Gerson, C. R. (1997). Detecting potential hearing problems in young children. Healthy Child Care America, 1(3), 3-4.

The lack of early detection of hearing problems in children is a major public health problem. The average age at which moderate to severe hearing impairment is detected in children is 2 to 3 years of age, but these problems can be and should be identified and treated much sooner. If undetected and untreated, hearing loss in children leads to delayed speech and language development and can contribute to emotional, social, and academic problems.

A 1994 Joint Committee on Infant Hearing Position Statement calls for the identification of infants with hearing loss before age 3 months and intervention by age 6 months. Working together, health professionals, child care providers, and parents can increase the rate of early identification of hearing-impaired children 

Identifying children who should be tested

Parents and caregivers should become familiar with the average ages (months) at which infants and toddlers develop speech and language. Pediatricians and other health care professionals can provide communication and other developmental information. Excellent brochures on this topic are available from the American Speech-Language-Hearing Association at 1-800-638-8255 or through e-mail at actioncenter@asha.org.

What should child care providers do if they are concerned about a child's hearing? The child care provider can suggest to parents that a hearing test would be a good idea and can encourage them to discuss this issue with the child's pediatrician or primary care clinician. A health professional who consults with the child care program also may be able to encourage the parent to proceed. The child's primary care provider may choose to conduct a hearing screening for a preschool age child, but infants and young toddlers will need a referral for special test. Providing informing about local organizations that test children and how to make an appointment may encourage a parent to have their child's hearing checked. Any child who has a history of frequent ear infections and who shows signs of poor hearing, not following directions, poor pronunciation, or behavioral problems should have a hearing test.

A parent's concerns about hearing should never be dismissed. Parents are usually the first to suspect a hearing loss, and the earlier a loss is found the better the chances of preventing language and learning delays. Despite concerns about health care cost containment, a hearing test is never wasted if there is a concern about hearing or if language is delayed.

No hearing test should be done on a child whose ears are filled with wax. The wax must be cleaned before any testing is done, and the pediatrician or clinician should check and make sure this has been done before sending the child for testing. A hearing test can be done with fluid in the ears, and this is valuable because it will indicate how much hearing loss is caused by the fluid.

What is the pediatrician's role?

The pediatrician should consider a hearing evaluation in the following situations:

• Children who fall into the high-risk population, for example, craniofacial abnormalities, prematurity, intrauterine infection history, meningitis, genetic conditions related to hearing loss, or a family history of hearing loss.
• A child who has a speech or language delay, for example, no babbling in a 6-month-old, no words by 18 months, or no word combinations by age 2.
• A child whose parent is concerned about hearing. Hearing losses at specific frequencies or unilateral losses may be present despite normal language. Hearing loss is still detected very late in many children, significantly impairing their ability to learn language and delaying their cognitive development.
• A child whose eardrums are consistently impossible to see due to wax or small canals. (These may need to be cleaned and evaluated by an otolaryngologist.)

The pediatrician or primary care provider should conduct ongoing exams when a child has middle ear fluid until it has cleared. If present for several months without clearing, consultation with an otolaryngologist should be considered. Remember that little is lost by testing the normal child, but much is lost by not testing the hearing-impaired child.

How can hearing be tested?

The following is an overview of methods of testing hearing in children.

1. Behavioral Testing
Behavioral testing involves placing a child in a soundproof booth to see if she will respond to sound, as we would expect for a child of that age. Babies in the first month or two of life will startle to a very loud noise. If an infant does not do this, a hearing problem may exist. This is called sound field audiometry. However, reliance on startling alone may not identify smaller but still significant losses.

Older infants will turn their heads to noises that get their attention. Eventually they can learn that a bunny or bear will light up when there is noise and they will look for the animal when they hear the noise. If they do not look, they did not hear it. This is called visual response audiometry.

Most toddlers up to age 3 or 4 can learn to put a toy in a box when they hear the noise. If they do not put the toy in, they did not hear the noise. This is called conditioned play audiometry.

Most children with a developmental age of 4 or older can wear earphones and raise their hands when they hear a sound. This is called air conduction audiometry. When they are a little older, they can respond to a bone vibrator which helps to determine whether a hearing problem is in the middle or inner ear in cases where both ears are not the same. This is called bone conduction audometry.

A behavioral test is a better measure of hearing and generally should be tried first in the overwhelming majority of children, even older infants.

2. Brainstem Evoked Response Testing (BER, ABR, BSER)
The Brainstem Evoked Response Testing method is used with children who cannot respond in the soundproof booth, usually due to developmental issues. No responses are required from the child. The child sleeps, with or without sedation. Ear phones and electrodes are placed on the child to record activity from the hearing nerve.

The test measures high-pitched sounds better than low-pitched sounds. This is not a direct measure of hearing, but a measure of nerve activity. This procedure is frequently used by hospitals to test newborn infants.

3. Otoacoustic Emissions (OAE)
Otoacoustic emisssions is a very new method of hearing testing and also can be done in children who cannot respond to behavioral testing. This is a very fast test that can be used for screening in the newborn nursery. This test is based on the fact that the ear not only hears noise, but also makes noise. By measuring the very faint noises made by the ear, the test estimates how well the ear hears. An ear that does not hear will not make the expected noises. These noises are much too faint to be heard by our ears, but there are machines that can measure them.

4. Central Auditory Processing Testing (CAP)
Some children age 5 and up can be tested for their ability to process the sounds they hear. Some children hear very well, but have difficulty deciding what to do with the sound once they hear it. This begins in the base of the brain and transmits information to the higher centers, which then tells us what we heard. These children may be smart but have trouble following directions in school. They may have trouble in noisy environments. They may be children who had lots of trouble with ear infections when they were younger and developed difficulty dealing with sound as a method of communication. A child must be able to speak in full sentences and have reasonably advanced language to take this test. If a child care provider or parent has any doubt about slower then normal sound and speech-language development in a child, these concerns should be discussed with the child's primary care provider, and hearing testing should be seriously considered.

This article may be reproduced for noncommercial educational purposes.