Most children hear and listen to sounds at and even before birth. They learn to talk by imitating the sounds they hear around them and the voices of their parents and caregivers. But that’s not true for all children. In fact, about two or three out of every 1,000 children in the United States are born with detectable hearing loss in one or both ears. More lose hearing later during childhood. Children who have hearing loss may not learn speech and language as well as children who can hear. For this reason, it’s important to detect hearing loss as early as possible.

Because of the need for prompt identification of and intervention for childhood hearing loss, universal newborn hearing screening programs currently operate in all U.S. states and most U.S. territories. With help from the federal government, every state has established an Early Hearing Detection and Intervention Program. As a result, about 98% of babies have their hearing screened before 1 month of age.

The most important time for a child to learn language (spoken or signed) is in the first 3 years of life, when the brain is developing and maturing. In fact, children with typical hearing begin learning speech and language in the first 6 months of life. This is why it is so important to screen and start interventions for hearing loss as early as possible. Research shows that children with hearing loss who get help early develop better language skills than those who don’t.

Your baby’s hearing should be screened before he or she leaves the hospital or birthing center. If not, make sure the baby is tested during the first month of life. If your baby’s hearing was not tested within 1 month of birth, or if you haven’t been told the results of the hearing screening, ask your child’s doctor today. Quick action will be important if the screening shows potential hearing loss.

Two different tests are used to screen for hearing loss in babies. Your baby can rest or sleep during both tests.

• Otoacoustic emissions (OAE) tests whether some parts of the ear respond to sound. During this test, a soft earphone is inserted into your baby’s ear canal. It plays sounds and measures an "echo" response that occurs in ears with normal hearing. If there is no echo, your baby might have hearing loss.
• The auditory brain stem response (ABR) tests how the auditory nerve and brain stem (which carry sound from the ear to the brain) respond to sound. During this test, your baby wears small earphones and has electrodes painlessly placed on his or her head. The electrodes adhere and come off like stickers and should not cause discomfort.

Hearing Screening

Hearing screening is a test to tell if people might have hearing loss. Hearing screening is easy and not painful. In fact, babies are often asleep while being screened. It takes a very short time — usually only a few minutes.

Babies

• All babies should be screened for hearing loss no later than 1 month of age. It is best if they are screened before leaving the hospital after birth.
• If a baby does not pass a hearing screening, it’s very important to get a full hearing test as soon as possible, but no later than 3 months of age.

Older Babies and Children

• If you think a child might have hearing loss, ask the doctor for a hearing screening as soon as possible.
• Children who are at risk for acquired, progressive, or delayed-onset hearing loss should have at least one hearing test by 2 to 2 1/2 years of age. Hearing loss that gets worse over time is known as acquired or progressive hearing loss. Hearing loss that develops after the baby is born is called delayed-onset hearing loss.
• If a child does not pass a hearing screening, it’s very important to get a full hearing test as soon as possible.

Full Hearing Test

All children who do not pass a hearing screening should have a full hearing test. This test is also called an audiology evaluation. An audiologist, who is an expert trained to test hearing, will do the full hearing test. In addition, the audiologist will also ask questions about birth history, ear infection and hearing loss in the family.

There are many kinds of tests an audiologist can do to find out if a person has a hearing loss, how much of a hearing loss there is, and what type it is. The hearing tests are easy and not painful.

Some of the tests the audiologist might use include:

Auditory Brainstem Response (ABR) Test or Brainstem Auditory Evoked Response (BAER) Test

Auditory Brainstem Response (ABR) or Brainstem Auditory Evoked Response (BAER) is a test that checks the brain’s response to sound. Because this test does not rely on a person’s response behavior, the person being tested can be sound asleep during the test.

ABR focuses only on the function of the inner ear, the acoustic (hearing) nerve, and part of the brain pathways that are associated with hearing. For this test, electrodes are placed on the person’s head (similar to electrodes placed around the heart when an electrocardiogram (EKG) is done), and brain wave activity in response to sound is recorded.

Otoacoustic Emissions (OAE)

Otoacoustic Emissions (OAE) is a test that checks the inner ear response to sound. Because this test does not rely on a person’s response behavior, the person being tested can be sound asleep during the test.

Behavioral Audiometry Evaluation

Behavioral Audiometry Evaluation will test how a person responds to sound overall. Behavioral Audiometry Evaluation tests the function of all parts of the ear. The person being tested must be awake and actively respond to sounds heard during the test.

Infants and toddlers are observed for changes in their behavior such as sucking a pacifier, quieting, or searching for the sound. They are rewarded for the correct response by getting to watch an animated toy (this is called visual reinforcement audiometry). Sometimes older children are given a more play-like activity (this is called conditioned play audiometry).

With the parents’ permission, the audiologist will share the results with the child’s primary care doctor and other experts, such as:

• An ear, nose and throat doctor, also called an otolaryngologist
• An eye doctor, also called an ophthalmologist
• A professional trained in genetics, also called a clinical geneticist or a genetics counselor

If the results show that your baby may have hearing loss, make an appointment with a pediatric audiologist—a hearing expert who specializes in the assessment and management of children with hearing loss. This follow-up exam should be done as soon as possible, ideally by the time the baby is 2 to 3 months old. The audiologist will conduct tests to determine whether your baby has a hearing problem and, if so, the type and extent of that problem.

