Related to this topic: Leaflets | Support | Patient+ | UK Guidelines | News | Weblinks | Equipment | Books | Your Experience | Other resources | Glossaries
Print options: Printer friendly version of this leaflet (html)     Other options:  AddThis Social Bookmark Button (what's this?)

PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Hearing Testing and Screening in Young Children

Children with untreated hearing loss, especially if it is permanent and substantial, are likely to have severe difficulty in acquiring language skills. In particular, it is thought that if there is no stimulation of neural pathways involved with hearing and speech within the first 6 to 12 months of life, the ability to develop spoken language may be permanently lost. Sign language can be learned at any age. Language problems can lead to educational difficulties, with associated social and psychological problems.

Early diagnosis of childhood deafness and appropriate intervention, including hearing aids, cochlear implants, education and social support, can substantially improve the outcome.

Levels of hearing loss

An audiogram measures the threshold level (the quietest sound) that is heard at different frequencies. This is recorded as the decibel hearing level (dBHL) for that frequency. Hearing loss is classified from mild to profound by the average threshold level over a range of frequencies:

  • Mild - 20-39 dBHL (cannot hear whispers)
  • Moderate - 40-69 dBHL (cannot hear conversational speech)
  • Severe - 70-89 dBHL (cannot hear shouting)
  • Profound - 90 dBHL or more (cannot hear sound when it usually becomes painful)

It is not uncommon for children to have a predominantly high frequency hearing loss where the threshold dBHL may be near normal at low frequencies, but their hearing threshold becomes progressively higher with increasing frequencies of sound. This causes inability to distinguish consonants and may present with mispronunciation of words.

Epidemiology of hearing loss

In the UK, the prevalence of permanent hearing loss is nearly 2 per 1000 children at age 9-16 years.1

  • Sensorineural hearing loss
    • CongenitalAbout 1 in 1000 children are born with a sensorineural hearing loss sufficient to need hearing support.
      • About 95% are due to lesions within the cochlea. The rest have a problem with the auditory nerve or central connections.
      • About 25% will benefit from cochlear implants.
      • About 90% are born to parents who hear normally.
      • About 50% have other disabilities too.
      In some cases the hearing loss is not apparent at birth but becomes progressive in childhood.

      Incidence is 10 times higher in babies admitted to neonatal intensive care.
      Other risk factors include:
      • family history of congenital deafness such as Usher's syndrome. About 30% have a genetic cause and genetic counselling may be appropriate
      • dysmorphic features
      • congenital infections, especially congenital rubella and cytomegalovirus.
      • About 30% have no cause identified.
    • Acquired
      • Meningitis causes up to 1 in 5 cases of profound hearing loss but the incidence is dropping due to HIB and MenC vaccines.
      • Mumps can cause deafness that is usually unilateral. Both this and congenital rubella syndrome may become more frequent if the trend of falling uptake of MMR vaccine is not reversed.
      • Other causes are rare.
  • Conductive hearing loss
    • A small number of children have congenital conductive hearing loss caused by rare disorders of the ear canal or middle ear.
    • Glue ear (otitis media with effusion or OME) is very common and typically causes temporary episodes of hearing loss in younger children. About 1 in 10 pre-school children have some degree of glue ear at any one time.

      Glue ear can occur in addition to other problems and may aggravate existing hearing loss.
Screening tests for hearing loss

Parents may quickly recognise a baby with severe or profound hearing loss, but moderate hearing loss or high frequency hearing loss may go unnoticed for several years unless formally tested. The improved outcome in children with early detection of hearing loss justifies hearing screening of all children.

Neonatal hearing screening tests2

Automated Otoacoustic Emissions (AOAE) test In the healthy cochlea, vibration of the hair cells in response to noise generates acoustic energy, known as otoacoustic emissions. Otoacoustic emission testing therefore measures the integrity of the inner ear. A probe is placed in the ear canal and generates wide-band clicks. Acoustic energy produced in response to the clicks is detected by a microphone within the probe. Automated OAE screeners display the results of the test as either pass or refer, requiring no test interpretation by screening personnel.
The test takes between one and five minutes in ideal conditions, with optimal test techniques. In practice, the average total time for testing, including discussion of the procedure with the parents, settling the baby, performing the test and recording the results, may be between 15 and 20 minutes.

