Tag Archives: Hearing loss in children

Poor performance in school! Could it be hearing loss?

Your child performing poor in school! You may have to visit an ENT specialist and Audiologist for his Hearing Test.   Even a slight hearing loss in a child is often a reason behind poor performance in class.

Hearing loss doesn’t essentially mean complete inability to hear. It may be slight hearing disorder, only one sided hearing loss, conductive loss caused by recurrent ear infections or problem with sensory auditory processing skills (where even hearing tests may show normal hearing)

 Most parents and teacher may not be aware of Spectrum of pediatric hearing loss and many years can pass before a student is diagnosed and treated. Sometimes it will be taken as attention deficit disorder or normal childhood behaviour or ignorance.

hearing-loss school performance Vashi, Navi Mumbai

Even mild hearing  loss can compromise communication skills and school performance.

Specific effects of Hearing Loss on children-

  • Children with untreated hearing loss may have lower self esteem, they have tendency to isolate themselves and there is lack of class participation.
  • Have difficulty in understanding complex sentences.
  •  There could also be slow vocabulary development and Problem with sentence structure as compare to children with normal hearing.
  • Children may have unclear speech and their speech may be difficult to understand.

 Treatment Of Hearing Loss-

ENT Specialist can treat some types of hearing loss, (conductive hearing disorder which involves outer or middle ear). Such as most ear fluid and Ear infections are managed with medication or simple surgery  to drain the fluid out from middle ear by putting tiny tubes/grommets.

For other types of hearing loss (Sensorineural hearing loss) Hearing aid or cochlear implant, Bone Anchored hearing aids are provided which does not cure hearing loss but may help a child

Children who received early intervention at 6 month of age have been shown years later to have language skills similar to those of children of the same age who have normal hearing.

 Knowing early regarding childhood hearing loss and initiating early treatment- medical, surgical or use of hearing  aids /cochlear implants are critical for the development  of speech, language, and communication skills in children with hearing loss and shown to increase school performance.

 Even mild hearing loss can compromise academic performance. And You should visit an ENT specialist to find out condition of external and middle ear and an audiologist for hearing test and to manage hearing problems.

Hearing Screening in Newborn

When Mishi (name changed) was born her parents were extra cautious for her hearing as her elder sister now 4 years old has cochlear implantation done.

They visited audiologist for hearing evaluation. Their worst fears was confirmed, Mishi now 6 months has severe to profound hearing loss and is fitted with hearing aids. But there is hope, as she is young she will most probably lead normal life like her elder sister which was intervened early and appropriately.

On the other hand khushi is 3 and ½ years old, pediatrician immediately referred her to audiologist for delayed speech, thanks to increasing awareness in Navi Mumbai. But even after confirmation of hearing loss, they are not willing for intervention as her father thinks she will start talking with time.


Importance of assessing hearing in a new-born child:

Two out of every 100 children under 6 years of age have permanent moderate deafness and 1-4 out of every 1,000 newborns have significant hearing loss.

Birth to 3 years are critical for speech and language development and if child does not hear the sound, he can not speak, even a mild or one sided hearing loss can affect speech language skills, academic & intellectual skills, and it affects individual for the rest of his life.

“American Academy of Pediatrics recommends new born hearing screening and periodic hearing testing for first three years of life. Joint Committee on Infant Hearing (JCIH, 1994) recommends that all infants with hearing loss should be identified by 3 months of age, and should be fitted with hearing aids or cochlear implant and receive services to help them learn to listen and speak by 6 months of age.


Importance of OAE hearing screening:

Newborns, infants and children below 5 years are difficult to diagnose by routine tests. Traditional subjective methods of behavioral observation to ringing bells and hand clapping are not fully reliable as child may respond to some sound because of residual hearing or they may take cues from visual prompts, at the same time child with normal hearing may not respond.

Prior to Objective tests such as OAE, infants with hearing loss typically remained unidentified until 2 ½ years of age. – far too late for optimal language development.

Advances in technology make it possible to assess the hearing of infants even while they are asleep.


Method for hearing screening Otoacoustic Emission (OAE):  

A small probe is placed in the child’s ear canal. This probe delivers a low-volume sound stimulus into the ear, which travels from middle ear to inner ear. If hearing is good this sound will bounce back as echo generated by outer hair cells of cochlea (called OAE)  and is measured with a microphone.

