Hearing Loss in Children

Overview

The scope of this page is hearing loss in children aged birth to 18 years.

See the Hearing Loss (Newborn) Evidence Map, the Hearing Loss (Early Childhood) Evidence Map, the Hearing Loss (School-Age) Evidence Map, and the Language and Communication of Deaf or Hard of Hearing (DHH) Individuals Evidence Map for summaries of the available research on this topic.

Hearing-related terminology may vary depending upon context and a range of factors. See the American Speech-Language-Hearing Association (ASHA) resource on hearing-related topics: terminology guidance for more information.

For the purpose of this page, hearing loss refers to a partial or total inability to hear or “hearing thresholds outside the range of typical hearing” when describing audiologic assessment results and diagnoses. There is some support of alternative terminology, such as “reduced hearing” or “decreased hearing levels” to describe those born without the ability to hear. The Joint Committee on Infant Hearing (JCIH) offers further perspective on terminology on page two of the Year 2019 Position Statement (JCIH, 2019).

Hearing loss can be categorized as conductive, sensorineural, or mixed. It can result from problems with the ear (outer, middle, and/or inner), cranial nerve eight (CN VIII), and/or the central auditory system. Hearing loss has a variety of causes and may be

bilateral or unilateral,
symmetrical (degree and configuration of hearing loss are the same in each ear) or asymmetrical,
progressive or sudden in onset,
fluctuating or stable, and
present at birth or acquired.

Some children are identified with hearing loss during a newborn hearing screening conducted shortly after birth. See the ASHA Practice Portal page on Newborn Hearing Screening. Other cases of childhood hearing loss may have a later onset and/or be progressive in nature. In addition, some mild hearing losses, hearing losses confined to specific frequency ranges, and auditory neuropathy may not be identified through newborn hearing screening due to limitations of the test equipment or testing methodology used. For this reason, audiologic monitoring over time is important for all children, especially for those who may be at risk for hearing loss. See the ASHA Practice Portal page on Childhood Hearing Screening for more information.

Exposure to language is critical to speech and language development, communication, literacy, learning, and psychosocial well-being. Unidentified hearing loss can impact early spoken language access. Early identification of hearing loss and implementation of intervention services have been shown to have positive outcomes on overall development in deaf and hard of hearing children (Moeller et al., 2016; Sininger et al., 2010; Yoshinaga-Itano et al., 2018). See the ASHA Practice Portal page on Early Intervention for more information.

The assessment, treatment, and management of hearing loss and related disorders in children involves interprofessional processes and collaboration. Audiologists, speech-language pathologists, otolaryngologists, pediatricians, and other specialists may be involved depending on the child’s needs. See the ASHA resource on interprofessional education/interprofessional practice (IPE/IPP) for more information on interprofessional collaborative practice.

Children who are deaf and hard of hearing and their family (including parents, guardians, family members, caregivers, and support system members for the purpose of this page) are integral to assessment, treatment, early intervention, and management processes. These processes include planning, decision making, and service delivery. Comprehensive hearing health provision models include person- and family-centered approaches (Grenness et al., 2014; Sass-Lehrer, 2004). An international panel of experts described the guiding principles of family-centered early intervention for children who are deaf and hard of hearing, which include partnership between families and professionals, informed decision making, and access to support services (Moeller et al., 2013). Families who are actively involved and engaged in the assessment and treatment processes achieve better outcomes and promote successful language development in children who are deaf and hard of hearing (Costa et al., 2019; DesJardin, 2006). ASHA resources on this topic include focusing care on individuals and their care partners and the ASHA Practice Portal page on Cultural Responsiveness.

Incidence and Prevalence

The incidence of a disorder or condition refers to the number of new cases identified in a specified time period. Prevalence refers to the number of individuals who are living with the disorder or condition in a given time period.

Worldwide, approximately 34 million children present with a hearing loss greater than 35 dB in the better hearing ear and requiring (re)habilitation (World Health Organization [WHO], 2021b). In 2019, 5,934 newborns born in the United States were identified with permanent hearing loss (a prevalence rate of 1.7 per 1,000) when screened by Early Hearing Detection and Intervention (EHDI) newborn hearing screening programs (Centers for Disease Control and Prevention, 2021). The prevalence of hearing loss increases with age. By adolescence, estimates vary from 3.5 per 1,000 cases of bilateral sensorineural hearing loss (Korver et al., 2017; Morton & Nance, 2006) to 23 per 1,000 cases of unilateral and bilateral hearing loss (Lin et al., 2011). School-age children with hearing loss often present with co-occurring developmental disabilities such as intellectual disability (23%), cerebral palsy (10%), autism spectrum disorder (7%), and/or vision impairment (5%; Van Naarden Braun et al., 2015).

WHO (2016) estimates that as many as 60% of hearing loss cases in children are the result of preventable causes, while approximately 40% of all cases are due to non-preventable causes (e.g., genetic factors). Some of the most common causes of childhood hearing loss include the following:

