Evaluating Hearing in Infants and Small Children
Michelle R. Petrak, Ph.D. CCC-A
I n the past several years, consider-
able data has been obtained sup-
porting the need for newborn and
infant hearing screening while
emphasizing the benefits of early
intervention for very young children
with hearing impairments (1,2.
Yoshinaga-Itano, 1995, Yoshinaga-
Itano et al 1998). According to the
National Institutes of Health (NIH),
otoacoustic emissions (OAE) and
auditory brainstem response (ABR)
testing are recommended for infant
hearing screenings (3. NIH, 1993).
The primary objective of infant
screening is to obtain reliable, ear-
specific and frequency-specific
information on auditory function, as
quickly as possible (4. Bachmann,
1998). Once hearing loss is con-
firmed, the audiologist must assess
the type and degree of hearing loss,
the needs of the child and the family
and the appropriate rehabilitation
instruments and strategies so inter-
vention can begin as quickly as pos-
sible.
ABR, when applied to newborns
and very young children, is a reliable
tool for approximating hearing
thresholds and audiometric configu-
rations. (5. Oates et al, 1998). The
use of ototoxic drugs, oxygenation
and ventilation procedures, as well as
the incidence of bilirubin problems,
and other abnormalities in newborns
has helped force the rebirth of the
ABR. ABR is the “gold standard” in
the demonstration of hearing abnor-
malities in infants.
It is well accepted that the most
reliable measurement of hearing in
children is conventional audiometry.
Techniques such as visual reinforce-
ment audiometry (VRA) are avail-
able and are very successful assess-
ment tools for children 6 months of
age and older. However, in the first
few months of life, behavioral
audiometry tests are unreliable. This
is why audiologists rely more on
physiological tests to determine hear-
ing sensitivity in newborns and very
young children.
For many audiologists, ABR test
protocols for the adult population are
well known and accepted. However,
when addressing infants, protocols
and practices need to be revised.
Eventually, standardized infant pro-
tocols will be developed and will
become widely accepted. This paper
reviews some basic issues and meth-
ods related to recording auditory
responses using ABR and other audi-
tory evoked potentials in newborns
and infants.
Auditory Brainstem
Response Testing
ABR is not a hearing test. ABR is
a measure of synchronized nerve fir-
ing along the auditory brainstem
pathways in response to auditory
stimuli. ABR is essentially unaffect-
ed by the state of consciousness and
responses can be recorded at or near
auditory threshold. ABR can identify
and quantify hearing loss in infants
and other patients unable or unwill-
ing to participate in behavioral test-
ing. Importantly, information
obtained from ABR can be used
to select hearing aids and to prelimi-
narily set their electroacoustic
parameters.
I. Electrodes and Electrode
Application
It is important to select electrodes
designed specifically for infants.
There are a variety of smaller elec-
trodes designed for use with infants.
Sterile electrodes are necessary.
Types of electrodes:
a. Disposable electrodes and leads.
These provide the safest connection.
They are used once and then the
entire unit is disposed of.
b. Disposable electrodes with
reusable leads. The electrodes are
individually packaged to provide
sterility. After use, the electrode is
disposed of and the lead wire must be
re-sterilized.
c. Reusable electrodes and leads.
These are completely reusable; there
is nothing to dispose of. Both the
electrode and the lead are re-steril-
ized after each use.
The infant’s skin should be carefully
and gently abraded before the elec-
6/2001
trodes are applied. The impedances
should be less than 5000 ohms. A sin-
gle channel recording is acceptable.
Contralateral recordings in infants
can be considerably different than
ipsilateral recordings and hence com-
parisons are not always useful.
(Edwards, 1985)
a. The negative electrode is connect-
ed to the nape of the neck or ipsilat-
eral earlobe or mastoid.
b. The positive electrode is connect-
ed to the high forehead as near to Cz
as possible.
c. The common electrode is connect-
ed to the forehead (vertical mon-
tage). Some research findings sug-
gest the nape of the neck provides a
larger wave V response than does the
ear/mastoid location (King and
Sininger, 1992). If wave I is required
for neurodiagnostic procedures, a
horizontal montage is recommended.
II. Transducers:
a. Insert Earphones
(a.k.a. “inserts”)
Inserts have several advantages
including disposable neonatal
eartips, reduced stimulus artifact,
decreased background noise, less
chance of crossover, higher interaur-
al attenuation, decreased likelihood
of collapsed canals, increased com-
fort, and smaller tubing with a better
chance of fitting an infants ear. A cor-
rection factor is needed to account
for the length of the tubing and the
associated acoustic delay. The cor-
rection factor is usually 0.9 ms and
most manufacturers of ABR equip-
ment automatically account for this
difference.
b. Headphones
Typical TDH-49 headphones are
still available with most ABR sys-
tems. Headphones are calibrated sep-
arately from the insert earphones.