If you need help finding a pediatric audiologist, ask your pediatrician or the hospital staff who conducted your baby’s screening. They may even be able to help you schedule an appointment. You can also try the directories provided by the American Academy of Audiology or the American Speech–Language–Hearing Association. If the follow-up examination confirms that your baby has hearing loss, he or she should begin receiving intervention services as soon as possible, ideally by the age of 3 to 6 months.

The pediatric audiologist may recommend that your baby visit a pediatric ear, nose, and throat (ENT) physician who specializes in conditions affecting the ear, known as a pediatric otologist. A pediatric otologist can determine possible causes of hearing loss and recommend intervention options. If your child has siblings, the audiologist or otologist may also recommend that their hearing be tested.

The follow-up exam revealed that my baby’s hearing is fine. Does that mean we don’t need to check his or her hearing again?

Not necessarily. Hearing loss can occur at any time of life. Some inherited forms of hearing loss don’t appear until a child is older. If your baby was exposed to certain infections before being born, they are more likely to have gradual hearing loss during childhood. Other factors, such as childhood illness, ear infection, head injury, certain medications, and loud noise are also linked to hearing loss in children. If you have concerns about your child’s hearing at any age, talk to your pediatrician right away.

When interventions begin early, children with hearing loss can develop language skills that help them communicate freely and learn actively. The Individuals with Disabilities Education Act ensures that all children with disabilities have access to the services they need to get a good education. Your community may also offer additional services to help support your child.

Your baby’s health care team will help you find services and methods to overcome communication barriers. You may also be referred to a speech-language pathologist or a teacher who is experienced in working with children with hearing loss. Talk to and communicate with your child often and stay up-to-date with all health care appointments.

Depending on your baby’s hearing loss and communication needs, some of these devices and tools may help to maximize his or her communication skills.

• Hearing aids. Worn behind the ear, hearing aids help make sounds louder and clearer. Hearing aids can be used for different degrees of hearing loss in babies as young as 1 month. A pediatric audiologist who is experienced in treating infants and children can help you choose the best hearing aid and make sure that it fits securely and is properly adjusted.
• Cochlear implants. If your child cannot benefit from a hearing aid, your doctor or audiologist may suggest a cochlear implant. This electronic device can provide a sense of sound to people who are profoundly deaf or hard-of-hearing. The device converts sounds into electrical signals and carries them past the nonworking part of the inner ear to the brain. Cochlear implants can be surgically placed in children as young as 12 months, or sometimes earlier.

  With training, children with cochlear implants can learn to recognize sounds and understand speech. Studies have also shown that many eligible children who receive a cochlear implant early (before 18 months of age) can develop spoken language skills at a rate comparable to children with normal hearing, and many succeed in mainstream classrooms. Some doctors now recommend the use of two cochlear implants, one for each ear. An audiologist or otolaryngologist who specializes in cochlear implants can help you decide if a cochlear implant is appropriate for your child.

• Assistive devices. As your child grows, other devices may be useful. Some devices help children hear better in a classroom. Others amplify one-on-one conversations or make talking on the phone or watching TV and videos easier.

Children who are deaf or hard-of-hearing can learn to communicate in several ways. Find out as much as you can about the communication choices and ask your health care team to refer you to experts if you want to know more. Because language development begins early, regardless of the communication mode you choose, you should engage with your child and begin intervention as soon as possible.

Common approaches used to help children with hearing loss communicate and interact with others include:

• Listening and spoken language (also known as auditory-verbal): works to strengthen listening, talking, and reading skills through the use of natural hearing and hearing devices such as hearing aids and cochlear implants, without the use of manual communication.
• Auditory-oral:emphasizes residual natural hearing in combination with amplification devices and technology to help children develop speech and spoken-language skills. It includes the use of speech reading and natural gestures in the communication process.
• Cued speech: is a system of specific hand shapes and placements that represent groups of consonants and vowels and that are used in combination with natural lip movements.
• American Sign Language: is a visual-manual, natural language that is used in the American Deaf community.
• Combined approaches: use aspects of various communication approaches, some of which are listed above, to expose children who are deaf or hard-of-hearing to many ways to communicate with others.

Like all children, children who are deaf or hard-of-hearing can develop strong academic, social, and emotional skills and succeed in school. Find out how your school system helps children with hearing loss. With your input, your child’s school will develop an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) for your child, and you should ask if an educational audiologist is available to be part of the academic team. Explore programs outside of school that may help you and your child and talk with other parents who have already dealt with these issues. The Individuals with Disabilities Education Act ensures that children with hearing loss receive free, appropriate, early-intervention services from birth through the school years.

Use this timeline to get started.