Approximately 50% of all hearing loss in newborns is due to genetic factors, 15% of which are syndromic (i.e., resulting from syndromes often associated with hearing loss) and 35% of which are nonsyndromic (Smith et al., 2005; WHO, 2021a).
Maternal infections leading to congenitally acquired infections (e.g., cytomegalovirus, rubella) are responsible for 40% of all non-genetic hearing loss in newborns (Cohen et al., 2014; WHO, 2021a).
WHO (2021a) estimates that 14% of children impacted by certain acquired infections and vaccine-preventable diseases (e.g., measles, mumps, Streptococcus pneumoniae, varicella-zoster virus, meningitis) may experience hearing loss, of which 5% may be profound.
Complications and/or conditions at birth such as prematurity, low birth weight, hypoxia (i.e., lack of oxygen), and neonatal jaundice (i.e., hyperbilirubinemia) are responsible for 17% of childhood hearing loss (WHO, 2016).
Exposure to ototoxic medication taken by children or those who are pregnant results in 4% of childhood hearing loss (WHO, 2016).
An estimated 12.5% of children and adolescents aged 6–19 years (approximately 5.2 million) have suffered permanent damage to their hearing from excessive exposure to noise (Centers for Disease Control and Prevention, 2020; Niskar et al., 2001).
Emerging evidence suggests that poor nutrition during childhood corresponds with higher prevalence of hearing loss (Emmett et al., 2018; Jung et al., 2019).
By the age of 10 years, 80% of children experience at least one episode of otitis media, which can cause temporary conductive hearing loss (Schilder et al., 2016). Worldwide, more than three in 1,000 people are estimated to have a permanent hearing loss (30 dB or more in the better ear) due to otitis media (Monasta et al., 2012).

Signs and Symptoms

Signs and symptoms of hearing loss in infants and toddlers vary and may include the following:

lack of startle to loud noises
absence of reaction to voices
lack of attempts to locate the source of a sound
attention to some sounds but not others
interruption in babbling and making new sounds
delay in reaching developmental milestones

Signs and symptoms of hearing loss in children may include the following:

delayed speech and/or language development
speech sound disorder
difficulty in following or understanding instructions
frequent requests for repetition
use of increased volume on the TV or other listening devices
difficulty effectively expressing themselves (e.g., in oral and/or written language)
frustration with communication breakdowns
feeling of exhaustion at the end of a school day
academic, behavioral, or social difficulties at school (e.g., concerns regarding literacy, pragmatic and social communication skills, and executive functioning)

Causes

Hearing loss in children can be attributed to a variety of etiologies, and the cause is sometimes unknown. It may be congenital (i.e., present at birth) or acquired (i.e., develops after birth).

Hearing loss due to genetic causes may present at birth or develop later in life. Most genetic hearing loss can be described as autosomal recessive or autosomal dominant. Rarer types of genetic hearing loss include X-linked (i.e., related to the sex chromosome) or mitochondrial inheritance patterns.

Genetic syndromes have a group of signs and symptoms that together indicate a specific disease. Many genetic syndromes include hearing loss as one of the symptoms. In fact, 20% of babies with genetic hearing loss have a syndrome (Morton & Nance, 2006). Examples of genetic disorders that may include hearing loss as a symptom include

Causes of congenital hearing loss related to complications of pregnancy or birth include

the absence or malformation of parts of the outer and/or middle ear (e.g., atresia, stenosis);
anoxia (i.e., lack of oxygen);
birth injuries;
complications associated with the Rh factor in the blood/jaundice;
hyperbilirubinemia;
inner ear malformations (e.g., Mondini malformation, large vestibular aqueduct);
low birth weight;
maternal diabetes;
maternal infections (e.g., rubella, cytomegalovirus, herpes simplex virus);
prematurity;
toxemia during pregnancy; and
toxins, including drugs and alcohol consumed by the mother during pregnancy.

Causes of acquired hearing loss in children include

cerumen,
ear infections (e.g., external otitis, otitis media),
encephalitis,
excessive noise exposure,
head trauma (e.g., traumatic brain injury, damage to middle or inner ear structures),
meningitis,
ototoxic medications,
the presence of a foreign body, and
viral infection (e.g., measles, mumps, chicken pox).

Roles and Responsibilities

Roles and Responsibilites of Audiologists

Audiologists play a central role in the identification, screening, assessment, diagnosis, management, treatment, and (re)habilitation of children who are deaf and hard of hearing. The professional roles and activities in audiology include clinical and educational services (e.g., diagnosis, assessment, planning, counseling, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).

The following roles and responsibilities are appropriate for audiologists:

As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists who serve this population should be specifically educated and appropriately trained to do so. The Joint Committee on Infant Hearing (2019) notes that “audiologic diagnosis of the infant is the sole purview of the audiologist with specific skills, knowledge, and access to all necessary equipment for infant and early childhood audiologic diagnostic evaluations” (p. 12).

Roles and Responsibilities of Speech-Language Pathologists

SLPs play a role in the identification, screening, assessment, and (re)habilitation of children who are deaf and hard of hearing. Professional roles and activities in speech-language pathology include clinical and educational services; prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

The following roles and responsibilities are appropriate for SLPs:

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Collaboration With Other Professionals

A child- and family-centered plan of care for a child who is deaf or hard of hearing will involve a team of collaborative professionals. The composition of an interprofessional team will vary based on the needs of the child and their family. These professionals may include, but not be limited to, the following:

audiologist (i.e., clinical audiologist, educational audiologist)
classroom teacher
counselor
developmental pediatrician
early interventionist
family practice physician
genetic counselor
occupational therapist
ophthalmologist
otolaryngologist
pediatrician
psychologist
physical therapist
sign language specialist
social worker
SLP
teacher of the deaf and hard of hearing

See the ASHA resource on interprofessional education/interprofessional practice (IPE/IPP) for more information on this topic.

Counseling

Counseling and education for a child who is deaf or hard of hearing and their family begins during the initial contact. Along with providing information on the overarching topics related to hearing loss, the audiologist can offer guidance and support the informed decision-making process of the child and family regarding potential goals, supports, and services to be implemented, including amplification options if appropriate. It is important that all information, education, resources, and answers to questions are provided in a manner that is understandable to the child and/or their family and in the language(s) that they use. See the ASHA resource on health literacy for more information.

Topics and issues addressed through counseling may include

the impact of hearing loss on child development,
language and communication modalities,
coping and compensatory strategies,
identification and response to barriers to effective implementation of amplification or other supports, and
realistic expectations for treatment.

