A Parent's Guide to Having a Pediatric Hearing Assessment

Your child’s hearing is vital for their language development, learning, speech, social-emotional skills, and quality of life. A pediatric hearing assessment offers an in-depth look at how your child hears and processes sound, and detects early signs of hearing loss.

At Bloor Hearing Clinic, we’re committed to supporting your child’s hearing health with timely assessments, clear answers, and personalized care. We believe that early detection leads to better outcomes for every stage of your child’s development.

In this guide, we’ll break down everything you need to know about pediatric hearing assessments, whether for newborn or school-aged children. We’ll cover types of hearing tests and what happens if hearing loss is detected.

Importance of Pediatric Hearing Assessments

Hearing plays a foundational role in a child’s spoken language and language development. Even mild or partial hearing loss in children can impact speech, learning, and social development. Early hearing detection through a thorough evaluation can lead to appropriate intervention, such as hearing aids, cochlear implants, or speech therapy, especially during early childhood, when brain plasticity supports the most effective outcomes.

The American Academy of Pediatrics (AAP) recommends that every child undergo hearing screening at birth, followed by hearing assessments at key developmental milestones or when significant risk factors are present. This is supported by all 50 states. The AAP supports a comprehensive EHDI program that includes screening, audiological evaluation, intervention, and ongoing surveillance of communicative development. The goal of early intervention is to prevent or minimize the long-term effects of delayed diagnosis, which can include lower educational and employment levels in adulthood.

In Canada, one unique aspect of pediatric hearing assessment is that newborn hearing screening programs vary by province, with each province setting its own protocols, timelines, and funding models. There is a strong emphasis on early intervention through public healthcare, which allows even families in remote or underserved areas to access services through mobile clinics or tele-audiology. This decentralized yet inclusive approach is designed to reduce delays in diagnosis and make hearing care accessible regardless of location or income level, which is especially important in a geographically large country.

Newborn Hearing Screen

A newborn hearing screening is a test done soon after birth to identify hearing loss in infants. It’s a simple, painless, and often quick test that can be done in the hospital or at a health center. There are two main methods or tools used in the screening test to check for possible hearing impairment, namely:

1. Otoacoustic Emissions (OAE)

   • How it works: A small probe is placed in the baby’s ear, and it sends out gentle sounds. A microphone in the probe picks up any “echoes” (OAEs) that the baby’s inner ear produces in response.

   • What it does: It measures how well the inner ear is working and whether it’s producing the expected sounds.

   • When it’s done: Often done shortly after birth, especially in the well-baby nursery.

   • Procedure: The test is typically done while the baby is quiet or sleeping.

2. Auditory Brainstem Response (ABR)

   • How it works: Small sensors (electrodes) are placed on the baby’s head and neck, and small earphones are used to play clicking sounds into the baby’s ears.

   • What it does: It measures the brain’s response to those sounds, indicating how well the auditory nerve and brain stem are processing sound.

   • When it’s done: ABR testing is often done when a baby doesn’t pass OAE testing or if a baby has specific risk factors for hearing loss.

   • Procedure: The baby is usually asleep during the test, and the sensors are gently placed on the head.

It’s important to understand that a baby’s hearing screening is not diagnostic. If a baby passes the screen, it generally means their ears responded to the sound stimuli at the time. But it doesn’t guarantee normal hearing long-term.

Babies who don’t pass will need further testing through a diagnostic hearing assessment to determine if there’s sensorineural, conductive, or auditory neuropathy spectrum disorder present.

Pediatric Hearing Assessment Eligibility

A child is eligible for a pediatric hearing loss assessment at any age, from birth to adolescence, depending on developmental milestones, parental concerns, or medical history.

In Canada, pediatric hearing assessments are generally available to all children, with specific eligibility criteria depending on the province and program. Newborns receive universal hearing screening, and children with identified risk factors or concerns are referred for further assessment.

Eligibility often considers the following:

• In Newborns:

  • All newborns undergo hearing screening as part of the Infant Hearing Program.