When testing infants and small chil-
dren, the size of the headphones can
be a barrier. It is often necessary to
remove the headphone cups from the
headband and hold them (the cup
portion) to the baby’s ear. It is also
important to insure that the receiver
is lined up with the ear canal.
Newborn ears are also prone to col-
lapse from pressure applied from the
earphone.
c. Bone Conduction
A conductive hearing loss can be
effectively ruled out by performing
ABR using a standard B-70 bone
conductor (BC). Importantly, the B-
70 oscillator used for standard BC
testing must be recalibrated for ABR
use. Clinically, the two cannot be
interchanged. The accuracy of bone
conducted responses is dependent on
proper pressure applied to the bone
conductor, proper calibration of the
bone conduction oscillator for ABR
purposes, and optimal anatomic
placement. It is good practice to
apply pressure to the bone conductor
using a single finger, when testing an
infant (Bachman and Hall, 1998).
The best placement appears to be the
mastoid (Yang et al, 1987). Bone
conduction ABRs can be obtained
with either click or tonal stimuli.
Normative data collection is high-
ly recommended to assure that bone
conducted ABRs have a well estab-
lished and constant relationship to
traditional, air conduction derived
audiometric thresholds.
Stimuli
a. Clicks
A click stimulus is an electrical
impulse, typically 100 microseconds
in duration. The click is a broadband
signal containing a wide range of fre-
quencies in its spectral presentation.
Importantly, the click demonstrates
the highest energy in the frequency
range from 2 kHz – 4KHz. An ABR
generated with a click can be ade-
quate for screening hearing, but it
cannot provide frequency specific
information across the entire speech
region, which is necessary for proper
hearing aid fittings.
b. Tone Burst
Gating an ongoing electrical sig-
nal through an electronic switch or
some other type of modulation tech-
nique generates a tone burst. The
stimulus rise time reacts with the fre-
quency in a complicated way (see
ramp and plateau). Responses to tone
bursts provide relatively accurate
estimates of auditory sensitivity and
can accurately predict the audio-
gram. Ideally, a tone burst concen-
trates energy at a single pure-tone
frequency. This causes activation of
the basilar membrane of the cochlea
that is sensitive to that specific fre-
quency. A pitfall of tone bursts is that
a stimulus with a very brief onset
may produce spectral splatter in and
around unwanted frequencies.
Several types of masking and enve-
lope patterns are used to reduce spec-
tral splattering caused by tone bursts
and hence concentrate on specific
tonal regions of the cochlea. A 500
Hz tone burst produces a response
with a much different morphology
compared to a click response. The
tone burst produces a broad wave V
without readily defined peaks.
III. Stimulus Parameters
a. Rate
Repetition rate is a significant
parameter variable. Site of lesion
studies are usually obtained with
slow repetition rates of 20 pulses per
second, or less. Slower repetition
rates tend to preserve waveform mor-
phology. As rate is increased, wave-
form morphology becomes poorer. It
is also important to assure that an
adequate interstimulus interval is
chosen. Even though slower rates
provide better morphology, faster
repetition rates can be used to expe-
dite threshold testing. Infants can
easily be screened using rates up to
39.1 clicks/sec. Nonetheless, it is
often useful to reduce the presenta-
tion rate when approaching thresh-
old. Odd number stimulus rates are
advisable to reduce interference with
60 Hz electrical noise.
b. Ramp, Plateau and
Duration
With tone bursts, frequency and
duration can be controlled separately.
Higher frequencies can rise from
zero to maximum amplitude in a very
brief time period because the dura-
tion of their cycles is shorter. Lower
frequencies require longer rise times.
A very brief rise time causes stimulus
energy to spread to frequencies on
both sides of the intended signal.
Since the rise time, however speci-
fied, interacts with the stimulus fre-
quency and spectral dispersion, some
uncertainty about point of stimula-
tion in the cochlea accompanies the
use of tone bursts. A Blackman ramp
helps maximize synchrony and mini-
mize spectral splatter. This type of
window works best without a
plateau, such as a ramp 2-0-2 setting,
which has a rise and fall time of 2 ms
each without a plateau present.
c. Frequency
Most ABR systems on the market
today can cover a wide range of fre-
quencies. The most common fre-
quency range tested is 500 Hz-4
KHz. This information is needed to
determine intervention strategies.
d. Polarity
Polarity refers to the phase of the
signal. Rarefaction is produced by
initially pulling the earphone
diaphragm away from the tympanic
membrane and condensation is pro-
duced by initially pushing the
diaphragm toward the tympanic
membrane. Alternating polarity
switches back and forth between
condensation and rarefaction.
