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Hearing Screening

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Universal newborn screening programs aim to screen hearing in all infants by age 1 month, identify all babies with hearing loss by age 3 months, and provide interventions by age 6 months. [Joint: 2007] Though most cases of permanent sensorineural hearing loss are detected through universal hearing screening in the newborn nursery, hearing loss may begin after the perinatal period (late-onset) or be progressive.
The American Academy of Audiology advises school-based screening in preschool, kindergarten, and grades 1, 3, 5, and either 7 or 9. [American: 2011] The American Academy of Pediatrics (AAP) recommends subjective assessment of hearing (and assessment of risk for hearing loss) at all well-child examinations and objective hearing screening at school entry. When possible, the AAP also advises objective office-based screening for children ages 4,5, 6, 8, 10, 12, 15, and 18 years old.
Developmental abnormalities, poor cognitive function, or behavioral problems (e.g., autism/developmental delay) may preclude accurate results on routine audiometric screening; referral to an otolaryngologist and a pediatric audiologist who have the necessary equipment and expertise to test infants and young children should be considered.
The following algorithms provide further guidance.

Risk Factors

Risk factors that may warrant screening beyond that routinely recommended include:
  • Caregiver or clinician concern regarding speech, language, or hearing delay based on surveillance or developmental screening
  • Family history of permanent childhood hearing loss
  • Birth weight <1500 g
  • Neonatal intensive care ≥5 days (although some recommend any NICU length of stay) [Garinis: 2018]
  • A history of ECMO (5-28% of ECMO survivors had hearing loss on follow-up testing) [Garinis: 2018]
  • Hyperbilirubinemia requiring exchange transfusion
  • Ototoxic medications >5 days including aminoglycosides and glycopeptide antibiotics (gentamicin and tobramycin), loop diuretics (furosemide), and chemotherapy
  • Mechanical ventilation >5 days
  • Intrauterine TORCH infections, such as cytomegalovirus, herpes, rubella, syphilis, and toxoplasmosis
  • Conditions associated with hearing loss, such as neurofibromatosis type 2, osteopetrosis, and syndromes, such as Usher, Waardenburg, CHARGE, Alport, Pendred, and Jervell, and Lange-Nielson
  • Neurodegenerative disorders, such as Hunter syndrome, or sensory-motor neuropathies, such as Friedreich ataxia and Charcot-Marie-Tooth syndrome [Harlor: 2009]
  • Culture-positive postnatal infections associated with sensorineural hearing loss, including confirmed bacterial and viral (especially herpes viruses and varicella), and meningitis
  • Head trauma, especially basal skull/temporal bone fracture that requires hospitalization
  • Recurrent/persistent otitis media with effusion >3 months (or less if any other risk factors, such as speech delay) [Rosenfeld: 2016]
See Early Childhood Hearing Outreach Initiative (NCHAM) for information on screening young children with otoacoustic emissions in the office. [Liming: 2016]

How is Hearing Screened?

Hearing screening is typically a simple evaluation providing “pass/fail” results. It is commonly performed in the newborn nursery or birthing center, primary care clinic, school, and daycare settings. People other than audiologists may be trained to provide hearing screening, including nurses, early intervention specialists, medical technicians, medical assistants, and teachers. Failed hearing screens should trigger more extensive diagnostic testing performed in a hearing clinic. Passing results usually do not require further hearing evaluations unless there is a strong index of suspicion.
The most common methods used to test children’s hearing include:
  • Otoacoustic emission (OAE) testing
  • Auditory brainstem response (ABR) testing or brainstem auditory-evoked response (BAER)
  • Pure-tone testing/audiogram

Otoacoustic Emission (OAEs)

Often used in newborn nurseries to screen hearing in infants, the OAE involves placing a small probe in the baby’s ear that measures the small sounds generated by hair cells in the cochlea (inner ear) as these hair cells respond to clicks presented in the frequency range of about 800-4000 Hz. This test can only determine if normal cochlear function is present – it cannot specify the degree (mild, moderate, severe, or profound) or type (conductive or sensorineural) of hearing loss, if present. Many pediatricians and early intervention specialists use OAE to screen for hearing loss in older toddlers and children. International guidelines from 2016 advise use of OAE and ABR for high-risk infants.

Auditory Brainstem Response (ABR) / Brainstem Auditory Evoked Response (BAER) Testing

Adult holding an infant with various monitoring devices
ABR hearing test
The ABR and BAER are often used in neonatal intensive care units to screen for hearing loss. They are and gaining favor in newborn nurseries [Liming: 2016] and used when conventional testing cannot be done. This is especially helpful for young children or older children with developmental delays that make behavioral testing unreliable. It can be performed on young infants during a natural sleep state. For older infants and toddlers, it is usually done with sedation because a child must be completely still during the test.
ABR involves recording the brain’s activity in response to clicking sounds in a frequency range from 500-4000 Hz delivered to the child’s ear. The intensity of the sound can be increased up to about 105 dB. Compared with the broad range of human hearing, the frequency range of this test is somewhat narrow. However, the range that is tested encompasses the common frequencies that are needed for speech and language development. The ABR is not a hearing test, but rather a test of the auditory-neural response to sound. ABR test reports may be complex, but the summary should include the clinically relevant findings and their implications for hearing and follow-up. See an example of a Child ABR Report (PDF Document 40 KB).

