What is the next step for infants who fail the Otoacoustic Emissions (OAE) screening, specifically regarding the Automated Auditory Brainstem Response (ABR) test?

ABR Testing After Failed OAE Screening

Infants who fail OAE screening should undergo diagnostic ABR testing as part of a comprehensive audiological evaluation by 3 months of age to confirm or rule out permanent hearing loss. 1

Immediate Next Steps

For Standard Nursery Infants

• Repeat OAE testing between 2-8 weeks after hospital discharge if the initial screening was failed 2, 3
• If the repeat OAE is also failed, refer directly for comprehensive audiological evaluation including diagnostic ABR 2, 3
• Do not delay beyond 3 months of age for definitive diagnosis 1

For NICU Infants (≥2 Days Admission)

• Bypass repeat OAE and refer directly to audiologist for diagnostic ABR testing 3
• These infants require ABR technology due to risk of auditory neuropathy/neural hearing loss that OAE cannot detect 2, 3

Understanding the Diagnostic ABR Test Battery

The comprehensive audiological evaluation for infants birth to 6 months should include 1:

• Frequency-specific ABR using air-conducted tone bursts - determines degree and configuration of hearing loss for each ear 1
• Click-evoked ABR with both condensation and rarefaction stimuli - essential to detect auditory neuropathy by identifying cochlear microphonic 1
• Distortion product or transient evoked OAEs 1
• Tympanometry using 1000-Hz probe tone 1
• Child and family history with risk factor evaluation 1
• Parental report of infant's responses to sound 1

Critical Limitations of Two-Stage Screening

Why ABR is Essential After Failed OAE

Approximately 23% of infants with permanent hearing loss at 8-12 months will pass automated ABR screening after failing OAE 4, 5. This occurs because:

• Most automated ABR screening equipment is designed to detect only moderate or greater hearing loss (>40 dB) 1, 4
• 77% of missed cases have mild hearing loss 4
• One study found 24% of infants who failed OAE but passed automated ABR were eventually diagnosed with hearing loss, comprising 52% of all infants with permanent hearing loss in that cohort 6

OAE Cannot Detect Neural Hearing Loss

• OAE only tests cochlear function, not cortical processing or neural pathways 1, 2
• Auditory neuropathy/auditory dyssynchrony will be missed by OAE alone 1
• Infants with hyperbilirubinemia, anoxia, or prolonged NICU stays are at particular risk 1

Common Pitfalls to Avoid

False Reassurance from Passed Automated ABR

• Do not assume normal hearing if automated ABR passes after failed OAE - proceed with diagnostic testing 4, 5, 6
• Automated ABR is a screening tool, not diagnostic 1
• Mild hearing loss (which affects language development) will be missed 4, 5

Loss to Follow-Up

• 13-31% of infants who fail initial screening do not return for follow-up 3
• Establish clear mechanisms for outpatient follow-up before hospital discharge 1
• Only 2% of low-risk infants who fail OAE actually have hearing loss, but this must be confirmed 2, 3

Parental Anxiety Management

• 3-14% of parents experience significant anxiety even after normal follow-up 3
• Communicate results face-to-face in a caring, sensitive manner 3
• Explain that most positive screening tests are false positives (93.3% overall) 3

Timeline Requirements

• Diagnosis must be confirmed by 3 months of age 1
• Diagnostic ABR can be performed as early as 3 months 3
• Hearing aid fitting should occur by 5-7 months if hearing loss confirmed 3
• Sedation may be required for diagnostic ABR as infant must remain quiet 1

Special Considerations for High-Risk Infants

Any infant with risk factors requires ongoing surveillance and at least one diagnostic audiology assessment by 24-30 months regardless of newborn screening results 3:

• Family history of childhood sensorineural hearing loss 3
• Congenital infections (TORCH) 3
• Craniofacial abnormalities 3
• Syndromes associated with hearing loss 3
• Hyperbilirubinemia requiring exchange transfusion 1
• Culture-positive sepsis 1

50-75% of infants with moderate-to-profound bilateral hearing loss have identifiable risk factors 2, 3, but 25-50% do not, emphasizing the importance of universal screening and appropriate follow-up.