Hearing Testing for Children: Timing and Recommendations
Hearing screening should begin at birth with universal newborn hearing screening, followed by objective screenings at regular intervals during well-child visits at 4,5,6,8,10,12,15, and 18 months, with all children requiring at least one diagnostic audiological assessment by 24-30 months of age if they have risk factors for hearing loss. 1, 2
Newborn and Early Infant Hearing Screening
Birth to 1 Month
- All newborns should undergo hearing screening before 1 month of age 1, 2
- Screening methods include:
- Otoacoustic emissions (OAE)
- Automated auditory brainstem response (ABR)
- NICU infants admitted for more than 5 days should have ABR included in their screening to detect neural hearing loss 2
Follow-up for Failed Screenings
- Infants who fail initial screening should receive comprehensive audiological evaluation by 3 months of age 1, 2
- Appropriate intervention should begin by 6 months for those with confirmed hearing loss 2
- Complete screening should be performed on both ears, even if only one ear failed the initial screening 2
Ongoing Hearing Assessment Schedule
Infancy to Toddlerhood (0-24 months)
- Objective hearing screenings should be scheduled at well-child visits at 4,5,6,8,10,12,15, and 18 months 1
- Age-appropriate testing methods include:
Preschool Age (2.5-4 years)
- Play audiometry is the recommended testing method 2
- Children aged 2-4 years are tested by being conditioned to respond to auditory stimuli through play activities 1
School Age (4+ years)
- Conventional audiometry can be used from age 4 years onward 1, 2
- Testing should be performed in a quiet environment using earphones 1
- Each ear should be tested at 500,1000,2000, and 4000 Hz 1
- Air-conduction hearing threshold levels greater than 20 dB at any of these frequencies indicate possible hearing loss and require referral to a pediatric audiologist 1
Special Considerations for High-Risk Children
Risk Factors Requiring Additional Monitoring
- All infants with risk factors for hearing loss should have at least one diagnostic audiological assessment by 24-30 months of age, even if they passed newborn screening 1, 2
- More frequent assessment is needed for children with:
Children with Developmental Delays
- Children with developmental abnormalities, cognitive impairments, or behavioral problems may require specialized testing approaches 1
- Referral to an otorhinolaryngologist and pediatric audiologist with appropriate equipment and expertise is recommended 1
Parental Concerns
- Any parental concern about hearing loss should be taken seriously and requires objective hearing screening of the child 1
- Parents often identify hearing concerns up to 12 months before healthcare providers 1
Common Pitfalls and Caveats
Testing Limitations
- ABR and OAE are tests of auditory pathway structural integrity but are not true tests of hearing 1
- Relying solely on OAE or ABR can miss mild hearing loss 2
- Behavioral pure-tone audiometry remains the standard for definitive hearing evaluation 1
Follow-up Challenges
- Loss to follow-up occurs in 6-15% of infants who fail screening 2
- 13-31% of infants who fail initial screening do not return for definitive testing 2
- Assuming a passed newborn hearing screen eliminates the need for ongoing monitoring can lead to missed cases of progressive or late-onset hearing loss 2
Testing Environment
- Ambient noise can significantly affect test performance, especially at lower frequencies (500 and 1000 Hz) 1
- Testing should be performed in a quiet environment, preferably in a separate closed or sound-proofed area 1
Universal newborn hearing screening has significantly reduced the age of identification of hearing impairment from 12-13 months to 3-6 months, highlighting the importance of early and ongoing screening 2, 3. Timely identification and intervention for hearing loss is critical to prevent delays in speech, language, and social-emotional development 4.