• Children with Risk Factors:

  • Children with risk factors for hearing loss, such as a family history of hearing loss, certain congenital infections, or medical conditions, are eligible for further assessment.

• Children with Concerns:

  • Parents, caregivers, educators, or primary care physicians can refer children for assessment if they have concerns about a child’s hearing or communication development.

• Children Referred from Screening:

  • If a child fails a newborn hearing screening or other audiologic screening, they are referred for a more in-depth assessment.

• Children with Developmental Delays:

  • Children with developmental delays, particularly in communication, may also be eligible for assessment.

• Children with Fluctuating or Permanent Hearing Loss:

  • Children identified with fluctuating or permanent hearing loss are eligible for assessment.

Provincial programs and community clinics offer hearing assessments and screenings for newborns and infants, especially for those who were not screened in the hospital, with varying eligibility criteria. Children may be referred to specialized audiologists for more in-depth assessments and services.

When to Consider Having a Pediatric Hearing Assessment

Many parents expect that their child will show clear signs if they’re having trouble hearing, but the everyday signs of hearing loss can often be subtle, especially in the early stages. Some children may compensate well or appear to be listening, even when they aren’t processing sounds accurately. This is why timely pediatric hearing assessments are so critical: they help identify problems early, before they begin to affect language skills, social development, or academic performance.

The best time to test hearing isn’t always when problems are obvious. It’s when risk factors, parental concerns, or developmental delays appear. These assessments can be for children who have failed a newborn hearing screening and those with ongoing ear infections, speech delays, or trouble understanding spoken language. Here’s what to watch for at different ages.

Newborn up to Age 2

In the first two years of life, hearing plays a huge role in how children begin to develop language and connect with the world. If hearing loss is present during this window, even if it’s mild or fluctuating, it can interfere with how the brain learns to interpret sound stimuli. That’s why early hearing detection is a top priority in infant healthcare.

You should seek a hearing evaluation for very young children if:

• They failed their newborn hearing screen – Even if your baby passes in one ear, a full diagnostic hearing assessment is essential to confirm normal hearing in both ears.

• They have significant risk factors – This includes a family history of childhood hearing loss, time spent in a neonatal intensive care unit, exposure to infections like CMV, or the presence of genetic syndromes that may affect the inner ear or auditory nerve.

• There are speech or language delays – If your child isn’t babbling, turning to loud sounds, or recognizing voices by six months, it could be a sign they’re not hearing adequately.

• They experience chronic middle ear problems – Recurring ear infections, persistent middle ear effusions, or fluid behind the eardrum can cause conductive hearing loss that disrupts speech and language development.

Ages 3 and Up

For older children, especially those in preschool or elementary school, subtle signs of hearing impairment may appear in the form of academic struggles, behavioral issues, or language difficulties. Because these symptoms can be mistaken for attention or learning problems, hearing tests are often an overlooked but necessary step.

Consider scheduling a child’s hearing test if your child:

• Struggles in noisy environments – Children with hearing loss may struggle to filter background noise and focus on a teacher’s voice or group conversation.

• Has trouble following instructions – If your child frequently misunderstands you or needs repetition, they may not hear all the sound waves accurately.

• Speaks too loudly or doesn’t speak much at all – Children who don’t hear themselves clearly may develop unclear speech patterns or delayed vocabulary.

• Frequently asks “what?” or misunderstands words – This could indicate that certain hearing thresholds are missing, particularly in the high-frequency range.

• Has a history of loud sound exposure or ear canal issues – Ongoing damage from loud noises, untreated infections, or a foreign object in the ear canal can contribute to hearing difficulties.

Any delay in identifying and managing hearing loss can have long-term effects on your child’s development. If you’re unsure, it’s better to test your hearing early and rule out concerns than to wait for problems to worsen. An expert hearing assessment can give you clear answers and peace of mind.

