Congenital or acquired hearing loss in infants and children has been linked with lifelong deficits in speech and language acquisition, poor academic performance, personal-social maladjustments, and emotional difficulties. Identification of hearing loss through neonatal hearing screening, regular surveillance of developmental milestones, auditory skills, parental concerns, and middle-ear status and objective hearing screening of all infants and children at critical developmental stages can prevent or reduce many of these adverse consequences. This report promotes a proactive, consistent, and explicit process for the early identification of children with hearing loss in the medical home. An algorithm of the recommended approach has been developed to assist in the detection and documentation of, and intervention for, hearing loss.

  1. Every child with 1 or more risk factors on the hearing risk assessment should have ongoing developmentally appropriate hearing screening and at least 1 diagnostic audiology assessment by 24 to 30 months of age.

  2. Periodic objective hearing screening of all children should be performed according to the recommendations for preventive periodic health care.1 

  3. Any parental concern about hearing loss should be taken seriously and requires objective hearing screening of the patient.

  4. All providers of pediatric health care should be proficient with pneumatic otoscopy and tympanometry. However, it is important to remember that these methods do not assess hearing.

  5. Developmental abnormalities, level of functioning, and behavioral problems (ie, autism/developmental delay) may preclude accurate results on routine audiometric screening and testing. In this situation, referral to an otorhinolaryngologist and a pediatric audiologist who has the necessary equipment and expertise to test infants and young children should be made.

  6. The results of abnormal screening should be explained carefully to parents, and the child's medical record should be flagged to facilitate tracking and follow-up.

  7. Any abnormal objective screening result requires audiology referral and definitive testing.

  8. A failed infant hearing screening or a failed screening in an older child should always be confirmed by further testing.

  9. Abnormal hearing test results require intervention and clinically appropriate referral, including otolaryngology, audiology, speech-language pathology, genetics, and early intervention.

Failure to detect congenital or acquired hearing loss in children may result in lifelong deficits in speech and language acquisition, poor academic performance, personal-social maladjustments, and emotional difficulties. Early identification of hearing loss and appropriate intervention within the first 6 months of life have been demonstrated to ameliorate many of these adverse consequences and facilitate language acquisition.2  Supportive evidence is outlined in the Joint Committee on Infant Hearing's “Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs,” which was endorsed by the American Academy of Pediatrics (AAP).3  This evidence also is part of the rationale for the AAP statement “Newborn and Infant Hearing Loss: Detection and Intervention,”4  which endorses universal hearing screening and reviews the primary objectives, important components, and recommended screening methods and parameters that characterize an effective universal hearing screening program. Furthermore, the AAP statement “Recommendations for Preventive Pediatric Health Care”1  promotes objective newborn hearing screening as well as periodic hearing screening for every child through adolescence (Table 1).

All providers of pediatric health care need to recognize children who are at risk of or who suffer from congenital or acquired hearing loss, be prepared to screen their hearing, and assist the family and arrange for proper referral and treatment by identifying available hearing resources within their communities. In addition, the pediatric health care professional can play an important role in communication with the child's schoolteacher and/or nurse and special education professionals to facilitate proper accommodation and education once a hearing deficit has been confirmed.

This clinical report replaces the previous 2003 clinical report and seeks to promote a proactive, consistent, and explicit process for the early identification of children with hearing loss in the medical home. To assist in the detection and documentation of and intervention for hearing loss, an algorithm of the recommended approach with key points has been developed (Fig 1), as have several tables.

Some degree of hearing loss (Table 2) is present in 1 to 6 per 1000 newborn infants.5  Most children with congenital hearing loss are potentially identifiable by newborn and infant hearing screening. However, some congenital hearing loss may not become evident until later in childhood. Hearing loss also can be acquired during infancy or childhood for various reasons. Infectious diseases, especially meningitis, are a leading cause of acquired hearing loss. Trauma to the nervous system, damaging noise levels, and ototoxic drugs can all place a child at risk of developing acquired hearing loss.6,7  Otitis media is a common cause of usually reversible hearing loss. Certain physical findings, historical events, and developmental conditions may indicate a potential hearing problem. These conditions include, but are not limited to, anomalies of the ear and other craniofacial structures, significant perinatal events, and global developmental or speech-language delays. All older infants and children should be screened for risk factors involving hearing problems. A summary of high-risk indicators for hearing loss and developmental milestones are included in Tables 3 and 4, respectively. All infants with a risk indicator for hearing loss, regardless of surveillance findings, should be referred for an audiologic assessment at least once by 24 to 30 months of age, even if the child passed the newborn hearing screening. Children with risk indicators that are highly associated with delayed-onset hearing loss, such as having received extracorporeal membrane oxygenation or having cytomegalovirus infection, should have more frequent audiological assessments. Key point 1: Every child with 1 or more risk factors on the hearing risk assessment should have ongoing developmentally appropriate hearing screening and at least 1 diagnostic audiology assessment by 24 to 30 months of age (Table 1).

Although questionnaires and checklists are useful for identifying a child at risk of hearing loss, studies have shown that only 50% of children with hearing loss are identified by the comprehensive use of such questionnaires.8,9  Key point 2: Periodic objective hearing screening of all children should be performed according to the recommendations for preventive periodic health care1  (Table 1).

If a parent or caregiver is concerned that a child might have hearing loss, the pediatrician needs to assume that such is true until the child's hearing has been evaluated objectively. Parental concern is of greater predictive value than the informal behavioral examination performed in the physician's office.10  Parents often report suspicion of hearing loss, inattention, or erratic response to sound before hearing loss is confirmed.11  One study showed that parents were as much as 12 months ahead of physicians in identifying their child's hearing loss.3  Key point 3: Any parental concern about hearing loss should be taken seriously and requires objective hearing screening of the patient.