As a member of an interprofessional care team, the SLP also plays a key role in counseling the child and/or family regarding language and communication needs and the effects of hearing loss on child development. Referrals for formal counseling by a mental health provider (e.g., school counselor, psychologist) may also be indicated.

The Ida Institute offers tools specifically designed for counseling children and families (e.g., My Hearing Explained for Children). ASHA’s audiology patient education handouts may be helpful during child and family counseling activities. For more information on this topic, visit the ASHA Practice Portal pages on Counseling in Audiology and Speech-Language Pathology and Cultural Responsiveness.

Assessment

See the Assessment section of the Hearing Loss (Newborn) Evidence Map, the Hearing Loss (Early Childhood) Evidence Map, and the Hearing Loss (School-Age) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

For guidance and considerations on infection control practices during the assessment process, see the ASHA page on infection control resources for audiologists and speech-language pathologists.

Identification/Screening

The Joint Committee on Infant Hearing (JCIH) Year 2019 Position Statement endorses a 1–3–6 global benchmark for hearing loss identification and intervention in infants. The goals include the following:

All infants undergo a hearing screening prior to discharge from the hospital and no later than 1 month of age.
All infants who do not pass their newborn hearing screening (and/or rescreening) are referred immediately for a comprehensive audiologic and otologic evaluation to be completed by 3 months of age.
All infants identified as deaf and hard of hearing receive a referral for early intervention services immediately after diagnosis and no later than 6 months of age along with access to audiologic services including appropriate hearing aid, cochlear implant, and hearing assistive technologies as determined by the child’s needs and the family’s preferences.

The JCIH endorses specific screening protocols for well babies, babies in the newborn intensive care unit, and those who are born significantly preterm and/or experience prolonged hospitalization.

Regardless of previous hearing screening outcomes, all infants are encouraged to receive ongoing surveillance of communicative development beginning at 2 months of age. Suggested monitoring also includes regular surveillance of developmental milestones, auditory skills, parental concerns, and middle ear status performed in the medical home and consistent with the American Academy of Pediatrics pediatric periodicity schedule [PDF] (JCIH, 2019).

See the ASHA Practice Portal pages on Newborn Hearing Screening and Childhood Hearing Screening for more information on this topic.

Comprehensive Audiologic Assessment

The purpose of the comprehensive and child-centered audiologic assessment is to

assess the integrity of the auditory system in each ear,
measure hearing sensitivity across frequencies,
determine the type of hearing loss (i.e., conductive, sensorineural, mixed),
establish a baseline for future monitoring,
provide ear-specific information needed to guide the selection and fitting of hearing technologies,
assess any impact or possible impact of hearing loss on daily function and quality of life, and
initiate child and family education.

Comprehensive assessment is performed on both ears, even if only one ear does not pass the screening test. Audiologic assessment for children aged birth to 18 years may include the following:

case history
medical referral
developmental screening
otoscopy
audiologic test battery, including

acoustic immittance testing procedures (i.e., tympanometry, wideband reflectance, acoustic reflex testing)
auditory evoked potential testing (i.e., auditory brainstem response [ABR] testing, automated steady-state response [ASSR], otoacoustic emissions [OAEs])
behavioral testing (i.e., behavioral observation audiometry [BOA], pure-tone audiometry, speech audiometry)

self-assessments and/or parent and family assessments (e.g., communication inventories)

Case History

Accurate diagnosis of hearing loss relies on the audiologist’s interpretation of a test battery within the context of the child’s medical and developmental history. Case history information may indicate a need for modification of evaluation procedures. For example, the audiologist may choose to include an evaluation of the high-frequency region of the cochlea (i.e., above 4000 Hz) for a young child with a history of ototoxic drug exposure. Modification of routine assessment procedures also may be necessary when evaluating a child with multiple disabilities. A thorough case history, preferably recorded using a standard form (e.g., a form developed by the assessment center), may include the following:

child’s age
hearing health history (including regarding the onset of hearing loss)
prenatal and birth history
medical history (including current medications and medication history)
developmental milestone information
family history of hearing loss
results of genetic testing
presence of developmental disabilities
current communication status and needs (including current and preferred language/communication system)
current educational status and services
child and/or family goals and expectations (including responses to questionnaires and/or self-assessment tools regarding communication and quality of life)
information about support systems

See the ASHA Practice Portal page on Cultural Responsiveness for information on gathering a case history and ethnographic interviewing.

Medical Referral

A range of factors influence the establishment of a child’s medical home in relation to hearing health care. For more information on what constitutes a medical home for children who are deaf and hard of hearing, see National Center for Hearing Assessment and Management: Medical Home. A pediatrician or a family physician may be the first medical professional involved in a child’s hearing health care. Referrals to other medical specialists (e.g., otolaryngologist, ophthalmologist, geneticist, neurologist) are based on a child’s specific needs, concerns, and/or signs and symptoms. Specialists can help determine the etiology of the hearing problems, identify related conditions, and provide recommendations for medical and/or surgical treatment. See the American Academy of Pediatrics Early Hearing Detection & Intervention Implementation Tip Sheet [PDF] for examples of tools (i.e., checklists, screening algorithms) to support medical home providers in monitoring a child’s hearing, making appropriate referrals, and collaborating with pediatric specialists.

Developmental and Communication Screening

A complete audiologic assessment typically includes a developmental screening to assess the child’s progress on reaching developmental milestones.

Pediatric audiologists and speech-language pathologists (SLPs) are involved in developmental screening and functional auditory assessment of their patients. Children who are deaf and hard of hearing also typically receive a complete developmental assessment and are evaluated across various domains (e.g., cognition, communication, social skills, adaptive skills).

Areas that are monitored include

developmental milestones,
prelinguistic communication,
receptive and expressive language status,
speech development as applicable,
auditory skill development,
functional auditory performance, and
social and emotional development.

