Hearing Problems
Hearing is very important for your child to learn to talk. If you are concerned about your child’s hearing, you can get a hearing test at any age. It is never too early. Even young babies can have hearing tests.
Hearing milestones
It may be hard to know if your child has a hearing problem, as children can’t always tell us if they do not hear. Below are some signs of hearing. If you do not see these signs in your child, you may want get a hearing test for your child.
- Reacts to loud sounds with startle reflex
- Is soothed and quieted by soft sounds
- Turns head to you when you speak
- Is awakened by loud voices and sounds
- Smiles in response to voices when spoken to
- Seems to know your voice and quiets down if crying
- Looks or turns toward a new sound
- Responds to "no" and changes in tone of voice
- Imitates his/her own voice
- Enjoys rattles and other toys that make sounds
- Begins to repeat sounds (such as ooh, aah and ba-ba)
- Becomes scared by a loud voice or noise
- Responds to their own name, telephone ringing, someone's voice, even when not loud
- Knows words for common things (cup, shoe) and sayings (bye-bye)
- Makes babbling sounds, even when alone
- Starts to respond to requests such as "come here"
- Looks at things or pictures when someone talks about them
- Plays with own voice, enjoying the sound and feel of it
- Points to or looks at familiar objects or people when asked to do so
- Imitates simple words and sounds; may use a few single words meaningfully
- Enjoys games like peek-a-boo and pat-a-cake
- Follows one-step commands when shown by a gesture
- Follows simple directions such as "give me the ball" without being shown
- Often uses words they have learned
- Knows 10 to 20 words
- Points to some body parts when asked
- Understands simple "yes-no" questions (are you hungry?)
- Understands simple phrases (in the cup, on the table)
- Enjoys being read to
- Points to pictures when asked
- Understands "not now" and "no more"
- Chooses things by size (big, little)
- Follows two-step commands, such as "get your shoes and come here"
- Understands many action words (run, jump)
Risk factors for hearing loss
You may also want to take your baby to an audiologist to have their hearing checked if any of the following risk factors apply:
- Serious infection at birth
- Difficult birth, which affected breathing
- Weight at birth was less than 1500 grams
- Head, face or ears do not look normal
- Intensive care stay as a baby
- Brain condition
- Close family member had a hearing problem in childhood
Hearing aids
A hearing aid is a device worn on the ear that amplifies sound. There are basically two types of hearing aids: air conduction hearing aids and bone conduction hearing aids, with several styles in each type.
Your audiologist chooses a hearing aid and designs it to amplify sound based upon your child’s hearing loss. The hearing aid provides the greatest amplification at the frequencies (pitches) where your child has the most hearing loss; and the least amplification at the frequencies where your child has the least hearing loss.
We will adjust your child’s hearing aid carefully to keep loud sounds within your child’s comfortable listening range. Hearing aids do not make hearing normal again, but they can help make speech sound clearer and easier to hear.
- Hearing aids brochure (PDF)
Air conduction hearing aids amplify sounds, and present the louder sounds through the ear canal and middle ear to the nerve of hearing.
We usually fit younger children with behind-the-ear hearing aids (see below). Children can use behind-the-ear hearing aids with a personal FM system to help them hear the teacher in the classroom. When children get older and are no longer growing quickly, they can sometimes switch to in-the-ear hearing aids.
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The dispensing audiologist will provide you with step-by-step instructions for using and caring for the hearing aid. We often program hearing aids for children, to reduce the need for changing many of the settings.
We typically recommend these for children who have conductive hearing loss, where sound doesn't reach the nerve properly, most often because of a malformed outer or middle ear.
Bone conduction hearing aids rest on the skull and are held in place by either a soft headband or a hard plastic headband. In older children they can be attached to an implanted fixture in the skull.
Soft headband bone conduction hearing aid
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The hearing aid is held in place by a soft headband. It is important that the headband provides a firm contact between the skull and the hearing aid. Several companies make and sell headbands. Speak to your audiologist about which one is best for your child.
Hard plastic headband bone conduction hearing aid
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The hearing aid is held in place by a hard plastic headband. We typically use these when a soft band cannot provide the amount of amplification your child needs. Speak to your audiologist about which style of headband is best for your child.
Bone-anchored hearing systems (BAHS)
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A BAHS sends sound directly from the microphone into the inner ear by vibrating through the skull.
The difference between an anchored aid and a headband aid is that a BAHS delivers the sound more directly to the inner ear through a fixture in the skull, rather than resting on the skull with a headband. It should improve what your child hears without the need for a headband.