Thorough physical examination is an essential part of evaluating a child for hearing loss. Findings on head and neck examination associated with potential hearing loss include heterochromia of the irises, malformation of the auricle or ear canal, dimpling or skin tags around the auricle, cleft lip or palate, asymmetry or hypoplasia of the facial structures, and microcephaly.12  Hypertelorism and abnormal pigmentation of the skin, hair, or eyes also may be associated with hearing loss, as in Waardenburg syndrome. The presence of renal abnormalities (Alport syndrome), cardiac anomalies (prolonged QT interval in Jervell and Lange-Nielsen syndrome), and other syndromes should also prompt evaluation of hearing. Abnormalities of the eardrum should alert the physician to the possibility of hearing loss. Cerumen impactions can obscure the tympanic membrane, preventing an accurate examination, and may cause hearing loss. Dense cerumen impactions should be removed before diagnostic testing. A leading cause of acquired hearing loss is otitis media with effusion. Temporary hearing loss has been demonstrated during episodes of acute otitis media. The child with repeated or chronic otitis media with effusion is at high risk of acquired hearing loss and should undergo comprehensive hearing evaluation.13,14  Key point 4: All providers of pediatric health care should be proficient with pneumatic otoscopy and tympanometry. However, it is important to remember that these methods do not assess hearing.

In addition to universal newborn hearing screening and regular surveillance of developmental milestones, auditory skills, parental concerns, and middle-ear status, objective screenings for hearing loss should be performed periodically on all infants and children in accordance with the schedule outlined in the AAP statement “Recommendations for Preventive Pediatric Health Care”1  (Table 1). The technology used for hearing screening should be age appropriate. The child also should be comfortable with the testing situation; young children may need preparation. A variety of objective tools have been developed for screening tests. The choice of tool to use in screening depends on the child's age, degree of cooperation, and available resources. Screenings should be conducted in a quiet area where visual and auditory distractions are minimal. For children for whom screening is not possible because of developmental level, referral to a pediatric audiologist should be initiated for appropriate physiologic and/or behavioral audiological assessment. Various tests performed by audiologists are outlined in Table 5.

Conductive hearing loss may be the most common cause of infant hearing screening failures.15  Objective middle-ear assessment can best be performed by tympanometry. Tympanometry measures relative changes in tympanic membrane movement as air pressure is varied in the external auditory canal. Tympanograms (Fig 2) can most simply be classified as types A, B, and C depending on the curve shape relative to 0 as the pressure is changed (www.audiologyonline.com/askexpert/display_question.asp?question_id=451).

The presence of a type A, high-peaked tympanogram significantly decreases the probability that middle-ear effusion is the cause of hearing loss. A type B, flat tympanogram has the highest probability of the presence of middle-ear effusion or tympanic membrane perforation, which are both likely to cause some degree of hearing loss. A type C tympanogram, with a peak shifted toward negative pressure, has a low probability of middle-ear fluid and associated hearing loss. Type B and C tympanograms require clinical correlation and possibly further evaluation and treatment. Traditionally, tympanograms have been obtained by using low-frequency probe tones. These tones have been historically inaccurate for infants younger than 6 months. The use of a high-frequency probe tone (1000 Hz) was recently shown to be a better measure of middle-ear status in infants and young children. These tympanograms are generally not classified as A, B, or C but rather as peak or no peak.

Evoked otoacoustic emissions (OAEs) are acoustic signals generated from within the cochlea that travel in a reverse direction through the middle-ear space and tympanic membrane out to the ear canal. These signals are generated in response to an auditory stimulus, either clicks or tone bursts. The signals may be detected with a very sensitive microphone/probe system placed in the external ear canal. The OAE test allows for individual ear assessment, can be performed quickly at any age, and does not depend on whether the child is asleep or awake. Mild degrees of motion artifact do not interfere with test results; however, screening results are frequently influenced by the presence of middle-ear pathologic abnormalities. The OAE test is an effective screening measure for middle-ear abnormalities and for moderate or more severe degrees of hearing loss, because normal OAE responses are not obtained if hearing thresholds are approximately 30- to 40-dB hearing levels or higher. The automated OAE screener provides a pass-fail report; no test interpretation by an audiologist is required. The OAE test does not further quantify hearing loss or hearing threshold level. The OAE test also does not assess the integrity of the neural transmission of sound from the eighth nerve to the brainstem and, therefore, will miss auditory neuropathy and other neuronal abnormalities. Infants with such abnormalities will have normal OAE test results but abnormal auditory brainstem response (ABR) test results. A “failed” OAE test only implies that a hearing loss of more than 30 to 40 dB may exist or that the middle-ear status is abnormal.

One objective physiologic means of screening hearing is the automated ABR. This instrument measures cochlear response in the 1- to 4-kHz range with a broadband click stimulus in each ear. Many ABR screening instruments incorporate built-in artifact rejection for myogenic, electrical, and environmental noise interference, which ensures that data collection is halted if testing conditions are unfavorable. The automated screener provides a pass-fail report; no test interpretation by an audiologist is required. A “fail” report on an automated ABR implies a hearing level of worse than 40 dB. Automated ABR can test each ear individually and can be performed on children of any age. Motion artifacts interfere with test results. For this reason, the test is performed best in infants and young children while they are sleeping. If the test cannot be performed because of motion artifact, sedation may be necessary. The ABR is currently used in many newborn screening programs.

ABR and OAEs are tests of auditory pathway structural integrity but are not true tests of hearing. Even if ABR or OAE test results are normal, hearing cannot be definitively considered normal until a child is mature enough for a reliable behavioral audiogram to be obtained. Behavioral pure-tone audiometry remains the standard for hearing evaluation. Hearing thresholds at specific frequencies can be determined, and the degree of hearing loss can be assigned. If there are distractions or the room is not sound treated, pure-tone audiometry in the office should be considered solely a screening test.

Children 2 to 4 years of age are screened or tested more appropriately by play audiometry. These children are conditioned to respond to an auditory stimulus through play activities, such as dropping a block when a sound is heard through earphones. Air-conduction hearing threshold levels of greater than 20 dB at any of these frequencies indicate possible hearing loss, and referral to a pediatric audiologist should be made.

For children aged 4 years and older, conventional screening audiometry can be used. The child is asked to raise his or her hand when a sound is heard. The test should be performed in a quiet environment using earphones, because ambient noise can affect test performance significantly, especially at lower frequencies (ie, 500 and 1000 Hz). Each ear should be tested at 500, 1000, 2000, and 4000 Hz. Air-conduction hearing threshold levels of greater than 20 dB at any of these frequencies indicate possible hearing loss, and referral to a pediatric audiologist should be made.