Otoscopy

Otoscopy is used to ensure that there are no contraindications to placing an earphone or probe into the ear canal. It is essential for the audiologist to verify that the external auditory canal is free of obstructions (e.g., foreign objects, impacted cerumen, vernix) and that there is no drainage from the middle ear. To the extent possible, the audiologist examines the tympanic membrane with regard to color, position, and abnormalities. A visual inspection for obvious structural abnormalities (e.g., ear pits, ear tags, atresia, low-set ears) of the pinna and/or ear canal is typically included in this assessment.

Audiologic Test Battery

The order and selection of tests to be included in the audiologic test battery may vary based on the child’s age, medical history, and developmental status. Audiologic tests may include acoustic immittance testing, auditory evoked potential testing, and behavioral testing.

Acoustic Immittance Testing

Tympanometry is used to assess middle ear function and aid in the determination of hearing loss type (i.e., conductive, mixed, sensorineural). During testing, a tympanometry probe is placed in the ear canal in a manner that creates an airtight seal. The probe emits a probe tone, varies air pressure in the ear canal, and records immittance data. These data include ear canal volume, peak pressure, and compliance. A visual representation of the data is created on a graph called a tympanogram and categorized by type: A, B, C, As, or Ad. More information on the main tympanogram types can be found under the Assessment section of the ASHA Practice Portal page on Hearing Loss in Adults.

Most commonly, single-frequency tympanometry is performed, which assesses middle ear movement in response to a single-frequency probe tone. In children over 9 months of age, a 226-Hz probe tone is an appropriate stimulus. In infants younger than 9 months, use of a 1000-Hz probe tone yields the most sensitive measurement of middle ear function. A conventional low-frequency (220 or 226 Hz) probe tone in this population can result in a false-negative finding in ears with middle ear effusion.

Wideband acoustic reflectance assesses the middle ear response across a range of frequencies (typically between 250 Hz and 8000 Hz) and can be used as a tool to observe middle ear status in infants. While it has been shown to be sensitive to middle ear effusion, additional research would be needed prior to this measurement replacing single-frequency tympanometry in this population.

Acoustic reflex testing is completed in conjunction with tympanometry to assess middle ear function. These measurements provide information about the integrity of the acoustic reflex pathway, which includes the middle ear, inner ear, vestibulocochlear nerve, cranial nerve seven (CN VII), and lower brainstem. Acoustic reflex thresholds (ARTs), the sound pressure levels at which the acoustic reflex is triggered, are measured ipsilaterally and contralaterally utilizing 500-Hz, 1000-Hz, and 2000-Hz stimuli. In infants under 9 months of age, use of a single higher probe tone frequency (e.g., 1000 Hz) provides a more reliable measurement.

ARTs are considered normal if they occur between 85 dB SPL and 100 dB SPL. Elevated or absent ARTs are suggestive of a disruption within one or more of the structures along the acoustic reflex pathway. Depending upon the degree and location of the pathology, transmission of the probe tone signal and/or measurement of the ART may be affected. Response patterns, in conjunction with other audiologic test results, can be used to determine the site of lesion or location of auditory pathology. Acoustic reflex testing is a valuable component in the differential diagnosis of children with suspected auditory neuropathy, as ARTs would be expected to be absent in all conditions.

Auditory Evoked Potential Testing

Auditory brainstem response (ABR) testing is the gold-standard procedure for the estimation of hearing thresholds in children who are too young (i.e., less than 6 months of age) to complete pure-tone testing utilizing behavioral test methods (JCIH, 2019). Infants under 3 months of age can often be tested during natural sleep (i.e., without sedation) or quiet feeding times. Active or older infants may require monitored conscious sedation or general anesthesia to allow adequate time for the acquisition of high-quality recordings and sufficient frequency-specific information. ABR testing may be included in the test battery of children older than 6 months if behavioral audiometric test results are inconclusive or if the neurological integrity of the auditory system through the level of the brainstem is in question. It is important that the hearing abilities of all children are confirmed through behavioral responses as soon as a child can complete this type of testing, as ABR testing only measures the electrophysiologic response of the auditory system up to the level of the brainstem.

During ABR testing, insert earphones are used to deliver auditory stimuli to the ears, and neural responses are recorded through electrodes placed on the child’s forehead and mastoid area or earlobe. A sound-attenuated room with special consideration given to the ambience (e.g., dimmed lights) is an appropriate environment for this testing.

Threshold Estimation

When performing ABR testing for the purpose of threshold estimation, frequency-specific stimuli (e.g., tone burst or chirp) are used. Responses are measured across a range of test frequencies, most commonly 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz. Stimulus intensity is decreased until the lowest repeatable response is obtained. Results are marked (e.g., =, ≤, >) according to how the threshold was obtained. Depending upon test frequency and the degree of hearing loss, ABR thresholds (in dB nHL) can differ from behavioral thresholds (in dB HL) by up to 25 dB (McCreery et al., 2015). Correction factors may be applied when analyzing ABR thresholds to ensure the most accurate estimation of behavioral hearing levels.

Insert earphones are typically used for air-conduction ABR testing unless the infant’s or child’s anatomy does not support their use. In cases of abnormal air-conduction ABR results or a suspected conductive hearing loss component, bone-conduction ABR thresholds provide information on the type of hearing loss. Bone-conduction ABR testing may be influenced by the pressure of the bone oscillator against the skull and the developmental age of the child when the skull bones are fully ossified. Mastoid or temporal bone placement has been shown to yield more reliable results than forehead placement, especially in infants (Seo et al., 2018). Abnormal or absent ABRs are suggestive of hearing loss (conductive, sensorineural, or mixed) or other disruption in neural transmission (e.g., auditory neuropathy).

