Hearing Evaluation in Children

If your child is deaf or hard of hearing (DHH), the sooner he or she is diagnosed, the better. Early intervention will provide you with the most treatment options for your child.

Path to improved health

Children who have hearing loss are being diagnosed sooner than ever. This is due to newborn hearing screenings. Every state has an Early Hearing Detection and Intervention (EHDI) program. In most cases, if your baby is born in a hospital, this early hearing screening takes place before you and baby even go home.

If you do not give birth in a hospital, you should have your baby’s hearing screened before he or she is 1 month old.

There are two hearing tests commonly used for newborn hearing screening: otoacoustic emissions and automated auditory brainstem response.

Otoacoustic emissions (OAE)

The screening is not painful and takes only a few minutes. In fact, it will be done while your baby is sleeping. A technician will insert soft, spongy earphones and a microphone into baby’s ear canals. When the cochlea is stimulated by a sound, the outer hair cells of the cochlea vibrate. The technician can measure this vibration.

Automated auditory brainstem response (AABR)

Like the OAE, this hearing screening is not painful and is typically performed while your baby is sleeping. It takes 5 to 10 minutes to complete. Testing the auditory pathway makes it possible to detect auditory neuropathy, a less common cause of hearing loss. For this test, earphones are placed in the ear canal. Sensors (electrodes) are placed on baby’s scalp. The electrodes are used to measure brainstem response to sound.

For most babies, these screenings will confirm that they can hear. Even if your baby does not pass this first screening, it may not mean that he or she has permanent hearing loss. Fluid in the middle ear is sometimes to blame. Or, if baby moved during the test, it can cause a faulty result. Only about 3 in 1,000 babies are born with permanent hearing loss.

No matter the reason, if your baby failed the newborn screening, he or she will be referred to a children’s hearing specialist (pediatric audiologist). It is very important to arrange for this evaluation as soon as possible (no later than 3 months of age).

Diagnostic auditory brainstem response (ABR)

If your baby failed the newborn hearing screening, the next test will likely be a diagnostic ABR. Sometimes, this test can be done while baby is sleeping. Sometimes baby stirs or wakes during this test. This can affect test results. For this reason, it’s possible that your hearing specialist may recommend a sedated ABR.

Behavioral hearing test

For this type of test, the child (usually with a parent) is seated in a sound booth. The sound booth creates a very quiet listening environment so that he or she won’t be distracted by other noise and can focus only on the sound created within the booth.

The hearing specialist (audiologist) then presents sounds, either through speakers in the booth or through earphones. For infants, the audiologist will monitor response (if any) to these noises (head turning toward noise, startle response, etc.). Older children will be able to raise their hands when they hear a noise.

The results of this test will be plotted on an audiogram, which is a graph that shows precisely the sounds your child can hear. The results mapped on the audiogram will help determine the degree of your child’s hearing loss (if any): mild, moderate, severe, or profound.

Auditory steady state response (ASSR)

Similar to the ABR, the ASSR uses electrodes (sensors) to measure the brain’s response to sound. It is an automated test that determines the degree of hearing loss (if any).

Acoustic reflex test

Also called the middle-ear-muscle reflex, this test uses spongy earphones to deliver sound to the ear in order to test an involuntary muscle reflex in the middle ear.


This test takes only a few seconds and can reveal if there is fluid in the middle ear or impacted wax. It can also determine if the conduction bones of the middle ear aren’t making contact. For the test, your hearing specialist will place a spongy earplug-like device in your child’s ear.

Hearing tests at school

When your child begins kindergarten, the health education department in most states will arrange for hearing screenings, usually through middle school. These screening are typically administered by the school nurse or speech language pathologist. Sometimes the screening environments are not ideal, but these tests provide an invaluable service. Children who have mild hearing loss not be properly diagnosed were it not for at-school screenings.

Hearing tests at your doctor’s office

Your child’s hearing should also be checked at your doctor’s office at every well-child visit (annual physical). A nurse will typically administer the hearing screening just after weighing and measuring your child.

Keeping your ears healthy

There are many ways to take care of your ears and protect yourself—and your child—from future hearing loss.