Types of Pediatric Hearing Assessments

A pediatric hearing assessment isn’t a one-size-fits-all process. Audiologists select different hearing tests based on your child’s age, hearing status, developmental level, and whether your child is verbal or nonverbal. Some tests measure how the ear and hearing nerve respond to sound stimuli, while others assess how well your child hears speech or understands language in real-world environments.

Below is a breakdown of the main tests used during a comprehensive hearing evaluation for children.

Acoustic Reflex Measures

This test measures how the middle ear muscles contract in response to loud sounds. A small probe is placed in the ear canal, and sounds are played to trigger a reflex. If the reflex is absent or abnormal, it may indicate issues with the hearing nerve, auditory pathway, or middle ear function. While not a test of hearing thresholds, it helps identify problems that may not be obvious during other types of hearing screening.

Auditory Brainstem Response (ABR)

The Auditory Brainstem Response test (also called automated auditory brainstem response, or AABR, in newborn screening) measures how sound travels from the external ear through the auditory nerve and into the brainstem. Small electrodes are placed on your baby’s head while they sleep or rest quietly, and clicks or tones are played through soft earphones.

ABR is essential in identifying sensorineural hearing loss, especially in infants, and can help detect auditory neuropathy spectrum disorder—a condition where the inner ear detects sound, but the brain has trouble processing it.

Conditioned Play Audiometry (CPA)

Ideal for toddlers and preschoolers, CPA turns hearing testing into a game. The child is taught to perform a simple task, like putting a block in a bucket, every time they hear a sound. This method engages young children while allowing audiologists to measure hearing thresholds across different frequencies. It’s useful for identifying mild to moderate hearing loss that could impact language development.

Otoacoustic Emissions (OAE)

OAE testing checks for healthy function in the inner ear, specifically the hair cells that respond to sound. A soft probe is placed in the ear canal, recording the sound waves the cochlea naturally produces in response. OAEs are quick, quiet, and especially useful for newborns, nonverbal children, or those who cannot participate in behavioral tests. A lack of emissions may signal hearing loss, middle ear effusion, or inner ear damage.

Pure Tone Audiometry

This is the go-to test for school-aged children and older. The child wears headphones and listens to a series of tones at different volumes and pitches. They indicate when they hear sounds, often by raising a hand or pressing a button. It provides detailed information on the child’s hearing thresholds and helps determine the presence and degree of hearing loss, whether conductive, sensorineural, or mixed.

Sound Field Testing

In cases where a child can’t wear headphones (due to discomfort or medical reasons), sound field testing is performed in a specially designed booth using speakers. Sounds are played from different directions, and the child’s responses are observed. While it doesn’t test each ear individually, it gives useful information about a child’s functional hearing, particularly when used with visual reinforcement or play.

Speech Recognition Testing

This test measures not just if a child can hear, but how well they can understand spoken language. Audiologists present words or sentences at different loudness levels, sometimes with background noise, to mimic real-life listening situations, like a classroom. Difficulty understanding speech, even with normal hearing thresholds, can signal an issue with auditory processing.

Tympanometry

Tympanometry assesses the eardrum’s movement in response to slight air pressure changes in the ear canal. It’s a fast and painless way to detect middle ear problems such as fluid buildup, perforated eardrum, or Eustachian tube dysfunction. Since these issues can cause temporary conductive hearing loss, tympanometry is often paired with other tests to clarify the whole picture.

Visual Reinforcement Audiometry (VRA)

VRA is commonly used for infants between 6 months and 2 years. It involves playing sounds through speakers or earphones while the baby is conditioned to look toward the sound source. When they respond, they’re rewarded with a visual cue, like a flashing light or moving toy. This method helps audiologists estimate hearing levels in very young children in a non-invasive, child-friendly way.

Preparing Your Child for a Pediatric Hearing Assessment

Getting ready for your child’s hearing test doesn’t have to be stressful. In fact, a little preparation can go a long way in helping your child feel calm, cooperative, and engaged, especially if it’s their first time. Creating a familiar and relaxed environment will allow the audiologist to get the most accurate results during the hearing assessment.

