Brain Stem Evoked Response
Newborn Hearing Screening
Carol Schulman-Galambos, PhD, Robert
\s=b\ Brain stem evoked response audiom-
etry (BERA) has been used as an auditory
screening procedure in three groups of
newborn infants. Group 1 consisted of 220
normal-term infants who were tested with-
in 72 hours of birth; no hearing abnormal-
ities were uncovered (386 ears), and their
threshold responses (for clicks) lay
between a 10- and 20-dB hearing level (re:
adult). Group 2 consisted of 75 newborns
who were treated in an intensive care unit
for one to 14 weeks; four were found to
have severe sensorineural hearing loss
(seven ears) at the time of discharge.
Group 3 consisted of a group of 325
infants, 1 year or older, who had
previously been discharged from the
same intensive care unit; of these infants,
an additional four showed severe sensori-
neural hearing loss. All abnormalities that
were identified by BERA were subse-
quently confirmed by conventional au-
diometric measures. The estimate of an
incidence of severe hearing loss in one of
50 infants who required intensive care in
the neonatal period calls for careful test-
ing of this population.
(Arch Otolaryngol 105:86-90, 1979)
The of the Conference
consensus
Newborn Hearing Screening,
on
which was held in San Francisco in
1971,' was that no acceptably objective
and reliable technique for newborn
hearing screening was then available.
Since that conference, a new tech-
Submitted for publication May 15, 1977;
accepted Oct 10, 1977.
From the Speech, Hearing, and Neurosensory
Center, Children's Hospital and Health Center,
and the Department of Neurosciences, Universi-
ty of California, San Diego.
Deceased.
Reprint requests to Speech, Hearing, and
Neurosensory Center, Children's Hospital and
Health Center, 8001 Frost St, San Diego, CA
92123 (Dr Galambos).
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Audiometry in
Galambos, MD, PhD
nique, brain stem evoked response
audiometry (BERA), has been devel¬
oped. The BERA technique permits
objective and precise measurement of
the function of the peripheral audi¬
tory system.
The BER, recorded from scalp elec¬
trodes, consists of a series of waves
that reflect the activation of the
eighth nerve and, successively, of
auditory brain stem structures
through at least the inferior collicu-
lus.-'"4 When recorded at low-stimulus
rates (one to ten per second), seven
waves can be identified in adults;
when recorded at faster rates (30 to 45
per second as in the present studies),
only wave V, according to Jewett and
Williston's5 nomenclature, is regularly
seen.
The latency of this wave V has been
shown to vary systematically as a
function of stimulus intensity for
animals and man within a given age
group, and as a function of increasing
maturation of the organism.'' " electrically shielded) room that was adja¬
We have reported previously on the
normal BER of infants and children7
and of premature infants," and de¬
scribed one year's experience with the
clinical application of the BERA
method in a pediatrie population.'-
The application of this new method to
the problem of newborn hearing
screening, both in a normal newborn
population and in a special-risk popu¬
lation of neonatal intensive care unit
(ICU) survivors, is the subject of this
communication.
NORMAL NEWBORN SAMPLE
Subjects
Brain stem evoked response audiometry
was performed on 220 newborn infants in
the nursery on the obstetrical ward of a
service that has approximately 3,000 births
each year. Measurements were made only
on infants who were judged by the attend¬
ing physicians to be normal, healthy, and
full term. They ranged in postnatal age
from 7 to 72 hours and in estimated gesta-
tional age from 38 to 42 weeks (S 39.8=
weeks). The sample in which measure¬
ments were made represented about a
fourth of the population of the nursery
during the time of the study. No a priori
selection of these subjects was made; the
technician made recordings on as many
available infants as she had time for
during the hours she worked (six hours
each day, four days each week).
Procedure
The principles and procedures for record¬
ing the BER, used in our laboratory, have
been described in detail elsewhere.'3 Mea¬
surements were made on a clinical averag¬
er (Nicolet model CA-1000), which was
located in a quiet (but not sound-treated or
cent to the nursery. Infants were scheduled
for testing only after feeding when they
would be in natural sleep.
Recordings were made as already de¬
scribed," through surface electrodes that
were attached to the scalp at the vertex
and the active mastoid, with the contralat¬
eral mastoid grounded. Clicks of 0.1-ms
