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Summary: American Indian children have three times the rate of otitis media compared to the general population, yet prospective cohort studies of OME and hearing loss have not been previously reported in American Indian infants. Between 1997 and 2003, a cohort of 421 infants was enrolled at birth from Minnesota American Indian reservations and an urban clinic and followed to age 2 years. This study reports OAE hearing screening results related to OME diagnoses, as well as risk for recurrent hearing screening failure and OME in American Indian infants and children. Methods: Infants were prospectively assessed at regular intervals with pneumatic otoscopy, distortion product otoacoustic emissions, and tympanometry by nurses who were trained in all procedures and validated on pneumatic otoscopy. Results: In the newborn period, 23.5% of infants failed hearing screening in at least one ear. Hearing screening failures increased to 29.9% from 2 to 5 months of age. Technical fail results due to excessive noise occurred frequently in infants 6–24 months of age, making interpretation of true pass and fail rates questionable in older infants. OAE test result was associated with OM diagnosis, and this relationship strengthened with age, with the strongest association above 6 months of age. Conclusions: A high rate of hearing screening failures occurred among American Indian infants in the first 5 months of age, and was significantly associated with a correspondingly high rate of otitis media. Only one infant out of 366 was identified with sensorineural hearing loss, thus essentially all of the hearing screening failures reflected either a middle ear origin or other temporary problems. OAE screening provided a valuable hearing screening measure in this population at high risk for recurrent otitis media, but due to excessive noise in infants 6 months and older, practical use of OAE screening is limited. Use of behavioral assessment is needed after 6 months of age, when high rates of OME persist in this population. Increased efforts to develop public and medical education, as well as screening, diagnosis and treatment programs are needed to detect and decrease recurrent OME in American Indian infants and children. [Copyright &y& Elsevier]