Here are practical steps to make the process smoother:

• Schedule the appointment at the right time: Choose a time when your child is typically well-rested and fed. For babies and toddlers, mid-morning tends to be ideal. A tired or hungry child may be restless or less responsive during the assessment, affecting how accurately their hearing status is evaluated.

• Explain what to expect using simple, reassuring language: For older children, frame the experience in a positive light. Tell them it’s a chance to “play a listening game” or “see how well their ears work”. Avoid saying anything that might suggest it’s a test they could fail, as this can create unnecessary anxiety. Let them know they’ll be listening to different sounds and sometimes pointing, playing, or looking at lights.

• Bring comfort items: For very young children, bring along a favorite blanket, soft toy, or pacifier. These familiar items help them settle into the environment and can reduce fussiness, especially if the testing room feels unfamiliar or clinical.

• Avoid exposure to loud noises before the test: Protect your child’s hearing thresholds by keeping them away from loud sounds (like concerts, headphones, or power tools) for at least 24 hours before the appointment. Temporary threshold shifts can result from noise exposure, leading to inaccurate test outcomes.

• Inform the clinic of any special needs in advance: If your child has anxiety, sensory sensitivities, developmental delays, or a history of medical trauma, be sure to tell the audiologist when booking the appointment. Pediatric audiologists are trained to adapt the hearing evaluation process for children with unique needs, using visuals, breaks, or even alternative testing methods to make it more accessible and stress-free.

In general, children respond better when the environment is calm, the expectations are clear, and the process feels playful rather than clinical. Making your child feel safe and supported is the key to getting a reliable and effective pediatric hearing assessment.

How Pediatric Hearing Assessments Are Conducted

A pediatric hearing assessment begins with a case history, where the audiologist asks about your child’s birth history, developmental milestones, and past illnesses. They also look for any risk factors for hearing loss, such as NICU stay, family history, or frequent ear infections. This helps determine the most appropriate testing approach.

Next, a physical examination of the external ear and ear canal is done using an otoscope to check for blockages, wax buildup, or signs of middle ear effusion.

The audiologist then chooses one or more hearing tests based on your child’s age, ability to follow instructions, and any suspected hearing impairment. Objective tests like ABR or OAE may be used for infants and very young children. Older children may participate in more interactive methods like Conditioned Play Audiometry or Pure Tone Audiometry.

All tests are safe, non-invasive, and painless. The full assessment typically takes 30 to 90 minutes, depending on the child’s cooperation and the number of tests needed. For infants, testing is often done while they’re naturally asleep, though mild sedation may occasionally be required for more in-depth evaluations like diagnostic ABR.

Throughout the process, the audiologist focuses on keeping your child comfortable and relaxed, ensuring the most accurate picture of their hearing status.

What Happens if Hearing Loss Is Detected

If a pediatric hearing assessment confirms hearing loss, the audiologist will explain the type (sensorineural, conductive, or mixed) and the degree of severity. This information helps determine the most appropriate path forward. The next steps may include:

• Fitting hearing aids or bone-anchored hearing aids to improve access to sound, depending on the type and location of the hearing loss

• Considering cochlear implants for children with severe to profound sensorineural hearing loss who do not benefit from hearing aids

• Speech-language therapy to support spoken language and language development, especially if delays are present

• Medical evaluation to explore genetic testing or other underlying causes

• Planning early intervention services tailored to the child’s needs—these may include therapy, education support, and family counseling

• Monitoring with periodic hearing assessments to track any changes in hearing status and adjust treatment as needed

Timely intervention, especially during the first years, can make a significant difference in a child’s development and ability to succeed in school and life.

Conclusion

A pediatric hearing assessment gives crucial insight into your child’s hearing and overall development. While a newborn hearing screening is an important first step, it’s not the full picture. If you have concerns, trust your instincts and ask for further testing. Identifying hearing impairment early enables access to appropriate intervention, whether that means hearing aids, therapy, or simply peace of mind. One thing is sure – being proactive about your child’s hearing test is one of the most impactful decisions you can make for their future.