Newborn hearing screening is the standard of care in hospitals nationwide. The primary purpose of newborn hearing screening is to identify newborns who are likely to have hearing loss and who require further evaluation. A secondary objective is to identify newborns with medical conditions that can cause late-onset hearing loss and to establish a plan for continued monitoring of their hearing status (Joint Committee on Infant Hearing [JCIH], 2007). The EHDI guidelines include hearing screening completion by 1 month of age, diagnosis of any hearing loss by 3 months of age, hearing aid selection and fitting within 1 month of confirmation of hearing loss if parents choose that option, and entry into early intervention (EI) services by 6 months of age.
In 2014, 96.1% of babies born in the United States had their hearing screened before 1 month of age (Centers for Disease Control and Prevention [CDC], 2016), and 6,163 infants were diagnosed with permanent hearing loss.
Screening programs target permanent childhood hearing loss (PCHL) irrespective of type. However, some protocols are more effective at identifying types and degrees of hearing loss within different populations (i.e., well-baby nursery or neonatal intensive care unit [NICU]).
Passing a screening does not mean that a child has normal hearing across the frequency range. Because minimal and frequency-specific hearing losses are not targeted by newborn hearing screening programs, newborns with these losses may pass a hearing screening. Because these losses have the potential to interfere with the speech, language, and psychoeducational development of children (Yoshinaga-Itano, DeConde Johnson, Carpenter, & Stredler-Brown, 2008), monitoring of hearing, speech, and language milestones throughout childhood is essential.
Audiologists, by virtue of academic degree, clinical training, and license to practice, are qualified to provide guidance, development, implementation, and oversight of newborn hearing screening programs. See ASHA's Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles and responsibilities for audiologists include the following:
As indicated in the Code of Ethics (ASHA, 2016a), audiologists who work in this capacity should be specifically educated and appropriately trained to do so.
Speech-language pathologists (SLPs) who work in birthing hospitals may also be called upon to perform newborn hearing screenings. SLPs play a role in the hearing screening, speech/language/communication assessment, and rehabilitation of individuals with hearing loss and the referral of individuals suspected of having hearing loss to an audiologist. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for SLPs in hearing screening programs for children ages 0-6 months include the following:
As indicated in the Code of Ethics (ASHA, 2016a), SLPs who work in this capacity should be specifically educated and appropriately trained to do so.
Universal newborn hearing screening (UNHS) programs typically include
A state policy of performing screening without obtaining parent/guardian permission, or at least informing parents/guardians about screening, may violate constitutional protections of the parental/guardianship role (Berge, 1992; Clayton, 1992; Fleischman, Post, & Dubler, 1994). Although many hospitals have global consents for all newborn hearing screening procedures, screeners and personnel should be aware of hospital and state regulations regarding parent/guardian refusal.
See the ASHA State-by-State resource for more information.
Various personnel may perform newborn hearing screenings. A screener may be an audiologist, an SLP, a nurse, a paraprofessional, or a trained volunteer. All screeners are trained in, and competent to use, the technology and protocol specific to the screening program. It is important for the screener to have a familiarity with JCIH guidelines, EHDI process, and hospital/clinic protocols, including standard precautions and patient confidentiality standards (ASHA, 2013).
Newborns cared for in the well-baby nursery are screened as close to hospital discharge as possible and prior to 1 month of age. NICU newborns are screened when they are ready for discharge and/or when they are medically stable.
Newborns who have initially passed a hearing screening are rescreened if readmitted to the hospital in the first month of life or if risk factors for hearing loss develop during the infant's hospital stay following the initial screening. State laws and hospital protocols may vary regarding which hospital is responsible for screening newborns who are transferred from one hospital to another.
Screening can be done in a nursery or a quiet room with the infant resting quietly or sleeping. A sound booth is not needed. The preferred method for testing is to have the newborn resting quietly in his/her bassinette – although, if needed, the newborn can be held.
