Common causes of hearing loss are genetic defects in neonates and ear infections and excessive cerumen in children. Many cases are detected by screening, but hearing loss should be suspected if children do not respond to sounds or have delayed speech development. Diagnosis is usually by electrodiagnostic testing (evoked otoacoustic emissions testing and auditory brain stem response) in neonates and by clinical examination and tympanometry in children. Treatment for irreversible hearing loss may include a hearing aid, cochlear implant, or bone-anchored hearing aid.
Topic Resources
In 2020 in the United States, childhood hearing loss was detected in 1.8/1000 infants screened (1). On average, 1.9% of children reported trouble hearing. Hearing impairment is slightly more common among boys than girls; the average male:female ratio is 1.24:1.
Hearing loss has significant developmental, social, educational, and economic impact on children. Early identification and early mitigation of hearing loss to promote oral communication are critical for personal and social development (2).
(See also Evaluation of Hearing Loss.)
General references
1. Centers for Disease Control and Prevention (CDC): Hearing Loss in Children: Data and Statistics About Hearing Loss in Children. Accessed January 3, 2025.
2. Lieu JEC, Kenna M, Anne S, Davidson L. Hearing Loss in Children: A Review. JAMA. 2020;324(21):2195-2205. doi:10.1001/jama.2020.17647
Etiology of Hearing Impairment in Children
COVID-19 infection may impact hearing in children of any age (1).
Neonates
The most common causes of hearing loss in neonates are
Congenital cytomegalovirus (CMV) infection (2)
Genetic defects (see table Some Genetic Causes of Hearing Loss)
Congenital CMV infection is the most common intrauterine infection in the United States. CMV infection may account for as much as 21% of all sensorineural hearing loss at birth. In addition, because CMV infection also may cause late-onset hearing loss, CMV may account for as much as 25% of sensorineural hearing loss present at 4 years of age (3, 4, 5).
Screening for CMV is being gradually incorporated into newborn screening protocols in the United States and internationally (6).
Some Genetic Causes of Hearing Loss
Syndrome | Inheritance Pattern | Clinical Findings |
|---|---|---|
Branchio-oto-renal syndrome (Melnick-Fraser syndrome) | Most have hearing loss and ear abnormalities Associated with renal abnormalities and branchial cleft cysts or fistulas | |
Jervell and Lange-Nielsen syndrome | Profound congenital hearing loss Abnormal cardiac rhythms (eg, prolonged QTc interval) Increased risk of syncope and sudden death | |
Pendred syndrome | Progressive hearing loss Associated with simple nontoxic goiter (euthyroid goiter), congenital goiter, and vestibular symptoms | |
Stickler syndrome | Hearing loss varies in degree and may become more severe over time Associated with bony and skeletal abnormalities Many have severe nearsightedness | |
Usher syndrome | Accounts for 3 to 6% of all children who are deaf and another 3 to 6% of children who are hard of hearing Associated with retinitis pigmentosa Three clinical types | |
Waardenburg syndrome | When hearing loss occurs, it is congenital Associated with pigmentary changes in hair, eyes, and skin Four recognized types, each with different physical characteristics | |
AD = autosomal dominant; AR = autosomal recessive. | ||
Risk factors for hearing loss in neonates include the following:
Low birth weight (eg, < 1.5 kg)
Apgar score < 5 at 1 minute or < 7 at 5 minutes
Hypoxemia or seizures resulting from a difficult delivery
Prenatal infection with rubella, syphilis, herpes, cytomegalovirus, or toxoplasmosis
Craniofacial anomalies, particularly those that involve the external ear
Sepsis or meningitis
Ventilator dependence
Family history of early hearing loss
Infants and children
The most common causes of hearing loss in infants and children are
Middle ear effusions, including otitis media with effusion
Other causes in older children include head injuries, loud noises (including loud music), use of ototoxic medications (eg, aminoglycosides, thiazides), viral infections (eg, mumps), tumors or injuries affecting the auditory nerve, foreign bodies of the ear canal, and, rarely, autoimmune disorders.
