 1
  • Confirmation of hearing loss requires at least one ABR test in children <3 years 2
  • Any abnormal objective screening result (OAE or automated ABR failure) 1

How ABR Should Be Performed

Age-Specific Protocols:

Infants 0-6 months:

  • Perform during natural sleep without sedation 1
  • Test in quiet state; motion artifacts interfere with results 1

Infants >6 months and older children:

  • Sedation often required due to motion artifact 1
  • Age-appropriate sedation: oral triclofos for 3-24 months, IV propofol for >24 months 3

Technical Requirements:

Diagnostic ABR must include 1, 2:

  • Electrodes placed on child's head to detect neurologic responses
  • Insert earphones or ear inserts for ear-specific testing (test each ear individually)
  • Frequency-specific tone bursts at multiple frequencies (500,1000,2000,4000 Hz) across varying sound levels to estimate an audiogram 1
  • Click-evoked ABR using both condensation and rarefaction stimuli 2
  • Bone conduction testing to differentiate conductive from sensorineural hearing loss 1

Complete Diagnostic Battery:

The comprehensive evaluation must include 2:

  • Child and family history
  • Frequency-specific ABR with air-conducted tone bursts
  • Click-evoked ABR (condensation and rarefaction)
  • OAE testing (distortion product or transient evoked)
  • Tympanometry with 1000-Hz probe tone
  • Clinician observation of auditory behavior

Critical Technical Points:

Quality control measures 4:

  • Use appropriate display scale settings
  • Apply templates of expected response properties
  • Use objective criteria for residual noise, signal level, and signal-to-noise ratio
  • Employ cross-checks (immittance measures, OAEs, functional hearing assessments)

Important caveat: ABR tests auditory pathway structural integrity but is not a true test of hearing because it does not assess cortical processing of sound 1. Even with normal ABR/OAE results, hearing cannot be definitively considered normal until behavioral audiometry is obtained 1.

Timing Requirements:

  • Confirmation of hearing loss: Complete by 3 months of age 2
  • Amplification fitting: Within 1 month of diagnosis if families elect amplification 2
  • Follow-up for risk factors: At least one diagnostic assessment by 24-30 months even if passed newborn screening; earlier and more frequent for high-risk conditions 2

Referral Pathway:

Any infant failing automated ABR screening should be referred directly to a pediatric audiologist with expertise in evaluating newborns and young infants, not simply rescreened 2. The audiologist must have skills in diagnostic ABR and auditory habilitation services including amplification device selection 2.

References

3
Research

Frequency-specific auditory brainstem response testing with age-appropriate sedation.

International journal of pediatric otorhinolaryngology, 2018

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.