  • Do not use cotton swabs in your ears.
  • Don not listen to music at full volume.
  • Use ear protection or ear plugs to muffle the noise if you’re going to be around loud noises, whether you’re around loud equipment or even at a concert.
  • Turn down your television to the lowest volume at which you can hear it clearly.
  • Keep your ears dry.
  • Reduce the risk of ear infections by treating upper respiratory infections properly and in a timely manner.

Things to consider

If diagnostic hearing tests do reveal that your baby or child has hearing loss, you have many decisions to make. The type of hearing loss your child has will drive many of your choices.

Hearing loss

Hearing loss can be categorized into degrees (amount of hearing is lost) and also into types (the kind of hearing loss). In general, there are four degrees of hearing loss and two types of hearing loss.

Degrees of hearing loss include:

  • Mild – With this degree of hearing loss, your child probably has difficulty hearing in noisy environments but can understand language well in quiet environments.
  • Moderate – A moderate hearing loss will most often mean that your child has difficulties hearing and understanding regular speech sounds. Increasing the volume helps.
  • Severe – Children with a severe hearing loss cannot hear regular speech sounds at all. They can sometimes hear shouting.
  • Profound – The degree of hearing is worst in this category of loss. Even with a hearing aid, it’s improbable that your child will be able to hear speech sounds.

Types of hearing loss include:

  • Conductive hearing loss – This type of hearing loss is associated with a problem in the middle ear that prevents sound to travel from the outer ear to the eardrum. It can be caused by ear infections, impacted earwax, fluid on the middle ear, or even the middle ear not forming the way it was supposed to form. This type of hearing loss can often be medically corrected.
  • Sensorineural hearing loss – This is the most common type of hearing loss. Sensorineural hearing loss is caused by damage to the inner ear (cochlea) or to the nerves that connect the cochlea to the brain. It can be caused by genetics (hearing loss runs in your family), by illness (or medications for some illnesses that are toxic to your ears), by the inner ear not developing the way it was supposed to develop, or by exposure to loud noises. It also can be caused as a result of getting older. There is usually not a medical or surgical correction for sensorineural hearing loss.

Instruments to improve sound

Depending on the type and degree of hearing loss your child has, there is equipment that can help give him or her access to sound. Having access to sound can help your child develop spoken language.

  • Hearing aids – These devices are typically worn behind the ears and are used to amplify sound. They make everything louder. Hearing aids are often a good option for people who have mild to moderate hearing loss, and sometimes even severe hearing loss. They do not offer much benefit for people with profound hearing loss.
  • Cochlear implants – For people with profound or severe-to-profound hearing loss, cochlear implants are an option that will provide them with sound or a sense of sound. The implant is an electronic medical device that is surgically implanted behind or above the ear and inside the cochlea (inner ear). The speech processor part of the cochlear implant is worn externally and includes a microphone.

When to see a doctor

Even with all of the hearing screenings that are put in place to catch hearing loss as early as possible, you are always your child’s best advocate. If you suspect that your child can’t hear well, call you doctor and request a hearing screening.

Symptoms of hearing loss in babies and young children

  • Your baby doesn’t startle to loud noises (even when sleeping).
  • Your baby does not imitate sounds.
  • Your baby doesn’t turn to your voice when not facing you.
  • Your baby doesn’t notice when toys make noise.
  • Your child isn’t speaking at an age-appropriate time.
  • Your child doesn’t respond to simple directions when age-appropriate.

Symptoms of hearing loss in children 3 to 4 years old

  • Your child cannot answer simple questions (who, where, why).
  • Your child is not speaking or does not speak in sentences.
  • Your child does not come when you call to him or her from another room.
  • Your child does not respond to music on the radio or responds only when the volume is turned up to a loud level.

Symptoms of hearing loss in children 4 to 6 years old

  • Your child does not pronounce words correctly.
  • Your child speaks loudly even in a quiet environment.
  • Your child avoids speaking to adults and other children.
  • Your child does not enjoy it when you read to him or her.

Questions for your doctor

  • Where should I take my child for a hearing screening?
  • Is my child hard of hearing or just not listening?
  • How can I recognize hearing loss if it develops as my child gets older?
  • Hearing screenings seem subjective. Is there a more precise way to evaluate hearing?
  • If my child has hearing loss, could his or her hearing return?
  • What caused my child’s hearing loss?
  • No one in my family is deaf. How can my child be deaf?