A newborn must pass the screening in both ears during one session for the screening to be considered a "pass." Otherwise, the newborn will be referred for rescreening. If the newborn does not pass in one ear, both ears must be rescreened. If the newborn passes the screening or the rescreening and has no risk factors for late-onset or progressive hearing loss, then the screening is complete. If the newborn passes the screening or the rescreening and has risk factors for late-onset or progressive hearing loss, then it will be very important to monitor the newborn's hearing during early childhood (Harlor & Bower, 2009; JCIH, 2007).
Care should be taken not to screen newborns more times than recommended in the protocol. The probability of an erroneous "pass" outcome (i.e., of infants with hearing loss passing the screening) increases with every screen.
All procedures must ensure the safety of the patient and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse must be carried out according to facility-specific infection control policies and procedures and according to the manufacturer's instructions (Siegel, Rhinehart, Jackson, Chiarello, & Healthcare Infection Control Practices Advisory Committee, 2007).
Auditory brainstem response (ABR) and otoacoustic emissions (OAEs) are appropriate physiologic measures for screening the newborn population. Both are noninvasive and available in automated versions that are easily utilized by trained hospital staff.
Both ABR and OAE technologies will miss delayed-onset hearing loss, mild hearing loss, or hearing loss that is present only at isolated frequencies. Both ABR and OAE responses are affected by outer or middle ear dysfunction. When a transient middle ear condition is present, both technologies will likely result in the newborn not passing the screening. Both OAE and ABR screening reflect physiologic processes within the auditory system and identify hearing loss most accurately from 2kHz to 4kHz.
Automated technologies (those that determine pass/refer) do not require interpretation. Automated screening equipment often has test parameters set by the manufacturer, and, therefore, different equipment may yield different screening results (New York State Department of Health, Early Intervention Program, 2007).
Even if diagnostic (i.e., nonautomated) technology is used, and an audiologist is interpreting the results, procedures in the nursery are limited to screening (pass/refer). Equipment that is used should be calibrated and maintained according to the manufacturer's specifications.
The factors that influence the selection of screening technology include
ABR activity is a direct measurement of the neural response to sound that is generated along the auditory system from the level of the cochlea and through the VIII nerve and pontine-level of the brainstem and that correlates with behavioral hearing measures in the mid- to high-frequency region. The ABR is recorded using surface electrodes that are attached to the infant's head. Click stimuli are presented through insert or muff-style earphones that are worn on both ears. ABR measurements are sensitive to neural auditory disorders (i.e., auditory neuropathy). Auditory neuropathy is a neural hearing loss that leaves cochlear (outer hair cell) function intact. It is more prevalent in the NICU population than in the well-baby nursery population (D'Agostino & Austin, 2004). ABR screening is less sensitive to outer ear debris than OAE screening, resulting in lower referral rates.
Most automated equipment presents click stimuli at 35 dB nHL at a rate of 30-37 clicks per second. If the equipment allows a choice of stimulus levels, the screening program audiologist can adjust to lower click levels.
For automated ABR (AABR), manufacturers use their own proprietary stopping rule, based on a template comparison or statistical algorithms. Most instrumentation does not allow operators to change the stopping rule criteria.
The infant should be asleep or resting quietly for the test and positioned to reduce muscle artifact. The screener visually inspects the outer part of the ear canal to ensure that the canal is clear of debris and places the transducer. Both ears are screened during each session.
OAEs – either transient-evoked OAEs (TEOAEs) or distortion product OAEs (DPOAEs) – are measured using a sensitive probe microphone inserted into the infant's ear canal. OAEs are a direct measure of outer hair cell and cochlear function in response to acoustic stimulation. They yield an indirect estimate of peripheral hearing sensitivity. OAEs are not sensitive to disorders central to the outer hair cells, such as auditory neuropathy. OAEs will be absent when there is outer or middle ear dysfunction or debris/blockage in the ear canal.
