Childhood Hearing Loss and Hearing Screening

Newborn hearing screening and the 1-3-6 goal

In the United States, nearly all newborns have their hearing checked before they leave the hospital or birth center, usually in the first day or two of life. Two quick, painless tests are used, often while the baby sleeps. Otoacoustic emissions (OAE) testing places a tiny soft earpiece in the ear to measure the echo a healthy inner ear makes in response to sound. Automated auditory brainstem response (ABR or AABR) testing uses small sensors on the head to check how the hearing nerve and brain respond to sound played through soft earphones.

If your baby does not pass the first screen, try not to worry. A result of 'refer' or 'did not pass' is common and often has nothing to do with permanent hearing loss; fluid or vernix in the ear canal, movement, or a noisy room can all affect it. It simply means your baby needs a repeat screen or a fuller hearing evaluation. Public health programs use a helpful timeline sometimes called '1-3-6': complete screening by about 1 month of age, finish any needed diagnostic testing by 3 months, and begin early intervention services by 6 months if a hearing loss is confirmed. Keeping these follow-up appointments is one of the most important things a parent can do.

A pass at birth is not a lifetime guarantee

Passing the newborn screen is great news, but it checks hearing at one moment in time. Some children develop hearing loss later in infancy or childhood, and some losses are progressive or are caused by later events such as certain infections or injuries. That is why your child's clinician keeps asking about hearing and checking it at well-child visits, with more formal hearing tests recommended at several ages during the school years. Schools also screen hearing. Above all, if you ever suspect your child is not hearing well, say so; a parent's concern is reason enough to arrange a hearing check, no matter what an earlier screen showed.

Signs of possible hearing loss by age

Signs vary with age, and having one of them does not mean your child has hearing loss. Still, these are worth mentioning to your clinician:

• Babies (birth to about 12 months): not startling at loud sounds, not soothing to a familiar voice, not turning toward sounds or your voice by around 6 months, or little to no babbling.
• Toddlers and preschoolers: few or no words by around 15 months, speech that is hard to understand for their age, not responding to their name, not following simple directions, or wanting the TV very loud.
• Older children: frequently saying 'what?' or asking for repeats, seeming to hear only sometimes, struggling to hear in noisy places, watching faces very closely, or falling behind or seeming inattentive at school.

Hearing that seems to come and go, or a child who hears fine in a quiet room but struggles in a crowd, can be a clue to fluid in the middle ear and is worth checking.

Conductive, sensorineural, and mixed hearing loss

Audiologists describe hearing loss by where in the ear it happens. Conductive hearing loss occurs when sound is blocked on its way through the outer or middle ear, for example by earwax, fluid behind the eardrum (often called glue ear), an ear infection, or a problem with the eardrum or the tiny middle-ear bones; it is frequently temporary and often treatable. Sensorineural hearing loss involves the inner ear (the cochlea) or the hearing nerve, is usually permanent, and can range from mild to profound. Some children have a mixed loss, meaning both types are present. An audiologist works out the type, the degree, and which ears are affected, and that guides what happens next.

What causes hearing loss in children

Hearing loss has many possible causes, and sometimes no clear cause is found. Common contributors include:

• Genetic factors, which account for about half of congenital (present-at-birth) hearing loss and can occur even when no one else in the family is affected.
• Infections during pregnancy or around birth, such as congenital cytomegalovirus (CMV), which is acquired in the womb.
• Premature birth or complications that require newborn intensive care, including severe newborn jaundice.
• Certain medicines that can affect hearing, which clinicians weigh carefully and monitor when the medicine is truly needed.
• Some illnesses and injuries later in childhood, such as meningitis or a significant head injury.
• Persistent or repeated middle-ear fluid and infections, and, over time, exposure to very loud noise.

Because some hearing loss is present at birth while other types appear later, paying ongoing attention to your child's hearing matters throughout childhood.

What an evaluation and next steps look like

If screening or a concern points to a possible hearing problem, the next step is a full evaluation with a pediatric audiologist, and often an ear, nose, and throat doctor (otolaryngologist). Depending on your child's age, testing may include a repeat OAE, a diagnostic ABR (especially for infants), tympanometry to check how the eardrum and middle ear are working, and age-appropriate behavioral tests done in a sound booth. Your care team may also suggest imaging, genetic testing, an eye exam, or testing for congenital CMV to look for a cause. CMV testing is time-sensitive: a saliva or urine sample generally needs to be collected within about the first two to three weeks of life, because after that a positive result can no longer reliably tell an infection acquired before birth from one picked up later.

If a hearing loss is confirmed, the plan is built around your child and family. It may include treating reversible causes such as earwax or middle-ear fluid, enrolling in early intervention or school-based services, and, when appropriate, hearing technology such as hearing aids or, for some children with significant sensorineural loss, cochlear implants. Families are supported in choosing communication approaches that fit their child. Starting support early gives children the best chance to build language on track, so it is worth acting promptly rather than taking a 'wait and see' approach when there is a genuine concern.

When to seek care: Contact your child's clinician promptly if your baby does not startle or respond to sounds, if an older child loses words or skills they already had, if speech is not developing as expected, if you notice ongoing ear fluid, drainage, or pain or frequent ear infections, or if a newborn rescreen or diagnostic follow-up was missed. A sudden drop in hearing over hours to a few days is a medical emergency and needs same-day evaluation. Never push cotton swabs or other objects into the ear to remove wax. When in doubt, trust your instincts and ask for a referral to audiology.