Understanding Hearing Loss in Children
If you are a parent or a caregiver of a child with hearing loss, it can be a stressful and confusing journey. More than 90% of children with hearing loss are born to hearing parents, and therefore, it is often unexpected. Since 1999, federal law requires mandatory hearing screenings for all newborn babies in the United States. This has resulted in significantly earlier detection of hearing loss, which can lead to earlier intervention and improved outcomes.
If your child has been diagnosed with hearing loss and your goal is for your child to grow up with listening and spoken language, hearing aids are absolutely essential. This article will provide an overview of hearing loss and hearing aids for kids.
How is hearing loss diagnosed in babies?
The newborn hearing screening consists of one or two tests: otoacoustic emissions (OAEs) and auditory brainstem response (ABR). Protocols vary by state and by hospital. Often, babies will be tested, at least initially, with OAEs. This tests the function of the outer hair cells in the cochlea. Soft sounds are played in the ear, and a response from the hair cells is measured.
This test is advantageous because it is inexpensive to administer, it can be run in just a few minutes, and it will catch the majority of hearing losses present at birth. It only involves a small probe being placed in the baby’s ear, which contains both the speaker for the stimulus and the measurement of the response.
An ABR also measures hearing sensitivity but at the level of the brainstem. Similarly, sounds are played in the ears, but rather than the response being picked up by a probe, small electrodes are placed on the baby’s head (and sometimes shoulders, depending on their size) that record a response.
The ABR is more sensitive to mild hearing loss and will also catch certain types of hearing loss in which the outer hair cells are functional, but there are problems further along the auditory pathway. However, ABR is a more expensive and more time-consuming test to complete.
Both of these tests are useful in that they do not require any response from the baby but are, in fact, easier and faster to perform if the baby is sleeping. Some hospitals use ABR for all babies, while others use it for babies in the neonatal intensive care unit (NICU), those with other risk factors for hearing loss, and babies who have not passed an OAE screener. If a baby does not pass the hearing screening in the hospital, the parents or caregivers will be prompted to have the baby return for a follow-up screening in the weeks after birth, and potentially for a full diagnostic ABR.
What causes hearing loss in children?
Hearing loss, like many other diagnoses, can either be categorized as congenital (present at birth) or acquired (onset sometime after birth). Congenital hearing loss can be genetic, even if both parents have normal hearing. There are also genetic syndromes of which hearing loss is one symptom, such as Down syndrome, Usher syndrome, and Treacher Collins syndrome.
Furthermore, other factors, such as premature birth, maternal substance abuse, and infections, can also cause congenital hearing loss. One common cause is cytomegalovirus; this presents as a common cold or flu, but if a woman contracts it for the first time while pregnant, it can cause birth defects, including hearing loss.
Some states are implementing a specific screening for CMV at birth in babies because it is the leading cause of birth defects in the US. The newborn hearing screening protocol ensures that the vast majority of these congenital hearing losses are diagnosed within the first several weeks of life. Moreover, hearing loss can be acquired at any time during the lifespan. Often, it is associated with aging, but there are some conditions that cause a childhood-onset (or progression) of hearing loss.
Other causes for acquired hearing loss in childhood could be ototoxic drugs, such as chemotherapy, infections resulting in extreme fevers, or traumatic brain injury. Ear infections, known as otitis media, are also common in childhood due to the orientation of the Eustachian tube in babies and young children. Recurrent otitis media can cause some degree of hearing loss in kids, but it is typically not permanent and resolves when the ear infections resolve.
How are signs and symptoms of hearing loss identified in children?
Beyond the newborn hearing screening, there might not be another reason to routinely test a child’s hearing until they are entering kindergarten. This is why it is important to be aware of developmental speech and language milestones which, if they are not met, could indicate hearing loss or other delays. There are a lot of helpful resources that provide general expectations for speech and language development based on your kid’s age.
For example, at birth, we may only be looking for a startle response to loud sounds. In the latter half of the first year, babies should be able to localize where sounds are coming from, make some cooing and babbling sounds, and potentially start to say their first words.
By age two, they should have about 50 words and be able to put two words together (“more water,” “bye Daddy”). As kids get older, there are expectations of increased vocabulary, improved pronunciation, and acquisition of all the sounds of speech. Eventually, we expect children to comprehend complex questions and follow multi-step directions. If you have concerns that these milestones are not being met, you should consult your child’s pediatrician. Hearing loss is just one possibility that could be responsible for these symptoms.
Why is early intervention so important?