duration were presented at a rate of 30 or
45 per second through an earphone that
was taped to the subject's ear. The electri¬
cal activity of the brain was amplified
xlO', filtered between 150 and 1,500 Hz,
and responses to 1,000,2,000, or 4,000 clicks
were averaged. Each measurement was
replicated at least once. The latency of
wave V in milliseconds was obtained by
placing the computer's cursor on the peak
of the wave and by reading off the digital-
 Normal Newborn ICU Infant
ly displayed time.
The screening protocol called for mea¬
suring the response at a 60-dB hearing
level (HL) with one replication and at 30 dB
HL with one replication for one ear; if time 60 dB
permitted, recordings at 30 and 60 dB (also
with one replication) were made on the
second ear also.
In addition, the response threshold was
obtained on a series of 20 subjects; for 15 of
these subjects, measurements were made
at 60, 30, 20, and 10 dB and for the remain¬
ing five subjects, in 10-dB decrements
from 60 down to 10 dB. 30 dB
The following data were recorded for
each subject: sex, estimated gestational
age, age in hours when the BERA measure¬
ments were made, type of delivery (normal
vs cesarean section), latency of wave V for
each ear at each intensity measure, and
any comments that were relevant to the
test. Reliability of the test was rated 20 dB
"good," "fair," or "poor" on the basis of
how noisy the records were; noise came
from equipment (especially 60-Hz line
noise), from the patient (subject was, or
became, restless during the procedure), or
from the environment (occasional interrup¬
tions by the nursing staff in the normal
course of their running the newborn
10 dB
service). Approximately one hour was
required to obtain data from each patient,
half for the response measurements, and
half for obtaining parental permission,
Fig 1 .—Intensity series for two infants. Normal newborn (at left) showing wave V (arrows)
charting, and record keeping. down to 20 dB and absence at 10 dB. Infant from intensive care unit (ICU) with
gestational age of 37 weeks ready for discharge (at center); recording made with
RESULTS equipment (Nicolet CA-1000) as in normal newborn (at left). Recording (at right) of ICU
infant same as in (center) recording but using laboratory equipment. Duration of all
Measurements were made on a total recording was 20 ms.
of 386 ears. Sixty-five percent of these
tests were judged to have good relia¬ change of latency as a function of dB although test reliability was
bility, 20% were fair, and 15% were maturation is rapid in this period." "
judged good, ie, the subject slept
poor. Patient noise and equipment If one considers only data from those quietly throughout, and there was no
noise contributed about equally when normal newborns where reliability of 60-cycle interference. This patient
reliability was less than "good," with measurements was judged "good" and was referred to the Speech, Hearing
environmental noise interfering rare- who 39 to 40 weeks of estimated
were and Neurosensory Center, Children's
ly· gestational age, variability is consid¬ Hospital and Health Center, in San
Figure 1 shows a typical intensity erably reduced. These data are also Diego, for BERA retesting at 6 weeks
series normal newborn (at left).
on a shown in Fig 2 (at center). of age, at which time normal
Latency of wave V can be seen to For the subsample of 20 infants in responses were obtained bilaterally.
increase systematically as the intensi¬ whom threshold determinations were Therefore, this case must be consid¬
ty of the stimulus is decreased, as attempted, responses were obtained ered a false-positive outcome of the
expected.7 at 20 dB but not at 10 dB in all cases. screening procedure, probably the
Figure 2 shows the distribution of Figure 3 shows the latency-intensity result of a technical error that was
wave V latencies for the ears in function for all these ears. undetected during the initial testing.
normal newborns (at top) for the 60- Two subjects in this sample are of
and 30-dB stimuli. The variability in particular clinical interest. One was HIGH-RISK NEONATAL SAMPLE
this clinical sample, which is consider¬ the offspring of congenitally deaf Subjects
ably larger than we have found under parents; normal responses wereob¬ The Neonatal Intensive Care Unit of
laboratory conditions,7 was due in part tained bilaterally from this infant. Children's Hospital and Health Center, San
to the noisiness of some of the records, For the other infant, no response Diego (to which the Speech, Hearing and
and in part to the fact that the rate of could be obtained from either ear at 70 Neurosensory Center is attached both