Risk factors for hearing loss in children include those for neonates plus the following:
Skull fracture or traumatic loss of consciousness
Neurodegenerative disorders, including neurofibromatosis
Noise exposure
Etiology references
1. Swain SK, Panda S, Jena PP. Hearing loss and tinnitus among pediatric patients with COVID-19 infection: our experience. MGM J Med Sci. 2022;9(1):66-71. doi:10.4103/mgmj.mgmj_61_21
2. Goderis J, De Leenheer E, Smets K, et al. Hearing loss and congenital CMV infection: A systematic review. Pediatrics. 2014;134(5):972–982. doi10.1542/peds.2014-1173
3. Kimani JW, Buchman CA, Booker JK, et al. Sensorineural hearing loss in a pediatric population: Association of congenital cytomegalovirus infection with intracranial abnormalities. Arch Otolaryngol Head Neck Surg. 2010;136(10):999–1004. doi:10.1001/archoto.2010.156
4. Lo TH, Lin PH, Hsu WC, et al. Prognostic determinants of hearing outcomes in children with congenital cytomegalovirus infection. Sci Rep. 2022;12(1):5219. Published 2022 Mar 25. doi:10.1038/s41598-022-08392-w
5. Pinninti SG, Britt WJ, Boppana SB. Auditory and Vestibular Involvement in Congenital Cytomegalovirus Infection. Pathogens. 2024;13(11):1019. Published 2024 Nov 20. doi:10.3390/pathogens13111019
6. Therrell BL, Padilla CD, Borrajo GJC, et al. Current Status of Newborn Bloodspot Screening Worldwide 2024: A Comprehensive Review of Recent Activities (2020-2023). Int J Neonatal Screen. 2024;10(2):38. Published 2024 May 23. doi:10.3390/ijns10020038
Symptoms and Signs of Hearing Impairment in Children
If hearing loss is severe, the infant or child may not respond to sounds or may have delayed speech or language comprehension. If hearing loss is less severe, children may intermittently ignore people talking to them. Children may appear to be developing well in certain settings but have problems in others. For example, because the background noise of a classroom can make speech discrimination difficult, the child may have problems hearing only at school.
Not recognizing and treating impairment can seriously impair language comprehension and speech. The impairment can lead to educational, social, and psychological challenges and may affect employability later in life.
Diagnosis of Hearing Impairment in Children
Electrodiagnostic testing (neonates)
Clinical examination and tympanometry (children)
Screening all infants before age 3 months is often recommended and is legally mandated in most of the United States (1). The initial screening test is evoked otoacoustic emissions testing, using soft clicks made by a handheld device. If results are abnormal or equivocal, auditory brain stem evoked responses are tested, which can be done during sleep; abnormal results should be confirmed with repeat testing after 1 month.
If a genetic cause is suspected, genetic testing can be done.
In children, other methods can be used. Speech and overall development are assessed clinically. The ears are examined, and tympanic membrane movement is tested in response to various frequencies to screen for middle ear effusions. In children age 6 months to 2 years, response to sounds is tested. At age > 2 years, ability to follow simple auditory commands can be assessed, as can responses to sounds using earphones. Central auditory processing evaluation can be used for children > 7 years without neurocognitive deficits who seem to hear but not to comprehend.
Imaging is often indicated to identify the etiology and guide prognosis. For most cases, including when neurologic examination is abnormal, word recognition is poor, and/or hearing loss is asymmetric, gadolinium-enhanced MRI is done. If bone abnormalities are suspected, CT is done.
Continuous surveillance of hearing status in hearing-impaired children is critical for monitoring and managing adverse changes in hearing (2).
