Newborn HearingGuidelines for the early audiological assessment andmanagement of babies referred from the Newborn HearingScreening ProgrammeVersion 3.1July 2013NHSP Clinical GroupCo-Editors: John Stevens1, Graham Sutton2, Sally Wood2Contributors: Rachel Feirn3, Guy Lightfoot4, Rhys Meredith5, Sally Minchom6,Glynnis Parker7, Siobhan Brennan8, Rachel Booth91University of Sheffield, Sheffield, UKNewborn Hearing Screening Programme Centre, London, UK3Formerly of Children’s Hearing Centre, Bristol, UK.4Dept of Medical Physics and Clinical Engineering, Royal Liverpool University Hospital, Liverpool, UK.5Audiology Dept, Abertawe Bro Morgannwg Health Board, UK6Betsi Cadwaladr University Health Board, Wales, UK7Sheffield Children’s Hospital, Sheffield, UK8Regional Department of Neurotology, Sheffield Teaching Hospitals, Sheffield, UK9Audiology Dept, Central Manchester Hospitals, Manchester2Note added June 2014Correspondence to PPC, British Society of Audiology, 80 Brighton Rd, Reading, RG6 1PSIn this document there are references to ‘eSP’, for e-Screener Plus, the Electronic record system forNHSP in England. Users In countries which do not use eSP should ignore these sections.NHSP Early assessment guidelines v3.1July 2013Page 1 of 44

Amendment History:VersionDateAmendment History1.0March 20061.11.1September 2006December 20061.1March 20072.3December 20102.5March 20113.1July 2013Draft after extensive correspondence with national andinternational audiologists. Consultation via NHSP website Feb-March 2006.Revised version produced following comments receivedComments from NHSP Clinical Group incorporated. Approvedby NHSP Clinical Group with minor commentsAmendments made as agreed at Clinical Group March 2007.Submitted to Director for approval.Draft drawn up after extensive consultation within and outsideNHSP clinical group. Further consultation via NHSP websiteRevision following comments received from consultation periodand further discussion at clinical group Feb 2011Major revision through NHSP Clinical Group. Put out forconsultation in June. Revisions made based on commentsreceived. Issued for implementation with eSP changesNHSP Early assessment guidelines v3.1July 2013Page 2 of 44

CONTENTS1. Scope .52. Major changes to these guidelines from the 2011 version.53. Requirements for a newborn audiological assessment service .63.1 Equipment .63.2 Staff training and expertise.63.3 Accommodation.63.4 Communication with parents: Before the appointment .63.5 Communication with parents: During and after the appointment .63.6 Timing of tests .73.7 Clinical arrangements and time to allow for testing.73.8 Sedation .74. Test options.84.1 Use of tone pips or narrow band chirps .84.2 Use of headphones and inserts.84.3 ABR stimulus starting level .94.4 ABR stimulus level steps and testing at higher levels.95. Sequence of tests.105.1 Introduction.105.2 OAEs .105.3 AC ABR .115.4 BC ABR .115.5 Tests for ANSD.125.6 Auditory Steady State Responses (ASSR) .125.7 Tympanometry.125.8 Reactions to stimuli. .126. Special Cases .126.1 Permanent Unilateral hearing loss. .126.2 Atresia.127. ABR testing: technical considerations.137.1 Normal maximum stimulus levels .137.2 Definition of ABR threshold .138. Prediction of the estimated hearing threshold (dBeHL) .138.1 Introduction.138.2 Combined correction values .148.3 Entering values into prescription software for hearing aid fitting.158.4 Confidence limits (5% to 95%) of the estimated hearing threshold (eHL) .168.5 Prediction of the estimated hearing threshold from the ASSR threshold.169. Further testing and management.179.1 Satisfactory Hearing .179.2 Elevated thresholds .179.3 Mild bilateral hearing loss and Unilateral hearing loss .179.4 Further management and referral onwards.1810. Reporting .18NHSP Early assessment guidelines v3.1July 2013Page 3 of 44