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 60 dB HL 30 dB HL and for the remaining ten infants, in 10-dB
decrements from 60 down to 10 dB.
Normal Newborn ( =
386)
RESULTS
50
Figure (at center and right) shows
1
40 for a typical subject in this group, an
30 intensity series made with each of the
20 two instruments used in this study.
10 Morphologic differences between the
0 records are due to differences in the
Normal Newborn ( =
62) high- and low-frequency filtering
characteristics of the different am¬
50
40
plifiers, in the averaging computers
and in the properties of the X-Y plot¬
30 ters. Typical individual differences
20 between subjects because of variables,
10 such as the noise level of the EEG, are
0 lili j_ _ _L illustrated by a comparison of the
ICU Infants ( =
54) responses in Fig 1 (at center and
50 right).
Figure 2 shows the distribution of
40
latencies at 60 and 30 dB for infants
30
who were tested on discharge from
20 the ICU (at bottom), and Fig 3 shows
10 the latency-intensity curve for this
0
in r·» io co i^
population.
cr¡ .- > ö in co r·- ^ lo co r--
Threshold determinations yielded
ID i< od co co ·->
ni ( r-> co oó co öS cri
^ œ w m o * co (NIDO =!- co c\i id ó responses at 20 dB but not at 10 dB for
l¿ ID oó od cri IO i< od od öS öS oS
26 infants, at 30 dB but not at 20 dB
Latency of Wave V, ms for three infants, and at 40 dB but not
Fig 2.-Distribution of latencies at 60 dB HL (at left) and 30 dB HL (at right). All ears of at 30 dB for one infant. This last
normal newborns (at top) included those tested under "poor" conditions. Subsample (at result will be discussed further.
center) of all newborns had gestational age of 39 to 40 weeks, with "good" test reliability. Four cases in this sample of 75 are
Infants (at bottom), at discharge from intensive care unit (ICU), with presumed normal
of clinical interest. Three were at high
hearing and gestational age of 37 to 40 weeks. risk at the time of testing. One infant
physically and administratively), is a Procedure of a congenitally deaf mother was
regional center to which patients are Measurements were made in our clinical found to have no BER below 60 dB HL
admitted by transfer only, from a wide BERA laboratory with the use of the bilaterally. Two had been kernicteric
geographic area. Survivors are at risk for instrumentation and procedures that have on admission (serum bilirubin levels of
sensory and CNS disorders for a variety of been already described.'- The instrumenta¬ 38 mg/dL and 45 mg/dL, respective¬
causes, such as prematurity, problems of tion consists of commercially available ly); no BER was obtained for either
oxygénation, and the administration of components (TDH-39 earphone, Grason- ear at equipment limits (90 dB HL)
potentially ototoxic drugs. Stadler timers, click generator and atten¬ from one, while the other showed no
The subjects who were studied in this uator, Grass-Poll amplifier, Nicolet-1070
sample were 75 neonates who were housed response below 90 dB in one ear or
averager, and Hewlett-Packard X-Y plot¬
in the ICU. This sample included 54 below 80 dB in the other. The fourth
ter). The band-pass of the amplifier (Grass- infant was not obviously at risk for
patients who were presumed to have P511) was set at 300 to 1,000 Hz, and its
normal hearing, in whom routine BERA gain was x 10'. The infants were prepared hearing impairment and was actually
measurements were made; there were also for recording as described previously; they identified during our collection of
21 patients who were referred by the were in natural sleep at the time of testing, normative data. This patient had been
attending physician as at special risk for which was conducted in a double-cham¬ admitted for neonatal asphyxia. No
peripheral auditory problems as a result of, bered booth (IAC 1200 series) (the connect¬ BER could be obtained below 85 dB
for example, congenital familial deafness, ing door was left open so that the infants for the left ear or below 65 dB for the
high serum bilirubin levels, or long-term could be observed at all times).
right ear.
administration of potentially ototoxic Measurements were made at click inten¬
drugs. sities of 60 and 30 dB on one ear and at 30 Therefore, in this sample of 75
All patients were between 37 and 40
infants who were tested on discharge
dB (if time permitted, also at 60 dB) on the
weeks of gestational age (x 38.2 weeks)
=
second ear. from the ICU, four (5.3%) were shown
and between 1 and 14 weeks of postnatal In a subsample of 30 of these infants, an by BERA to have severely impaired
age, in open bassinets, and ready for attempt was made to estimate the thresh¬ hearing. These four infants later
discharge at the time the measurements old of response. For 20 of them, measure¬ received complete audiological work-
were made. ments were made at 60, 30, 20, and 10 dB, ups at which time the presence of