We attach the bone-anchored aid to a post that we implant in the skull. These are called bone-anchored hearing systems (BAHS). We do not implant these until the child is approximately 5 years old.
Cochlear implants
We may consider cochlear implants if hearing aids are of limited benefit.
A cochlear implant is a device that directly stimulates the hearing nerve. It can provide sound for people who have a severe to profound hearing loss and/or receive little or no benefit from conventional hearing aids. We usually do cochlear implant surgery after a child is at least one year of age.
Hearing aids and cochlear implants
Hearing aids make sounds louder. However, for children who have a severe to profound hearing loss, hearing aids may not provide enough consistent access to sound for them to understand speech. Cochlear implants may be a good option for these children.
Cochlear implants
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A cochlear implant is a device that is implanted into the inner ear. We surgically implant a tiny electrode into the cochlea (inner ear), and implant a receiver behind the ear. In the picture you can see the electrode (3) inserted into the inner ear (4). The receiver (2) is under the skin behind the ear. The recipient wears an external sound processor (1).
How it works
- The microphone in the sound processor picks up sound
- The sound processor converts the sound into a digital signal, and processes it
- It then sends the processed digital information to the transmitter coil
- The transmitter sends the information by radio waves to the receiver below the skin
- The receiver sends the information to the electrode array in the inner ear
- The electrodes send signals to the hearing nerve, which the brain recognizes/perceives as sound
Hearing loss
The type of hearing loss that your child has refers to the part of the ear that is affected.
Diagram of the ear
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Parts of the ear
- The outer ear includes the pinna (fleshy outside part of the ear), and the ear canal. These structures collect sound and direct it towards the eardrum
- The middle ear includes the eardrum, a space filled with air, and three small bones. These structures are responsible for conducting the sound from the outer ear to the inner ear. The Eustachian tube (normally closed) opens to equalize the air pressure in the middle ear
- The inner ear includes the cochlea and the balance organ. The cochlea contains tens of thousands of tiny hair cells that are each tuned to different pitches. These hair cells respond to incoming sound, and pass on information to the hearing nerve
Types of hearing loss
It is important to know what kind of hearing loss your child has because:
- It will help you to understand your child's hearing loss
- It will help to determine the best treatment plan for your child.
Conductive loss results from a problem in the outer or middle ear, affecting the way the sound travels through the ear.
A common cause of conductive hearing loss in children is fluid in the middle ear. Middle ear fluid can sometimes get better by itself. If middle ear fluid persists, becomes infected, or causes a hearing loss, your child might need medical treatment (i.e. antibiotics or tubes).
Conductive hearing loss can also be permanent, as in a malformation of the outer or middle ear (like ‘atresia’) that prevents sound from travelling through the ear. We often manage this type of hearing loss with hearing aids and/or surgery from an ear, nose and throat doctor, as well as early intervention services.
Sensorineural hearing loss results from a problem in the cochlea.
Your child may have been born with this type of hearing loss. It can also be the result of damage, disease, injury, or certain medications.
Sensorineural hearing loss is almost always permanent and cannot be improved with medicine or surgery. Usually, hearing aids or other listening devices are the best treatment for sensorineural hearing loss.
Mixed hearing loss is a combination of conductive and sensorineural hearing loss.
Auditory neuropathy is a hearing disorder in which sound enters the inner ear normally but the transmission of signals from the inner ear to the brain is impaired.
Slight hearing loss
Normal hearing sensitivity is defined as hearing at 15 dB or better. A slight hearing loss is defined as hearing sounds beginning around 20-25 dB.
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This diagram shows the range of normal hearing and slight hearing loss. The further towards the bottom of the graph, the more severe the hearing loss.
A few speech sounds are also plotted, indicating the approximate frequency (pitch) and intensity (loudness) of each sound. These speech sounds are representative of speech at average loudness, at close proximity, and in a quiet environment.
Speech sounds differ in terms of frequency (pitch) and intensity (loudness). Vowel sounds such as A, E, I, O and U tend to be lower in frequency (pitch) and louder in intensity. Consonants such as S, P, T, SH, K and F tend to be higher in frequency (pitch) and softer in intensity.
The amount of hearing loss your child has will determine how he or she will be able to hear normal conversational speech.