Assessment of Integrity of Cranial Nerve Eight (CN VIII)

In infants and children with suspected auditory neuropathy or other retrocochlear pathology, ABR testing may be completed utilizing insert earphones and high-intensity click stimuli. Click stimuli between 80 dB nHL and 90 dB nHL are adequate in most situations to identify Waves I, III, and V on the resulting waveform. Response morphology is analyzed, and absolute and interpeak wave latencies are compared to age-matched normative data to assess neural synchrony. Responses are obtained using rarefaction and condensation clicks to distinguish between cochlear and neural dysfunction. A catch trial (i.e., signal running but not delivered to the ear) can rule out a stimulus artifact that may be misinterpreted as the cochlear microphonic.

Automated steady-state response (ASSR) is obtained utilizing amplitude- and frequency-modulated pure tones with carrier frequencies of 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz. ASSR analysis is mathematically based. The specific method of analysis to define threshold is dependent on the manufacturer’s statistical detection algorithm. The clinical utility of ASSR as a test measure for threshold estimation in infants younger than 6 months is being investigated.

Otoacoustic emissions (OAEs) are a valuable component of the pediatric audiologic assessment as an objective measurement of cochlear function. A sensitive probe microphone measures sounds generated by functioning outer hair cells in response to tonal stimuli. Since measurement of OAEs is dependent upon normal transmission of sound through the middle ear, it is beneficial to complete tympanometry prior to measurement of OAEs (especially in children with suspected middle ear effusion or a history of the same). While OAEs can be used to infer hearing status, they cannot be used as a diagnostic measure of hearing abilities. In children with auditory neuropathy or other neural or post-neural auditory pathologies, OAEs are expected to be normal despite abnormal hearing abilities. For this reason, OAEs are performed in conjunction with other tests of threshold estimation and cranial nerve eight (CN VIII) integrity if auditory problems are suspected.

OAEs are best measured in a quiet environment (e.g., in a sound booth) while an infant is resting quietly. A snug probe fit is essential for valid and reliable recordings. Ears are typically being tested one at a time, with the infant placed on their side and the ear being screened facing up. In active children who are unable to rest quietly, these measurements can be obtained in conjunction with ABR testing under monitored conscious sedation or general anesthesia. Responses are calculated utilizing averaging techniques within the measurement software and compared to clinic-specific normative data.

Transient Evoked Otoacoustic Emissions (TEOAEs)

TEOAEs are recorded in response to a transient click or tone burst signal, most commonly an 80 dB pSPL click stimulus. Normal distributions for this condition for normal hearing are documented in the literature (Hussain et al., 1998).

Distortion Product Otoacoustic Emissions (DPOAEs)

DPOAEs are recorded in response to pairs of pure-tone stimuli that are close in frequency and vary in intensity. The stimuli are designated F1 and F2, with F2 being the test frequency. Their levels are described using L1 and L2. Optimal test protocols typically include an F2/F1 ratio of 1.22 and an L1/L2 of 65/55 dB SPL. Normal distributions for these conditions are documented in the literature (Gorga et al., 1997).

Both TEOAEs and DPOAEs allow for assessment of outer hair cell function. DPOAEs allow for assessment at higher frequencies (i.e., > 5000 Hz) and are particularly useful for monitoring ototoxicity in children.

Behavioral Testing

Behavioral observation audiometry (BOA) techniques can be used in conjunction with electrophysiologic assessments to screen or predict hearing ability in infants up to 6 months of age or in those who cannot complete pure-tone testing. During BOA testing, the audiologist will observe the infant’s behaviors (e.g., sucking) in response to sound. It is best if the infant is tested while hungry (and able to have a bottle or nurse) or while resting quietly and sucking on a pacifier. Responses are unlikely to be captured down to levels consistent with the infant’s true hearing thresholds and are more appropriately described as minimum response levels. BOA allows a family member or caregiver to observe an infant’s response to sound, which can help them better understand their infant’s hearing diagnosis. This test technique alone is not adequate for diagnosing hearing loss or fitting of amplification devices. However, it can be used to gauge functional benefit from hearing technology once fit.

BOA may initially be completed in the sound-field condition utilizing warble-tone or noise band stimuli prior to attempting testing with insert earphones if there are no anatomical contraindications.

Pure-tone audiometry is the only true measure of hearing sensitivity. Electrophysiologic measurements and behavioral observation techniques can be used to estimate hearing thresholds. However, as soon as developmentally possible, pure-tone thresholds are obtained to confirm hearing levels. Test techniques may include visual reinforcement audiometry (VRA), conditioned play audiometry (CPA), conventional audiometric techniques, or a combination of these methods depending upon the child’s developmental level. Pure-tone testing can be completed using air- and bone-conduction measures. Insert earphones are the preferred transducer for ear-specific air-conduction testing. Insert earphones are lightweight, hygienic, and less likely to cause collapsed ear canals or crossover of loud sounds than supra-aural headphones. Testing typically begins with the better hearing ear. Pulsed pure-tone stimuli are presented to the child at various frequencies and intensities until thresholds are identified. Pure-tone threshold is defined as the level at which the child responds to the stimulus about 50% of the time. The response may be in the form of a head turn, play action, verbal response, hand raise, or other action. Thresholds are displayed visually on a graph called an audiogram.

Visual Reinforcement Audiometry (6 Months and Older)

VRA is recognized as a method of choice for assessing infants and toddlers with a developmental age of approximately 6 through 24 months. This test method requires that the infant have the developmental ability to respond to conditioned procedures, sit, maintain head control, and turn their head. Correct responses are reinforced with visual stimuli (e.g., flashing lights, moving toys, or video clips). A test assistant may be present to center the child’s focus between stimulus presentations utilizing a quiet distractor (e.g., stacking blocks). It is important that the distractor be less interesting than the visual reinforcement.