Pure-Tone Testing / Audiogram

Boy with earphones raising hand while an adult sits next to him
Pure-tone testing
Hearing screening for children ages ≥3 years is commonly performed using a pure-tone test. This frequently consists of listening to sounds through headphones and raising a hand indicating when a beep is heard on that side. The results can be plotted on an audiogram that shows the frequency and decibel level of the individual’s hearing threshold. For young children (preschool through grade 1), recommendations are to add tympanometry in conjunction with pure tone screening (American Academy of Audiology Childhood Hearing Screening Guidelines (PDF Document 684 KB)).
The Human Hearing Chart shows human hearing in hertz frequencies (with real-life examples) and the range that audiograms test.
Human hearing chart
For children who are unable to participate in hearing screening, a referral for a hearing evaluation is advised. The Human Hearing Chart (PDF Document 1.0 MB) (right) shows human hearing in hertz frequencies and the range that audiograms test. The range of hearing that the audiogram represents is shown on the chart in the shaded area labeled “AUDIOGRAM.” Also, see an example of an Audiogram Showing Hearing Loss (PDF Document 269 KB).

Who Provides Pediatric Hearing Testing?

For failed hearing screens, diagnostic testing (“hearing evaluation”) should be performed by a licensed audiologist who is trained in testing children and has access to the testing equipment needed to evaluate children. Children with special health care needs are best served by a pediatric audiologist trained in working with this population. Early Intervention programs will usually offer hearing screening or testing, as will state programs focused on children with special health care needs and/or disabilities. Newborn screening programs can also guide you to reliable resources, particularly those focused on following up on abnormal newborn screens.

Costs and Insurance Coverage

The cost of hearing testing can range from <$100 for a screening evaluation to >$700 for a full diagnostic evaluation, depending on the comprehensiveness of testing. Sedated procedures will cost more because medical staff is needed to provide safe sedation with patient monitoring. In many cases, insurance and other third-party payers will cover the cost of testing. Co-pays and deductibles will apply, so each family should check their insurance benefits to understand the cost before testing is performed. Some insurance plans will require a referral from a physician.

Normal Hearing in Children

Normal hearing is essential for normal speech and language development in children. Even mild or fluctuating hearing loss can impact a child’s speech and language development. Though most children are now screened for hearing loss as newborns, it is important to retest hearing when there are concerns about hearing or speech/language development. Failure to meet the developmental milestones below should raise concern.
between 0-3 months, the child: between 3-6 months, the child:
  • Startles to a sharp clap within 3-6 feet
  • Can be awakened from sleep by sounds
    (without being touched)
  • Cries at sudden, loud noises (door
    slamming, dog barking)
  • Is reassured by laughter and sounds
    of pleasure
  • Is calmed by voice, appears to listen
  • May “coo” when being talked to
  • Responds to your voice by making sounds
  • Shows interest in contrasting sounds (loud-soft,
    high-low, etc.)
  • Knows mother’s or father’s voice
  • Enjoys making noises (crying, lip noises, tongue clacking)
  • Laughs, coos, and babbles for pleasure
  • Begins to turn head toward sounds
  • Responds to loving/angry tones of voice
  • Begins to look for soft speech sounds
  • May not startle as much as before
between 6-9 months, the child: between 9-12 months, the child:
  • Looks side to side to find where a sound
    is coming from — must be able
    to hear in both ears
  • Knows own name when others say it
  • Searches for sounds that are at eye level
    and downward
  • Plays pat-a-cake and peek-a-boo
  • Imitates simple sounds understands simple
    words (no-no, oh-oh)
  • Pays attention to music or singing
  • Knows names of family members even when
    person is not in sight
  • Searches for sources of sound (bell or squeak toy)
  • Can find a sound coming from behind self
  • Enjoys hearing new words
  • Imitates sound of cows, clocks, dogs, etc.
  • Uses first meaningful word
  • Babble sounds more like a conversation with some words
    you can recognize
  • Points to or looks at a familiar object when asked
  • Can wave “bye-bye” when asked to
  • Understands simple questions (“Where is Mommy?”)
No child is too young to be tested for hearing loss. The earlier hearing loss is detected, the sooner the child can be helped to hear normally and to develop his or her best communication and social skills.
The Hearing Loss and Deafness has detailed diagnoses and management information.