In approximately 30 seconds, the result is displayed on the screening unit as a “pass” or “refer.”

It is very important to remember that fail OAE  does not mean child have haring loss it just indicates that further  tests are required for full hearing evaluation. (BERA and ASSR test).


Newborn hearing screening in India:

 In developed countries like US it is mandatory to check hearing of each and every newborn within 48 hours of birth. But currently there are no mandatory rules or regulations for Newborn Hearing Screening in India and hence the identification of hearing loss is mostly at later ages.



OAE screening is proved to be reliable method of screening. If hearing screening is made mandatory for the newborns at the time of birth or within the first month of life many more cases of hearing & speech impairment could be avoided.

Hearing impairment must be corrected before the child reaches six months of age. Late intervention of the hearing loss will yield very poor results as the plasticity of the brain reduces drastically as the child grows older. Undetected hearing loss is big obstacle to educational achievement and socialization.

Mother’s instinct should never be ignored and probable hearing loss in the child should be subjected to audio logical assessment.  It should not be ignored withIt shall improve in the next few years” or ‘child did not hear because he was busy playing or watching television’.

For more information about OAE screening visit hearing screening protocol at Audicco

or mail at info@audicco.com

At Risk Children for Late Onset Hearing Loss

The Joint Committee on Infant Hearing 2000 position statement suggests that the following indicators place an infant at risk for progressive or delayed-onset sensorineural and/or conductive hearing loss.


  • Parental or caregiver concern regarding hearing, speech, language, and or developmental Delay
  • Family history of permanent hearing loss in childhood
  • Infections after birth such as bacterial meningitis
  • Head trauma
  • Repeated or persistent bouts of ear infections lasting at least 3 months
  • Infections during pregnancy such as cytomegalovirus, herpes, rubella, syphilis, and toxoplasmosis
  • Syndromes associated with progressive hearing loss
  • Neonatal indicators such as persistent pulmonary hypertension
  • Unusual appearance of baby’s head, face or ears

Newborn Hearing Screening

  • Why Newborn Hearing  Screening?

  • How early should I have my baby’s hearing screened?

  • How is Hearing screening in newborn done?

  • What are the advantages of OAE screening?

  • What does ‘REFER’ or ‘FAIL’ mean?

  • What is the Hearing Screening Protocol at Audicco Gliriaa?

  • What are some of the warning signs of hearing loss in an infant?

Why Newborn Hearing  Screening?

Newborn babies learn to recognize the familiar sounds in their home in their first few months of life.  Baby if can’t hear the sound, can’t speak, profound hearing loss can lead to dumbness.  Even partial Hearing loss in children can impair normal development of speech & language, his emotional balance, academic & intellectual skills and it affects individual for the rest of his life.

Subjective methods, such as ringing bells and hand clapping have not proven to be reliable for screening. Prior to Objective hearing tests such as OAE, infants with hearing loss typically remained unidentified until 2 ½ years of age. – far too late for optimal language development.

How early should I have my baby’s hearing screened?

  Your baby should have a hearing screening at birth or within the first month of life. If hearing loss is confirmed, it’s important to consider the use of hearing Aids or Cochlear Implant by 6 months of age. Hearing should be tested as child grows at any time on slightest suspicion of hearing deficit by Parents, care givers, teachers and family doctors.

How is Hearing screening in newborn done?

The procedure is performed with a portable hand held screening unit.

OAE screening–A small probe is placed in the child’s ear canal. This probe delivers a low-volume sound stimulus into the ear.

Tone or click stimuli are delivered, which travels from middle ear to inner ear where OAE is generated by the outer hair cells of the cochlea. This travels back and is measured with a microphone.

In approximately 30 seconds, the result is displayed on the screening unit as a “pass” or “refer.”


Automated ABR screening – Disposable surface electrodes are placed high on the forehead, on the mastoid, and on the nape of the neck.

The click stimulus (usually set at 35 dB hearing level [HL]) is delivered to the infant’s ear via small disposable earphones designed to attenuate background noise.

As with OAE screening, the sound travels through the outer, middle, and inner ear. However, in ABR, the sound continues along the eighth nerve to the brain.

An electrical response from that nerve is picked up by electrodes strategically placed on the infant’s head. This response is recorded and analyzed.

