Little Heroes Pediatric Hearing Clinic

By Dr. JJ

Today’s blog is another more technical one, as we will be talking about sedated auditory brainstem response (ABR) procedures. This is a topic sometimes misunderstood by the medical team who is not familiar with audiology, and is a procedure, therefore, that can be over-prescribed by physicians. In this blog, we will discuss what a sedated ABR is, who needs one, and how the process for getting one should (in our humble, yet very expert opinion) work.

What is a Sedated ABR?

A few months back, we posted a video to our YouTube channel discussing just this. As you may remember, an ABR (sedated or non-sedated) is a just a procedure audiologists use to estimate a patient’s hearing sensitivity when the patient is unable to participate in the standard measure of hearing. For children, we standardly use visually reinforced audiometry (VRA) or conditioned-play audiometry (CPA). But, as I say, when they are unable to participate in this testing, we can estimate what patients can hear by measuring neural responses to sounds from the brain.

There are a couple of limitations to the ABR. The first is that the ABR is very sensitive to body movement and other noises. Because we are looking at the brain’s response to sounds, the data we see can become hard to interpret if the patient is wiggly or wakeful. When doing the ABR on infants, the procedure is usually smooth sailing, because infants are good nappers, and we can get good, reliable data to confirm or rule out elevated hearing thresholds or hearing loss. However, when children are older, napping outside of the bed can be tricky to accomplish, and asking children to sit with their eyes closed for an hour is . . . basically impossible.

The second limitation is that ABR data is only an estimation of the patient’s hearing sensitivity. It’s true that ABR data strongly correlates to behavioral test results; however, there is a reason why testing in a sound booth is gold-standard. We want to know how patients use sound, not just whether their brain shows neural responses to sound. ABRs do not give us sufficient data the way a comprehensive behavioral exam for hearing can.

Sometimes, children may show high risks for hearing loss and do not reliably participate in behavioral assessments for hearing. When this happens, it’s imperative to work aggressively to completely understand the child’s hearing needs so that timely and appropriate intervention can be provided. Thus, a sedated ABR may be recommended. A sedated ABR is just an ABR where the child is medically induced to a sedated (sleep-like) state, so that we don’t have the interference of wiggly bodies that may make reliable ABR data hard to obtain.

Who Needs a Sedated ABR?

As mentioned, children at high risk for hearing loss who do not provide reliable results for behavioral assessments may be good candidates for a sedated ABR. Here at Little Heroes, we believe that very few children need a sedated ABR if you can find a competent, aggressive team of pediatric audiologists. Most often, we see referrals from physicians for a sedated ABR because the child in question has other learning or developmental disabilities and is difficult to condition to the methods used for behavioral assessments of hearing. However, other disabilities should not be an immediate indicator for a sedated ABR procedure. When audiologists are informed and understand the unique needs for children with other disabilities, test methods can be adjusted so that the child in question can be reliably tested. Here at Little Heroes, we do this all the time.

Usually, the catch is that audiologists are trying to use test methods for behavioral testing that are not developmentally appropriate for the child, so reliable results are not obtained. Just because a child is six years old, for example, does not mean they are able to raise their hands when they “hear the beep”. Depending on their situation, they may still only have the developmental capacity to turn their head when they hear sounds, and in this case VRA would be the appropriate test method.

How Do I Get a Sedated ABR?

Sedated ABRs can only occur if a referral from a medical doctor is provided. (Again, this is why it can sometimes be tricky, because physicians may not consult with an audiologist and can over over-refer, thinking that these procedures are a good catch-all for children. But sedation comes with risks that should be considered, especially if behavioral testing can be reliably obtained.) Once that medical referral is obtained, the physician’s office should send that referral to the audiology department of whatever facility is being used to complete the sedated ABR. A good pediatric audiology clinic, once they get this referral, should investigate to make sure, from their end, that the child really is a good candidate for a sedated ABR before moving forward with scheduling the procedure.

There are two criteria that we, here at Little Heroes, require before being okay with a referral for sedated ABR:

1. All behavioral methods have been appropriately attempted and thoroughly documented.
   1. Thoroughly documented means that the report for the attempted assessment describes the efforts made to ensure best possible test results, including:
      1. Use of a test aid (can be a second audiologist or qualified assistant),
      2. Use of developmentally appropriate methods,
      3. Multiple attempts using either multiple appointments or multiple listening breaks.

2. Child is already going to be sedated or put under anesthesia for another procedure.

For the second criteria, common examples we’ve experienced are when a child is getting tympanostomy tubes placed for ear infections or are getting imaging through sedation (e.g., MRI, CT scan). In these cases, if the child is unreliable in their behavioral assessments for hearing, and if they are already getting sedated for other medical procedures, it may be efficient to tack on that sedated ABR. However, at Little Heroes, we believe that sedating for the sole purpose of testing hearing can usually be avoided.

Are We Against Sedated ABRs?

Absolutely not! They have their place and can provide important information that is otherwise unattainable. However, even beyond the risk of sedation, sedated ABRs can be an emotionally traumatic experience for the child and a big financial burden to the family. We believe it’s always better to attempt the conventional alternatives before jumping to something that may be a disadvantage to the family.

Are you concerned that your child needs a quality hearing assessment? Call us today or schedule online! We’re here for you.