Diagnostic Guidelines for Hearing Loss in Infants and Children

Primary Clinical Applications

The American Academy of Pediatrics recommends automated ABR as the mandatory screening method for all NICU infants hospitalized >5 days to detect neural hearing loss that otoacoustic emissions (OAEs) would miss 3
For well-infant nurseries, either automated ABR or OAEs can be used as the initial screening tool, according to the American Academy of Pediatrics 1
Infants who fail automated ABR screening in the NICU should be referred directly to an audiologist for comprehensive diagnostic evaluation, bypassing rescreening, as recommended by the American Academy of Pediatrics 3

When permanent hearing loss is suspected, diagnostic ABR must include frequency-specific ABR using air-conducted tone bursts at multiple frequencies to create an audiogram-like map of hearing thresholds, as recommended by the American Academy of Pediatrics 5
Click-evoked ABR with both condensation and rarefaction stimuli should be used to detect cochlear microphonics and rule out auditory neuropathy/dyssynchrony, particularly in infants with risk factors, according to the American Academy of Pediatrics 2, 4
Bone-conduction ABR should be used when indicated to differentiate conductive from sensorineural hearing loss, as recommended by the American Academy of Pediatrics 6

ABR provides ear-specific results obtained through insert earphones, does not require patient cooperation, and can test across multiple frequencies, according to the American Academy of Pediatrics 1, 9
ABR is NOT a true test of hearing because it only assesses auditory pathway structural integrity up to the brainstem—it does not evaluate cortical processing of sound, as noted by the American Academy of Pediatrics 1, 9, 5

The diagnostic battery must include otoacoustic emissions (OAEs) to assess cochlear function, tympanometry with 1000-Hz probe tone to rule out middle ear pathology, and behavioral audiometry as soon as developmentally appropriate, as recommended by the American Academy of Pediatrics 2, 4, 1, 5, 6

Infants with confirmed hearing loss must receive diagnostic evaluation completed by 3 months of age, hearing aid fitting within 1 month of diagnosis if family chooses amplification, and early intervention services initiated by 6 months of age, according to the American Academy of Pediatrics 2, 3, 4, 7
For children with risk factors who pass newborn screening, at least one diagnostic audiology assessment (including ABR if behavioral testing is unreliable) should occur by 24-30 months of age, with earlier and more frequent assessment for high-risk conditions, as recommended by the American Academy of Pediatrics 3