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Hearing and hearing loss - babies and children

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ALERT: Consult your doctor if there has been a sudden change in your child’s hearing. Some conditions require prompt treatment to prevent permanent damage

Hearing well is important to your child's development. If there are any difficulties hearing, finding them early is important.  If children born with a hearing loss receive help by 6 months of age, they have a good chance of developing speech and language.

Contents

Your child’s hearing and speech milestones

Age

Signs of Normal Hearing

Birth to 3 months

  • Startle to loud sudden noises such as door slamming or vacuum cleaner (may blink, stiffen or cry)
  • React to familiar  voices (e.g. calm down when hearing parent’s voice)
  • Makes cooing and gurgling sounds

3 to 6 months

  • Beginning to search for the direction of a sound (sound localisation)
  • Vocalises in response to familiar sounds like a parent
  • Wil react to the tone of voice (e.g. smiling or crying)
  • Begin to make simple speech sounds like “ba” and “ga”

6 to 9 months

  • Looks in the direction of sounds (even quiet sounds)
  • Babbles and makes repetitive sounds like “mama”
  • Understands simple words like “no”, bye-bye’

9 to 12 months

  • Responds to soft and loud sounds
  • Searches for sounds if they are made out of sight
  • Imitates animal and speech sounds
  • Enjoys babbling  tunefully
  • Recognise the names of common objects like shoe, cup, milk

12 to 18 months

  • Follow responses to name and familiar words by 12 months
  • Use first words around 12 months
  • Follow simple instructions  like “kiss mummy”
  • By 18 months use 15-20 words and understand 50 words

18 to 24 months

  • Combine words into short , 2 word phrases
  • Listen to simple stories and songs
  • Begin to use pronouns like “me” and “mine”

2 to 3 years

  • Uses 2 to 3 word sentences
  • Follows multi-step instructions like “take your toys and put them in the basket”
  • Can name many objects
  • Speech is understood by people who spend most time with the child

**Hearing loss should be considered in babies and children who do not do these things. If you are not sure if your child is hearing well, have their hearing tested by a qualified audiologist. For more information on the free service provided by Children’s Audiology Service, visit the Hearing Assessment Service page.

Older Children:

Things to look out for:

  • Inconsistent responses to sounds
  • Inattentiveness
  • Asking for repeats
  • Listening to the TV/music at loud volumes
  • Difficulty hearing or understanding when listening at a distance or in background noise
  • Starting to talk later than other children
  • Use incorrect words or sounds or have unclear speech

How is a child's hearing tested?

A child is never too young to have a hearing test. There are hearing tests suitable for all ages and stages of development. The audiologist will take these into consideration when testing your child.

Hearing Assessment Tests - Behavioural

Birth to 6 months:

  • Children under six months are unable to tell us when they hear and generally only respond to loud sounds and familiar voices.
  • A baby’s hearing can be screened very quickly using an Automated Auditory Brainstem Response (AABR) test which tests the child’s hearing pathway through to the brain. It is conducted whilst the baby is asleep and is usually done in the first few days after birth by the hospital midwife or community health nurse. Either a “pass” or “refer” result can be achieved with this test.
  • If a baby does not pass this test, they may be referred for an Auditory Brainstem Response (ABR) assessment. This test gives more detailed information on a baby’s hearing. The ABR is conducted by a paediatric audiologist and is offered at multiple locations in South Australia. Visit the Universal Neonatal Hearing Screening page for more information.

6 months to 4 years:

  • Hearing assessments for children in this age group usually involves teaching children to respond to different sounds that come from a speaker.
  • These tests provide a result for the child’s overall hearing (how well the ears work together) rather than individual ear information.
  • Tympanometry (test of middle ear health) and otoacoustic emission (OAE, test of inner function) can also be used to provide further information about the child’s ear health and hearing status.

From 4 years:

  • Children 4 years and older are generally happy to wear headphones and participate in ‘listening games’ to show us what they can hear in each ear individually.
  • Tympanometry and OAE testing is also included to provide information about middle ear health and inner ear function.
  • Speech testing (asking the child to repeat words or sentences or point to objects) can be used to identify how clearly children are hearing speech.