If the child does not pass the screening, earphones should be removed and instructions carefully repeated to the child to ensure proper understanding and attention to the test and then rescreened with the earphones repositioned. A child whose repeat test shows hearing thresholds of greater than 20 dB at any of these frequencies, especially if there is no pathologic abnormality of the middle ear on physical examination, should be referred for formal hearing testing. Key point 5: Developmental abnormalities, level of functioning, and behavioral problems (ie, autism/developmental delay) may preclude accurate results on routine audiometric screening and testing. In this situation, referral to an otorhinolaryngologist and a pediatric audiologist who has the necessary equipment and expertise to test infants and young children should be made (Table 5). Key point 6: The results of abnormal screening should be explained carefully to parents, and the child's medical record should be flagged to facilitate tracking and follow-up.

It is important to remember that a “fail” report on any 1 of a combination of tests warrants additional testing. It is also important to remember that failure of speech, language, and hearing screening assessments warrants additional testing (Tables 69).

The ABR test may be used as a diagnostic tool by audiologists for more definitive diagnosis of hearing loss. Usually performed in children in natural sleep up to approximately 3 to 6 months of age and then under sedation for older infants, diagnostic ABR can provide not only a general level of hearing but also frequency-specific hearing data. Diagnostic ABR is performed with different frequency tone bursts and across varying sound levels to effectively estimate an audiogram. Diagnostic ABR can also be performed with bone conduction to separate conductive from sensorineural hearing loss. Diagnostic ABR is often the definitive test used by audiologists in children and infants who are unable to cooperate with other methods of hearing testing. Audiologic evaluation using ABR or auditory steady-state response provides frequency-specific hearing thresholds by air and bone conduction in each ear separately. ABR is the gold standard for determination of hearing thresholds in infants younger than 6 months and in children who cannot be tested behaviorally.

Children as young as 6 to 24 months can be tested by means of visual reinforced audiometry (VRA). This technique conditions the child to associate speech or frequency-specific sound with a reinforcement stimulus such as a lighted toy or animated toy or video clips. VRA is performed by an audiologist with experience testing young children. This testing is not readily applied in screening programs, because infants younger than 6 months' developmental age cannot perform the task, and sound-treated rooms are needed. The results of VRA can approximate those of conventional audiometry.

Children with unilateral or mild hearing loss also should be evaluated further. Studies have shown such children to be similarly at risk of adverse communication skills as well as difficulties with social, emotional, and educational development.16 

Key point 7: Any abnormal objective screening result requires audiology referral and definitive testing. Screening will only result in benefit for the patient if abnormal test results are confirmed and appropriate intervention is provided. Most studies that have evaluated the success rate of infant hearing screening programs have described a fairly high rate of failure to confirm a failed screen with definitive testing. A similar problem could also occur in screening older infants and children. Improving the physician's involvement not only in screening but also in arranging and confirming appropriate follow-up testing and intervention is necessary to achieve optimal speech, language, and hearing.

Key point 8: A failed infant hearing screening or a failed screening in an older child should always be confirmed by further testing. Audiologists may repeat the audiometric test as described above in a sound booth and using a variety of other tests. ABR can also be used for definitive testing of the auditory system. A diagnostic ABR is usually performed under sedation or general anesthesia in children aged approximately 3 to 6 months and older. The test is performed with frequency-specific stimuli and presentation levels to approximate hearing threshold levels. Diagnostic ABR provides information that is accurate enough to allow for therapeutic intervention. Hearing aids can be fitted with information obtained from a diagnostic ABR. Audiologic assessment and intervention is an ongoing process. The child requires regular audiologic reevaluations to determine if there is fluctuating or progressive hearing loss. Middle-ear monitoring is also essential. Hearing aid selection, fitting, verification, and validation require ongoing and regular visits with the audiologist. Candidacy for cochlear implantation should be considered when there is limited residual hearing or when progress with amplification is insufficient. Recommendations to the family regarding cochlear implantation should be based on a team evaluation that includes audiology, otology, psychology, speech-language pathology, and other intervention personnel.

Most providers of pediatric health care realize the importance of referring to an otolaryngologist, an audiologist, and a speech-language pathologist. Less recognized is the potential benefit of genetic and ophthalmologic evaluation of children and infants with sensorineural hearing loss.17 

Especially in young infants and children, referral to an otolaryngologist for a complete diagnostic assessment is essential. More than 90% of the children with permanent hearing loss are born to “hearing” parents, resulting in a sense of urgency for parents of newly identified children with hearing loss to seek out answers regarding etiology, risk of progression, implications, and other questions. If children are indeed identified with sensorineural hearing loss, a variety of diagnostic tests can be recommended depending on the patient's history and physical examination. Otolaryngologists may play a role in diagnosis and treating middle-ear fluid or other middle-ear disorders as well as assisting in the definitive diagnosis of the cause of sensorineural hearing loss.18  Diagnostic testing may include imaging of the temporal bone to identify structural defects; genetic tests, such as for abnormalities of the Connexin gene; and, occasionally, evaluation for other metabolic defects. Evaluation by a geneticist and genetic testing can be important for diagnosis as well as for providing the family with information for future planning purposes.

The hearing health care team (comprising the audiologist, otolaryngologist, teachers of the child with hearing impairment, speech-language pathologists, and other educational and medical personnel) should assist the family with intervention for hearing loss. Interventions may include observation with increased attention to speech and language development, hearing aids, auditory-assisted systems for the school environment, or more invasive surgical hearing devices such as cochlear implants or bone-anchored hearing aids. The goal is to provide families with appropriate options so that they may make well-informed decisions. Interventions should be driven by family desires and guided by accurate and timely information from all hearing-related health care professionals. Family goals and expectations are influenced by culture, parental education, level of income, availability of local resources, language in the home, and more. The role of the hearing health care team is to assist families in identifying all the options available to them and to support them throughout the ongoing decision-making processes that will occur throughout the child's development. All members of the hearing health care team, in conjunction with parents and on the basis of informed choice, should recognize that no decision regarding intervention is “final,” and periodic opportunities should be identified for discussion regarding progress, alternative interventions, and new developments.

Medical follow-up includes ongoing evaluation and management of the adequacy of hearing rehabilitation; observation for potential complications of hearing rehabilitation, such as otitis externa and cerumen impactions; and monitoring for appropriate speech and language development.