Alternating polarity is often used to
reduce noise and eliminate the
cochlear microphonic. The initial
phase of the stimulus and the intensi-
ty of the stimulus interact in a com-
plex manner to produce changes in
waveform latency. Currently, there
are no industry standards for these
parameters. Hence, knowledge of
how stimulus and recording parame-
ters impact the waveform is neces-
sary for interpreting test results and
for efficiently maximizing test
parameters and clinical efficacy.
Additionally, it is important to
understand stimulus and recording
parameters when comparing data
from one clinic to another with
respect to normative data and unusu-
al test results. One useful “rule of
thumb” regarding polarity is to make
sure the polarity you are testing with
is the same as was used to collect the
normative data.
IV. Acquisition Parameters
a. Gain
Gain of 100,000 is typical and is
sufficient to record ABR’ from
babies.
b. Filters
Filter settings primarily affect the
auditory response with respect to
amplitude. Most audiologists agree
there is little significant ABR infor-
mation obtained with the high fre-
quency (low-pass) filter set above
3000 Hz. There is much less agree-
ment on low frequency (high-pass)
settings, since there can be a signifi-
cant increases in noise as this setting
is lowered. There are two types of fil-
ters. (a) High frequency filters allow
low frequency sounds to pass
through and cut off high frequency
sounds. When testing infants, these
filters are often set at 1500 Hz. (b)
Low frequency filters allow high fre-
quency sounds to pass through and
cuts-off lower frequencies. These fil-
ters are often set at 30 Hz. A notch
filter is used only when artifact is
uncontrollable by other means. A
notch filter provides some protection
against electrical interferences, such
as the hum that can be heard from
fluorescent lighting.
c. Analysis Time (Epoch)
and Sweeps
The analysis time or epoch is the
period of time, after the stimulus is
presented, in which data are collect-
ed and appear in the analysis win-
dow. This window needs to be long
enough to display the entire
response. Babies have longer laten-
cies for wave V than adults. Hence,
the window should be at least 20-22
ms. When selecting an epoch it is
important to allow enough time for
possible interactions in analysis time
and stimulus rate. The interstimulus
interval is the time period between
two successive stimuli. The inter-
stimulus interval decreases as the
rates of stimulation increases and
vice versa.
Each time a stimulus is presented
and data is recorded, one sweep
occurs. In ABR and in most auditory
evoked potentials, it is necessary to
average many sweeps. Generically,
this is referred to as signal averaging.
The component of the sweep, which
contains the “signal,” is essentially
held constant and is therefore ampli-
fied across many repetitions, where-
as the more random physiologic
background “noise” is averaged out
to essentially zero. Some authors
have described this as “allowing the
ABR to emerge from the noisy back-
ground.” It is common to collect
1500-2000 sweeps. More sweeps are
used in noisier backgrounds. It is per-
missible to stop data collection after
1000 sweeps, if you have well
defined waveforms and peaks.
 Calibration
When testing with ABR equip-
ment, the signal presented is much
shorter in duration than pure tone
signals used in conventional audiom-
etry. This means that an 80 dB HL 1
kHz tone burst is not perceived with
equal loudness compared to a 1 kHz
pure tone. There are no international
standards for ABR.
It is the responsibility of either the
manufacturer or the clinician per-
forming the test to determine the nor-
mative values for clicks and tones.
This is easily accomplished by per-
forming listening tests on normal
hearing listeners. To calibrate a tone
burst, the point at which the listener
can just barely detect the tone burst is
designated “0 dB nHL”. This allows
the audiologist to compare the tone
burst data collected with audiometric
estimates of hearing.
Many manufacturers provide
default dB nHL values. However,
you must bear in mind that those val-
ues are only valid if used under sim-
ilar recording parameters. If your test
protocols differ from those that were
used by the manufacturer, then you
must provide corrections to the dB
nHL default values. dB nHL values
change with parameter settings such
as rate and ramp/plateau. For exam-
ple, the faster the click rate the easier
it is to perceive a stimulus, and hence
the lower the intensity needed to
achieve threshold.

Summary
Suggested test parameters for auditory brainstem response when testing newborns and infants:

Test ABR Air ABR air conduction ABR Bone

conduction tone bursts conduction
Epoch 15 ms 22 ms 22 ms
Sweeps 1500-2000 1500-2000 1500-2000
Stimulus 100 usec click 500 and KHz tone 100 usec click
burst
Ramping Blackman
Ramp/plateau 2-0-2
Polarity Rarefaction Rarefaction Alternating
Rate 27.7/sec 39.1/sec 27.7/sec
Filters 100-3KHz 50-1500 Hz 50-1500 Hz
Transducer Inserts Inserts Bone
Author: Dr. Petrak is a clinical audiologist and product manager for evoked potential and otoacoustic emission
technologies at ICS Medical in Schaumburg, IL. Readers can find out more about these technologies by calling
1-800-289-2150 and requesting information or they can visit ICS’ website at www.icsmedical.com.

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