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Permanent Childhood Hearing Loss
Audiologic Assessment

Auditory Brainstem Response (ABR)



External Scientific Evidence

Evidence-Based Practice Guidelines
New York State Department of Health, Early Intervention Program; U.S. Department of Education

Clinical Practice Guideline: Report of the Recommendations. Hearing Loss, Assessment and Intervention for Young Children (Age 0-3 Years)
New York State Department of Health, Early Intervention Program. (2007).
Albany (NY): NYS Department of Health, Publication No. 4967, 354 pages.
Added: July 2012

This evidence-based and consensus-based guideline provides recommendations for the assessment and intervention of hearing loss for young children ages birth to three. The guideline targets parents and professionals. Recommendations of interest to audiologists and speech-language pathologists include screening, assessment, and management of hearing and assessment of communication. Each recommendation is provided with a strength of evidence rating defined as Level A (strong evidence), Level B (moderate evidence), Level C (limited evidence), Level D1 (consensus panel opinion based on topics where a systematic review has been conducted), and Level D2 (consensus panel opinion not based on findings from a systematic review).

  • “Physiologic tests that may require sedation (such as the ABR) are recommended for children whose hearing assessment results are unreliable or inconsistent and whose auditory status remains unknown. ABR is an appropriate test for children suspected of hearing loss who are developmentally delayed or are too young (under 5 months) for reliable conditioned behavioral testing procedures” (Level D2 Evidence).

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Evidence-Based Systematic Reviews
Diagnostic Challenges and Safety Considerations in Cochlear Implantation Under the Age of 12 Months
Vlastarakos, P. V., Candiloros, D., et al. (2010).
International Journal of Pediatric Otorhinolaryngology, 74(2), 127-32.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: August 2012

This is a systematic review of the literature examining the diagnostic, surgical, and anesthetic challenges associated with cochlear implantation in children before the age of 12 months.


  • “Visual reinforcement audiomentry (VRA) which may be used for behavioral testing in late infancy, is not applicable in young infants, due to their inability to make reliable direct head-turn responses towards sound sources. In addition, children with additional disorders as well as prematurity may also not be able to complete VRA testing. Objective audiometric tests (OAE, ABR, and ASSR) may be the only method of assessing candidacy for early cochlear implantation…” (p. 128).

  • “Even after applying the strictest diagnostic criteria and obtaining more than one waveforms for each stimulus, challenges with regard to the accuracy of the investigation especially in difficult cases, may be encountered. Moreover, ABRs assess a narrow frequency range; therefore cases with useful residual hearing (i.e., normal or near normal hearing in the lower frequencies) are usually missed, thus resulting to inappropriate amplification” (p. 128).

  • “ASSRs are a relatively recent method which shows better specificity in various frequencies compared to ABRs. They are also more objective, as they relate the prediction of an auditory response to statistical criteria, which are incorporated in their software, and not to the examiner’s level of expertise” (p. 128).

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Clinical Expertise/Expert Opinion

Consensus Guidelines
American Academy of Audiology

Audiologic Guidelines for the Assessment of Hearing in Infants and Young Children
Retrieved from
Added: May 2013

This guideline provides recommendations for the assessment of auditory function in infants and young children. The target audience of this guideline is audiologists. Select recommendations are provided below; for the full set of recommendations, please review the guideline document.


  • A pediatric audiologic assessment test battery includes a case history, otoscopy, behavioral observation, visual reinforcement audiometry, conditioned play audiometry, physiologic assessments (e.g., tympanometry, otoacoustic emission testing), and electrophysiologic audiometry (e.g., auditory brainstem response, auditory steady state response).

  • ABR is used to estimate ear-specific hearing levels at individual frequencies and determine type of hearing loss.

  • ABR testing is frequently used for newborns and infants or children (of any age) who are unable to provide accurate or reliable responses to behavioral testing. 

  • For ABR testing, "it is imperative that children sleep soundly for a prolonged period of time, to obtain clean, low-noise electrophysiologic recordings. Natural sleep is best but when this cannot be assured, sedation is necessary" (p. 44).

  • Middle ear effusion (MEE) is not a contraindication to testing and testing should not be delayed due to MEE.

  • If there is not a response to ABR testing at 2000 Hz by air conduction up to equipment limits, the child should be assessed for auditory neuropathy spectrum disorder.

  • Infants with elevated air conduction thresholds, should undergo bone conduction threshold testing with tonal ABR.

  • "In contrast to air conduction thresholds, no correction should be applied to ABR 500 or 2000 Hz ABR bone conduction thresholds in infants" (p. 47).

  • At 500 Hz, only air-bone gaps in excess of 15-20 dB "should be considered clinically significant for middle ear involvement in infants" (p. 48).

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Joint Committee on Infant Hearing

Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs
Joint Committee on Infant Hearing (2007).
Pediatrics, 120(4), 898-921.
Added: July 2012

This consensus-based guideline provides recommendations for screening infants for hearing loss, assessing infants identified as at-risk for hearing impairment, and providing appropriate early intervention for infants with hearing impairment. The intended audience of these guidelines is not specified, however they are relevant to all professionals involved in the screening, assessment or treatment of hearing in infants.


  • Infants who do not pas an ABR screening in the NICU should receive a direct referral to an audiologist for re-screening and, a comprehensive assessment including ABR when indicated.

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Commission for the Early Detection of Hypoacusis (CODEPEH), Spain

Early Hearing Detection and Intervention: 2010 CODEPEH Recommendation
Trinidad-Ramos, G., de Aguilar, V. A., et al. (2010).
Acta Otorrinolaringologica Espanola, 61(1), 69-77.
Added: July 2012

This guideline provides recommendations for early hearing detection and intervention (EHDI) programs. The target audience of this guideline is audiologists and speech-language pathologists. Recommendations are provided in the areas of screening, audiological evaluation, intervention and surveillance.


  • “To confirm a permanent hearing loss in children under 3 years old, it is necessary to have carried out at least one ABR test” (p. 72).

  • Diagnostic confirmation of hearing loss should be based on multiple tests and “should always include ABR, tympanometry, stapedial reflex (using 1000 Hz as a sound carrier), and TEOAE, repeated at least 2 times with a difference of one to 4 weeks” (p. 71).

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NHS Newborn Hearing Screening Programme Clinical Group (UK)

Newborn Hearing Screening and Assessment: Guidelines for the Early Audiological Assessment and Management of Babies Referred from the Newborn Hearing Screening Programme
Stevens, J., Sutton, G., et al. (2011).
England: NHS Newborn Hearing Screening Programme Clinical Group, 41 pages.
Added: July 2012

This consensus-based guideline provides recommendation for the early audiologic assessment of infants referred from the newborn hearing screening program.


  • Tone pip ABR is recommended as “the primary method of measuring hearing threshold except under special circumstances” (p. 9).

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Client/Patient/Caregiver Perspectives

No information was found pertaining to client/patient/caregiver perspectives.

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