Problems and how to help
The effects of slight hearing loss are subtle, but may include difficulty in:
- Hearing faint or distant speech (when a person is at a distance greater than three feet)
- Hearing the fine distinctions in word sounds, such as the S sound in plurals (lady vs. ladies) and possessives (Tommy vs. Tommy’s). Verb tenses might also be unclear (is vs. was, fill vs. filled)
- Hearing in background noise, such as a noisy classroom or restaurant, or with the television on in the room
- Following a fast-paced conversation
- Picking up subtle conversational cues
- Focusing on what the teacher is saying in the classroom
Your child might experience problems like these:
- Difficulty in school when the classroom is noisy or if he or she is not seated close to the teacher
- Becoming fatigued in school from the increased effort it takes to listen
- Responding inappropriately if he or she has missed parts of a conversation
Some things you can do to help your child in the classroom:
- Make sure your child’s teacher knows about your child’s hearing loss
- Your child should sit close to the teacher where good eye contact is possible
- If your child has one ear that hears better, that ear should be on the side closer to the teacher
- Your child might benefit from a Soundfield or personal FM system. In these systems, the teacher wears a microphone which transmits either to a headset worn by your child, or to speakers in the classroom. In both cases, the teacher’s voice is amplified so that it is more easily heard above the background noise of the classroom
Effects of hearing loss
How well your child will understand speech depends on the degree and configuration of hearing loss. Hearing loss is divided into categories depending on the severity.
Categories of hearing loss
Here are the categories of hearing loss, and how you can expect your child to hear speech.
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This diagram shows the categories of hearing loss. The further towards the bottom of the graph, the more severe the hearing loss.
A few speech sounds are also plotted, indicating the approximate frequency (pitch) and intensity (loudness) of each sound. The speech sounds are plotted at levels of loudness if they were spoken in average conversational loudness in a quiet environment.
Speech sounds differ in terms of frequency (pitch) and intensity (loudness). Vowel sounds such as A, E, I, O and U tend to be lower in frequency (pitch) and louder in intensity. Consonants such as S, P, T, SH, K and F tend to be higher in frequency (pitch) and softer in intensity.
The amount of hearing loss your child has will determine how he or she will be able to hear normal conversational speech.
- Normal hearing (0-15dB): Your child will likely be able to detect and discriminate all speech sounds even at very quiet levels
- Slight (20-25dB) and mild hearing loss (25-40dB): Your child might have difficulty hearing faint or distant speech and have difficulty in group environments. Your child will likely be able to hear sounds at close distances and in quiet environments
- Moderate (40-55dB) and moderately severe hearing loss (55-70dB): Your child might have difficulty detecting and discriminating consonants (e.g. the S, SH, TH, CH, F, K and P sounds). They might rely on combined clues from several sounds, words, and patterns of speech to understand what is said
- Severe hearing loss (70-90dB): Your child might be able to identify environmental sounds. He or she might be able to discriminate vowels but will likely have difficulty discriminating consonants
- Profound hearing loss (90-105dB): Your child will likely only hear loud environmental sounds and feel vibrations
Children often have hearing loss that is a combination of different levels for different pitches. An example is a mild hearing loss in the low pitches and a severe hearing loss in the high pitches.
Follow-up: recommended next steps
Untreated hearing loss can have significant negative effects on speech and language development.
Early intervention services (or early communication support services), medical treatment and/or hearing devices can significantly minimize the negative effects of hearing loss. Children usually need to use sign language, hearing aids or other hearing devices for permanent hearing loss.
Work with your audiologist and other professionals to get appropriate treatment and a follow-up plan for your child’s hearing loss.
- Download the Effects of Hearing Loss pamphlet (PDF) for more information
Unilateral (one-sided) hearing loss
Approximately 2 babies in every 1,000 births have a unilateral hearing loss. A newborn hearing-screening test can identify a unilateral hearing loss within the first few months of life. We may even give the test before your newborn child leaves the hospital.
There are many strategies you can use to enhance your child’s listening skills. There are also specific changes that you can make to the home environment, to make listening easier for your child.
A unilateral hearing loss affects your child in several ways:
- Hearing in background noise: Important sounds, such as the speech of your child’s caregiver, are not as clear and are harder for your child to hear when there is other noise in the background
- Finding or localizing a sound: Most children find it difficult to tell where a sound is coming from when they do not have the same hearing in both ears
- Language development: Children learn to speak by saying what they hear. If your child does not hear speech clearly, it may be more difficult for your child to develop clear speech
- Hearing soft sounds: Soft voices and voices that are far away may be more difficult for your child to understand
Speech and language development
Children learn to talk by listening to those around them. Some children with a unilateral hearing loss may experience difficulties learning new words or pronouncing all words clearly.