TEOAEs use a high-level click, approximately 80 dB pSPL, and a subtraction (sometimes referred to as nonlinear) paradigm to reduce stimulus artifact. DPOAEs use mid-level stimuli (f1 primary = 65 dB SPL and f2 primary = 55 dB SPL).
Many manufacturers program response criteria into the OAE unit. At least three test frequencies – of 2000 Hz, 3000 Hz, and 4000 Hz – are evaluated during the screening. Usually, signal-to-noise ratios (SNRs) of at least 6 dB are used; however, some manufacturers will set their own SNRs. DPOAE SNRs vary, depending on whether mean SNR is calculated or mean plus 1 or 2 standard deviations of noise. In addition, a minimum absolute DPOAE level of 5 dB SPL is imposed.
The infant should be asleep or resting quietly for the test and positioned to reduce muscle artifact. A snug probe fit is essential for valid and reliable recordings. Ears should be screened one at a time, with the infant placed on his/her side and the ear being screened facing up. The screener visually inspects the outer part of the ear canal to ensure that the canal is patent and clear of debris. Prior to insertion of the probe, a gentle massage of the area below the tragus helps to open a collapsed canal or dislodge debris that may be blocking the canal.
In OAE screenings, the stimulus level is calibrated in each ear according to the manufacturer's specifications. After stimulus-level requirements have been met, OAEs are collected to meet stopping criteria. If OAEs do not appear to be present, the probe is taken out and inspected to determine if the probe is blocked with cerumen or vernix. A blocked probe should be cleaned and reinserted, and the screening should be repeated.
Screening protocols can be broadly classified into four different categories:
The choice of protocol for a newborn hearing screening program is based on the specific needs of the population (i.e., well-baby nursery or NICU) and requirements of the state or hospital program.
ABR can be used in both the NICU and the well-baby nursery. The rationale for an "ABR-only" protocol is that both neural and cochlear hearing losses will be detected using one type of technology. ABR screening is recommended by the JCIH (2007) for newborns cared for in the NICU for more than 5 days because they are at greater risk for neural hearing loss.
Consider the following factors when using an ABR-only screening approach:
Otoacoustic emissions – either transient-evoked OAEs (TEOAEs) or distortion product OAEs (DPOAEs) – are recommended for use in well-baby nurseries. Because OAEs are sensitive to outer ear debris and middle ear fluid that may be present at birth, most OAE screening protocols involve an outpatient rescreening of those newborns who do not pass the screening at hospital discharge.
Consider the following factors when using an OAE-only screening approach:
To provide options for newborn hearing screening and to reduce overall program costs, a two-tier screening approach can be used. In this approach, OAE screening is completed on both ears first, followed in the same session by an ABR only for those newborns who do not pass the OAE screening. Each ear must pass the OAE screening to be considered a "pass." If the OAE screening is not passed in one or both ears, an ABR screening test is performed. If the infant passes the ABR, the baby has "passed" the hearing screening. If one or both ears do not pass the ABR, the infant is referred for outpatient diagnostic testing.
The rationale behind a two-tier approach is that OAEs have lower disposables cost and are faster to perform than ABR. However, OAEs have a higher refer rate than ABR. Conducting an OAE screening first reduces the number of newborns who require an ABR screening.
Consider the following factors when using a two-tier screening approach:
In a two-technology protocol, newborns must pass both an OAE screening and an ABR screening. Both ears are tested with ABR and OAEs, and each ear must pass both tests to be considered a "pass." Although pass/refer rates are available for this protocol in the NICU (Berg, Spitzer, Towers, Bartosiewicz, & Diamond, 2005) and in the well-baby nursery (Berg et al., 2011), no sensitivity or specificity data are available.
If a newborn does not pass the screening for one or both technologies, he/she can be rescreened with that technology (or technologies) one time only: either before hospital discharge or in an outpatient setting. If the newborn does not pass one or both of the second screenings in one or both ears, the newborn is referred for outpatient diagnostic testing.