Initial testing is typically performed in the sound field utilizing warble-tone stimuli at octave intervals between 250 Hz and 4000 Hz. Audiologists may begin by obtaining low-frequency (e.g., 500 Hz) and high-frequency (e.g., 4000 Hz) responses and then proceed to other test frequencies if the infant has not fatigued. Minimum response levels are typically obtained down to 20 dB HL. If the infant can reliably complete VRA in the sound field, testing may then be completed utilizing insert earphones. If testing results are consistent with a hearing loss, bone-conduction testing may be performed to determine the type of loss.

Conditioned Play Audiometry (24 Months and Older)

CPA is the use of play techniques to obtain pure-tone thresholds. Children are conditioned to perform a task (e.g., place a block in a bucket or a peg in a board) every time they hear a sound. CPA is best suited for children with a developmental age between 2 and 4 years but may be utilized in older children who require frequent or additional measures of auditory sensitivity to keep their attention. Air-conduction testing is performed using insert earphones, unless contraindicated, followed by bone-conduction testing as needed. Sound-field testing may be useful for some children when initially conditioning them to the task as well as to allow parents and/or caregivers to observe. Thresholds are obtained between 250 Hz and 8000 Hz in both ears if clinically feasible.

Conventional Audiometry (4 Years and Older)

Conventional audiometric techniques (e.g., pushing a button or raising a hand in response to a sound) can typically be used once a child has reached the developmental age of 4 or 5 years. Air- and bone-conduction testing is completed bilaterally, using masking as necessary to prevent crossover. Insert earphones are typically used, unless contraindicated, for air-conduction testing and for delivery of masking during bone-conduction testing. Pulsed pure-tone stimuli are typically used, and thresholds are obtained between 250 Hz and 8000 Hz for air-conduction testing and between 500 Hz and 4000 Hz for bone-conduction testing. Extended high-frequency testing may be completed if there are specific concerns about noise or ototoxic exposure.

Speech audiometry measures are used to cross-check pure-tone thresholds, aid in determining the site of lesion, plan treatment, and monitor a child’s ability to understand speech. Speech audiometry measures are used to determine thresholds for speech stimuli as well as the ability to understand speech presented at suprathreshold levels.

In infancy, speech stimuli can be used to elicit behavioral and/or startle responses. When a child can sit supported and turn their head toward sound and/or be conditioned to place a block in a bucket or perform another play task, VRA or CPA techniques can be utilized to measure thresholds to speech stimuli. Eventually, threshold and suprathreshold testing can be performed using age-appropriate and linguistically appropriate speech perception tests (closed-set and/or open-set). Open-set speech perception tests require a spoken or signed response, whereas closed-set speech perception tests allow for a pointing (or other gesture) response. A child’s developmental age and/or abilities and their vocabulary level are important considerations in test selection. There are several commercially available pediatric speech audiometry measures.

Speech stimuli can be delivered to the child using monitored live voice or recorded speech materials. Results obtained using recorded speech materials are more reliable and accurate and allow for greater standardization across test sessions.

Speech Awareness Threshold/Speech Detection Threshold (SAT/SDT)

An SAT or SDT is a measure of the level at which a child can detect a sound 50% of the time. This threshold does not assess a child’s ability to recognize or identify what they are hearing. SAT/SDT testing utilizing monitored live voice may facilitate engagement and provide greater flexibility in this population. Insert earphones are utilized, if possible, to obtain ear-specific data. However, measures in the sound field can be utilized to familiarize the child with the sounds and the audiologist with the child’s response patterns.

Speech Recognition Threshold (SRT)

An SRT is the lowest level in decibels at which a child can correctly identify a word 50% of the time. If possible, SRTs are obtained in both ears utilizing insert earphones and familiar and age-appropriate spondee words.

Word Recognition Testing

Word recognition testing is completed at suprathreshold levels to assess a child’s discrimination ability using age-appropriate lists of phonetically balanced monosyllabic words. The presentation level is often 40 dB to 50 dB above the child’s SRT or at their most comfortable listening level. Word recognition testing is intended to provide an assessment of a child’s maximum (i.e., best) discrimination ability. Therefore, various presentation levels may be used. Results are recorded as percent correct.

Additional Assessment Considerations

Monitored Conscious Sedation and General Anesthesia

Sedation may be necessary to achieve reliable results on some infants and young children during physiologic assessments of auditory function. Sedation of pediatric patients has potential serious risks, such as hypoventilation, apnea, airway obstruction, cardiopulmonary impairment, and risks to cognitive function. If sedation is required for audiologic testing, the child will undergo testing at a facility with professionals who are experienced in handling adverse or paradoxical responses to sedation. Oversight by skilled medical personnel and the availability of age- and size-appropriate equipment and medications as well as continuous monitoring are essential during these procedures (American Academy of Pediatrics, 2006). For some children, use of conscious sedation is contraindicated. In these cases, use of general anesthesia may be necessary. This determination is made by the otolaryngologist or the child’s primary health care provider in conjunction with a pediatric anesthesiologist.

Multilingual Speakers

When assessing multilingual children who use spoken language, implications around the child’s phonetic inventory, phonology, and syntax are important considerations. Using English words only to evaluate multilingual listeners may lead to faulty clinical impressions. Evaluating multilingual speakers in the language(s) that they use will give the most accurate picture of their speech recognition ability. See the ASHA Practice Portal pages on Collaborating With Interpreters, Transliterators, and Translators and Cultural Responsiveness for more information on this topic.

Sign Language Users

Some children may use sign language as their primary language or come from families who use sign language as their primary language. Collaboration with qualified sign language interpreters is essential. See the ASHA Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators for more information.