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 severe,irreversible, sensorineural loss
was independently confirmed, and
appropriate treatment was started in
each case.

HIGH-RISK FOLLOW-UP GROUP

These subjects belong to a group of ICU
survivors who participated in an ongoing
study that was designed to evaluate the
mental and motor outcome of disorders
that require intensive care.14 They are
included in this study because we have ICU Infants
8.0
identified four cases of peripheral hearing -

loss among them. The children in this

group are seen at six months, 12 months,
and subsequently at yearly intervals after
7.5
discharge. Their discharge diagnoses in¬ -

clude prematurity (less than 37 weeks of

gestational age), neonatal asphyxia (Apgar
score less than 5 at one minute and less
than 7 at five minutes, or requiring resus¬
citation in delivery room), respiratory
distress syndrome, and inappropriately low
weight for gestational age. Of these
infants, 325 who are 12 months of age or
older have been examined for language
competence. All who demonstrate signifi¬
cant language delay are screened by the
BERA test; if this is abnormal, they
receive a complete audiologic workup.
The manner in which the BERA test was
applied was essentially that described
previously for the infants in the high-risk
neonatal group. Thus far, four of these
children who demonstrated language delay
(three of whom are included in a already
published report'2) show severe sensorineu¬
ral hearing impairment that requires
amplification. None of them is in the group
of 27 who are common to studies 2 and 3
(high-risk neonatal and follow-up groups),
which argue that infants who passed the
BERA test on discharge from the ICU are
unlikely to develop severe auditory impair¬
ment thereafter. No specific cause can be
assigned for three of the cases; two infants
weighed less than 1 kg at birth, and one
had been asphyxiated. The fourth infant
suffered fracture of the right temporal
bone during a traumatic delivery; BERA
shows his right ear to be profoundly
impaired and, for some unknown reason,
his left to be mildly impaired.
When these four infants are added to the
four who were identified in the high-risk
neonatal group, a total of eight in the
high-risk population of 373 have been
shown to have significant hearing impair¬
ment. This is an incidence of 1.0:46.6 or
2.14%.
COMMENT
The data from these studies will be
discussed under the following three
10
Intensity,
Fig 3.—Latency-intensity functions for
latency in infant samples is assumed
gestational age.
headings: (1) the threshold of hearing
(for clicks) in newborns, both the
newly born, and infants of the same
gestational but greater postnatal age;
(2) the incidence of hearing loss in a
high-risk population of infants; (3) the
feasibility of screening newborns
with the use of BERA.
Response Threshold to Clicks
As shown in Fig 3, infants of about
40 weeks of gestational age regularly
yield BERA responses to clicks of 20
dB. This result, which is consistent
with earlier reports based on some¬
what smaller samples,7" means that
the auditory threshold of the newborn
lies below 20 dB, and so must be close
to that of adults. From our compari¬
sons of the properties of adult and
newborn BERAs as the acoustic stim¬
uli approach threshold in strength, we
estimate the infant threshold (for
clicks) to be about 10 dB above the
adult. There is, in any event, no large
30 40
dB HL
normal infants and adults. Differences in mean
to be result of slight difference (1.6 weeks) in
difference between them according to
the BER measurements.
According to Bradford,'' the new¬
born threshold by respiratory audiom¬
etry is at 0 dB (re: ANSI-1969) at 1,000
and 3,000 Hz. By contrast, the heart
rate method estimated the threshold
for 500 and 3,000 Hz to be at 90 dB for
newborns."1 Other methods (cribo-
gram, behavioral) either do not
attempt to establish threshold or yield
uncertain values for it. Though we
have had no direct experience with
respiratory audiometry, the ease with
which the BERA method yields reli¬
able values certainly makes it an
outstanding candidate for those inter¬
ested in auditory threshold determi¬
nations in newborns and young chil¬
dren.
As a practical matter, we do not
routinely attempt to obtain the BERA
threshold, since the response is small,
relatively unstable, and time-consum¬
ing to obtain. For this reason, we stop
with the 30-dB response that, if it