Automated Auditory Brainstem Responses (AABR) test This measures not only the integrity of the inner ear, but also the auditory pathway. It can therefore detect the rare condition of auditory neuropathy, in children who are deaf but have normal otoacoustic emissions (because the cochlea is normal). The stimulus (either clicks or tones) is presented using earphones or an ear canal probe, and the electrophysiological response from the brainstem is detected by scalp electrodes. Automated devices allow screening to be performed by non-specialists. Responses from a large number of stimulus presentations are averaged and the automated screener uses a response algorithm to produce a result. The level is set at about 35 decibels. This test takes 15 minutes, but once again this time may be longer if a child is restless, and does not include time for discussion and preparation before the test.

Neonatal screening in the UK

Pilot studies using the AOAE test for screening neonates, found it effective at detecting hearing problems early.3 Following the pilots, universal neonatal screening using the AOAE test has been introduced in the UK from 2006 (replacing the distraction test done at 8 months). The AABR test is used for babies who fail the AOAE test.4,5 Note that both these tests are screening tests only, and a baby who fails them will need further audiological assessment. Most babies referred from screening tests will not be found to have hearing loss on further testing.2

For babies who have had neonatal intensive care, protocols differ from the well baby screening. This is to allow detection of auditory neuropathy, a condition which is rare in well babies, but which can account for approximately 10% of hearing loss in the neonatal intensive care unit. Most neonatal intensive care unit screening programs use AABR for this reason.2,5

Universal neonatal screening using the AOAE test can achieve coverage of over 90%; the sensitivity of the test is 90% or more, and the specificity is about 95%.6

There was some controversy about the relative value of universal and targeted screening. Targeted screening is substantially cheaper per case identified and universal screening has many false positives.7 However, targeted screening leaves many cases undetected and is not the preferred technique in the UK. As technology improves it is also possible that AABR will be the test of choice.8

Test limitations in neonatal screening2
Both the AOAE and the AABR screen require a quiet baby and a quiet testing environment. Restlessness may result in the test being discontinued. AOAE relies on a functional outer, middle and inner ear, and AABR a functional outer, middle and inner ear, and lower auditory pathway. These screening tests are not designed to detect central hearing impairment (where hearing loss is secondary to dysfunction of the pathways from brainstem to auditory cortex). As both tests are made via the external ear, debris in the canal or middle ear fluid can affect the accuracy of the test. In particular, OAE testing may be affected by amniotic fluid in the ear canal when testing is conducted in the first 48 hours following birth. This may account for some false positive results.

Screening tests for infants and children

  • Distraction test - aged 7-8 months The health visitor distraction test is largely of historical interest as it has been replaced by the universal neonatal screening programme using the AOAE test. The neonatal screening programme has greater sensitivity and specificity and is substantially cheaper per case discovered, compared with the distraction test.6
  • The school entry 'sweep test' This is a modified pure tone audiometry test which checks that the child can hear four frequencies at a set decibel level. It is routine in most areas in the UK. Most children with severe or profound hearing loss will have already been diagnosed. However, occasionally this test picks up a progressive hearing loss. Milder and unilateral cases of sensorineural hearing loss may also be diagnosed for the first time. Also, many cases of glue ear are detected. Although these may not require active treatment, it is useful for teachers and parents to know which children have temporary hearing loss.
  • The whispered voice test can also be used to detect hearing impairment in children, but it has not been adequately evaluated as a screening tool.9
Referring children for hearing assessment

Who should be referred?

Hearing should be assessed in children newly diagnosed with learning, behavioural, speech and language problems. Also, always take seriously any parental concern about hearing loss in a child, even if a previous hearing test was normal. Because:

  • Some hearing disorders, including congenital ones, are progressive and may not manifest for several months or years1
  • The AOAE and AABR tests are sometimes inconclusive.
  • Glue ear is common and easily missed.
  • High frequency hearing loss may present as 'learning delay'. Many everyday sounds are low frequency, so a child with high frequency hearing loss may respond to these common low frequency sounds. But they may not be able to hear intelligible speech.

