What is the best method for hearing screening in newborns?

Best Method for Newborn Hearing Screening

The best method for hearing screening in newborns is a two-stage protocol using otoacoustic emissions (OAE) followed by automated auditory brainstem response (ABR) for those who fail the initial OAE screening. 1

Recommended Screening Protocol

Two-Stage Approach

• First stage: Otoacoustic emissions (OAE) testing for all newborns
• Second stage: Automated auditory brainstem response (ABR) for infants who fail the initial OAE test

This two-stage approach offers the best balance between sensitivity and specificity while being practical for universal implementation. The American Academy of Pediatrics recommends that:

• Screening should be performed no later than 1 month of age 1
• Comprehensive audiological evaluation should be completed by 3 months for those who fail screening 1
• Appropriate intervention should begin by 6 months for those with confirmed hearing loss 1

Special Considerations for High-Risk Infants

• NICU infants admitted for more than 5 days should have ABR included in their initial screening to detect neural hearing loss 1
• Infants who fail automated ABR testing in the NICU should be referred directly to an audiologist 1

Effectiveness of Two-Stage Protocol

The two-stage OAE/ABR protocol has demonstrated significant benefits:

• Reduces the age of identification of hearing impairment from 12-13 months to 3-6 months 1
• Decreases the age of hearing aid fitting from 13-16 months to 5-7 months 1
• Provides good specificity (98.8%) while maintaining reasonable sensitivity (66.7%) 2

However, it's important to note that this protocol has limitations:

• The two-stage protocol may miss approximately 11% of affected ears 3
• About 23% of infants with permanent hearing loss at 9 months of age might pass the A-ABR screening 4

Implementation Considerations

For optimal screening outcomes:

• Equipment must be well-maintained
• Staff should be thoroughly trained
• Quality control programs should be in place to reduce false positives 3
• Complete screening should be performed on both ears, even if only one ear failed initially 1

Follow-up Protocol

• Infants who fail in-hospital screening should be referred for repeat testing between 2-8 weeks after discharge 1
• All infants with risk factors for hearing loss should have at least one diagnostic audiological assessment by 24-30 months, even if they passed newborn screening 1
• More frequent assessment may be needed for children with certain risk factors (CMV infection, syndromes associated with progressive hearing loss, family history) 1

Common Pitfalls to Avoid

1. Loss to follow-up: 6-15% of infants who fail screening are lost to follow-up, and 13-31% of infants who fail initial screening do not return for definitive testing 1

2. False reassurance: Passing newborn hearing screening does not eliminate the need for ongoing monitoring, especially in high-risk infants 1

3. Parental anxiety: False positives can cause significant parental anxiety, with 25-50 false positives for each true case in low-risk populations 1

4. Missing mild hearing loss: Standard screening protocols are primarily designed to detect moderate to severe hearing loss and may miss milder cases 1

By implementing a systematic two-stage OAE/ABR screening protocol with appropriate follow-up mechanisms, healthcare providers can effectively identify newborns with hearing impairment and facilitate early intervention, which is crucial for optimal speech and language development.