Consider the following factors when using a two-technology screening approach:
The American Academy of Pediatrics (AAP) recommends that every newborn have a medical home to provide coordinated, comprehensive, primary care that is accessible and family centered. The medical home plays a key role in supporting EHDI systems and detecting late-onset hearing loss (Mehl & Esquivel, 2016). Although initial newborn hearing screenings are not typically conducted in the medical home, the JCIH recommends that the pediatric primary care provider regularly monitor all infants and children for hearing loss and communication development in the medical home (JCIH, 2007). This allows for the identification of children with either missed newborn, late-onset, or progressive hearing loss, regardless of the presence or absence of high-risk indicators at birth. The onset of hearing loss can occur at any time in a child's life. Developmental milestones, hearing skills, and speech and language milestones should be monitored in all children, consistent with the Bright Futures/AAP periodicity schedule [PDF]. See the Childhood Hearing Screening Practice Portal page for more information on this topic.
Newborn hearing screening documentation requirements are based on hospital and state mandates or protocols and can include the recording of screening results into the medical record, electronic health record, birth certificate, discharge summary, or state EHDI data system. In addition, screening results must be provided to the family and the newborn's physician. Patient records must be in full compliance with the Health Insurance Portability and Accountability Act (HIPAA, 1996).
Documentation of newborn hearing screening typically includes
Collecting parent/guardian and pediatrician contact information is critical in the effort to prevent loss to follow-up, especially for those newborns who do not pass the screening. To track newborn screenings effectively, states stipulate which information will be reported to the appropriate government agency (e.g., state EHDI program). See the ASHA State-by-State resource for a summary of requirements.
Providing appropriate counseling and education is an important part of the newborn hearing screening process.
Parent/guardian education regarding newborn hearing screening begins before an infant is screened. If information about the screening process is provided only after a mother is admitted to the hospital to deliver her child, she may not have the level of concentration needed to consider the information being presented. Educational materials can be included in patient education packets, as part of hospital prenatal education programs, and in public health clinic outreach programs. Materials should be written in plain language, culturally appropriate, and available in the preferred language of the family. Information should also be conveyed orally in the preferred language of the parents/guardians.
Educational materials typically include information on
Where possible, audiologists are the professionals who communicate with the family when an infant has not passed a hearing screening. When an audiologist is not available to convey results, other qualified individuals (e.g., SLPs, nurses, technicians, physicians) must be available to provide and explain screening outcomes.
When communicating screening results, consider that
If an infant is referred for further testing, the audiologist provides the information in such a way that the family feels supported yet clearly understands the importance of following up with further audiologic testing. If follow-up is needed, families should receive
Families of newborns who pass the hearing screening should be counseled about the need for ongoing surveillance and periodic monitoring.
In general, a baby who does not complete the recommended diagnostic or intervention process is designated as "lost to follow-up" (LTF). " Lost to documentation" (LTD) designates those infants who did not pass their hearing screening and whose diagnostic or intervention status has not been reported to the EHDI program.
There has been a slow but steady decline in the U.S. LTF/LTD rates. In 2014, 34.4% of the infants who did not pass their final newborn hearing screening did not complete follow-up and were categorized as LTF/LTD (CDC, 2016).
Populations at particular risk for LTF include infants born in home births, border babies (babies who live in one state but are born in another), and babies born in one hospital and transferred to another. The medical home plays a major role in the care of infants who do not pass or do not receive a newborn hearing screening by helping families understand the EHDI process and encouraging prompt follow-up. The medical home can ensure that appropriate and timely steps are taken to identify children who are deaf/hard of hearing through rescreening and referrals for diagnostic evaluations and early intervention services (CDC, 2015; Mehl & Esquivel, 2016).
The National Initiative for Children's Healthcare Quality (NICHQ) identified several strategies to decrease loss to follow-up for infants who do not pass their hearing screening, including the following:
There are ongoing efforts to improve EHDI systems so that babies who do not pass their newborn hearing screening are not LTF or LTD.
