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Hearing Testing

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Normal Hearing in Children

Normal hearing is essential for normal speech and language development in children. Even mild or fluctuating hearing loss can impact a child’s speech and language development. Though most children are now screened for hearing loss as newborns, it is important to retest hearing when there are concerns about hearing or speech/language development. Failure to meet the developmental milestones below should raise concern.
When hearing and language development are normal,
between 0-3 months, the child: between 3-6 months, the child:
  • startles to a sharp clap within 3-6 feet
  • can be awakened from sleep by sounds
    (without being touched)
  • cries at sudden, loud noises (door
    slamming, dog barking)
  • is reassured by laughter and sounds
    of pleasure
  • is calmed by voice, appears to listen
  • may “coo” when being talked to
  • responds to your voice by making sounds
  • shows interest in contrasting sounds (loud-soft,
    high-low, etc.)
  • knows mother’s or father’s voice
  • enjoys making noises (crying, lip noises, tongue clacking)
  • laughs, coos, and babbles for pleasure
  • begins to turn head toward sounds
  • responds to loving/angry tones of voice
  • begins to look for soft speech sounds
  • may not startle as much as before
between 6-9 months, the child: between 9-12 months, the child:
  • looks side to side to find where a sound
    is coming from — your baby must be able
    to hear in both ears
  • knows own name when others say it
  • searches for sounds that are at eye level
    and downward
  • plays pat-a-cake and peek-a-boo
  • imitates simple sounds understands simple
    words (no-no, oh-oh)
  • pays attention to music or singing
  • knows names of family members even when
    person is not in sight
  • searches for sources of sound (bell or squeak toy)
  • can find a sound coming from behind self
  • enjoys hearing new words
  • imitates sound of cows, clocks, dogs, etc.
  • uses first meaningful word
  • babble sounds more like a conversation with some words
    you can recognize
  • points to or looks at a familiar object when asked
  • can wave “bye-bye” when asked to
  • understands simple questions (“Where is Mommy?”)
No child is too young to be tested for hearing loss. The earlier hearing loss is detected, the sooner the child can be helped to hear normally and to develop his or her best communication and social skills.

How is Hearing Tested?

The most common methods used to test children’s hearing include:
  • Audiogram
  • Otoacoustic emission (OAE) testing
  • Auditory brainstem response (ABR) testing or Brainstem Auditory Evoked Response (BAER) testing
Audiogram

Pure tone testing, represented by an audiogram, is the foundation of an audiological evaluation. Pure tone test results are used to confirm normal hearing or describe the configuration and severity of hearing loss. Most pure tone testing is performed in a sound-treated booth using headphones, through which tones are delivered. The patient is instructed to raise her or his hand or push a button when a tone is detected. With children or special-needs adults, play or visually-reinforced techniques can be used to assess responses to the tones. Screening using pure tone testing by audiometer should be conducted in a sound-treated booth or quiet area.
Pure tones are described in terms of their frequency (in cycles per second or Hz) and intensity (decibels or dB). They can be delivered through headphones, ear inserts, or a bone oscillator. Tones can also be presented through speakers but they require modification and are then referred to as frequency-modulated or FM tones. The most commonly evaluated frequency range is 250 Hz to 8000 Hz (low to high frequency), tested in whole octave steps (250, 500, 1000, 2000 etc.). Hearing threshold, measured in decibels (dB) for each frequency, is the softest level at which the person can hear the tone. For children who cannot be trained to listen for or clearly indicate the softest sound they can hear, minimal response level describes the softest sound to which the child appears to consistently respond – this level is most likely above threshold.
Audiogram
An audiometer can also be used to test speech reception and recognition. Words are presented via a microphone and the patient is asked to repeat what he or she hears or the tester may observe a behavioral response (child turns to voice or points to body part when asked). This testing can indicate how softly and clearly the child can hear speech.
Thresholds or minimal response levels are documented on a graph called an audiogram. It shows how high the decibel level needs to be for a person to hear each frequency with each ear. If a person hears sound at 25 dB or less, hearing is considered normal.

The Human Hearing Chart to the left shows human hearing in hertz frequencies and the range that audiograms test. The range of hearing that the audiogram represents is shown on the chart in the shaded area labeled “AUDIOGRAM.” You can view a larger version of the Human Hearing Chart (PDF Document 1.0 MB). Image courtesy of Primary Children's Medical Center. Also, see an example of an Audiogram Showing Hearing Loss (PDF Document 269 KB).