However, it lacks frequency-specific information and requires increased preparation time prior to testing.

What are the advantages of OAE screening?

Handheld otoacoustic emissions (OAE) screening is the most practical method for screening infants and toddlers because it :

  • objective and not dependent on a behavioral response from the child
  • Reliable and efficient
  • Help to detect sensorineural hearing loss and wide range of hearing-health concerns.
  • Is quick and painless
  • Simple and portable


What does ‘REFER’ or ‘FAIL’ mean?


Refer, an absent response to a click, does not always mean total deafness, but it does mean that your baby needs his/her hearing looking at more carefully.

The ear will not pass the screening if there is –

(a)  Blockage in the ear canal by wax or  amniotic,

(b) Structural problem or excess fluid in the middle ear

(c) Impaired cochlea that is not responding normally to sound.

What is the Hearing Screening Protocol ?

 All newborn should be screened at birth, or, within a month’s time.


Visual inspection – Outer ear abnormalities, foreign objects or blockage in the ear canal, any fluids draining from the ear, or noticeable odor; if any abnormal conditions are present, medical management should be done by ENT specialist.


Ist OAE screening – If both Ears Pass the test, the child’s hearing screening is considered complete

Those who have high-risk for hearing loss should be followed up at intervals of 6 months even if they are cleared at the screening. (As per Joint Committee on Infant Hearing 2000 position statement)

If the child does not pass the screening on any ear child is evaluated and managed by ENT specialist for a possible middle ear disorder within 3 months of age.

Repeat OAE screeningAfter treatment and/or medical clearance is obtained, the OAE screening is repeated.

If the ear passes the test, no further screening

However, if the ear dues not pass the Repeat test child is referred to a pediatric audiologist for complete Hearing evaluation like BERA (ABR), ASSR and Impedance.

Appropriate measures such as hearing aid fitting initiated before 6 months.


What are some of the warning signs of hearing loss in an infant?

If your child does not startle to loud noises or awaken from sleep by very loud noises in the house.

If your child is not babbling repetitively (ba ba, da da, etc.) by 8-10 months or

if your child doesn’t turn to localize the source of your voice by 7-8 months, you should be suspicious.

Ask for an objective set of tests. 

How hearing impairment is diagnosed in infant and young children?

Hearing loss can range from a mild impairment to profound loss. Conductive hearing loss is largely preventable and can be managed by medicine/surgery. Sensor neural hearing loss may need fitting with hearing aids.

Early identification of hearing loss in newborn and young children is of critical as he develops language and speech by hearing to his surroundings.

In general neonates and infants could be tested by BERA, children in the age group of 2 – 3 yrs could be screened using free – field audiometry, children above 4 yrs could be conditioned and then a audiometry can be performed to test hearing impairment.

Babies should be screened for hearing at birth especially high risk ones.

Child with mild hearing loss is generally labeled as inattentive or slow learner. Hearing should be tested as child grows at any time on slightest suspicion of hearing deficit by Parents, care givers, teachers and family doctors.

Screening for hearing has been done for many years but still does not detect hearing impairment as early as desirable. Mother’s instinct for her child is usually correct even at early age and should not be neglected.

The type of tests used to identify hearing loss depend on the age of the child, and include:

* Behavioural observation audiometry (BOA) – for babies less than seven months of age.

It consists of making noises, such as shaking a rattle close to ear, and then observing the baby’s response.

* Distraction method – it is formalized method of behavioral observation audiometry for children 7-19 months.

Infant sits on mother’s lap and one tester standing in front uses toys to raise attention. Other tester behind the child presents signals like shaking a rattle, or drum beat. First tester observes the child’s response. Response may be head turn, eye turn, frowning, sucking etc. After each response the signal intensity used to elicit a response is measured.

* Visual reinforcement orientation (VRA) – useful for children 7-30 months of age. The baby is taught to move their head towards sound by pairing it with an interesting visual stimulus, located in the direction of the speaker.  Their response to different sounds can then be measured. Test is done in sound proof room with speaker and headphone. The ears can be tested individually if the baby tolerates headphones.

* Performance audiometry test – older children are taught to respond to sounds by a performing a simple action or playing a game, such as dropping a marble when they hear the sound.