By 1 month old:

By 2-3 months old:

By 3-6 months old:

Ongoing:

Some babies are born with hearing problems. Other children are born with normal hearing and begin to have hearing problems as they grow older.

It’s important to know what to expect as your baby grows, because hearing problems can delay the development of voice, speech, and language skills. The checklist below presents the average age by which most babies accomplish a variety of early speech and language skills. Typically, a child may not accomplish all the items in an age category until he or she reaches the upper age in the age range.

Find your child’s age range in the checklist. Check “yes” or “no” for each item. After you complete the checklist, if any of the items are checked “no,” show it to your child’s doctor. Tell the doctor if you think your child has trouble hearing.

Talk to your doctor

If you think your child may have a hearing problem, here are some things that your doctor might ask you about:

• Do others in the family, including brothers or sisters, have a hearing problem?
• Did the child’s mother have medical problems in pregnancy or delivery (experienced a serious illness or injury or needed drugs or medications)?
• Was the child born early?
• How much did the child weigh at birth?
• Did the child have physical problems at birth?
• Does the child rub or pull on his or her ear(s) often?
• Has the child ever had scarlet fever?
• Has the child ever had meningitis?
• How many ear infections has the child had in the past year?
• How often does the child have colds, allergic symptoms, or ear infections?

Some words the doctor may use are:

• Audiogram: a chart that shows how well you can hear.
• Audiologist: a person who tests and measures hearing.
• Earache: pain deep inside the ear.
• Otitis media: middle ear infection.
• Otolaryngologist: a doctor who treats diseases and problems of the ear, nose, and throat.
• Otologist: a doctor who treats diseases of the ear.
• Pediatrician: a doctor who takes care of infants and children and who treats their diseases.
• Speech-language pathologist: a health professional trained to evaluate and treat people with speech or language disorders.

What are voice, speech, and language?

Voice, speech, and language are the tools we use to communicate with each other.

Voice is the sound we make as air from our lungs is pushed between vocal folds in our larynx, causing them to vibrate.

Speech is talking, which is one way to express language. It involves the precisely coordinated muscle actions of the tongue, lips, jaw, and vocal tract to produce the recognizable sounds that make up language.

Language is a set of shared rules that allow people to express their ideas in a meaningful way. Language may be expressed verbally or by writing, signing, or making other gestures, such as eye blinking or mouth movements.

Your baby’s hearing and communicative development checklist

Birth to 3 Months

• Reacts to loud sounds
• Calms down or smiles when spoken to
• Recognizes your voice and calms down if crying
• When feeding, starts or stops sucking in response to sound
• Coos and makes pleasure sounds
• Has a special way of crying for different needs
• Smiles when he or she sees you

4 to 6 Months

• Follows sounds with his or her eyes
• Responds to changes in the tone of your voice
• Notices toys that make sounds
• Pays attention to music
• Babbles in a speech-like way and uses many different sounds, including sounds that begin with p, b, and m
• Laughs
• Babbles when excited or unhappy
• Makes gurgling sounds when alone or playing with you

7 Months to 1 Year

• Enjoys playing peek-a-boo and pat-a-cake
• Turns and looks in the direction of sounds
• Listens when spoken to
• Understands words for common items such as “cup,” “shoe,” or “juice”
• Responds to requests (“Come here”)
• Babbles using long and short groups of sounds (“tata, upup, bibibi”)
• Babbles to get and keep attention
• Communicates using gestures such as waving or holding up arms
• Imitates different speech sounds
• Has one or two words (“Hi,” “dog,” “Dada,” or “Mama”) by first birthday

1 to 2 Years

• Knows a few parts of the body and can point to them when asked
• Follows simple commands (“Roll the ball”) and understands simple questions (“Where’s your shoe?”)
• Enjoys simple stories, songs, and rhymes
• Points to pictures, when named, in books
• Acquires new words on a regular basis
• Uses some one- or two-word questions (“Where kitty?” or “Go bye-bye?”)
• Puts two words together (“More cookie”)
• Uses many different consonant sounds at the beginning of words

2 to 3 Years

• Has a word for almost everything
• Uses two- or three-word phrases to talk about and ask for things
• Uses k, g, f, t, d, and n sounds
• Speaks in a way that is understood by family members and friends
• Names objects to ask for them or to direct attention to them

3 to 4 Years

• Hears you when you call from another room
• Hears the television or radio at the same sound level as other family members
• Answers simple “Who?” “What?” “Where?” and “Why?” questions
• Talks about activities at daycare, preschool, or friends’ homes
• Uses sentences with four or more words
• Speaks easily without having to repeat syllables or words

4 to 5 Years

• Pays attention to a short story and answers simple questions about it
• Hears and understands most of what is said at home and in school
• Uses sentences that give many details
• Tells stories that stay on topic
• Communicates easily with other children and adults
• Says most sounds correctly except for a few (l, s, r, v, z, ch, sh, and th)
• Uses rhyming words
• Names some letters and numbers
• Uses adult grammar

This checklist is based upon How Does Your Child Hear and Talk?, courtesy of the American Speech–Language–Hearing Association.