These efforts may include the following:
Various quality indicators and benchmarks can be used to evaluate quality assurance and performance relative to screening and diagnosis, including the following (JCIH, 2007):
Other quality assurance indicators may include
States can also evaluate their programs as they report the statewide findings to the CDC. CDC data collection includes the number of
Privacy regulations – including HIPAA, Family Education Rights and Privacy Act (FERPA), Part C Privacy Regulations (Individuals with Disabilities Education Act [IDEA]), and state privacy reporting laws – may affect the sharing of information among service providers. Audiologists and other EHDI stakeholders must understand and abide by these regulations and develop procedures to ensure that information is shared in a timely way to avoid LTF. See the National Center for Hearing Assessment and Management (NCHAM, 2008) white paper, Impact of Privacy Regulations [PDF]. Regardless of whether or not a consent form is required, a parent/guardian signature can be used to document that the family has been informed of the screening results and next steps. Audiologists are responsible for understanding how privacy laws are interpreted in their specific states or programs.
All 50 states and the District of Columbia have EHDI programs established either by law or by voluntary compliance. See the ASHA State-by-State resource for more information.
Newborn hearing screening funding varies from state to state. States procure funds from fees, Medicaid, the Title V Maternal and Child Health Block Grant program, and state general revenues. The trend is to identify funding sources other than grants to ensure program continuity should grant support become unavailable. Costs associated with newborn hearing screening include those associated with the tests (equipment, disposables, staff time) and those associated with program management (data entry, data analysis, follow-up activities, outcomes monitoring).
Through the EPSDT program, a set of services and benefits are mandated for all individuals under age 21 years who are enrolled in Medicaid. Federal rules encourage partnerships between state Medicaid and Title V agencies to ensure better access to and receipt of the full range of screening, diagnostic, and treatment services. EPSDT funds are an appropriate reimbursement source for screening and diagnostic services.
There are a number of CPT codes used to describe early hearing detection testing to a payer. Codes are defined by the payer or program. For specific instructions, see NCHAM State Contacts.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
Alexander, D., & Van Dyck, P. C. (2006). A vision of the future of newborn screening. Pediatrics, 117(Suppl. 3), S350-S354.
American Academy of Pediatrics. (2017). Early Hearing Detection and Intervention (EHDI). Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/PEHDIC/pages/early-hearing-detection-and-intervention.aspx
American Speech-Language-Hearing Association. (2016a).Code of ethics [Ethics]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of practice]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2018).Scope of practice in audiology [Scope of practice]. Available from www.asha.org/policy/.
Berg, A. L., Prieve, B. A., Serpanos, Y. C., & Wheaton, M. A. (2011). Hearing screening in a well-infant nursery: Profile of automated ABR-fail/OAE-pass. Pediatrics, 27, 269-275.
Berg, A. L, Spitzer, J. B., Towers, H. M., Bartosiewicz, C., & Diamond, B. E. (2005). Newborn hearing screening in the NICU: Profile of failed auditory brainstem response/passed otoacoustic emission. Pediatrics, 116, 933-938.
Berge, P.H. (1992). Setting limits on involuntary HIV antibody testing under Rule 35 and state independent medical examination statuses. Florida Law Review, 44, 767-805.
Centers for Disease Control and Prevention. (2015). Doctors and infant hearing. Retrieved from https://www.cdc.gov/features/infant-hearing/
Centers for Disease Control and Prevention. (2016). Summary of 2014 national EHDI data. Retrieved from https://www.cdc.gov/ncbddd/hearingloss/ehdi-data2014.html
Clayton, E. W. (1992). Issues in state newborn screening programs. Pediatrics, 90, 641-646.
D'Agostino, J. A., & Austin, L. (2004). Auditory neuropathy: A potentially under-recognized neonatal intensive care unit sequela. Advanced Neonatal Care, 4, 344-353.
Fleischman, A. R., Post, L. F., & Dubler, N. N. (1994). Mandatory newborn screening for human immunodeficiency virus. Bulletin of the New York Academy of Medicine, 71, 4-17.