Resources

Information & Support

For Professionals

National Center for Hearing Assessment and Management (USU)
A national resource center for the implementation and improvement of comprehensive and effective Early Hearing Detection and Intervention (EHDI) systems; Utah State University.

Early Childhood Hearing Outreach Initiative (NCHAM)
The ECHO initiative provides extensive information, including tutorials and resource links, to support health care providers screening for hearing in young children; National Center for Hearing Assessment and Management.

Early Hearing Detection and Intervention (AAP)
Enhances clinical knowledge of the EHDI program and screening guidelines and helps to ensure that newborn screening results are communicated to families and reported according to state laws. Also has links to state chapters, EHDI experts, and resources; American Academy of Pediatrics and the Early Hearing Detection and Intervention Program.

Hearing Loss in Children – Recommendations and Guidelines (CDC)
Collection of recommendations and guidelines related to hearing screening and hearing loss in infants and children; Centers for Disease Control.

For Parents and Patients

My Baby's Hearing (NIDCD)
Information for families about hearing screening and hearing loss, follow-up, amplification options, and more. A link to the site in Spanish is on the home page; Boys Town National Research Hospital and the National Institute on Deafness and Other Communication Disorders.

Hearing Loss in Children (CDC)
Information, statistics, screening/diagnosis, and treatments; from the Centers for Disease Control and Prevention.

OAE Video (kidshearing.org)
A 1-minute video demonstrating use of OAE testing from infanthearing.org.

Practice Guidelines

Harlor AD Jr, Bower C.
Hearing assessment in infants and children: recommendations beyond neonatal screening.
Pediatrics. 2009;124(4):1252-63. PubMed abstract / Full Text

Joint Committee on Infant Hearing.
Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs.
Pediatrics. 2007;120(4):898-921. PubMed abstract / Full Text

Liming BJ, Carter J, Cheng A, Choo D, Curotta J, Carvalho D, Germiller JA, Hone S, Kenna MA, Loundon N, Preciado D, Schilder A, Reilly BJ, Roman S, Strychowsky J, Triglia JM, Young N, Smith RJ.
International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Hearing loss in the pediatric patient.
Int J Pediatr Otorhinolaryngol. 2016;90:251-258. PubMed abstract
Expert opinion by the members of the International Pediatric Otolaryngology Group on the workup of hearing loss in the pediatric patient.

Rosenfeld RM, Shin JJ, Schwartz SR, Coggins R, Gagnon L, Hackell JM, Hoelting D, Hunter LL, Kummer AW, Payne SC, Poe DS, Veling M, Vila PM, Walsh SA, Corrigan MD.
Clinical Practice Guideline: Otitis Media with Effusion (Update).
Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41. PubMed abstract
Update of a 2004 guideline co-developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME).

Tools

Bright Futures/AAP Periodicity Schedule (PDF Document 119 KB)
Recommendations for preventive pediatric health care; American Academy of Pediatrics.

Office Visit Hearing Assessment Algorithm (AAP)
One-page algorithm accounting for risk factors and screen results from Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening Allen D. Buz Harlor, Charles Bower; Committee on Practice and Ambulatory Medicine, Pediatrics October 2009.

Algorithm for Pediatric Medical Home Providers (AAP) (PDF Document 243 KB)
One-page algorithm for screening, evaluation, and intervention of infants 0-6 months old; from the American Academy of Pediatrics Early Hearing Detection and Intervention (EHDI) program.

Guidelines for Medical Home: Reducing Loss to Follow-Up in Newborn Hearing Screening (AAP) (PDF Document 160 KB)
One-page algorithm for follow-up of the newborn hearing screen beginning with the first newborn pediatric patient care visit; National Center for Medical Home Implementation, sponsored by the American Academy of Pediatrics.

Services for Patients & Families Nationwide (NW)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: August 2011; last update/revision: April 2020
Current Authors and Reviewers:
Author: Jennifer Goldman, MD, MRP, FAAP
Authoring history
2013: update: Jennifer Goldman, MD, MRP, FAAPCA
2011: first version: Nancy Hohler, AuD, MBAA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

American Academy of Audiology.
American Academy of Audiology.
(2011) https://www.cdc.gov/ncbddd/hearingloss/documents/AAA_Childhood-Hearing....

Joint Committee on Infant Hearing.
Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs.
Pediatrics. 2007;120(4):898-921. PubMed abstract / Full Text

Liming BJ, Carter J, Cheng A, Choo D, Curotta J, Carvalho D, Germiller JA, Hone S, Kenna MA, Loundon N, Preciado D, Schilder A, Reilly BJ, Roman S, Strychowsky J, Triglia JM, Young N, Smith RJ.
International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Hearing loss in the pediatric patient.
Int J Pediatr Otorhinolaryngol. 2016;90:251-258. PubMed abstract
Expert opinion by the members of the International Pediatric Otolaryngology Group on the workup of hearing loss in the pediatric patient.