* Oto-acoustic emission – certain sounds generated by the inner ear can be recorded to check the function of the tiny hair cells in the cochlea.

* Auditory brainstem response testing – to check the electrical activity in the brain in response to a sound. Electrodes are placed on the head to measure the brain waves. It is most popular test for neonatal hearing assessment and for detection of hearing loss.

* Transtympanic Electrocochleography – to check the cochlea for signs of electrical activity in response to sound. It is better indicator of hearing threshold than any other auditory evoked response in children. An electrode is threaded through the eardrum to touch the cochlea and it requires general aneasthesia in children.

* Impedance audiometry or Tympanometry – a probe which snugly fits into the ear and air is pumped into the ear canal. Neonates and young infants may be examined so long as the probe tone is 660 Hz and not 220 Hz. Stapedius reflex are used to assess middle ear disfunction. Impedance audiometry is not an alternative to behavioral audiometry.t

** Hearing test for older children are same as for adult

Management of fluid in middle ear or ‘glue ear’

fluid in middle earPopularly known as ‘glue ear’,  Otitis media with Effusion or fluid in the middle ear is the commonest cause of hearing difficulty and most frequent reason for visits to Otorhinolaryngology (ENT) clinic in children. More common during the age when child is developing speech and language skills by hearing to his surroundings,  because it is not painful, it may present as speech and language delay or defects.

Underlying mechanism in collection of fluid in the middle ear may be either Blockage of Eustachian tube or Increased production of mucus in middle ear:

Children have shorter and more horizontal tubes and immune system are not well developed, that is the reason which explains more common ear infection in a child. If Eustachian tube gets blocked because of some reason middle ear air replacement fails and potential vacuum forms, this vacuum draws fluid inside the middle ear.

This could be basis of effusion in Baro-trauma, adenoids, viral infections (as evidenced by association of OME with influenza), second hand smoke, allergy, immunological factors, birth defects(such as cleft palate), cystic fibrosis, or cilia abnormality (as in Kartageners syndrome).

In some cases Eustachian tube is patent; here other factors like increased mucus production in the middle ear as is seen in upper respiratory infection or allergy, may play a role.

Benign and malignant tumor should always be ruled out in adult having otitis media with effusion in one ear.

Treatment: –

Medical treatment:

There is high rate of spontaneous resolution; most episodes are short lived and 75% of cases resolve in 3 months so normally a ‘wait and watch’ policy is advised.

According to ‘American Academy of Otorhinology-Head and Neck Surgery’ (AAO-HNS): –

  • Child is kept under observation with regular follow ups for first three months.
  • If condition lasts longer than 3 months, a hearing test is conducted and child re-evaluated. If hearing is within normal range (below 20 decibels) child is prescribed with antibiotics and kept on periodic check-ups for 4-6 months.

Management is aimed to encourage natural process; useful measures are control of environment factors, management of allergy, nasal decongestant drops, and  Valsalva’s maneuver (Forced expiration with both the mouth and nose closed à Increased air pressure in nasopharynx à opening of the Eustachian tube).

Surgical treatment:

Child is considered for surgical treatment if OME lasts for more than 4-6 months, or there is hearing loss more than 20 decibels or child is at risk of developmental delays because of recurrent problem.

Mainstay of treatment is myringotomy (a small incision is made in ear drum and fluid is suctioned out) and placement of ventilation tubes (Grommets).

Procedure takes less than 30 minutes, ear tube falls out after few months and incision heals spontaneously. Ear tube relieves pain and restores hearing.

There are chances of relapses in 20%-50% children and tube placement may have to be repeated.

Sometimes removal of adenoids is to be done along with tubal placement.

Management of risk factors: –

  • Well balanced healthy diet with fresh fruits and vegetables rich in antioxidants and lacto bacillus.
  • Avoidance of bottle feeding and pacifiers
  • Restricting exposure to day care
  • Wash hands and toys frequently
  • Avoidance of passive smoking
  • Management of associated nasal conditions
  • Avoidance and management of allergy
  • Pneumococcal and flu vaccine

Studies have evaluated that antibiotics and other medicines have short term effect and no long term cure. Putting ventilation tubes is effective but some newer studies have questioned the role in view of spontaneous resolution and frequent need for repeat tubal placement.

Several studies are being conducted but there are still so many unanswered questions and still need for proper research.