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 displays a clearly defined wave shape
and a wave V latency appropriate for
age, is considered to indicate essen¬
tially normal cochlear function. If an
infant shows no response at 30 dB but
does so at 40 dB, as did one of those in
the high-risk neonatal group, we
suspect the infant to have a mild
conductive problem. The infant in this
group with a threshold at 40 dB would,
by this criterion, be regarded as
suspect for auditory problems.
A comparison of the BERA findings
for infants who are similar in gesta¬
tional age but different in postnatal
age yields several findings of interest.
Thus, Fig 3 shows the wave V latency
for the normal newborns to be slightly
but consistently shorter than for ICU
infants. This difference can be attri¬
buted in part at least (and probably
entirely) to the difference in their
mean gestational ages (the normal
newborn mean is 1.6 weeks older).
However, the maturational decrease
in wave V latency has been estimated
at 0.3 to 0.5 ms per week in this
period,7811 and since in our sample,
the decrease is somewhat smaller than
expected (about 0.1 ms), the question
of whether auditory maturation pro¬
ceeds somewhat more rapidly in
prematurely born infants is a possibil¬
ity. Though this seems unlikely, the
question cannot be answered with the
present data.
Finally, the data from the normal
newborn sample indicate the absence
of significant conductive hearing loss
due to unabsorbed mesenchymal tis¬
sue or fluid in the middle ear during
1. California State Department of Public
Health: Conference on Newborn Hearing Screen-
ing: Proceedings Summary and Recommenda-
tions. San Francisco, Feb 23-25, 1971.
2. Starr A, Achor J: Auditory brainstem
response in neurological disease. Arch Neurol
32:761-768, 1975.
3. Starr A, Hamilton A: Correlation between
confirmed sites of neurological lesions and abnor-
malities of far-field auditory brainstem response.
Electroencephalogr Clin Neurophysiol 41:595-608,
1976.
4. Stockard JJ, Rossiter VS: Clinical and path-
ologic correlates of brainstem auditory response
abnormalities. Neurology 27:316-325, 1977.
5. Jewett D, Williston J: Auditory-evoked far-
fields averages from the scalp of humans. Brain
94:681-696, 1971.
6. Jewett DL, Romano MN: Neonatal develop-
ment of auditory system potentials averaged
from the scalp of rat and cat. Brain Res 36:101-
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the first postnatal day of life. Even
though the stimuli that were used, ie,
clicks, are not optimal for testing at¬
tenuation at the low frequencies,
which such transient middle ear inclu¬
sions would introduce, the results
support Keith's findings17'1* of normal
middle ear function as measured by
impedance audiometry in the new¬
born.
Hearing Loss in a
High-Risk Population
In groups 2 and 3, we examined a
population of 373 premature infants,
all of whom had been at risk for
hearing disorder (among other possi¬
ble abnormalities), and we identified
by BERA eight with severe peripheral
losses that required amplification.
This incidence, 2.14%, is to be com¬
pared with the zero incidence in our
sample of 220 normal newborns. It
would appear desirable to examine a
much larger sample of at-risk infants
to ascertain how valid the surprisingly
high 2.14% estimate may be for this
group.
Feasibility of BERA for
Newborn
Screening
As these data show, BERA unques¬
tionably meets the criteria for an
objective and reliable method for
assessing newborn hearing according
to the recommendations of the Con¬
ference Newborn Hearing Screen¬
on
ing.1 However, the complexity and
cost of the test, requiring as it does
expensive instrumentation and a
trained technician, does not meet the
References
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8. Schulman-Galambos C, Galambos R: Brain
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criterion of the conference for use in
the normal newborn nursery, where
the expected incidence of hearing loss
is about 1:2,000.
However, when one considers the
population of neonatal ICU survivors
who are described in this study, a
different picture emerges. According
to our estimate, the incidence in this
population approximates one in 50.
We recognize, of course, that this may
not be the true incidence in this popu¬
lation, given the limited size of our
sample and the way it was selected.
However, the number of infants who
are identified and securely docu¬
mented as having severe to profound
sensorineural loss in our sample
argues for a probable high incidence
in this population. For this group, the
BERA seems to be an efficient screen¬
ing test, and its cost seems to be
justified to us. Therefore, we have
recommended to our hospital adminis¬
tration that they institute routine
BERA testing on all ICU infants prior
to discharge.
study was supported by grants HD-10636-
This
01 (Dr Schulman-Galambos) and NS11707 (Dr
Galambos) from the University of California, San
Diego.
The authors thank Jan Labar, MA, for assem¬
bling the data on the newborn population; the
parents of these newborns; the staff of Sharp
Hospital, San Diego, where the measurements
were made; Alan Schumacher, MD, Morton
Cohen, MD, the staff of the Intensive Care Unit
at Children's Hospital, San Diego, and the
parents of the infants who were tested there.
Kristen Gist, MA, took care of the infants in the
high-risk follow-up group; Donald Krebs, PhD,
and Robert Sandlin, PhD, provided space and
equipment used in testing; and the Nicolet
Instrument Co, Madison, Wis, loaned the clinical
averager (model CA-1000).
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13. Schulman-Galambos C, Galambos R: Re-
cording the Brainstem Evoked Response: A
Manual, 1975 (mimeograph).
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vors. Proc Soc Pediatr Res, 1976.
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17. Keith RW: Impedance audiometry with
neonates. Arch Otolaryngol 97:465-467, 1973.
18. Keith RW: Middle ear function in neo-
nates. Arch Otolaryngol 101:376-379, 1975.