11. Recording onto eSP .1912. Glossary.20Appendix A: Guidance and protocols available on the NHSP website .21Appendix B: Some examples of different hearing impairments and expectedtest results. .22Example 1: Unilateral conductive with detail on process and choice of tests .22Example 2- Bilateral conductive .23Example 3- Unilateral sensorineural loss .23Example 4 – Bilateral sensorineural loss .24Example 5 – Bilateral mixed loss .24Example 6 – Auditory neuropathy spectrum disorder .24Example 7 - Atresia – Refer to appendix G.24Appendix C: Masking.25Appendix D1: Stimulus level corrections.28Appendix D2: Maximum stimulus levels for ABR using inserts .30Appendix E1: Offsets to predict the estimated hearing level from the ABRthreshold.31Appendix E2: Derivation of confidence limits for the estimated hearingthreshold.34Appendix E3: ASSR – Provisional set of ASSR offset and stimulus correctionvalues .36Appendix F: Predictive value of AC ABR in PCHI cases .37Appendix G: Testing babies with atresia .38Appendix H: Checklist for Audiological Assessment .39Appendix I: Combined dBnHL to dBeHL correction values–by transducer 40References.41NHSP Early assessment guidelines v3.1July 2013Page 4 of 44

1. Scope5101520253035This document gives guidance on the early audiological assessment and management of babiesreferred from the newborn hearing screen. The term “early” is used to denote the period betweennewborn screen referral to the time at which reliable behavioural assessment may be undertakeni.e. 7-8 months corrected age. However the focus of this guidance is on the critical period forassessment up to 12 weeks corrected age.It describes some prerequisites for the provision of the service, issues related to the timing andorganisation of the service and issues related to the choice, timing and order of test procedures. Itshould be read in conjunction with the latest NHSP Guidance for auditory brainstem responsetesting in babies and other guidance and protocols relating to newborn hearing screening,assessment and follow up available on the NHSP website ( Theseare listed in Appendix A.2. Major changes to these guidelines from the 2011 versionThe main changes that have been made from the 2011 guidelines are as follows:1. Many sections have been restructured.2. Narrow band chirps are now acceptable as an alternative to tone pips for ABR testing, withnHL to eHL correction values being provided.3. Revised advice on the use of TEOAE as the first test in ‘well babies’4. BC testing at 0.5kHz and 1kHz is now acceptable, with nHL to eHL correction valuesprovided.5. Correction values have been changed from ‘values to be subtracted’ to ‘values to beadded’.6. A summary table of corrections by transducer has been added as a new Appendix.7. Revised correction value for BC testing at 4kHz.8. The highest level at which masking is not required for BC is now 15dBeHL rather than 20.9. Removed advice suggesting switching to click ABR when the 4kHz tpABR threshold issignificantly raised ( 80dBnHL), and text added to use of click ABR in section 5.3.10. Advice on when it is acceptable to exceed the normal maximum stimulus level.11. Updated advice on entering thresholds into prescription software for hearing aid fitting.12. More accurate data for the predictive value and confidence intervals of ABR.13. Guidance on further management and referral has been completely rewritten, and is nolonger based on bands of 4kHz ABR threshold.14. The Appendix of FAQs has been removed.Note that eSP is being updated in August 2013 to incorporate the changes to the new nHL to eHLcorrection values in this guidance.NHSP Early assessment guidelines v3.1July 2013Page 5 of 44

403. Requirements for a newborn audiological assessment service3.1 Equipment45Equipment to carry out ABR threshold measurement using tone pips (or narrowband chirps) andclicks by both air and bone conduction is required. Equipment to record TEOAEs and highfrequency tympanograms is also needed. Check the NHSP website for information on equipmentand for recommended equipment settings. Equipment should have a documented annualcalibration, including calibration to the RETSPLs and RETFLs given on the NHSP website.Regular safety and electrical testing is also required in accordance with local protocols.3.2 Staff training and expertise5055Staff carrying out threshold measurement for both AC and BC ABR require experience andexpertise in accurately interpreting ABR waveforms, determining thresholds (including when andhow to use masking) and dealing with unusual or unexpected waveforms or results. They shouldalso have expertise in cochlear microphonic and otoacoustic emissions testing, and intympanometry in babies. It is also essential that staff with