# Newborn Hearing Screening > Newborn hearing screening in MBBS ENT: OAE and ABR two-tier protocol, the 1-3-6 rule, risk registers and the NPPCD programme context. - Canonical URL: https://prepelephant.com/topics/mbbs/ent/newborn-hearing-screening - Exam / course: MBBS · Subject: ENT - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Newborn Hearing Screening", PrepElephant, https://prepelephant.com/topics/mbbs/ent/newborn-hearing-screening ## Direct answer Universal newborn hearing screening exists because congenital hearing loss — affecting roughly one to two per thousand well babies and several-fold more in neonatal intensive care graduates — is invisible at the bedside and ruins language if found late. The two-tier protocol screens every baby with otoacoustic emissions before discharge; babies who refer — or who carry risk factors — proceed to automated auditory brainstem response, with diagnosis confirmed by three months and intervention begun by six. The tests measure physiology, not behaviour: emissions test outer hair cell function, brainstem response tests the whole pathway up to the auditory brainstem. ## What you must remember - **The 1-3-6 rule:** screen by one month, confirm the diagnosis by complete audiological evaluation by three months, and begin intervention by six months — the framework every screening programme, including India's, is built around. - **Test of the first tier:** transient otoacoustic emissions, quick and needing no electrodes; ears with hearing better than roughly 30-35 dB pass, so emissions screen hearing, not deafness thresholds. - **Test of the second tier:** automated auditory brainstem response (AABR), which additionally covers the auditory nerve and brainstem and catches auditory neuropathy spectrum disorder that emissions alone will miss. - **Risk register justifying ABR regardless of emission results:** neonatal intensive care stay exceeding about five days, family history of childhood hearing loss, in-utero TORCH infection, craniofacial anomalies, hyperbilirubinaemia at exchange level, bacterial meningitis, ototoxic drugs, and syndromes such as Pendred, Usher and Waardenburg. - **Timing facts:** screening is best done after 24-48 hours of life, because vernix or amniotic fluid in the canal gives false referrals in the first day; unilateral referral still demands full evaluation of both ears. - **Why screen at all:** congenital hearing loss is the commonest congenital sensory deficit, and parental suspicion or bedside clap tests detect it far too late — after the critical language period begins closing. - **Indian programme context:** the National Programme for Prevention and Control of Deafness, launched in 2006, drives early detection and rehabilitation infrastructure, while the Rashtriya Bal Swasthya Karyakram screens children for birth defects including hearing loss, and the ADIP scheme funds devices and cochlear implants for eligible children. ## A screening pathway followed to diagnosis A term baby born by normal delivery fails the right-ear otoacoustic emission twice before discharge. Step one is rescreening at one month — many pass once the canal dries, which is why screening is repeated before diagnosing. The baby refers again. At three months she undergoes diagnostic auditory brainstem response testing with frequency-specific stimuli: thresholds elevated to 90 dB nHL bilaterally confirm profound sensorineural hearing loss. Ophthalmology, genetics and cardiac evaluation screen for syndromic associations, and magnetic resonance imaging checks cochlear morphology and the eighth nerve. By five months she wears bilateral hearing aids with auditory-verbal therapy; aided assessment shows insufficient speech access, so she is counselled for implantation under the ADIP scheme, in her second year, with realistic spoken-language outcomes. Every step was fixed by the 1-3-6 timetable, and each month of delay after six erodes the outcome. Intensive care graduates, in contrast, go straight to ABR-based screening because auditory neuropathy and progressive loss are over-represented among them. ## Where students slip Candidates mix up what each test measures: emissions assess outer hair cells only, so a baby with auditory neuropathy — intact hair cells, dys-synchronous nerve — can pass emissions and be deaf; that single sentence is a standing viva question. The second slip is calling a failed screen a diagnosis: screening sorts babies into pass and refer, and only diagnostic brainstem testing at three months labels the hearing loss. Third, forgetting that screening should not be done on day zero, or that well-baby and intensive-care protocols differ — both are distinction-level details in Indian university examinations, where the NPPCD name and launch year earn their own mark. ## Frequently asked questions ### Which two tests form the newborn hearing screening protocol? Transient otoacoustic emissions as the first tier for all babies, with automated auditory brainstem response for those who refer or carry risk factors, together covering cochlear and neural function. ### What is the 1-3-6 rule in newborn hearing screening? Screening completed by one month of age, diagnostic audiological confirmation by three months, and intervention with hearing aids or implantation begun by six months. ### Why do NICU graduates need ABR-based screening rather than OAE alone? Intensive care babies have higher rates of auditory neuropathy spectrum disorder and progressive loss, which spare emissions but are detected by brainstem response testing. ### What causes a false referral on newborn OAE screening? Vernix or amniotic fluid in the ear canal, middle-ear effusion, a restless baby or testing within the first day of life — hence repeat screening at one month before diagnosis. ### Which Indian programmes support early detection of childhood deafness? The National Programme for Prevention and Control of Deafness for detection and rehabilitation, Rashtriya Bal Swasthya Karyakram for child screening, and the ADIP scheme for assistive devices including cochlear implants.