For more detailed information on the hearing tests used, visit the Hearing Assessment Service page.

What does hearing loss mean?

Children diagnosed with hearing loss cannot hear sounds in the same way as other children. Having a hearing loss means children have lost some hearing in either one ear (unilateral) or both ears (bilateral) and the degree of hearing loss can be mild, moderate, severe or profound (or a combination of these). The degree of hearing loss is used to determine the best next step for each child. It is important to note that regardless of the degree of a child’s hearing loss, all hearing losses are unique and affect each child differently.

Mild hearing loss (21dB- 40dB)

  • Your child can hear normal conversation in quiet situations but may not hear whispers, soft sounds, or some word endings.  Background noise in playgroup, kindergarten, classrooms and other environments, (for example parties or family gatherings), may make it harder for your child to hear. Hearing aids or assisted listening devices may be recommended.

Moderate hearing loss (41dB- 70dB)

  • Your child may not hear normal, conversational speech clearly. However, they will hear a person if they speak in a loud voice. A moderate hearing loss makes it hard for your child to understand what you are saying, especially when there is background noise. This can affect their speech and language development because not all words and sounds are heard clearly. Hearing aids or assisted listening devices are commonly recommended.

Severe hearing loss (71-90dB)

  • Your child will not hear most speech sounds and may only be able to pick out a few loud sounds and words. This makes it difficult for them to continue developing speech and language, unless sounds and speech are amplified for them by hearing aids or other assistive listening devices.

Profound hearing loss (91dB and above)

  • Your child will be unable to hear people talking and most sounds in the environment. With this degree of hearing loss, it is very hard to develop clear speech and language without the help of a hearing aid. In some cases, a cochlear implant may be used to increase the amount of sounds the child can hear. In some cases, families may choose to use sign language as a way to communicate with their child instead of or in addition to developing spoken language.

Unilateral hearing loss

  • Unilateral hearing loss is the term used when one ear has a hearing loss (with any degree of loss) while the other ear has normal hearing.
  • The effects of a unilateral hearing loss are not always immediately obvious as the child can hear well in one ear and may develop speech and language at a similar rate to normally hearing peers.
  • A unilateral hearing loss may cause a child to have difficulty:
    • Locating where a sound is coming from
    • Hearing or understanding softly spoken speech in noisy situations (e.g. in a classroom)
    • Understanding someone from a distance
    • Hearing when someone speaks to them on the side with the hearing loss.
  • There is no set management pathway for children with a unilateral loss. Sometimes a hearing aid or assisted listening device on the ear with the hearing loss can help. This depends on the degree of hearing loss as well as your child’s difficulties.

Types of hearing loss

Professionals usually talk about four different types of hearing loss:

  • Conductive hearing loss
  • Sensorineural hearing loss (SNHL)
  • Mixed hearing loss
  • Auditory Neuropathy Spectrum Disorder (ANSD)

To understand what these all mean, it is important to know that the ear has three parts: the outer ear (including the ear canal), the middle ear (including the eardrum and middle ear bones), and the inner ear (cochlea). In a healthy ear, sound travels through the outer and middle ear to the cochlea which transmits sounds via the auditory nerve to the brain.

Hearing - ear anatomy 2018

Conductive Hearing Loss (CHL)

  • A conductive hearing loss occurs when sound cannot reach the inner ear properly. This may be due to:
    • Wax blockage in the ear canal
    • Ear infection/fluid behind eardrum (otitis media)
    • Perforated eardrum
  • A conductive hearing loss is usually temporary and may be treated medically or surgically.
  • Children with a conductive hearing loss due to otitis media (ear infections) may have a fluctuating hearing loss.

Sensorineural Hearing Loss (SNHL)

  • Occurs when there is damage to the inner ear (cochlea) or auditory nerve.
  • A sensorineural hearing loss is most likely permanent and will affect how loud and clear sounds seem.

