The National Center for Evidence-Based Practice
in Communication Disorders
Home      PCHL-Assessment-Audiologic-Otoacoustic-Emissions

Permanent Childhood Hearing Loss
Audiologic Assessment

Otoacoustic Emissions (OAE) 


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).

OAEs should be incorporated as part of the audiologic test battery. However some limitations are noted, specifically:
  • OAE results will not yield information regarding the degree and configuration of hearing loss.

  • Lack of emissions does not verify that permanent hearing loss is present.

  • OAE test results alone will not identify children with hearing loss due to auditory neuropathy.

  • Middle ear pathology, environmental noise and other factors may affect OAE results (Level C Evidence).

  • “It is recommended that the decision to perform a cochlear implant not be based solely on the results of the behavioral audiogram or electrophysiologic studies” (Level D2 Evidence) (p. 161).

» See full summary and quality ratings

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. 
Added: July 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).

  • “OAEs… display results in impaired and normal-hearing populations. Although their sensitivity and specificity can be improved with different analysis tools, they remain useful only in the hearing screening stage and in identifying children with auditory neuropathy. OAEs are totally inadequate, however, in the diagnosis of profound deafness, as they are not able to discriminate an infant with moderate, severe, or profound deafness” (p. 129).

» See full summary and quality ratings

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).

  • OAEs are not a direct measure of hearing but instead evaluate cochlear/outer hair cell function. "OAEs provide information about the status of auditory periphery and, in the absence of middle ear disorder, the likelihood of sensory hearing loss" (p. 30).

  • As part of a pediatric audiologic test battery, OAEs can help predict auditory sensitivity and provide information to determine the site of the auditory disorder or establish the type and degree of hearing loss.

  • OAEs may also provide a physiologic confirmation or crosscheck of findings from behavioral testing.

  • "TEOAEs are most effective in separating normal ears from non-normal ears in the region of 2000 to 4000 Hz, with slightly poorer separation at 1000 Hz" (p. 33).

  • "DPOAEs are most effective in separating normal from non-normal ears in the region of 1500 to 6000 Hz" (p. 34). Somewhat poorer identification is noted at 1000 Hz or less and at 8000 Hz.

» See full summary and quality ratings

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.

  • For infants birth through a developmental age of 6 months, the test battery should include:

    • Child and family history including an assessment of risk factors and parental reports of the infant’s response to sounds

    • Frequency-specific ABR with air-conduced bursts and bone-conducted bursts as needed

    • Click-evoked ABR

    • OAEs (transient evoked or distortion product)

    • 1000 Hz tympanometry

    • Clinical observations of the infant’s auditory behavior.

  • For children with a developmental age between 6 and 36 months, the test battery should include:

    • Child and family history including information on the child’s attainment of communication milestones and parental report of the child’s auditory and visual behaviors

    • Behavioral audiometry (visual reinforcement or conditioned–play audiometry) consisting of pure tones across the frequency range as well as speech detection and speech recognition measures

    • OAE

    • Tympanometry and acoustic reflex thresholds

    • If reliable responses cannot be obtained through behavioral audiometry, the child should receive an ABR.

» See full summary and quality ratings

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.

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).

» See full summary and quality ratings

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.


  • An audiologic assessment should include the following:

    • OAEs

    • Air conduction tone pip ABR

    • Bone conduction ABR

    • ASSR

    • Tympanometry – A high frequency probe tone of 1 kHz should always be used for babies less than 6 months of age.

    • Reactions to stimuli

  • Some requirements for newborn audiologic assessment include:

    • “Equipment to carry out ABR threshold measurement using tone pips and clicks by both air and bone conduction” (p. 7)

    • Staff with expertise and the “ability to accurately interpret ABR waveforms, to accurately determine thresholds (including when and how to use masking) and to know how to deal with unusual or unexpected waveforms or results. Expertise should also include measurement of cochlear microphonics, otoacoustic emissions and tympanometry in babies” (p. 7).

    • A quiet environment, usually a sound-treated/proofed room.

» See full summary and quality ratings

Client/Patient/Caregiver Perspectives

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



Use the images below to navigate to other sections of the Permanent Childhood Hearing Loss evidence map.