Diagnosis references
1. Bower C, Reilly BK, Richerson J, Hecht JL; COMMITTEE ON PRACTICE & AMBULATORY MEDICINE; SECTION ON OTOLARYNGOLOGY–HEAD AND NECK SURGERY. Hearing Assessment in Infants, Children, and Adolescents: Recommendations Beyond Neonatal Screening. Pediatrics. 2023;152(3):e2023063288. doi:10.1542/peds.2023-063288
2. Joint Committee on Infant Hearing. Year 2019 position statement: principles and guidelines for early hearing detection and intervention programs. J Early Hear Detect Interv. 2019;4(2):1–44. doi:10.15142/fptk-b748
Treatment of Hearing Impairment in Children
Hearing aids, cochlear implants, or bone-anchored hearing aids
Hearing aids for some types of transient hearing loss
Sometimes teaching a nonauditory language
Reversible causes and abnormalities are treated. Treatment may include removal of cerumen and medical and/or surgical management of middle ear effusion, including the surgical insertion of tympanostomy tubes. Hearing aids may be used for some types of transient hearing loss.
If hearing loss is irreversible, a hearing aid can usually be used. They are available for infants as well as children. If hearing loss is mild or moderate or affects only one ear, a hearing aid or earphones can be used. In the classroom, an FM auditory trainer can be used. With an FM auditory trainer, the teacher speaks into a microphone that send signals to an FM receiver near or worn by the student.
If hearing loss is sensorineural and cannot be managed with hearing aids, a cochlear implant may be needed . Cochlear implantation in children under age 12 months is becoming increasingly common and has shown benefit for communication and development (1).
If hearing loss is conductive and cannot be managed with hearing aids, bone-anchored hearing aids (BAHAs) may be used in people over 5 years of age (2).
Children may also require therapy to support their language development, such as being taught a visually based sign language.
The COVID-19 pandemic required hearing specialists to develop ways of remotely monitoring and interacting with children with hearing loss. Some of these methods, eg, remote monitoring and programming of devices and online or in-app speech therapy techniques, may remain useful to patients now that most pandemic restrictions have been lifted (3, 4).
Although hearing loss related to COVID-19 infection is not fully understood at present, vaccination against SARS-CoV-2 virus has been reported to be protective against balance and hearing disorders in children (5, 6).
Treatment references
1. Culbertson SR, Dillon MT, Richter ME, et al. Younger Age at Cochlear Implant Activation Results in Improved Auditory Skill Development for Children With Congenital Deafness. J Speech Lang Hear Res. 2022;65(9):3539-3547. doi:10.1044/2022_JSLHR-22-00039
2. Azevedo C, Breda M, Ribeiro D, Mar FM, Vilarinho S, Dias L. Functional and patient-reported outcomes of bone-anchored hearing aids (BAHA): A prospective case series study. J Otol. 2023;18(1):7-14. doi:10.1016/j.joto.2022.11.002
3. Brotto D, Sorrentino F, Favaretto N, et al. Pediatric hearing loss management in the COVID-19 era: Possible consequences and resources for the next future. Otolaryngol Head Neck Surg. 2021;166(2):217–218. doi:10.1177/01945998211012677
4. Marom T, Pitaro J, Shah UK, et al. Otitis media practice during the COVID-19 pandemic. Front Cell Infect Microbiol. 2022;11:749911. doi:10.3389/fcimb.2021.749911
5. Kaliyappan K, Chen YC, Krishnan Muthaiah VP. Vestibular Cochlear Manifestations in COVID-19 Cases. Front Neurol. 2022;13:850337. Published 2022 Mar 18. doi:10.3389/fneur.2022.850337
6. Aldè M, Di Berardino F, Ambrosetti U, et al. Audiological and vestibular symptoms following SARS-CoV-2 infection and COVID-19 vaccination in children aged 5-11 years. Am J Otolaryngol. 2023;44(1):103669. doi:10.1016/j.amjoto.2022.103669
Key Points
Common causes of hearing loss in neonates are cytomegalovirus infection or genetic defects and in infants and older children are excessive cerumen accumulation and middle ear effusions.
Suspect hearing loss if a child's response to sounds or development of speech and language is abnormal.
Screen infants for hearing loss, beginning with evoked otoacoustic emissions testing.
Diagnose children based on results of clinical examination and tympanometry.
Treat irreversible hearing loss with a hearing aid, cochlear implant, or bone-anchored hearing aid and language support (eg, teaching sign language) as needed.