Speech and language evaluation by a speech-language pathologist with training in working with children with hearing loss is also important for documentation of baseline speech and language skills and implementing a program of intervention that reflects the family's choice regarding language development.

At least one third of children with hearing loss will have an additional coexisting condition.3  Because many causes of hearing loss are associated with abnormal ophthalmologic findings, formal ophthalmologic evaluation is appropriate, not only to assist with the diagnosis but also to optimize vision. A diagnosis of Usher syndrome with associated progressive hearing and vision loss may influence communication choices.

Children with hearing loss should also be monitored for developmental and behavioral problems (attention-deficit/hyperactivity disorder, autism, learning disabilities) and referred for additional evaluation when necessary. Health care professionals can use screening tools to evaluate young children periodically for such concerns (Table 7) and refer for additional evaluation when concerns arise.

A medical professional should participate as an active member of a family's hearing health care team after diagnosis and provide input to assist in the adequacy of the rehabilitative efforts to monitor the child for progression and additional disabilities.

Key point 9: Abnormal hearing test results require intervention and clinically appropriate referral, including otolaryngology, audiology, speech-language pathology, genetics, and early intervention. Pediatric health care professionals should maintain a list of referral resources available in their community for children with hearing loss and should advocate for increasing options and choices for families. Otolaryngologists, audiologists, and speech-language pathologists with special training and experience in treating children should be consulted for specific diagnosis, counseling, and treatment. Pediatric health care professionals should collaborate to refer the child for comprehensive educational counseling and treatment services. Communication among professionals caring for a child with hearing loss is essential to ensure appropriate case management.

Robert D. Walker, MD, Chairperson

Edward S. Curry, MD

Lawrence D. Hammer, MD

Allen D. “Buz” Harlor Jr, MD

James J. Laughlin, MD

Andrea J. Leeds, MD

Herschel R. Lessin, MD

Section on Administration and Practice Management

Olivia Whyte Thomas, MD

National Medical Association

Heather Fitzpatrick, MPH

Jennifer Mansour

David H. Darrow, MD, DDS, Chairperson

Charles Bower, MD

Sukgi Susan Choi, MD

Ellen Sue Deutsch, MD

Scott R. Schoem, MD

Mark S. Volk, MD, DMD

Aleksandra Stolic, MPH

Christoph U. Lehmann, MD

Partnership for Policy Implementation

FIGURE 1

Hearing-assessment algorithm within an office visit. CMV indicates cytomegalovirus; ENT, ear, nose, and throat.

FIGURE 1

Hearing-assessment algorithm within an office visit. CMV indicates cytomegalovirus; ENT, ear, nose, and throat.

FIGURE 2

Tympanograms. Type A: normal. Type B: abnormal, needs medical attention. Type C, borderline normal; monitor; may need medical attention.

FIGURE 2

Tympanograms. Type A: normal. Type B: abnormal, needs medical attention. Type C, borderline normal; monitor; may need medical attention.

TABLE 1

Recommendations for Preventive Pediatric Health Care1 

StageAgeSensory Screening: 6. Hearing Infancy
 Prenatal  
 Newborn a 
 3–5 d1  b 
 By 1 mo b 
 2 mo b 
 4 mo b 
 6 mo b 
 9 mo b 
Early childhood 12 mo b 
 15 mo b 
 18 mo b 
 24 mo b 
 30 mo b 
 3 y b 
 4 y a 
Middle childhood 5 y a 
 6 y a 
 7 y b 
 8 y a 
 9 y b 
 10 y a 
Adolescence 11 y b 
 12 y b 
 13 y b 
 14 y b 
 15 y b 
 16 y b 
 17 y b 
 18 y b 
 19 y b 
 20 y b 
 21 y b 
StageAgeSensory Screening: 6. Hearing Infancy
 Prenatal  
 Newborn a 
 3–5 d1  b 
 By 1 mo b 
 2 mo b 
 4 mo b 
 6 mo b 
 9 mo b 
Early childhood 12 mo b 
 15 mo b 
 18 mo b 
 24 mo b 
 30 mo b 
 3 y b 
 4 y a 
Middle childhood 5 y a 
 6 y a 
 7 y b 
 8 y a 
 9 y b 
 10 y a 
Adolescence 11 y b 
 12 y b 
 13 y b 
 14 y b 
 15 y b 
 16 y b 
 17 y b 
 18 y b 
 19 y b 
 20 y b 
 21 y b 
a

To be performed.

b

Risk assessment, with appropriate action to follow if positive.

TABLE 2

Definitions of Hearing Loss

Hearing LossDefinition
Mild On average, the most quiet sounds that people can hear with their better ear are between 20 and 40 dB. People who suffer from mild hearing loss have some difficulties keeping up with conversations, especially in noisy surroundings. 
Moderate On average, the most quiet sounds heard by people with their better ear are between 40 and 70 dB. People who suffer from moderate hearing loss have difficulty keeping up with conversations when not using a hearing aid. 
Severe On average, the most quiet sounds heard by people with their better ear are between 70 and 95 dB. People who suffer from severe hearing loss will benefit from powerful hearing aids, but often they rely heavily on lip reading, even when they are using hearing aids. Some also use sign language. 
Hearing LossDefinition
Mild On average, the most quiet sounds that people can hear with their better ear are between 20 and 40 dB. People who suffer from mild hearing loss have some difficulties keeping up with conversations, especially in noisy surroundings. 
Moderate On average, the most quiet sounds heard by people with their better ear are between 40 and 70 dB. People who suffer from moderate hearing loss have difficulty keeping up with conversations when not using a hearing aid. 
Severe On average, the most quiet sounds heard by people with their better ear are between 70 and 95 dB. People who suffer from severe hearing loss will benefit from powerful hearing aids, but often they rely heavily on lip reading, even when they are using hearing aids. Some also use sign language. 

Adapted from: European Group on Genetics of Hearing Impairment. Martini A, ed. European Commission Directorate, Biomedical and Health Research Programme (HEAR) Infoletter 2, November 1996;8.