Mixed Hearing Loss

  • Mixed hearing loss is a combination of a conductive and sensorineural hearing loss.
  • It occurs when sounds cannot pass through the outer and middle ear correctly (e.g. due to wax, fluid) and there is also damage to the inner ear (cochlea or auditory nerve).

Auditory Neuropathy Spectrum Disorder (ANSD)

  • A rare condition where sound enters the ear normally but there is a problem with how the sound is transmitted along the auditory nerve to the brain.
  • The cochlea receives the sound but the brain cannot recognise it.
  • Hearing losses with ANSD can range from mild to profound or there may be no hearing loss at all.
  • ANSD can cause difficulty with making sense of speech, regardless of the hearing levels.

Common Causes of Hearing Loss in Children

The cause of hearing loss is often difficult to identify and in some cases it may not be possible to identify a cause of deafness or hearing loss.

Middle ear infections (otitis media)

  • Bacteria and viruses that cause colds and flus, tonsillitis and sinusitis are the most common cause of middle ear infection. If these bacteria enter the middle ear, they can cause ear pain and fever.
  • If inflammation of the middle ear occurs due to infection, fluid from surrounding tissue may enter the middle ear space. The fluid can persist long after the infection has cleared.
  • The fluid may  begin to affect your child’s hearing as it stops the ear drum and middle ear drum bones from moving as they should.
  • In most cases the fluid will resolve by itself within 3 months. Occasionally it will stay for longer. In these cases, medical management of your child’s ear health may be required.
  • If a child has multiple ear infections, fluid may remain in the ear for a long time. It can become thick  and sticky – this is called ‘glue ear’.
  • Read more in our topic Middle ear infections (Otitis Media.

Wax blocking ear canals

  • Having some wax in the ear canal is a good thing! Wax can protect the ear from infection and foreign bodies.
  • In most people, wax gradually works its way out of the ear canal naturally.
  • In cases of significant wax build up where the wax completely blocks a child’s ear canal, a hearing loss can occur.
  • To keep ears clean, only clean the outer shell gently with a soapy finger or wash cloth.
  • Using cotton buds is NOT recommended as it is likely to push the wax deeper into the ear canal.
  • In cases of significant build up, removal by GP may be required. Your GP may recommend the use of wax drops to soften the wax before it is removed.
  • If a hearing loss persists after wax removal, your child should be seen by an audiologist, your GP or an Ear, Nose and Throat specialist.

 Other causes include:

  • Holes in the eardrum (perforations)
  • Long-term exposure to loud noise
  • Ototoxic medication
  • Degenerative disorders that damage the auditory nerve
  • Inherited conditions/genetic cause
  • Infections that occur during pregnancy (e.g. Rubella, Cytomegalovirus)
  • Infections after birth (e.g. meningitis)
  • Structural abnormalities of the ear
  • Premature birth (especially less than 1500grams)
  • Head injury.

Permanent hearing loss

  • 1 to 2 children per 1000 births are born with a significant permanent hearing loss.
  • In Australia, 3 to 6 children in every 1000 have some degree of hearing loss.
  • 2 to 3 per 1000 children have a permanent hearing loss before they turn 5.
  • More than 11,000 Australian children under 17 are fitted with hearing aids or cochlear implants.
  • Permanent hearing loss is usually due to damage to the inner ear (cochlea). This is called a sensorineural loss.
  • 50-60% of permanent hearing loss has a genetic cause while 40-50% has a non-genetic cause (e.g. due to congenital infections).
  • Research has shown that early diagnosis and intervention makes a difference. Children who are diagnosed and start receiving intervention early, have better language outcomes than those who start later.
  • For more information on permanent hearing loss and management visit our topic Children with hearing loss.

How to interpret results

  • Hearing loss is measured in decibels (dB) which is the loudness of sounds, and Hertz (Hz) which is the pitch/frequency of sounds.
  • Humans with healthy ears can hear sounds ranging between 20Hz and 20,000Hz however audiologists usually test between 250Hz and 8000Hz as most sounds in speech occur within this range.
  • A 250Hz tone will sound like a deep, low pitched horn while a high pitched tinkling bell will fall around 4000Hz.
  • On an audiogram, the decibel (volume) scale runs down the graph while the Hertz (frequency/pitch) scale runs across the graph (see audiogram below).
  • A hearing threshold refers to the softest sound that the child can hear at each frequency.
  • A circle represents the right ear and a cross represents the left ear.
  • In most cases, thresholds of 20 decibels or better indicate hearing within the normal range.

