BERA Testing for 4-Month-Old with Ear Tag and Normal OAE
A 4-month-old infant with an ear tag (preauricular tag) and normal initial OAE should undergo BERA testing now, as ear tags are a recognized risk indicator for hearing loss that warrants comprehensive audiological evaluation regardless of passing newborn screening. 1
Why BERA is Indicated Now
Ear tags are a recognized risk factor that places this infant in a high-risk category requiring diagnostic ABR (BERA) testing beyond routine screening, even with normal OAE results 1
OAE screening has significant limitations - research demonstrates that approximately 23% of infants with permanent hearing loss at 8-12 months pass automated ABR screening after failing OAE, with 77% having mild hearing loss that screening may miss 2, 3
OAE does not assess the complete auditory pathway - it only tests cochlear function and does not evaluate neural hearing loss or auditory neuropathy, which BERA can detect 1
Timing and Testing Protocol
BERA should be performed at this 4-month visit using frequency-specific ABR with air-conducted tone bursts to create a comprehensive map of hearing thresholds across frequencies 1
Include click-evoked ABR with both condensation and rarefaction stimuli to rule out auditory neuropathy/auditory dyssynchrony, as some infants with neural hearing loss have no obvious risk indicators beyond anatomical anomalies 1
Sedation may be required for the infant to remain quiet during testing, as motion artifact can compromise results 1
Additional Concurrent Testing
Tympanometry using a 1000-Hz probe tone should be performed to assess middle ear function, as infants younger than 6 months require high-frequency tone probes 1
Repeat OAE testing (distortion product or transient evoked) should be included in the diagnostic battery 1
Clinical observation of auditory behavior and detailed family history of childhood-onset hearing loss should be documented 1
Critical Pitfall to Avoid
Do not delay BERA testing until later developmental milestones - the goal is to confirm or rule out hearing loss by 3 months of age to enable intervention before 6 months, which is critical for optimal language and cognitive development 1. At 4 months, this infant is already past the ideal diagnostic timeline, making immediate BERA testing urgent rather than optional.
Follow-Up Based on Results
If BERA confirms hearing loss, amplification should begin within 1 month and coordination with early intervention services should be expedited 1, 4
If BERA is normal, the infant still requires ongoing surveillance with age-appropriate behavioral audiometry (visual reinforcement audiometry) starting at 6-9 months, as late-onset hearing loss can occur 1
Medical evaluation by otolaryngology should be arranged regardless of BERA results to evaluate the ear tag and any associated craniofacial anomalies that may indicate syndromic hearing loss 1