TABLE 3

American Academy of Pediatrics Joint Committee on Infant Hearing Year 2007 Position Statement3 : Risk Indicators Associated With Permanent Congenital, Delayed-Onset, and/or Progressive Hearing Loss in Childhood

Caregiver concerna regarding hearing, speech, language, or developmental delay. 
Family historya of permanent childhood hearing loss. 
Neonatal intensive care of more than 5 days or any of the following regardless of length of stay: ECMOa, assisted ventilation, exposure to ototoxic medications (gentamicin and tobramycin) or loop diuretics (furosemide/Lasix), and hyperbilirubinemia19  that requires exchange transfusion. 
In utero infections such as CMVa, herpes, rubella, syphilis, and toxoplasmosis. 
Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags, ear pits, and temporal bone anomalies. 
Physical findings, such as white forelock, that are associated with a syndrome known to include a sensorineural or permanent conductive hearing loss. 
Syndromes associated with hearing loss or progressive or late-onset hearing lossa, such as neurofibromatosis, osteopetrosis, and Usher syndrome; other frequently identified syndromes include Waardenburg, Alport, Pendred, and Jervell and Lange-Nielson. 
Neurodegenerative disordersa, such as Hunter syndrome, or sensory motor neuropathies, such as Friedreich ataxia and Charcot-Marie-Tooth syndrome. 
Culture-positive postnatal infections associated with sensorineural hearing lossa, including confirmed bacterial and viral (especially herpes viruses and varicella) meningitis. 
10 Head trauma, especially basal skull/temporal bone fracturea that requires hospitalization. 
11 Chemotherapya
12 Recurrent or persistent otitis media for at least 3 months. 
Caregiver concerna regarding hearing, speech, language, or developmental delay. 
Family historya of permanent childhood hearing loss. 
Neonatal intensive care of more than 5 days or any of the following regardless of length of stay: ECMOa, assisted ventilation, exposure to ototoxic medications (gentamicin and tobramycin) or loop diuretics (furosemide/Lasix), and hyperbilirubinemia19  that requires exchange transfusion. 
In utero infections such as CMVa, herpes, rubella, syphilis, and toxoplasmosis. 
Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags, ear pits, and temporal bone anomalies. 
Physical findings, such as white forelock, that are associated with a syndrome known to include a sensorineural or permanent conductive hearing loss. 
Syndromes associated with hearing loss or progressive or late-onset hearing lossa, such as neurofibromatosis, osteopetrosis, and Usher syndrome; other frequently identified syndromes include Waardenburg, Alport, Pendred, and Jervell and Lange-Nielson. 
Neurodegenerative disordersa, such as Hunter syndrome, or sensory motor neuropathies, such as Friedreich ataxia and Charcot-Marie-Tooth syndrome. 
Culture-positive postnatal infections associated with sensorineural hearing lossa, including confirmed bacterial and viral (especially herpes viruses and varicella) meningitis. 
10 Head trauma, especially basal skull/temporal bone fracturea that requires hospitalization. 
11 Chemotherapya
12 Recurrent or persistent otitis media for at least 3 months. 

Risk indicators that are marked with

a

are of greater concern for delayed onset hearing loss. ECMO indicates extracorporeal membrane oxygenation; CMV, cytomegalovirus.

Reproduced with permission from: American Academy of Pediatrics, Joint Committee on Infant Hearing. Pediatrics. 2007;120(4):898–921.

TABLE 4

Developmental Milestones in the First 2 Years of Life

MilestoneAverage Age of Attainment, moDevelopmental Implications
Gross motor   
    Head steady in sitting 2.0 Allows more visual interaction 
    Pull to sit, no head lag 3.0 Muscle tone 
    Hands together in midline 3.0 Self-discovery 
    Asymmetric tonic neck reflex gone 4.0 Child can inspect hands in midline 
    Sits without support 6.0 Increasing exploration 
    Rolls back to stomach 6.5 Truncal flexion, risk of falls 
    Walks alone 12.0 Exploration, control of proximity to parents 
    Runs 16.0 Supervision more difficult 
Fine motor   
    Grasps rattle 3.5 Object use 
    Reaches for objects 4.0 Visuomotor coordination 
    Palmar grasp gone 4.0 Voluntary release 
    Transfers object hand to hand 5.5 Comparison of objects 
    Thumb-finger grasp 8.0 Able to explore small objects 
    Turns pages of book 12.0 Increasing autonomy during book time 
    Scribbles 13.0 Visuomotor coordination 
    Builds tower of 2 cubes 15.0 Uses objects in combination 
    Builds tower of 6 cubes 22.0 Requires visual, gross, and fine motor coordination 
Communication and language   
    Smiles in response to face, voice 1.5 Child more active social participant 
    Monosyllabic babble 6.0 Experimentation with sound, tactile sense 
    Inhibits to “no” 7.0 Response to tone (nonverbal) 
    Follows 1-step command with gesture 7.0 Nonverbal communication 
    Follows 1-step command without gesture (eg, “Give it to me”) 10.0 Verbal receptive language 
    Speaks first real word 12.0 Beginning of labeling 
    Speaks 4–6 words 15.0 Acquisition of object and personal names 
    Speaks 10–15 words 18.0 Acquisition of object and personal names 
    Speaks 2-word sentences (eg, “Mommy shoe”) 19.0 Beginning grammaticization, corresponds with vocabulary of ≥50 words 
Cognitive   
    Stares momentarily at spot where object disappeared (eg, yarn ball dropped) 2.0 Lack of object permanence (out of sight, out of mind) 
    Stares at own hand 4.0 Self-discovery, cause and effect 
    Bangs 2 cubes 8.0 Active comparison of objects 
    Uncovers toy (after seeing it hidden) 8.0 Object permanence 
    Egocentric pretend play (eg, pretends to drink from cup) 12.0 Beginning symbolic thought 
    Uses stick to reach toy 17.0 Able to link actions to solve problems 
    Pretend play with doll (gives doll bottle) 17.0 Symbolic thought 
MilestoneAverage Age of Attainment, moDevelopmental Implications
Gross motor   
    Head steady in sitting 2.0 Allows more visual interaction 
    Pull to sit, no head lag 3.0 Muscle tone 
    Hands together in midline 3.0 Self-discovery 
    Asymmetric tonic neck reflex gone 4.0 Child can inspect hands in midline 
    Sits without support 6.0 Increasing exploration 
    Rolls back to stomach 6.5 Truncal flexion, risk of falls 
    Walks alone 12.0 Exploration, control of proximity to parents 
    Runs 16.0 Supervision more difficult 
Fine motor   
    Grasps rattle 3.5 Object use 
    Reaches for objects 4.0 Visuomotor coordination 
    Palmar grasp gone 4.0 Voluntary release 
    Transfers object hand to hand 5.5 Comparison of objects 
    Thumb-finger grasp 8.0 Able to explore small objects 
    Turns pages of book 12.0 Increasing autonomy during book time 
    Scribbles 13.0 Visuomotor coordination 
    Builds tower of 2 cubes 15.0 Uses objects in combination 
    Builds tower of 6 cubes 22.0 Requires visual, gross, and fine motor coordination 
Communication and language   
    Smiles in response to face, voice 1.5 Child more active social participant 
    Monosyllabic babble 6.0 Experimentation with sound, tactile sense 
    Inhibits to “no” 7.0 Response to tone (nonverbal) 
    Follows 1-step command with gesture 7.0 Nonverbal communication 
    Follows 1-step command without gesture (eg, “Give it to me”) 10.0 Verbal receptive language 
    Speaks first real word 12.0 Beginning of labeling 
    Speaks 4–6 words 15.0 Acquisition of object and personal names 
    Speaks 10–15 words 18.0 Acquisition of object and personal names 
    Speaks 2-word sentences (eg, “Mommy shoe”) 19.0 Beginning grammaticization, corresponds with vocabulary of ≥50 words 
Cognitive   
    Stares momentarily at spot where object disappeared (eg, yarn ball dropped) 2.0 Lack of object permanence (out of sight, out of mind) 
    Stares at own hand 4.0 Self-discovery, cause and effect 
    Bangs 2 cubes 8.0 Active comparison of objects 
    Uncovers toy (after seeing it hidden) 8.0 Object permanence 
    Egocentric pretend play (eg, pretends to drink from cup) 12.0 Beginning symbolic thought 
    Uses stick to reach toy 17.0 Able to link actions to solve problems 
    Pretend play with doll (gives doll bottle) 17.0 Symbolic thought 