Symptoms of hearing loss: the child may be:10

  • inattentive or not reacting when called
  • talking too loudly, listening to TV at high volume
  • mispronouncing words
  • Unsettled at school; tired, grumpy or over-active

Refer if hearing loss is suspected (unless you are confident that the child has glue ear and you agree a period of 'wait and see' with the parents). Various tests can be performed by the audiological service depending on the age of the child and level of co-operation. For example, in the 'Toy test' the child points to toys named by the tester in a low voice. Pure tone audiometry is used with older children who can co-operate.

Children who have had bacterial meningitis should have a formal hearing assessment at 4-6 weeks after hospital discharge, as a matter of priority.10 Children recovered from a severe head injury, and those treated with ototoxic drugs, should also have a hearing assessment.

Babies with these risk factors should be referred for audiology monitoring, even if they pass the screening tests:4

  • parental or professional concern
  • high risk of middle ear problems, e.g. Down syndrome, cleft palate, craniofacial abnormalities
  • family history of childhood sensorineural hearing loss - in parents or siblings
  • Neonatal intensive care/special care or child who was ventilated for more than 5 days
  • jaundice or hyperbilirubinaemia requiring exchange transfusion
  • proven or possible congenital infection due to toxoplasmosis, rubella, cytomegalovirus or herpes
  • neurodegenerative or neurodevelopmental disorders
  • ototoxic drugs with monitored levels outside the therapeutic range

Where to refer

Babies with hearing loss found on neonatal screening, should be referred to local support programmes, for a multidisciplinary assessment and hearing support services.10,3 In the pilot studies, this has worked well and achieved early intervention.3

Other children with suspected hearing loss should be referred promptly to the local audiology service, or according to local protocols. If significant hearing loss is then diagnosed, all children should be referred to a specialist multidisciplinary team.10


Document references
  1. Russ S; Measuring the prevalence of permanent childhood hearing impairment. BMJ. 2001 Sep 8;323(7312):525-6.
  2. Coates,H and Gifkins,K; Diagnostic tests:Newborn hearing screening; Australian Prescriber 2003;Vol. 26:No. 4
  3. Hagan P; Screening newborn babies for hearing defect is effective, pilot finds; BMJ 2006;332:1176
  4. National Library for Health; Newborn Hearing Screening - well baby protocol - Map of Medicine; [As PDF]
  5. National Library for Health; Newborn hearing screeening - Neonatal intensive care protocol; Care pathway for NICU baby hearing screening
  6. NHS R&D Health Technology Assessment Programme - A critical review of the role of neonatal hearing screening in the detection of congenital hearing impairment (Davis) 177 pages, Volume 1, number 10
  7. Kemper AR, Downs SM; A cost-effectiveness analysis of newborn hearing screening strategies. Arch Pediatr Adolesc Med. 2000 May;154(5):484-8. [abstract]
  8. Dort JC, Tobolski C, Brown D; Screening strategies for neonatal hearing loss: which test is best? J Otolaryngol. 2000 Aug;29(4):206-10. [abstract]
  9. Pirozzo S, Papinczak T, Glasziou P; Whispered voice test for screening for hearing impairment in adults and children: systematic review. BMJ. 2003 Oct 25;327(7421):967. [abstract]
  10. Deafness Research Uk; Newborn hearing screening programme and screening after meningitis

Internet and further reading Acknowledgements EMIS is grateful to Dr N Hartree for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 2238
Document Version: 21
DocRef: bgp24573
Last Updated: 28 Jul 2007
Review Date: 27 Jul 2009
Patient UK Current Health News
















Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.

Advertise on this site




Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.

Advertise on this site


PS - Health and Poverty

Perhaps the biggest cause of ill health in the world is poverty. Help to Make Poverty History. For example, why not lend some of your money to disadvantaged communities to enable them to trade their way out of poverty through schemes such as Shared Interest.

See also MAKEPOVERTYHISTORY North East for details and links to campaigns against poverty.

^ Top of Page