Factors That Impact the Success of Natural-Sleep Auditory Brainstem Response in a Tertiary Care Multidisciplinary Clinic

Background: Hearing loss is the most common sensory disorder in children, affecting 0.1 percent of newborns. The auditory brainstem response (ABR) test is the gold standard diagnostic test for infants who are unable to participate in behavioral testing. ABR is preferably performed under natural sleep (NS-ABR) to avoid risks associated with general anesthesia and sedation. However, if the infant wakes up during an NS-ABR, the test must be stopped and may need to be repeated later. Delays in diagnosis can place the child at higher risk for delays in cognitive and educational development. Purpose: We sought to understand factors that contribute to successful NS-ABR. Research Design: This was an exploratory mixed methods study to understand the barriers in obtaining an NS-ABR that is clinically sufficient for management. Study Sample: We performed a retrospective review of 0- to 12-month-old children who underwent NS-ABR. Data Collection and Analysis: For the quantitative approach, we studied 86 consecutive infants of 0–12 months of age who underwent NS-ABR. For qualitative analysis, semistructured interviews and focus groups with audiologists were performed and analyzed using a thematic analysis approach. Results: Among the cohort of 86 infants, 164 NS-ABRs were performed. Sixty-three (73 percent) patients obtained a successful NS-ABR; only 65 (40 percent) of NS-ABRs were successful. The most common reasons for unsuccessful NS-ABR were poor sleep quality (n = 60/99, 61 percent), needing to “expand and confirm findings” (n = 26, 26 percent), and lack of or nonadherence to patient instructions (n = 27, 27 percent). Previous NS-ABR attempts and auditory steady-state response (ASSR) were significantly associated with successful NS-ABR (odds ratio [OR] = 1.46, 90 percent confidence interval [CI] = 1.13–2.05; OR = 4.65, 90 percent CI = 1.70–12.73, respectively). We identified four themes that impact success: inadequate logistical support for providers, inadequate emotional support for providers, providers juggling multiple tasks, and inadequate system scheduling flexibility. We triangulated these results to model interactions between factors that contribute to successful NS-ABR. Conclusions: NS-ABR is a diagnostic tool that can decrease patient exposure to sedation and anesthesia. This study suggests that individual, caregiver, provider, and systemic factors impact the success of NS-ABRs, especially for underserved populations. Multilevel interventions to improve success rates of NS-ABR would help decrease time from screening to diagnosis.