Modified from: Behrman RE, Jenson HB, Kliegman R, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, PA: Saunders; 2003.

TABLE 5

Audiologic Tests for Infants and Children

Developmental Age of ChildAuditory Test/ Average TimeType of MeasurementTest ProceduresAdvantagesLimitations
All ages Evoked OAEs/10-min test Physiologic test specifically measuring cochlear (outer hair cell) response to presentation of a stimulus; stimuli may be clicks (transient evoked OAEs) or tone pairs (distortion product OAEs) Small probe containing a sensitive microphone is placed in the ear canal for stimulus delivery and response detection Ear-specific results; not dependent on whether patient is asleep or awake; quick test time; screening test Infant or child must be relatively inactive during the test; not a comprehensive test of hearing, because it does not assess cortical processing of sound; OAEs are very sensitive to middle-ear effusions and cerumen or vernix in the ear canal 
Birth to 9 mo Automated ABR/15-min test Electrophysiologic measurement of activity in auditory nerve and brainstem pathways Placement of electrodes on child's head detects neurologic response to auditory stimuli presented through earphones or ear inserts 1 ear at a time Ear-specific results; responses not dependent on patient cooperation; screening test Infant or child must remain quiet during the test (sedation is often required); not a comprehensive test of hearing, because it does not assess cortical processing of sound 
9 mo to 2.5 y VRA/15- to 30-min test Behavioral tests measuring responses of the child to speech and frequency-specific stimuli presented through speakers or insert earphones Technique conditions the child to associate speech or frequency-specific stimuli with a reinforcer, such as a lighted toy or video clips; VRA requires a calibrated, sound-treated room Assesses auditory perception of child; diagnostic test. When performed with speakers, only assesses hearing of the better ear; not ear specific; if VRA is performed with insert, earphones can rule out a unilateral hearing loss 
2.5 to 4 y Play audiometry/ 15–30 min Behavioral test of auditory thresholds in response to speech and frequency-specific stimuli presented through earphones and/or bone vibrator Child is conditioned to respond when stimulus tone is heard, such as to put a peg in a pegboard or drop a block in a box Ear-specific results; assesses auditory perception of child; screening or diagnostic test. Attention span of child may limit the amount of information obtained 
4 y to adolescence Conventional audiometry/15- to 30-min test Behavioral test measuring auditory thresholds in response to speech and frequency-specific stimuli presented through earphones and/or bone vibrator Patient is instructed to raise his or her hand when stimulus is heard Ear-specific results; assesses auditory perception of patient; screening or diagnostic test Depends on the level of understanding and cooperation of the child 
All ages Diagnostic ABR Electrophysiologic measurement of activity in auditory nerve and brainstem pathways Placement of electrodes on child's head detects auditory stimuli presented through insert earphones 1 ear at a time Ear-specific results; multiple frequencies are tested, creating a map of hearing loss similar to an audiogram; responses not dependent on patient cooperation; diagnostic test Infant or child must remain quiet during the test (sedation is often required); not a true test of hearing, because it does not assess cortical processing of sound 
All ages Tympanometry Relative change in middle-ear compliance as air pressure is varied in the external auditory canal Small probe placed in the ear canal and pressure varied in the ear canal Tests for possible middle-ear pathology and pressure-equalization tube function Not a test of hearing; depends on ear canal seal; high-frequency tone probe needed for infants younger than 6 mo 
Developmental Age of ChildAuditory Test/ Average TimeType of MeasurementTest ProceduresAdvantagesLimitations
All ages Evoked OAEs/10-min test Physiologic test specifically measuring cochlear (outer hair cell) response to presentation of a stimulus; stimuli may be clicks (transient evoked OAEs) or tone pairs (distortion product OAEs) Small probe containing a sensitive microphone is placed in the ear canal for stimulus delivery and response detection Ear-specific results; not dependent on whether patient is asleep or awake; quick test time; screening test Infant or child must be relatively inactive during the test; not a comprehensive test of hearing, because it does not assess cortical processing of sound; OAEs are very sensitive to middle-ear effusions and cerumen or vernix in the ear canal 
Birth to 9 mo Automated ABR/15-min test Electrophysiologic measurement of activity in auditory nerve and brainstem pathways Placement of electrodes on child's head detects neurologic response to auditory stimuli presented through earphones or ear inserts 1 ear at a time Ear-specific results; responses not dependent on patient cooperation; screening test Infant or child must remain quiet during the test (sedation is often required); not a comprehensive test of hearing, because it does not assess cortical processing of sound 
9 mo to 2.5 y VRA/15- to 30-min test Behavioral tests measuring responses of the child to speech and frequency-specific stimuli presented through speakers or insert earphones Technique conditions the child to associate speech or frequency-specific stimuli with a reinforcer, such as a lighted toy or video clips; VRA requires a calibrated, sound-treated room Assesses auditory perception of child; diagnostic test. When performed with speakers, only assesses hearing of the better ear; not ear specific; if VRA is performed with insert, earphones can rule out a unilateral hearing loss 
2.5 to 4 y Play audiometry/ 15–30 min Behavioral test of auditory thresholds in response to speech and frequency-specific stimuli presented through earphones and/or bone vibrator Child is conditioned to respond when stimulus tone is heard, such as to put a peg in a pegboard or drop a block in a box Ear-specific results; assesses auditory perception of child; screening or diagnostic test. Attention span of child may limit the amount of information obtained 
4 y to adolescence Conventional audiometry/15- to 30-min test Behavioral test measuring auditory thresholds in response to speech and frequency-specific stimuli presented through earphones and/or bone vibrator Patient is instructed to raise his or her hand when stimulus is heard Ear-specific results; assesses auditory perception of patient; screening or diagnostic test Depends on the level of understanding and cooperation of the child 
All ages Diagnostic ABR Electrophysiologic measurement of activity in auditory nerve and brainstem pathways Placement of electrodes on child's head detects auditory stimuli presented through insert earphones 1 ear at a time Ear-specific results; multiple frequencies are tested, creating a map of hearing loss similar to an audiogram; responses not dependent on patient cooperation; diagnostic test Infant or child must remain quiet during the test (sedation is often required); not a true test of hearing, because it does not assess cortical processing of sound 
All ages Tympanometry Relative change in middle-ear compliance as air pressure is varied in the external auditory canal Small probe placed in the ear canal and pressure varied in the ear canal Tests for possible middle-ear pathology and pressure-equalization tube function Not a test of hearing; depends on ear canal seal; high-frequency tone probe needed for infants younger than 6 mo 

