Recommended Hearing Test After Questionable Screening Results
When initial hearing screening yields questionable or failed results, refer immediately to a pediatric audiologist for comprehensive audiological evaluation that includes auditory brainstem response (ABR) testing as the definitive diagnostic test. 1
Definitive Diagnostic Testing Protocol
Comprehensive audiological evaluation using ABR is the gold standard for confirming hearing loss when screening results are abnormal or doubtful. 1
For Infants and Young Children (Under 3 Years)
- Diagnostic ABR provides frequency-specific hearing data across different sound levels to effectively estimate an audiogram, making it the definitive test for children unable to cooperate with behavioral testing 1
- ABR can be performed with bone conduction to differentiate conductive from sensorineural hearing loss 1
- For infants up to 3-6 months, diagnostic ABR is performed in natural sleep; older infants require sedation 1
- At least one ABR test is mandatory as part of complete diagnostic evaluation for children younger than 3 years to confirm permanent hearing loss 1
For Children 2-4 Years Old
- Play audiometry is the most appropriate testing method, where the child responds to auditory stimuli through conditioned play activities 2
- Air-conduction hearing threshold levels greater than 20 dB at any frequency indicate possible hearing loss and require referral 2
For Children 4 Years and Older
- Conventional pure-tone audiometry becomes feasible and serves as the behavioral standard 3
- Behavioral pure-tone audiometry remains the gold standard for hearing evaluation when the child can cooperate 1
Essential Concurrent Testing
Tympanometry must be performed alongside hearing testing to assess middle ear function and identify persistent middle ear effusion, the most common cause of conductive hearing loss in children 1, 2
- Type B (flat) tympanograms indicate high probability of middle ear effusion or tympanic membrane perforation, both causing hearing loss 2
- Pneumatic otoscopy and tympanometry alone are insufficient—these assess middle ear status but do not measure actual hearing ability 1, 2
Critical Timing Requirements
- Any abnormal objective screening result requires immediate audiology referral and definitive testing 1
- Infants who fail screening should have comprehensive audiological evaluation completed by 3 months of age 1
- Do not delay assessment waiting for infections to resolve—this may miss critical periods for speech and language development 2
Common Pitfalls to Avoid
- Never assume hearing is normal based solely on passed newborn screening—acquired hearing loss from recurrent otitis media is common and would not have been detected at birth 2
- A "fail" report on any single test in a combination of screening tests warrants additional definitive testing 1
- For children with developmental abnormalities, autism, or behavioral problems that preclude accurate routine testing, refer to an otolaryngologist and pediatric audiologist with specialized equipment and expertise 1
- Ensure the child's medical record is flagged to facilitate tracking and follow-up after abnormal screening 1
Referral Requirements
Refer to audiologists with specific skills and expertise in evaluating newborns and young infants with hearing loss for both diagnostic evaluation and auditory habilitation services 1