Otoacoustic Emission (OAE)

Otoacoustic emission (OAE) testing is often used to test hearing in babies and small children and is the method most commonly used in newborn screening programs. The OAE involves placing a small probe in the baby’s ear that measures an active response, generated from the inner ear or cochlea, to clicks presented in the frequency range of about 800-4000 Hz. This test can only determine if normal cochlear function is present – it cannot specify the degree (mild, moderate, severe, or profound) or type (conductive or sensorineural) of hearing loss, if present. The range of hearing tested by OAE is shown on the human hearing chart in the shaded box labeled “OAE” (top near the middle). Many pediatricians and early intervention specialists use OAE to screen for hearing loss.

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

When conventional testing cannot be done, the ABR (aka Brainstem Auditory Evoked Response or BAER) is used. This is especially helpful with young children or older children with developmental delays that make behavioral testing unreliable. It can be performed on young infants during a natural sleep state. For older infants and toddlers, it is usually done with sedation because a child must be completely still during the test. ABR involves recording the brain’s activity in response to clicking sounds, in a frequency range from 500-4000 Hz, delivered to the child’s ear. The intensity of the sound can be increased up to about 105 dB. Compared with the broad range of human hearing, the frequency range of this test is somewhat narrow. However, the range that is tested encompasses the common frequencies that are needed for speech and language development. The ABR is not a hearing test but rather a test of the auditory-neural response to sound. ABR test reports may be complex but will include a summary that should include the clinical relevant findings and their implications for hearing and follow-up. See an example of a Child ABR Report (PDF Document 40 KB).
Infant ABR Hearing Test
Normal adult ABR curve


Infant receiving an ABR hearing test. Image
from the Provincial Health Servces Authority
of Canada website. Permission requested.

Normal adult ABR curves. Reprinted with permission from Journey into the World of Hearing, www.cochlea.org, R. Pujol et al., NeurOreille Montpelier.

Who Can Provide Pediatric Hearing Testing?

Hearing screening are often performed by para-professionals (MAs, CNAs) in a primary care office or other outpatient setting where there is oversight by a licensed medical provider. Diagnostic hearing testing should be performed by a licensed audiologist who is trained in testing children and has access to the various testing equipment needed to evaluate children. Children with special health care needs are best served by a pediatric audiologist trained in working with this population. Early Intervention programs will usually offer hearing testing, as will state programs focused on children with special health care needs and/or disabilities.

Costs and Insurance Coverage

The cost of hearing testing can range from less than $100 for a screening evaluation to $100-$700 for a full diagnostic evaluation, depending on the comprehensiveness of testing. Sedated procedures will cost more because medical staff is needed to provide safe sedation with patient monitoring. In many cases insurance and other third party payers will cover the cost of testing. Co-pays and deductibles will apply, so each family should check their insurance benefits to understand the cost before testing is performed. Some insurance plans will require a referral from a physician.

Resources

Information & Support

For Professionals

American Academy of Audiology
Resources for professionals who test, treat, and provide care to the deaf or hard of hearing.

Utah Medicaid Audiology Provider Manual
Utah Medicaid Program, past and current Audiology Provider Manuals.

Genetics in Primary Care Institute (AAP)
Contains health supervision guidelines and other useful resources for the care of children with genetic disorders; American Academy of Pediatrics.

For Parents and Patients

Support

Family Voices
A national, nonprofit, family-led organization promoting quality health care for all children and youth, particularly those with special health care needs. Locate your center or F2F HIC (Family-to-Family Health Information Center) by state on this site.

AUDIENT Alliance for Accessible Hearing Care
The AUDIENT Alliance for Accessible Hearing Care Program is designed for individuals whose income is above the government's established poverty levels, but still find it difficult to afford quality hearing care.

General

Hearing Tests (My Baby's Hearing)
Overview of hearing testing in children; Boys Town National Research Hospital.

Practice Guidelines

Harlor AD Jr, Bower C.
Hearing assessment in infants and children: recommendations beyond neonatal screening.
Pediatrics. 2009;124(4):1252-63. PubMed abstract / Full Text

Joint Committee on Infant Hearing.
Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs.
Pediatrics. 2007;120(4):898-921. PubMed abstract / Full Text

Tools

2017 Bright Futures Periodicity Schedule (AAP) (PDF Document 119 KB)
Recommendations for preventive pediatric health care; American Academy of Pediatrics.

Guidelines for Medical Home: Reducing Loss to Follow-Up in Newborn Hearing Screening (AAP) (PDF Document 160 KB)
One-page algorithm for follow-up of the newborn hearing screen beginning with the first newborn pediatric patient care visit National Center for Medical Home Implementation, sponsored by the American Academy of Pediatrics.

Services for Patients & Families in New Mexico (NM)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: August 2011; last update/revision: March 2013
Current Authors and Reviewers:
Contributing Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Authoring history
2011: first version: Nancy Hohler, AuD, MBAA
AAuthor; CAContributing Author; SASenior Author; RReviewer