If your goal for your kid is to develop spoken language, hearing is critical. We can only produce sound if we can hear it. Baby’s brains are rapidly growing and changing, and the capability for learning is immense in early childhood. Some of this neural plasticity slows as we age, and research has shown that there is a critical period for language development in the first two years of life.
This is not to say that children diagnosed with hearing loss after the age of two will never develop spoken language, but it becomes much more difficult at this point. Individuals who lose their hearing later on, even in childhood, will have already had a foundation of listening and spoken language to work from.
Hearing aids (or cochlear implants, depending on the degree of hearing loss) provide the brain with the access to sound that it needs in order to develop language. This technology needs to be worn during all waking hours for kids to have the best opportunity to stay on target with their peers. An audiologist will be responsible for diagnosing hearing loss and dispensing appropriate hearing aids. The child may also be seen by a speech-language pathologist or teacher of the deaf for speech therapy services to ensure they are making good use of their technology.
Progress with speech and language is measured based on “hearing age,” meaning that the developmental milestones are based on when technology was fit. For example, if a baby is not fit with hearing aids until six months old, the expectations for their listening and spoken language ability are that of a newborn, not a six-month-old. When that baby is a year old, they may only be achieving what a six-month-old with normal hearing would do. This is okay; the goal is to close that gap as quickly as possible. This is why early intervention is essential.
Parents can choose different communication options based on what works for their family. There are some schools of thought that support intensive auditory-only training, whereas others use a combination approach of a visual method (sign language or cued speech) in addition to listening with hearing aids and cochlear implants. There is no right or wrong method; your audiologist and/or early interventionist can help walk you through the pros and cons of communication strategies.
How do hearing aids work?
Hearing aids are devices worn on the ears that provide amplification based on a patient’s specific hearing loss. That is to say, they do not make all sounds equally louder but rather provide a prescribed amount of gain to different frequencies (pitches). Babies and very young children cannot perform a diagnostic hearing test where they are required to respond to sounds presented in a booth, but their audiogram can be estimated using ABR.
As they get older, behavioral hearing tests that are implemented align with their developmental abilities, such as turning their head in response to sounds and then progressing to placing a toy in a bucket when a sound is heard. Hearing aids for kids can be continually reprogrammed based on these test results, and the goal is to obtain a reliable behavioral audiogram as early as possible.
What kinds of hearing aids for kids are recommended?
Behind-the-ear (BTE) hearing aids for kids are recommended for a few essential reasons. First, they are the most durable style. Second, children’s ears are still growing, so it is easier and less expensive to replace ear molds as a kid grows and changes rather than replacing a custom hearing aid.
Soft silicone ear molds are flexible and comfortable, and if a child bumps their head or is hit with a ball, there is a lower risk of damage to the hearing aid or to the child’s ear. Many BTE hearing aids now are even waterproof! This is exciting for many parents as bath time or other opportunities to be in and around water are great incidental learning, and a lot of language can be gained during that time.
Older children and teens may be fit with receiver-in-canal (RIC)/receiver-in-the-ear (RITE) hearing aids. These hearing aids still have a piece that sits behind the ear, but it tends to be smaller than a BTE, and they use a thin receiver wire, which is more discrete than tubing and an ear mold. RIC hearing aids are not recommended for babies or younger children because the receiver wire can be easily damaged, and the retention is not as strong for babies and toddlers who are rolling, crawling, and early walkers.
The other type of hearing aid, an in-the-ear (ITE), is a custom device that is built using an ear mold impression. These are not commonly recommended for kids because of the hard material used and because kid’s ears are still growing and changing. It would be impractical and expensive to continually remake hearing aids for kids as they get older. It is possible that an older teenager would be drawn to this style to be more discrete than a BTE, though a RIC/RITE is probably a better option for this population.
Phonak and Oticon are the leading manufacturers of hearing aids for kids. The Phonak Sky Marvel line is a BTE hearing aid that comes in six bright colors and eight neutrals for the body of the hearing aid and offers seven color options for the ear hook.
This way, patients can mix and match. This hearing aid would be best suited for kids with severe to profound hearing loss. The Phonak Sky Lumity is a RIC device, also available in a variety of colors: six bright and eight neutrals. This would be suitable for older kids and teens. Oticon’s Opn Play also comes in RITE and BTE styles and is available in seven bright colors in addition to five neutral options.
Selecting the Right Hearing Aid for Your Child
What factors should I consider when choosing a hearing aid?
Hopefully, you are already in the hands of an excellent pediatric audiologist who will help you through this process. After a diagnosis of hearing loss and a recommendation for hearing aids, your child will need to be medically cleared by their pediatrician or an ear, nose, and throat physician prior to being fit with hearing aids. Depending on what is known about the hearing loss, this may involve some imaging or additional tests to determine the cause.
