the initial signs of hearing loss are very subtle and systematic neonatal hearing screening is the most effective tool for early detection of it . hearing loss affects around 3 out of every 1000 live births . in iran , the studies have shown different incidence of hearing impairment . for example , lotfy et al ( 2007 ) found that in hearing screening of neonates born in hedayat and milad hospital in tehran , 1 in 1000 neonates had hearing impairment , while ghasemi et al found an incidence of 2 out of every 1000 neonates . early diagnosis and immediate intervention play important role in the development and prognosis of children with hearing loss and decrease the impact of the condition on the child 's social , emotional , intellectual and linguistic development . behavioral techniques have a high number of false negative results . as electrophysiologic methods with greater sensitivity and specificity , the following may be used : auditory brainstem response ( abr ) automated auditory brainstem response ( aabr ) and evoked oto - acoustic emissions ( eoae ) . however , it is better to minimize false - positive results in developing a more reliable newborn hearing screening program . oae and abr tools are evolving and becoming more and more automated . determining which of them is most effective abr is a standard and very precise test in determining the average threshold of frequencies at 2000 - 4000 hz . the differences in the size of the external auditory canal and in the placement and type of earphone can produce small differences in the stimulus and therefore can lead to false negative results in mild hearing losses . however , the average time to carry out automated abr testing ranges from 8 to 15 min , and conventional oae tests take 2 to 13 min . in one study , all 2454 neonates born in 2001 - 2003 , were assessed by oae and 3117 neonates born in 2004 - 2006 , by aabr . screening by aabr had less false positive responses but it had high cost and needed more time for assessment . however , aabr and oae usually are used for screening , not for precise identifying of late hearing disorders . for precise identifying of hearing loss , complete abr tests ( frequency specific air and bone conduction ) should be used . according to iran statistics center if incidence of hearing loss is 2 per 1000 neonates , there will be 2500 neonates with hearing loss per year . without hearing screening tests , hearing loss will be identified and treated at the age of 2 - 3 years . therefore , it is necessary to secure holistic development of the child by detecting hearing loss at birth and providing remedial measures at the earliest . in our study , neonatal hearing screening is carried out on 1200 neonates born in baqiyatallah and najmiye hospitals in tehran , by teoae january 2008 - may 2009 . two hundred neonates were excluded from the study because they did not returned for abr test in the age of 3 months , so 1000 neonates completed the study . the sensitivity and specificity of teoae was compared with abr by statistic analyzes . also , the relationship between hearing loss and some risk factors ( age of parents , hyperbilirubinemia , hearing loss history in siblings or other family members , mother 's drug consuming during pregnancy , nicu stay , history of disease in other children , convulsion , antibiotics ) were studied in the two groups of impaired and normal abr . the goal of this study was to compare the results of a two - step screening process of teoae with diagnostic test of abr in a population of newborns . this research was observational cross - sectional study carried out between january 2008 and may 2009 . the hearing screening program was done in two hospitals ( baqiyatallah and najmiye ) in tehran . the teoae recordings were performed by echochek ecn06/07/4138 device ( auto dynamics co , england ) and abr by madsen ics - chartr ep , gn - otometrics co. ( version 5.4 ) ( table 1 ) . auditory brain stem response recording parameters the parents filled a questionnaire concerning biography and hearing loss history of their children . the audiologist conducted teoae and abr results in a non - sound silent room with the child in state of natural sleep in a common crib . the pass or fail responses of teoae and abr were recorded by audiologist and analyzed later by spss software . the average time for the total teoae measurement ( placement of electrodes and headphones not included ) , was 5 min in the initial screening test and 4 minutes in the rescreening test . they were retested in 10 - 15 days after birth by teoae and again all neonates were evaluated in the age of 3 months by abr . in other words , all neonates ( abnormal and safe neonates tested by oae at birth ) were tested by abr in the age of 3 months . data were presented as general numbers and percentage of positive or negative results obtained by newborn hearing screening and were collected in a central database and analyzed with spss version 17.0 . also , we analyzed the relationship between hearing loss incidence and risk factors by the methods of t - test and chi - square . after assessment of all neonates in 3 months by abr , if they had auditory disorders , were referred to an academic rehabilitation center for receiving appropriate treatment for speech and language skills . in addition , parents were informed for the need to return for rescreening in case of a first failure . out of the total population of 1000 newborns screened using teoae , 982 ( 98.2% ) had normal and 18 ( 1.8% ) impaired two - step teoae . tested with abr in 3 months , 991 ( 99.1% ) had normal and 9 ( 0.09% ) had impaired abr . hearing loss in 6 neonates , detected by teoae , was confirmed by abr in the age of 3 months . in other words , therefore , the false - positive rate of teoae was 1.2% in the initial newborn hearing screening . in the age of 3 months , out of the 1000 neonates , 9 showed hearing loss using abr of which 6 were identified by oae . newborn infants tested by two - stage teoae and abr ( n=1000 ) out of 9 neonates with hearing loss using abr , 2 had bilateral profound hearing loss , they received cochlear implantation . also , in this study , the sensitivity of teoae for identifying hearing loss was 66.7% and the specificity of it 98.8% . comparison of the effects of risk factors on the results of impaired abr and normal abr showed that in our study there is no difference between these two groups ( p>0.05 ) . table 3 shows the comparison of results of impaired abr and normal abr in these two groups . the incidence of hearing loss is different in various studies . according to wrightson ( 2007 ) , de michele ( 2010 ) found it 2 to 4 out of every 1000 newborns . in iran , lotfy et al ( 2007 ) , in hearing screening of neonates showed that among 1000 neonates born in tehran , only 1 had hearing impairment and ghasemi et al ( 2008 ) in mashhad city , found that the incidence was 2 per 1000 neonates . in our study the rate of hearing disorders was 9 out of 1000 neonates and deafness rate was 2 out of 1000 neonates . therefore , the early identification of hearing loss is very important for following auditory training and speech and language treatments in hearing impaired children . if a screening tool detects the majority of people with the same disorder , has validity and high sensitivity , and if it excludes most people without the disorder , has high specificity . abr is not affected by external ear wax or fluid and has high sensitivity and specificity . however , according to the american academy of family physicians , the sensitivity of oae in identification of hearing loss was 84% and its specificity 90% . in our study , the sensitivity ( 66.7% ) and specificity ( 98.8% ) of teoae for detecting hearing loss were high ; therefore , it is an effective tool for screening of neonates at birth . the oae screening is quicker and easier to perform than abr ; but it is affected by external ear wax or fluid . sometimes , in various studies , oae test is performed twice . an initial oae test is performed at birth and an oae retest performed 2 - 3 weeks later to decline referral rate for abr . for the initial screening in our study , infants were tested with teoae 24h after birth . all neonates ( hearing impaired and safe neonates tested by oae ) were tested by abr 3 months after birth . in iran , in a two - stage screening program using repeat screening with oae described by lotfy et al ( 2007 ) , the referral rate for oae is reported to be 7.7% when screening was performed within the first 24h after birth , and during second step it has been reported to be 1.67% . out of 1000 neonates , 18 ( 1.8% ) had hearing loss by two teoae tests . therefore , 12 responses of teoae were false positive . in the age of 3 months , out of 1000 neonates 9 had hearing loss by abr of whom 6 were identified by teoae . therefore , 3 responses of teoae were false negative . according to the joint committee on infant hearing ( jcih ) , only 2 - 5% of neonates with high risk registry have moderate or severe hearing loss and also 50% of neonates with congenital hearing loss have no evidence of risk factors . therefore , jcih suggested that hearing screening should be done in all neonates with or without high risk registry and also it is recommended to evaluate perfectly in 3 months hearing of neonates who failed in screening test . in our study , out of 9 neonates , 2 had nicu history , 1 had hearing loss history in family and 2 had history of mother 's drug consuming during pregnancy , the remaining 5 neonates had no risk factors . therefore , it is suggested that audiologists use hearing screening for all neonates not just for high risk babies . in other words , if the result of screening fails , complete hearing tests several weeks after birth should be done . in our study , abr was a very precise test for hearing of children and teoae results have shown various false negative and false positive rates , but the sensitivity and specificity of teoae was relatively high . therefore , teoae test can be used for the screening of neonates . according to these results , the importance of early diagnosis of hearing loss , high sensitivity , high specificity and easiness of teoae for implementation ( simple , non - invasive , short duration and cost effective method ) , we advise to use teoae as screening test for all neonates ( whether normal or high risk babies ) . although we evaluated teoae at birth for neonatal hearing screening and compared it with abr results in 3 months , it was carried out in two hospitals in tehran ; in a country like iran , which presents large ethnic differences , the same type of analysis should be performed in several regions . it is necessary to study generalized development of children by detecting hearing loss at birth and providing a screening test for assessment of them . in our study , we compared the results of teoae ( screening test ) with the results of abr ( diagnostic test ) and found sensitivity of teoae to be 66.7% and its specificity 98.8% . we conclude from these results that teoae is a good screening test for hearing loss of neonates ( whether normal or high risk babies ) , but because of false positive cases ( 12 cases out of 1000 ) its results must be confirmed with abr as a diagnostic test at three months of age as mentioned in jcih protocol .
objectivesince early detection ( specially before 6 months of age ) of deaf people leads to better hearing and speech outcome after treatment , several clinical trials have been performed in order to find a cost effective , short duration screening test for diagnosis of neonatal hearing impairment . 
 the aim of this study was to assess the sensitivity and specificity of transient otoacustic emission ( teoae ) test in newborns comparing with auditory brain stem response ( abr ) in the age of 3 months and to analyze the association between risk factors and hearing loss in neonates.methodsa cross - sectional study was conducted january2008 - may 2009 in tehran . 
 1000 newborns ( 526 boys and 474 girls ) were assessed . 
 first , all of neonates were evaluated by teoae 24h after birth . 
 if responses of oae were failing , they were retested 10 to 15 days after birth by teoae . 
 also , all neonates were assessed by abr in the age of 3 months . 
 descriptive statistics was used to analyze data.findingseighteen out of 1000 neonates failed double  checked teoae tests , of which 6 were confirmed by abr test ( 12 false positive results ) . 
 nine out of 1000 neonates had impaired abr tests , from these patients , 6 had failed oae as well , but 3 had normal oae ( 3 false negative results ) . from these 9 patients 2 had profound hearing loss and received cochlear implantation . 
 we found that oae has 66.7% sensitivity and 98.8% specificity in diagnosis of neonatal hearing impairment . 
 its positive and negative predictive value was 33.3% and 99.7% respectively . 
 also we did not find statistically significant relationship between hearing loss and risk factors.conclusionteoae as a simple , non - invasive , short duration and cost effective method , is a suitable test for neonatal hearing screening . even though only two thirds of patients were detected by this method , 
 99.7% negative predictive value makes it a good screening test . 
 we recommend oae as a suitable primary neonatal hearing screening all over the country .