Children With Risk Factors

The timing and number of hearing reevaluations for children with risk factors are customized and individualized depending on the relative likelihood of a subsequent hearing loss. A family history of hearing loss and any presenting caregiver concerns are important considerations. Infants who pass the neonatal screening but have certain risk factor(s) are to receive at least one diagnostic audiology assessment by 9 months of age (JCIH, 2019). Early and more frequent assessment may be indicated for children with risk factors such as the following (JCIH, 2019):

prolonged neonatal intensive care (i.e., more than 5 days)
in utero infections (e.g., cytomegalovirus, herpes, rubella, syphilis, toxoplasmosis, Zika virus)
hyperbilirubinemia requiring an exchange transfusion
asphyxia or hypoxic ischemic encephalopathy
syndromes associated with hearing loss
craniofacial malformations
infections associated with hearing loss (e.g., herpes, meningitis, encephalitis)
exposure to certain medications (e.g., aminoglycoside antibiotics and chemotherapy)
head trauma

Test Environment and Equipment Calibration

The accuracy of the audiologic assessment process is dependent upon maintaining appropriate specifications regarding the testing environment and equipment calibration. It is essential that all audiometric equipment be calibrated, functioning properly, and used in an acceptable test environment to ensure accurate test results (American National Standards Institute, 2018a, 2018b, 2020).

Exhaustive electroacoustic calibrations should be performed on a regular basis (e.g., annually) using instrumentation traceable to the National Institute of Standards and Technology. Functional inspection, performance checks, and bioacoustic checks may be conducted daily to verify equipment performance prior to use.

Assessment Results

A comprehensive audiologic assessment in an infant or a child may result in a thorough discussion of the results, education and counseling, early intervention and/or educational referrals, and other recommendations as appropriate.

Discussion of Results

The audiologist will provide the child and/or family with the results of any testing and discuss the implications of the findings (e.g., diagnosis of hearing loss). It is important that information is presented in a health-literate manner and in a format that is accessible to the child and family.

Education and Counseling

Topics that may be addressed with the child and family include the following:

the relationship between hearing, access to language, and communication development
available language and communication modalities and systems
amplification and hearing technology options
coping and compensatory strategies
availability of support groups (e.g., parent-to-parent groups)
rights to educational and community services
self-advocacy strategies
referral to other professionals and supports beyond the scope of the audiologist (e.g., early intervention services, psychologist, counselor)

See the ASHA Practice Portal page on Counseling in Audiology and Speech-Language Pathology for more information on this topic.

Early Intervention and Educational Referrals

By working closely with Early Hearing Detection and Intervention (EHDI) and the Individuals with Disabilities Education Act (IDEA) Part C programs, audiologists and SLPs can help promote seamless transitions between the diagnosis of hearing loss and participation in intervention services.

When a child under the age of 3 years is identified as having a hearing loss, a referral to the child’s state early intervention program is required as soon as possible and within 7 days of the identification (IDEA, 2011). Children diagnosed in infancy should begin receiving early intervention services by 6 months of age (JCIH, 2019). For details on the latest JCIH position statement, see the JCIH website. The National Center for Hearing Assessment and Management has information on EHDI state programs. More information is also available on the ASHA Practice Portal pages on Early Intervention and Newborn Hearing Screening.

Early intervention services for children aged birth to 3 years are typically home based and often include a parent/family coaching model. As children who are deaf and hard of hearing age out of early intervention, they may continue to be eligible for services under IDEA Part B, Section 619, until they enter (or are eligible under state law to enter) kindergarten or elementary school. Children aged 3 years and over who are diagnosed with hearing loss and are not already in an early intervention program are referred to their local school system.

Other Recommendations

Other recommendations may include the following:

follow-up with an audiologist for ongoing otologic and/or audiologic monitoring
referral to other professionals to ensure comprehensive services
assessment for amplification candidacy and/or other hearing technologies
implementation of accommodations
participation in an aural (re)habilitation program

See the ASHA Practice Portal page on Language and Communication of Deaf and Hard of Hearing Children for more information.

Treatment

See the Treatment section of the Hearing Loss (Newborn) Evidence Map, the Hearing Loss (Early Childhood) Evidence Map, and the Hearing Loss (School-Age) Evidence Map as well as the Services and Supports section of the Language and Communication in Deaf or Hard of Hearing (DHH) Individuals Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

For guidance and considerations on infection control practices during the treatment process, see the ASHA page on infection control resources for audiologists and speech-language pathologists.

Treatment Planning

Child- and family-centered treatment planning for children who are deaf and hard of hearing and/or with hearing loss of any type should include participation and input from the child (as age and developmentally appropriate) and family, as is possible. This includes child and family education and counseling. Priorities and goals for intervention are jointly agreed upon with recognition of the family’s preferences, values, beliefs, culture, and linguistic background. Recommendations for amplification, hearing assistive technology systems (HATS), educational service implementation, direct intervention, and/or referrals to other professionals occur as indicated.

International Classification of Functioning, Disability and Health

The World Health Organization (2001) published the International Classification of Functioning, Disability, and Health (ICF) as a classification of health and disability based upon functional status. This classification system can be used to assist clinicians in establishing goals and in determining specific outcomes that can be measured through client report.

Aural (Re)habilitation

Aural (re)habilitation can be defined as “an ecological, interactive process that facilitates one’s ability to minimize or prevent the limitations and restrictions that auditory dysfunctions can impose on well-being and communication, including interpersonal, psychosocial, educational, and vocational functioning” (ASHA, 2001, p. 4). Habilitative services refer to those services focused on attaining listening, language, and/or communication skills that have yet to be acquired (e.g., in the case of a child who is identified with hearing loss prelingually). Rehabilitative services refer to those services focused on maintaining, reestablishing, and/or improving current listening, language, and/or communication skills. The aural (re)habilitative process is designed to be interactive, individualized, and child- and family-centered. The roles of audiologists and speech-language pathologists (SLPs) in the provision of (re)habilitation services for children who are deaf and hard of hearing may be complementary; interrelated; and, at times, overlapping. See the ASHA Practice Portal page on Language and Communication of Deaf and Hard of Hearing Children for more information.