Harlor, Jr., A. D. B., & Bower, C. (2009). Hearing assessment in infants and children: Recommendations beyond neonatal screening. Pediatrics, 124, 1252-1263.
Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1938 (1996).
Health Resources and Services Administration. (2009). Enhancing communication: Improving care for infants with hearing loss. Washington, DC: U.S. Department of Health and Human Services.
Johnson, J., White, K., Widen, J., Gravel, J., James, M., Kennalley, T., . . . Holstrum, J. (2005). A multicenter evaluation of how many infants with permanent hearing loss pass a two-stage otoacoustic emissions/automated auditory brainstem response newborn hearing screening protocol. Pediatrics, 116, 663-672.
Joint Committee on Infant Hearing. (2007). Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics, 120, 898-921.
Kirkim, G., Serbetcioglu, B., Erdag, T. K., & Ceryan, K. (2008). The frequency of auditory neuropathy detected by universal newborn hearing screening program. International Journal of Pediatric Otorhinolaryngology, 72, 1461-1469.
Mehl, A., & Esquivel, M. (2016). Medical home & EHDI: The importance of appropriate & timely screening, diagnosis, management, & follow up. In L. R. Schmeltz (Ed.), The NCHAM eBook: A resource guide for early hearing detection and intervention. Retrieved from http://infanthearing.org/ehdi-ebook/2016_ebook/7%20Chapter7MedicalHome2016.pdf [PDF]
National Center for Hearing Assessment and Management (NCHAM). (2008, May). The impact of privacy regulations: How EHDI, Part C, & health providers can ensure that children & families get needed services. Retrieved from https://www.infanthearing.org/coordinator_orientation/section13/45_privacy_regs.pdf [PDF]
New York State Department of Health, Early Intervention Program. (2007). 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 Pub. No. 4967]. Albany, NY: Author.
Russ, S. A., Hanna, D., DesGeorges, J., & Forsman, I. (2010). Improving follow-up to newborn hearing screening: A learning-collaborative experience. Pediatrics, 126, S59-S69.
Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2007). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from https://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
Turchetta, R., Orlando, M. P., Cammeresi, M. G., Altissimi, G., Celani, T., Mazzei, F., . . . Cianfrone, G. (2012). Modifications of auditory brainstem responses (ABR): Observations in full-term and pre-term newborns. The Journal of Maternal-Fetal & Neonatal Medicine, 8, 1342-1347. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22122007
Vohr, B. R., Oh, W., Stewart, E. J., Bentkover, J. D., Gabbard, S., Lemons, J., . . . Pye, R. (2001). Comparison of costs and referral rates of 3 universal newborn hearing screening protocols. Journal of Pediatrics, 139, 238-244.
Yoshinaga-Itano, C., DeConde Johnson, C., Carpenter, K., & Stredler Brown, A. (2008). Outcomes of children with mild bilateral hearing loss and unilateral hearing loss. Seminars in Hearing, 29, 96-211.
Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Newborn Hearing Screening page:
In addition, ASHA thanks the members of the Newborn Hearing Screening Working Group whose work was foundational to the development of this content. Members of the working group included Beth Prieve (chair), Kathryn Beauchaine, Diane Sabo, Anne Marie Tharpe, and Anne Oyler (ex officio). ASHA Vice Presidents for Professional Practices in Audiology Jaynee Handelsman (2010-2012) and Donna Fisher Smiley (2013-2015) served as the monitoring officers.
ASHA also thanks the members of the Working Group on Loss to Follow-Up whose work was foundational to the development of this content. Members of the working group included Anne Marie Tharpe (chair), John Eichwald, Janet Farrell, Jeffrey Hoffman, Meredith Isola, Patti Martin, Amy M. Robbins, Lynn Spivak, Susan Wiley, and Pam Mason (ex officio). Gwendolyn D. Wilson, ASHA vice president for audiology practice (2007-2009), served as monitoring officer.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d). Newborn Hearing Screening. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Newborn-Hearing-Screening/.