Adapted with permission from: Bachmann KR, Arvedson JC. Pediatr Rev. 1998;19(5):155–165.

TABLE 6

Ten Ways to Recognize Hearing Loss: Adolescents (11- to 21-Year Visits)

1. Do you have a problem hearing over the telephone? 
2. Do you have trouble following the conversation when two or more people are talking at the same time? 
3. Do people complain that you turn the TV volume up too high? 
4. Do you have to strain to understand conversation? 
5. Do you have trouble hearing in a noisy background? 
6. Do you find yourself asking people to repeat themselves? 
7. Do many people you talk to seem to mumble (or not speak clearly)? 
8. Do you misunderstand what others are saying and respond inappropriately? 
9. Do you have trouble understanding the speech of women and children? 
10. Do people get annoyed because you misunderstand what they say? 
1. Do you have a problem hearing over the telephone? 
2. Do you have trouble following the conversation when two or more people are talking at the same time? 
3. Do people complain that you turn the TV volume up too high? 
4. Do you have to strain to understand conversation? 
5. Do you have trouble hearing in a noisy background? 
6. Do you find yourself asking people to repeat themselves? 
7. Do many people you talk to seem to mumble (or not speak clearly)? 
8. Do you misunderstand what others are saying and respond inappropriately? 
9. Do you have trouble understanding the speech of women and children? 
10. Do people get annoyed because you misunderstand what they say? 

Adapted from: National Institute on Deafness and Other Communication Disorders. Ten Ways to Recognize Hearing Loss. Bethesda, MD: National Institute of Health; 2006. NIH publication 01-4913. Available at: www.nidcd.nih.gov/health/hearing/10ways.asp.

