1 Indian Journal of Otology | January 2012 | Vol 18 | Issue 1 |

EDITORIAL
In India, there is around 6.0% incidence of hearing loss, out
of which approximately 50% sufer from conductive hearing
loss. Te universal screening t is a long way, even to the
high-risk group, which is due to asphyxias, premature birth,
hyperbilirubinemia, low birth weight, and others. Facility of
brainstem evoked response audiometry (BERA) is scarcely
available. Certainly, auditory BERA tells us about the hearing
status of a child on a pass/fail basis, and technically, automated
BERA is a simple and reliable screening test, but in a country
that is still struggling to spread its wings in controlling
deafness, the cost of equipment will defnitely be a deterrent
to its provision. Auditory steady state response (ASSR) or
oto-acoustic emission (OAE) cannot be thought of for routine
testing in India. In BERA, in the initial phase below the age
of 2 years in all cases, bone conduction (click and tone pip)
should be used to fully evaluate the hearing status of the child.
For terminology purpose and to properly divide subgroups,
frst 4 weeks (28 days) baby is considered as neonate, up to the
age of 3 years is considered as infant, from 3 years to 5 years
is considered as preschool, and up to 16 years is considered
as school-age child. While assessing the hearing acuity and
overall physical and mental development, one has to keep in
mind the gestational age, which is the time period between
conception and birth. Hence, in premature babies, delayed
response is expected. As the baby grows his responsiveness
to sound increases and gets mature to adult level at the age
of 10 years.
In behavioral observation audiometry (BOA), we assess the
babys response to diferent frequency intensity and duration
of sounds presented. While performing BOA, we have to
keep in mind
[1]
that the individual ear cannot be tested.
[2]

Te judgment of the audiologist may be biased
[3]
on repeated
testing or the baby may be habituated or exhausted
[4]
Te
responsiveness varies with the age for the same intensity.
Hence, a chart must be made displaying the guidelines of the
test and the response expected.
Although the newborn baby responds to 70 db noise by eye
blink, eye widening or startle, and between 6 weeks and 16
weeks by arousal, eye blink or eye shif, BOA is more useful
National deafness program and
behavioral enforcement
audiometry
between the age of 4 months and 3 years. Above the age of 4
months, baby responds to sound stimuli above 50 db hearing
loss (HL) generated by a toy or in free feld audiometry. Tis is
the age where BOA can be more useful in our Indian scenario
than physiological testing by evoked potential (EP) (BERA).
Te infant is able to localize the sound of 50 db at horizontal
level between 4 and 7 months. Te 10 and 15-month-old baby
can localize the sound by downward and upward eye or head
movement, respectively. Te only caution to be taken is that the
baby mimics for every action; hence, family member should
not be present and attendant has to be trained not to respond
or point during the test.
[5]
Te child response is enhanced at this age if the toy is lit up
or moves with the sound. Again, the duration of the sound
is important with the maturation; shorter the duration better
is the response. During the test, the child is seated on a clean
carpet/foor. Tere should be a collection of diferent colorful
toys, but out of reach and out of sight of baby. As per the
requirement, toy should be used and examinee must keep in
mind the comfort level of the baby along with exhaustion and
habituation. Usually three out of four tests are suggestive of a
positive test. A break of 10 minutes increases the total number
of positive responses at the age of 1 year.
The physiological test EP (BERA) is difficult to perform
because at times babies do not cooperate and require sedation.
Te child may be having a conductive hearing loss, which
should be assessed by bone conduction (both click as well
as tone pip) to assess the high frequency and low frequency,
respectively.
I conclude that behavioral enforcement audiometry screening
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2 Indian Journal of Otology | January 2012 | Vol 18 | Issue 1 |
Taneja: Deafness and behavioral audiometry
should be a part of the training program of all paramedical
workers, specifcally auxiliary nurse midwife and American
Speech and Hearing Association (ASHA). Tis is a simple
test that can easily be mastered with negligible equipment.
In all suspected cases apart from air conduction BERA, bone
conduction BERA and tympanometry with acoustic refex
should be performed. Every parent must be made aware
about the residual hearing and development of speech with an
early use of hearing aid. Signboard display should be placed
in every hospital or public place to make the parents aware
of early deafness.
Mahendra K Taneja
Editor-in-Chief,
Indian Journal of Otology, Delhi, India
E-mail: ijo_editor@rediffmail.com
REFERENCES
1. Moore JM, Wilson WR, Thompson M. Visual reinforcement of
head-turn responses in infants under 12 months of age. J Speech
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2. Stanley A. Gerfand. Essentials of audiology. 2
nd
ed. Seventh
Avenue, New York 10001: Thieme Medical Publisher, Inc; vol
333. p. 377-96.
3. Widen JE. Adding objectivity to infant behavioral audiometry.
Ear Hear 1977;14;49-57.
4. Culpepper B, Thompson G. Effects of reinforcer duration on the
response behavior of preterm 2-year-olds in visual reinforcement
audiometry. Ear Hear 1994;15:161-7.
5. Northern JL, Downs MP. Hearing in children. 4
th
ed. Baltimore:
Williams and Wilkins; 1991.
How to cite this article: Taneja MK. National deafness program
and behavioral enforcement audiometry. Indian J Otol 2012;18:1-2.
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