Ask the Expert – What To Do if Your Baby “Refers” on Newborn Hearing Screen

My baby failed the hearing screening so she is deaf, right?

This Ask the Expert article is a follow up to “Screening Newborns for Hearing Loss,” by Dr. Kirstin Chiasson. See that original article for a description of the newborn screening process, and for her amazing credentials.

Newborn undergoing screening (cutie-pie!)


Newborn undergoing screening (cutie-pie!)




Her follow up article, here, describes the next step if your baby “refers” on that newborn screen:

Guest Article by Dr. Kirstin Chiasson

Screening is a way to find babies who are at risk of hearing loss without doing a complete hearing test on every baby. Screenings only have two outcomes, a “pass” (low risk of hearing loss) or a “refer” (risk of hearing loss).

Hearing screenings are very accurate, but not 100% perfect.

There will be some babies who “referred” on the screening but who turn out to have normal hearing.

If you baby is “referred” based on their newborn hearing screening, you need to schedule a follow up hearing evaluation.

The goal of the first hearing evaluation appointment is to find out which babies referred on the hearing screening but have normal hearing, and which babies referred on the hearing screening and really have hearing loss.

How do you test my baby’s hearing? He can’t even sit up by himself!

Testing for hearing loss from the age of newborn to 6 months (or until the baby can hold his or her head up without help from mom or dad) is done by checking different parts of the hearing system anatomy, and determining if each part is working.

The hearing system is made up of the outer ear, the middle ear, the inner ear, and the hearing nerve.

Anatomy of the Ear

Anatomy of the Ear

The Outer and Middle Ear

The first part of the hearing system is the outer ear. The audiologist will use a magnified light (otoscope) to look into the ear canal. Looking “in the ear” allows the audiologist to determine if the ear canal and the ear drum (tympanic membrane) look normal.

There are three bones (ossicles) behind the ear drum that lead to the inner ear. [The audiologist cannot actually see these ossicles.]

However, the ossicles have to be able to vibrate so that sound can be carried from the air into the inner ear. A tympanometer is used to check the vibration of the ear drum and the three little bones. A small rubber tip is placed in the baby’s ear. A tone is played into the ear canal. A microphone reads how much of the tone bounces off the ear drum. This test evaluates the ability of sound to move from the ear canal to the inner ear. If there is a problem with the ear canal, the ear drum, or the three bones, there may be a hearing loss. This kind of hearing loss is called “conductive.” Conductive hearing loss can often be fixed by surgery.

Examples of Conductive Hearing Loss:

  • An example of a conductive hearing loss can result from too much wax (cerumen) in the external ear canal.
  • Another example results from fluid accumulation in the middle ear space, behind the ear drum – this is the typical temporary hearing loss common in children with recurrent or chronic ear infections.

The Inner Ear and Hearing Nerve

The outer and middle ear help the sound get from the air to the inner ear. The inner ear codes the sound for pitch and loudness. After the inner ear codes the sound, the hearing nerve sends the code up to the brain.

There are several different ways to check the inner ear and the hearing nerve.

Otoacoustic Emissions Testing (OAE)

When sound is played and is sent up to the brain, the brain tells the inner ear to listen more carefully. When the inner ear takes action and listens more carefully, a different sound, or echo, is actually created by the ear. This sound echo that is created by the ear is called an otoacoustic emission. OAE’s can be detected by very sensitive microphones.

Otoacoustic emissions testing is done by placing a small tip in the ear canal that has a speaker and a microphone. The speaker plays a tone or group of tones, and then the microphone measures the sound that the inner ear makes when it takes action to listen carefully. If we are able to record otoacoustic emissions, that tells us that the inner ear is probably coding sound the way it should.

Auditory Evoked Potential, or Auditory Brainstem Response (ABR)

The auditory evoked potential has many names and abbreviations. The most common is the auditory brainstem response, or ABR.

This test is like an EKG of the hearing signal as it moves through the hearing system to the brain. Small silver electrodes are taped behind the baby’s ears and on the baby’s forehead. A small speaker is placed in the baby’s ear and a clicking sound is played. When the hearing nerve fires it puts off electricity. The ABR is a measure of the electricity that the hearing nerve puts off each time a click is played to the ear. The audiologist will determine if the hearing nerve is responding to the click at a normal loudness.

If the inner ear or the hearing nerve is not working there may be a hearing loss. This type of hearing loss is called “sensorineural hearing loss,” and typically cannot be fixed with surgery. There are many potential causes of sensorineural hearing loss, all rare.

What Happens If My Baby Doesn’t Have a Normal Hearing Test?

If your baby does have hearing loss, your audiologist and otolaryngologist (ENT doc) will work with you and your family to make sure that your baby has as much access to communication as possible.

Note that sensorineural hearing loss can range from very mild – barely detectable – to profound deafness (rare). So don’t freak out if you are told that your baby has hearing loss. It will be difficult, but try to listen to the rest of what the audiologist and ENT doc are saying.

Your audiologist will help you assemble a team of professionals who are focused on your baby’s communication.  The team will include an ear nose throat (ENT) doctor, a speech language pathologist, an early intervention specialist, your baby’s primary care doctor, and possibly a genetics or family counselor. Each member of the team will help you manage your child’s individual needs.

The genetics counselor can provide a good idea of whether your baby’s hearing loss is inherited and, if so, what the chances are that you may have other children with similar hearing loss.

The thing to remember is this: the goal is for your baby to grow up having normal ability to communicate, normal speech and language.