Hearing - audiogram

Where can a child's hearing be tested?

Testing a child’s hearing is best done by an audiologist who specialises in paediatric testing. It is best if parents discuss any concerns about their child’s hearing with their family doctor and obtain a referral if a hearing test is required.

South Australia

There are several public services that specialise in testing children’s hearing in South Australia including:

  • Children’s Audiology Service
    (including the Universal Neonatal Hearing Screening program and Hearing Assessment Service)
    295 South Terrace
    Adelaide SA 5000
    Tel. (08) 8303 1530
    (Testing is also available at various other metropolitan and country sites – visit the Hearing Assessment Service page  for more information).
  • Audiology Department (part of Children’s Audiology Service)
    Women’s and Children’s Hospital
    72 King William Road
    North Adelaide   SA   5006
    Tel. (08) 8161 7492
    Web: WCH Audiology
  • Audiology Department
    Flinders Medical Centre
    Flinders Drive
    Bedford Park   SA 5042
    Tel. (08) 8204 4366 / 8204 5933
    Web: Audiology Clinic at Flinders Medical Centre

There are also a number of privately run hearing services for children. Ask your G.P about ones which may be available in your local area.

Frequently Asked Questions

Q: My baby did not pass its hearing screening, does that mean it has a hearing loss?
A: No. It is common for newborn babies to ‘refer’ on their first AABR screening. This is often due to congestion that is still present from birth. Babies who refer on either ear will receive a repeat screening. If they ‘refer’ on the second screening they will referred to receive a diagnostic ABR which will provide more detailed information about their hearing. For more information visit the Universal Neonatal Hearing Screening Program page.

Q: I had grommets as a child; does this mean my child will need them too?
A: Not necessarily. Grommets are a medical intervention used when a child has persistent fluid in their middle ear (otitis media). Almost all children will have a bout of otitis media in their childhood and while some family members do share a history of middle ear issues, not all will require medical intervention.

Q: My child has been found to have fluid in their middle ear. Does this mean they have an ear infection?
A: Not necessarily. Fluid can sit in the middle ear without being infected. For more information visit our topic 'Middle ear infections (Otitis Media)'

Q: My child woke up complaining that they can’t hear anything in one ear
A: If you feel that there has been a sudden change to your child’s hearing, it is recommended you consult your family doctor as soon as possible. Some conditions require prompt treatment to prevent permanent damage.

Q: Do I need a referral to see an audiologist?
A: Yes. Please see the Hearing Assessment Service page for more information.

Q: My child doesn’t like their ears being touched. Can they still be tested?
A: Yes. Paediatric audiologists have many strategies to test children who don’t like their ears being touched or who may not tolerate a conventional testing environment (e.g. children with Autism, ADHD). A battery of tests will be used to ensure that results can be obtained. In these cases more than one appointment may be needed to obtain reliable results. It is important that this information is included on the referral so that appropriate testing will be available for your child.

Q: My child has been diagnosed with a permanent hearing loss. What happens now?
A: Your audiologist will discuss the suitable management pathway for your child. This may include referrals to Audiology Departments at major public hospitals, ENT specialists, a Hearing Impairment coordinator, Australian Hearing or other support services. For more information about permanent hearing loss, visit our topic 'Children with hearing loss'.

Additional Information

Raising Children Network
http://raisingchildren.net.au/

Australian Hearing (AH)
http://www.hearing.com.au

Better Health Channel
www.betterhealth.vic.gov.au

References:

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The information on this site should not be used as an alternative to professional care. If you have a particular problem, see a doctor, or ring the Parent Helpline on 1300 364 100 (local call cost from anywhere in South Australia).

This topic may use 'he' and 'she' in turn - please change to suit your child's sex.

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