When should a newborn who has just completed universal hearing screening have a follow‑up audiologic evaluation?

Follow-Up Audiogram After Newborn Hearing Screening

Infants who fail the initial newborn hearing screening should receive repeat testing between 2 and 8 weeks after hospital discharge, with comprehensive diagnostic audiological evaluation—including frequency-specific ABR—completed by 3 months of age. 1, 2

Timeline for Follow-Up: The 1-3-6 Rule

The American Academy of Pediatrics establishes clear benchmarks for the entire screening-to-intervention pathway 1, 3:

• Screening: Complete by 1 month of age 1, 3
• Diagnostic evaluation: Complete by 3 months of age for all infants who fail screening 1, 3, 2
• Intervention: Hearing aids fitted and early intervention services initiated by 6 months of age 1, 3

Immediate Post-Discharge Protocol

For Infants Who Fail In-Hospital Screening

• Schedule outpatient rescreening between 2 and 8 weeks after discharge 1, 2
• If the infant fails the second screening, refer immediately for comprehensive audiological evaluation that must be completed no later than 3 months of age 1, 2

For NICU Infants Who Fail ABR Screening

• Do not send for routine outpatient rescreening 1, 3
• Refer directly to a pediatric audiologist for diagnostic evaluation, as NICU infants have 10-20 fold increased risk of neural hearing loss 1, 3

Comprehensive Diagnostic Evaluation (Birth to 6 Months)

When permanent hearing loss is suspected, the diagnostic battery must include 1, 2:

• Frequency-specific ABR using air-conducted tone bursts to determine degree and configuration of hearing loss in each ear 1, 2
• Click-evoked ABR with both condensation and rarefaction stimuli to detect cochlear microphonic and assess for auditory neuropathy 1, 2
• Otoacoustic emissions (distortion product or transient evoked) to assess cochlear outer hair cell function 1, 2
• Tympanometry using 1000-Hz probe tone (infant-appropriate) 1, 2
• Child and family history with risk factor evaluation 1, 2
• Parental report of infant's auditory responses 1

Understanding False-Positive Results

Parents require clear counseling about screening accuracy 1, 2:

• In low-risk populations, only 2% of infants who fail OAE screening actually have sensorineural hearing loss 1, 3
• Overall, approximately 6.7% of infants who fail in-hospital screening are eventually diagnosed with bilateral hearing loss 1, 3
• There are 25 to 50 false positives for each true case of hearing impairment in low-risk populations 1

Critical Pitfalls to Avoid

Do Not Assume a Passed ABR Means No Hearing Loss

• Approximately 23% of infants with permanent hearing loss at 9 months will have passed automated ABR screening after failing OAE 4
• Most automated ABR equipment is designed to detect moderate or greater hearing loss and will miss mild losses 4
• 77% of missed cases have mild hearing loss (≤40 dB hearing level) 4
• Recent evidence shows that 28% of infants who fail TEOAE but pass AABR have hearing impairment confirmed at 1-year follow-up 5

Do Not Delay Beyond 3 Months

• Visual reinforcement audiometry cannot be performed reliably before 8-9 months of age, making early ABR testing essential 1
• Diagnostic ABR can be performed as early as 3 months and should not be delayed 1, 2
• Early intervention before 6 months is critical for language development outcomes 1, 3

Do Not Ignore Loss to Follow-Up Risk

• 13% to 31% of infants who fail initial screening do not return for follow-up testing 1, 3
• Hospitals should implement systematic protocols including scheduled appointments before discharge, written instructions, and phone call reminders 6
• Nurse practitioner-led education interventions at bedside before discharge significantly improve follow-up rates 6

Special Populations Requiring Enhanced Surveillance

Even infants who pass newborn screening require ongoing surveillance if they have risk factors 1, 3:

• NICU admission ≥2 days 1, 3
• Family history of childhood sensorineural hearing loss 1, 3
• Congenital infections (TORCH agents) 1, 3
• Craniofacial abnormalities 1, 3
• Syndromes associated with hearing loss 1, 3
• Hyperbilirubinemia requiring exchange transfusion 1, 3
• Culture-positive sepsis 1, 3

These infants require at least one diagnostic audiology assessment by 24-30 months of age regardless of newborn screening results 1, 3

Timing Considerations for Optimal Screening

• Do not screen before 24 hours of life unless medically necessary, as false-positive rates are significantly higher due to middle-ear fluid, vernix, and cerumen 3
• Screening after the first 24 hours reduces false-positive results 3