TABLE 7

Developmental/Behavioral Screening Tools

ResourceDescriptionAge RangeWhere to Find
General developmental screening tools    
    Ages & Stages Questionnaire (ASQ) A series of 19 questionnaires used to screen infants and young children for developmental delays during the first 5 y of life 4–60 mo www.brookespublishing.com/tools/asq/index.htm 
    Ages & Stages Questionnaire: Social-Emotional (ASQ:SE) A series of 19 questionnaires used to screen infants and young children at risk for social or emotional difficulties, to identify behaviors of concern to caregivers, and to identify any need for further assessment 6–60 mo www.brookespublishing.com/tools/asqse/index.htm 
    Parents' Evaluation of Developmental Status (PEDS) A method for detecting developmental and behavioral-emotional problems in children Birth to 8 y www.pedstest.com 
    Parents' Evaluation of Developmental Status-Developmental Milestones (PEDS:DM) A collection of 6–8 items per age/encounter designed to replace informal milestones checklists with highly accurate items known to predict developmental status Birth to 11 y www.pedstest.com/dm 
Autism-specific screening tools    
    Checklist for Autism in Toddlers (CHAT) A screening tool for early detection of autism 18 to ≥24 mo www.autismresearchcentre.com/tests/chat_test.asp 
    Checklist for Autism in Toddlers (CHAT), Denver Modifications CHAT scoring modifications 18 to ≥24 mo  
    Checklist for Autism in Toddlers-23 (CHAT-23) Combination of M-CHAT and CHAT items 16–86 mo  
    Childhood Asperger Syndrome Test (CAST) A parental questionnaire to screen for autism spectrum conditions 4–11 y www.autismresearchcentre.com/tests/cast_test.asp 
    Modified Checklist for Autism in Toddlers (M-CHAT) 23-item scale pointing to express interest, responsiveness to name, interest in peers, showing behavior, response to joint attention, social imitation 16–48 mo http://depts.washington.edu/dbpeds/Screening%20Tools/MCHAT.doc 
    Pervasive Developmental Disorders Screening Test-II, Primary Care Screener (PDDST-II PCS) A parental questionnaire to screen for autism spectrum conditions 18–48 mo www.pearson-uk.com/product.aspx?n=1315&skey=2960 
Autism-specific or psychosocial screening tools    
    Pediatric intake form from Bright Futures Questionnaire to help gather a general understanding of the history, functioning, questions and concerns of the family Birth to 21 y www.brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdf 
ADHD screening tools    
    Vanderbilt rating forms Parent- and teacher-completed forms that help a clinician diagnosis ADHD and to categorize the problem into 1 of its various subtypes 6–12 y www.brightfutures.org/mentalhealth/pdf/professionals/bridges/adhd.pdf 
    AAP ADHD toolkit A comprehensive toolkit developed from evidence-based guidelines for the diagnosis and treatment of children with ADHD; this resource toolkit contains a wide array of screening, diagnosis, treatment, and support materials for clinicians and other health care professionals 6–12 y www.aap.org 
ResourceDescriptionAge RangeWhere to Find
General developmental screening tools    
    Ages & Stages Questionnaire (ASQ) A series of 19 questionnaires used to screen infants and young children for developmental delays during the first 5 y of life 4–60 mo www.brookespublishing.com/tools/asq/index.htm 
    Ages & Stages Questionnaire: Social-Emotional (ASQ:SE) A series of 19 questionnaires used to screen infants and young children at risk for social or emotional difficulties, to identify behaviors of concern to caregivers, and to identify any need for further assessment 6–60 mo www.brookespublishing.com/tools/asqse/index.htm 
    Parents' Evaluation of Developmental Status (PEDS) A method for detecting developmental and behavioral-emotional problems in children Birth to 8 y www.pedstest.com 
    Parents' Evaluation of Developmental Status-Developmental Milestones (PEDS:DM) A collection of 6–8 items per age/encounter designed to replace informal milestones checklists with highly accurate items known to predict developmental status Birth to 11 y www.pedstest.com/dm 
Autism-specific screening tools    
    Checklist for Autism in Toddlers (CHAT) A screening tool for early detection of autism 18 to ≥24 mo www.autismresearchcentre.com/tests/chat_test.asp 
    Checklist for Autism in Toddlers (CHAT), Denver Modifications CHAT scoring modifications 18 to ≥24 mo  
    Checklist for Autism in Toddlers-23 (CHAT-23) Combination of M-CHAT and CHAT items 16–86 mo  
    Childhood Asperger Syndrome Test (CAST) A parental questionnaire to screen for autism spectrum conditions 4–11 y www.autismresearchcentre.com/tests/cast_test.asp 
    Modified Checklist for Autism in Toddlers (M-CHAT) 23-item scale pointing to express interest, responsiveness to name, interest in peers, showing behavior, response to joint attention, social imitation 16–48 mo http://depts.washington.edu/dbpeds/Screening%20Tools/MCHAT.doc 
    Pervasive Developmental Disorders Screening Test-II, Primary Care Screener (PDDST-II PCS) A parental questionnaire to screen for autism spectrum conditions 18–48 mo www.pearson-uk.com/product.aspx?n=1315&skey=2960 
Autism-specific or psychosocial screening tools    
    Pediatric intake form from Bright Futures Questionnaire to help gather a general understanding of the history, functioning, questions and concerns of the family Birth to 21 y www.brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdf 
ADHD screening tools    
    Vanderbilt rating forms Parent- and teacher-completed forms that help a clinician diagnosis ADHD and to categorize the problem into 1 of its various subtypes 6–12 y www.brightfutures.org/mentalhealth/pdf/professionals/bridges/adhd.pdf 
    AAP ADHD toolkit A comprehensive toolkit developed from evidence-based guidelines for the diagnosis and treatment of children with ADHD; this resource toolkit contains a wide array of screening, diagnosis, treatment, and support materials for clinicians and other health care professionals 6–12 y www.aap.org 

ADHD indicates attention-deficit/hyperactivity disorder.

TABLE 8

Guidelines for Children with Abnormal Speech Development

Age, moReferral Guidelines for Children With “Speech” Delay
12 No differentiated babbling or vocal imitation 
18 No use of single words 
24 Single-word vocabulary of ≤10 words 
30 Fewer than 100 words; no evidence of 2-word combinations; unintelligible 
36 Fewer than 200 words; no use of telegraphic sentences; clarity <50% 
48 Fewer than 600 words; no use of single sentences; clarity ≤80% 
Age, moReferral Guidelines for Children With “Speech” Delay
12 No differentiated babbling or vocal imitation 
18 No use of single words 
24 Single-word vocabulary of ≤10 words 
30 Fewer than 100 words; no evidence of 2-word combinations; unintelligible 
36 Fewer than 200 words; no use of telegraphic sentences; clarity <50% 
48 Fewer than 600 words; no use of single sentences; clarity ≤80% 

Source: Matkin ND. Pediatr Rev. 1984;6:151.

TABLE 9

Guidelines for Children With Suspected Hearing Loss

Age, moNormal Development
0–4 Should startle to loud sounds, quiet to mother's voice, momentarily cease activity when sound is presented at a conversational level 
5–6 Should correctly localize to sound presented in a horizontal plane, begin to imitate sounds in own speech repertoire or at least reciprocally vocalize with an adult 
7–12 Should correctly localize to sound presented in any plane, should respond to name, even when spoken quietly 
13–15 Should point toward an unexpected sound or to familiar objects or persons when asked 
16–18 Should follow simple directions without gesture or other visual cues; can be trained to reach toward an interesting toy at midline when a sound is presented 
19–24 Should point to body parts when asked; by 21 mo, can be trained to perform play audiometry 
Age, moNormal Development
0–4 Should startle to loud sounds, quiet to mother's voice, momentarily cease activity when sound is presented at a conversational level 
5–6 Should correctly localize to sound presented in a horizontal plane, begin to imitate sounds in own speech repertoire or at least reciprocally vocalize with an adult 
7–12 Should correctly localize to sound presented in any plane, should respond to name, even when spoken quietly 
13–15 Should point toward an unexpected sound or to familiar objects or persons when asked 
16–18 Should follow simple directions without gesture or other visual cues; can be trained to reach toward an interesting toy at midline when a sound is presented 
19–24 Should point to body parts when asked; by 21 mo, can be trained to perform play audiometry 

Source: Matkin ND. Pediatr Rev. 1984;6:151.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account, individual circumstances may be appropriate.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict-of-interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

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