An aural and communication (re)habilitation plan may include, but not be limited to, the following types of intervention.

Education and Counseling

Child and family education and counseling is an ongoing process and requires providing information in a clear, understandable, and health-literate format. See the ASHA resource on health literacy for more information. The ASHA Practice Portal page on Counseling in Audiology and Speech-Language Pathology and ASHA’s audiology patient education handouts may also be helpful in this process.

Amplification

A comprehensive plan of care for a child who is deaf or hard of hearing may include the selection and fitting of a sensory device (e.g., hearing aid, cochlear implant). This process will include instruction and education on the effective use and appropriate care of the device as well as counseling on the adjustment to the device and realistic expectations for benefit and improvement.

See the ASHA Practice Portal pages on Hearing Aids For Children and Cochlear Implants for detailed information.

Hearing Assistive Technology Systems (HATS)

HATS include a variety of devices designed to improve audibility in specific listening situations. HATS may be used independently or in conjunction with hearing aids or cochlear implants. They may be for personal or group use. HATS can help children receive better access to sound and speech in challenging environments. Examples of HATS include the following:

Personal frequency modulation (FM) or digital modulation (DM) systems transmit speech signals directly from the speaker (through a microphone) to a child’s hearing aids and are frequently used in the school setting.
Sound field amplification systems amplify the speaker’s voice over the background noise for everyone in the room.
Classroom audio distribution systems [PDF] distribute sound evenly throughout a classroom or learning space to improve auditory access for children seated at a distance from the speaker.
An induction loop system uses hard-wire loops placed under floors or around walls to convert sound to magnetic forces, which cochlear implants and hearings aids with telephone switches or t-coils can convert back to sound.
A personal streaming system amplifies sound with systems such as streamers (Bluetooth), mini remote microphones, and digital applications.
A telephone amplifier amplifies speech heard over the phone.
A television assistive device and/or accessories use wireless streaming or a loop system to make TV volume more comfortable and the content clearer.

It is important that any hearing assistive technology used by a child goes through a verification and validation process (as well as daily checks) to ensure that it is working properly and for maximum benefit in each setting used. Clinical audiologists and educational audiologists can collaborate to ensure that any technology used by the child meets their needs both in and out of the classroom setting. For more information on HATS, see the ASHA resource on hearing assistive technology systems for children and the Educational Audiology Association resource titled Hearing Assistance Technology Guide [PDF] as well as visit Supporting Success For Children with Hearing Loss: FM Systems and Supporting Success For Children with Hearing Loss: Personal FM vs Sound Field FM (Classroom Audio Distribution System).

Early Intervention and Educational Services

Children who are deaf and hard of hearing can qualify for early intervention and/or educational services in a variety of ways. A child may have an individualized family service plan (IFSP), an individualized education program (IEP), or a Section 504 plan. See ASHA’s resource on eligibility and dismissal in schools and the ASHA Practice Portal page on Early Intervention for more information.

Both modifications (e.g., altered curriculum) and accommodations (e.g., classroom acoustics, strategic seating) are important considerations when defining service plans for children who are deaf and hard of hearing.

Direct Intervention

If eligible for direct intervention, audiologists and/or SLPs will create an individualized intervention plan for a child who is deaf or hard of hearing that is specific to their needs and goals. The plan will be based on continued child and family participation, with consideration given to the communication systems and language(s) used by the child and their family, and in consultation with other members of the child’s care team (e.g., teacher of the deaf, occupational therapist). An individualized plan may include, but not be limited to, the following components:

auditory training (e.g., listening skill development) and/or visual cueing to target speech perception, functional listening skills, and understanding of speech and language
cognitive-communication skills and strategies training to target social interaction, self-advocacy skills, executive functioning, and conversational strategies
speech and/or language development to target articulation, voice, expressive and receptive language, and/or literacy skills across applicable languages and communication modalities (e.g., spoken, signed, written)

Goals and interventions may change as the child’s skills and needs evolve and/or as the family identifies different priorities.

Service Delivery

See the Service Delivery section of the Hearing Loss (Newborn) Evidence Map, the Hearing Loss (Early Childhood) Evidence Map, and the Hearing Loss (School-Age) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Service delivery variables that may have an impact on treatment outcomes include dosage, format, provider(s), timing, and setting. Decisions about service delivery include all members of the child’s collaborative interprofessional care team and are made in a child- and family-centered manner with a focus on the child’s individual needs.

Resources

ASHA Resources

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

References

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About This Content

Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Hearing Loss in Children page:

In addition, ASHA thanks the members of the Working Group on Audiologic Assessment of Children From Birth to 5 Years of Age whose work was foundational to this document. Members of the working group were Allan O. Diefendorf (coordinator), Kathryn L. Beauchaine, Patricia Connelly, Robert J. Nozza, Jackson Roush, Diane L. Sabo, Anne Marie Tharpe, Judith E. Widen, and Pam Mason (ex officio). Susan Brannen (2000–2003) and Roberta Aungst (2004–2007) served as monitoring officers and vice presidents for professional practice in audiology.

ASHA also thanks the members of the Ad Hoc Committee, whose work was foundational to the development of this content. Members of the committee were Pam Mason (ex officio), Allan O. Diefendorf (chair), Kathryn L. Beauchaine, Diane L. Sabo, and Anne Marie Tharpe. Roberta B. Aungst, vice president for professional practices in audiology (2004–2006), served as monitoring vice president.

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Hearing Loss in Children [Practice Portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Permanent-Childhood-Hearing-Loss/

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.