A recent study looked at children with unilateral loss at age 3 and found that only the children with severe, or severe to profound, unilateral loss were having difficulty. This type of outcome is similar to other research studies on the subject.
Ask your care team for some strategies that help your child to develop good listening skills. This is called auditory training.
Things that you can do to modify your environment so that it is easier for your child to hear you
- Reduce or remove sources of background noise such as televisions and dishwashers. Move away from sources of noise that you can’t reduce
- Position your child so that the ear with normal hearing is directed toward the sound you want the child to hear
- When you are talking to your child, get close. Get even closer when you are in a noisy environment
Communication strategies that you can use to ensure that your child hears you
- Speak clearly to your child on the side where his/her hearing is normal
- Avoid shouting as it will actually add distortion to your speech, making it even harder to understand what you are saying
- Rephrase rather than repeat sentences that they do not understand
- Use visual cues (facial expressions, gestures)
- Speak clearly (not too loud or too soft; not too fast or too slow)
- Use appropriate facial expressions and body language
- Have visual aids on hand (pictures, books, toys)
- Get your child’s visual attention before speaking
- Be sure there is good lighting when you are speaking to your child
Amplification options
A hearing aid may be helpful depending on the nature of your child’s hearing loss. Your audiologist will be able to tell you if a hearing aid will help your child.
For school-aged children, there are a few assistive listening devices that may be helpful. For example, sound-field or personal amplification systems can help a child to hear better in the classroom. In these systems, the teacher wears a microphone which transmits either to a headset worn by your child, or to speakers in the classroom. In both cases, the teacher’s voice is amplified so that it is more easily heard above the background noise of the classroom.
Sources of health care support for your child’s hearing loss
- Visit an otolaryngologist (ENT) if middle ear fluid or infections are present
- Have your child’s hearing tested on a regular basis, as recommended by your audiologist
- Arrange classroom observation and consultation with a speech and language pathologist or hearing resource teacher in your child’s school district
- Ask your early interventionist for some strategies that help your child to develop good listening skills. This is called auditory training
As your child’s parent, you are part of a team. Your partners are your health-care provider, your audiologist, and your early interventionist who is familiar with hearing loss and auditory skill development. Your team can check to see if the unilateral hearing loss has an impact on speech and language learning.
Hearing loss is a common side effect of treatment for some types of cancer. Sometimes, the disease itself can cause hearing loss.
Some of the treatments for cancer that can damage hearing include:
- Chemotherapy drugs such as cisplatin
- Radiation to the head or brain
- Surgery involving the brain, ear or auditory nerve
- Some medications, including certain antibiotics and diuretics
The Audiology Department at BC Children's Hospital monitors the hearing of children who are undergoing treatment for cancer, and provides some follow-up hearing assessments once treatment is finished.
For more information on cancer treatments and hearing loss, refer to the CureSearch website.
You can find more information on the BC Children's Hospital Cancer and Blood Disorders web page.
Many babies with cleft palate have middle ear fluid at birth or in the newborn period. This fluid affects the baby’s hearing. By the time babies with cleft palates are 9 months old and are ready to have their palate repaired, most will have middle ear fluid and temporary hearing loss.
Why this happens
When a child has a cleft palate, some of the muscles that help a tiny tube in the ear to open may not function normally. This tube is called the Eustachian tube.
Many babies with a cleft palate and middle ear fluid will have surgery to put tubes in the ears to drain the fluid and help keep air in the middle ear. An ear, nose and throat ( ENT) doctor places the tubes. We usually do this surgery at the same time the baby is having surgery to repair the palate.
How middle ear fluid affects your baby’s hearing
When the middle ear is filled with fluid, the eardrum and the tiny bones in the middle ear can’t move as well as they should. It is harder for the sounds to get to the inner ear and sounds will be muffled. Put your hands over your ears to see what this might sound like.
You baby will have more trouble hearing softer sounds, and louder sounds will sound quieter.
Most babies with middle ear fluid and mild hearing loss will respond to sounds at home.
Middle ear fluid often changes . This means that your baby’s hearing can be better on some days, and worse on others.
Additional resources
Hearing screening, diagnostics and intervention
International support organizations
- Alexander Graham Bell
- National Center for Hearing Assessment and Management (NCHAM), Utah State University
- John Tracy Clinic
- American Speech-Language-Hearing Association (ASHA)