Special thanks to Dr. Chiasson for contributing. The next installment on this topic will review some of the most common misconceptions about hearing loss in children. Stay tuned.



Image Credit for Newborn Screening Pic:

Review of “Newborn Hearing Screening” by A. M DeMichele, PhD, on eMedicine:


Hi, I’m Russell Faust, author of this medical education blog.

Russell Faust, PhD, MD boogordoctor

Russell Faust

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  1. My daughter failed her hearing screening in June 2011 and then was found to have hearing within normal limits by an audiologist following a complete audiological evaluation. She just received another hearing screening at pediatrician today (3/2012) and again failed in both ears. We have another audiological evaluation set for Monday. How can a child fail the screen bilaterally and be found to have normal hearing? There doesn’t seem to be much reliability in this screening.
    Thank you for any information.

    • Russell A. Faust, PhD, MD says:

      Hi Liz,
      GREAT question, and I agree with your observation. The thing to keep in mind about hearing screens, or ANY hearing test, is that they reflect a “snap-shot” in time. That is, they only reflect the hearing at the time they are done. A normal result today does not tell us anything about the level of hearing yesterday, or what it may be tomorrow or next week. And, in children especially, hearing can fluctuate significantly over just a few days. That happens due to eustachian tube dysfunction, fluctuation in fluid in the middle ear, etc. Don’t be too discouraged by the hearing screen.
      Thanks for visiting and for sharing.

  2. My baby failed here hearing test when she was born, a third test was done today (she is 15 weeks) and it was detected that the problem is in the middle, she has no problem with her inner ear or drums, she was referred to an ENT and go back in 3 months to do the test again. I know that I should feel happy that she is not completely deaf, but I am at loss and fear for her future. She was born via C-section and the specialist think It can be fluid or wax, but only time will tell.

    Has anyone go through this?



    • Russell A. Faust, PhD, MD says:

      Hi Sonia,
      I’m hoping that other mothers who have been through a similar experience will reply to you here. I think that it’s a wonder more newborns don’t have fluid in the middle ear causing temporary conductive hearing loss. The majority of babies with what you describe resolve this without any help from us – no medicine, no surgery. It is appropriate to follow up with your ENT doc to be sure that the problem resolves.

  3. Hi,
    My baby just passed OAE test(she is 8 days only) and the guy said the right ear is not response as well as left ear. I have data report and asked me to show the report to Dr.
    Her Dr is on trip so I wanted to get help from you.
    Why right ear is not same left? which parameter in report is key parameter?

    Many thanks.

    • Russell A. Faust, PhD, MD says:

      Hi Mehdi,
      I’m sorry, but I am not the person to ask about the details of your baby’s OAE test – your questions are best directed to your pediatrician. If they cannot answer your questions, you might request a referral to a pediatric otolaryngologist. PEDIATRIC otolaryngologist; or pediatric audiologist.
      Thank you for your confidence in me, and for visiting. Please keep me updated.

  4. My baby failed all screening tests, including sedated ABR. He had no response at all in the right ear at 500 he. What does that mean? I could also tell he couldn’t hear on his left until 65 db. What can you tell me with that info? The dr that tested was not help and refer us to someone else (who we are waiting to see). Only said he did poorly. Very scientific term…sigh

    • Russell A. Faust, PhD, MD says:

      Hi Silvana:
      I’m so sorry to hear that there are so many doctors who avoid educating their patients. There’s no excuse for that!

      The answer to your question is complicated, and I can’t even give you a vague answer without knowing a detailed family history, prenatal history, perinatal history, as well as exam of your baby. I’m sorry, but you should have access to some very qualified experts in the Richmond area who can help you understand what is going on. And if not there, some of the very best ENT docs in the world are just down the road in Charlottesville at the UVA. They are true experts in hearing.

      Please return here after your visit and let me know what happens, how they treat you, and what you learn.
      Thank you for sharing, and best success with your little one!

  5. Thanks for your reply. There is no family history of hearing loss in either side. I had a very healthy pregnancy. I’m fit and only gained 23lbs. He was bor at 6lbs 4 oz. neither of us have any health issues. I just turned 34. He reacts to loud sounds e.x. Our dog barking. We are going to see someone Monday at VCU but the wait it’s torture. If you can tell me anythitn at all, I appreciate it. I do understand you might not be able to. I’ll update you next week, if that’s the case. Thank you!

    • Russell A. Faust, PhD, MD says:

      Hi Silvana:
      You should have some better idea of what is going on by now. I hope it’s good news, or that you at least have a better sense of what to expect.
      Thank you for visiting, and for sharing.

  6. Hi,
    Our daughter has turned 3 weeks today and has failed 2 screening tests. We have an appointment with the audiologist in two weeks. I banged some pots together while she was sleeping and she startled and woke up. I was the other side of the room and she couldn’t see me. There is no history of deafness on either side, baby was born normally, a week overdue. We have two other girls with normal hearing and my wife wasn’t ill at all during her pregnancy. I guess we will find out in two weeks when we have an ABR test but we are stressing out!
    What is the worst case scenario? Is the worst case scenario that baby is profoundly deaf in both ears and could be fitted with cochlear implants? Or could there be a scenario where they can’t do anything to help her?

    • Russell A. Faust, PhD, MD says:

      Hi Ben:
      Sorry that I didn’t get to your comment earlier.
      I hope you have good news by now.
      Thank you for visiting and for sharing.
      Please let me know how things go for your tiny little girl.

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