There are a few factors that will largely dictate a lot of the choice of hearing aids. The first is the comfort and fit of hearing aids on kids. Particularly on young babies but really all the way up through adolescence, a BTE hearing aid with a soft silicone ear mold will be recommended for durability, comfort, and flexibility for growth.
The degree of hearing loss will dictate the style of ear mold that is recommended. For more severe hearing losses, the child would be fit with a full shell ear mold with minimal venting, while more moderate hearing losses can warrant a more open fit style. As kids get older and become more responsible, they may graduate up to a RIC/RITE style hearing aid, which is more discrete and has some sound quality advantages because of the placement of the receiver (speaker) in the ear canal.
Hearing aids for kids have specific features such as tamperproof battery doors, LED indicator lights to show that the hearing aids are functioning, and a variety of retention options such as clips and cords to prevent the hearing aids from getting lost. In addition to these physical features, there are also pediatric-specific algorithms built into the hearing aids for kids to process sound in a way that is for them.
Kids have different listening needs than adults, in part because of the environments they are in, such as school, and in part because we want their brains to learn to hear a certain way. For example, while adult hearing aids are often actively searching for speech and reducing background noise, many audiologists feel that pediatric hearing aids for babies should be largely “omnidirectional.” This means that sound enters their auditory system more naturally so that their brains learn to filter through what is speech and what is noise. This can be adapted when children enter school and need more supported listening. These are all reasons for using hearing aids for kids.
What questions should I ask the audiologist?
Talk with your audiologist about their preferences for certain manufacturers. It is normal for them to be more comfortable with certain devices, and this is a good thing for your kid. Talk to them about the fit and style of the hearing aids, but also the warranties on the devices and the repair services. It is wise to prepare for the hearing aids to be lost and/or damaged at least once- kids play rough!
They will probably also have a preference for an ear mold manufacturer. The audiologist will take an impression of each ear. This can be tricky with young children, but rest assured it is not an overly uncomfortable experience, and they will probably get used to it over time. As their ears continue to grow, there will be many ear mold impressions in their future.
You should also talk to the audiologist about assistive technologies your kid may be using in addition to the hearing aids, such as an FM system in school. Most schools utilize Roger technology to provide improved signal-to-noise ratio for kids with hearing loss. Roger is manufactured by Phonak, but it is universally compatible with all hearing aids and cochlear implant brands.
Your child’s pediatric audiologist may want to talk with the educational audiologist to ensure the school has what they need for your kid and the hearing aids that are selected. If your kid attends a smaller private or charter school, you may have to work with the principal or other administrator to get what you need.
Additionally, talk with your audiologist about the trajectory of your kid’s hearing loss. If your child has severe-to-profound hearing loss, your audiologist will likely talk with you about cochlear implants. This is a surgical procedure that will provide access to sound that cannot be achieved with hearing aids for kids with this degree of hearing loss. This surgery is not performed until closer to 12 months of age, though, so hearing aids will be recommended in the interim period before surgery.
If the etiology of the hearing loss is known, we may expect it to stay relatively stable while others are progressive. Some types of hearing loss can have sudden, unpredictable drops in one or both ears. Continued monitoring and maintenance in these cases is essential. It is also possible that your child’s hearing will fluctuate, particularly if they are prone to excessive wax or recurrent ear infections. Your audiologist and physician can try to give you some idea of what to expect based on the profile of their hearing loss.
Fitting and Adjusting the Hearing Aid
How are hearing aids for kids fit?
Hearing aids for kids are programmed using proprietary manufacturer software. Your child’s audiogram will be entered into the software, which will prescribe specific amounts of gain at each frequency based on the degree of hearing loss in each ear. The first audiogram may be based on an auditory brainstem response test, depending on the child’s age, but the hearing aids will continually be reprogrammed based on behavioral test results. In addition, the software will take into account the acoustics of the ear mold when prescribing gain.
The programming itself can be done very quickly when kids are little, and a lot of the appointment time will be spent answering your questions and trying to condition the child to provide behavioral test results. It can take a lot of practice for children to reliably respond to sound.
You will see your audiologist regularly to ensure that appropriate progress is being made. The hearing aids for kids also have a technology called “datalogging”, which will show your audiologist exactly how many hours per day the hearing aids are being worn. This is the most important thing they will be checking because wear time is the only way to make progress. Depending on your child’s age, the audiologist and early interventionist will be using specific scales to track the developmental progress of speech and language development. The audiologist will spend time with you, ensuring that you feel comfortable putting the hearing aids on properly.
One common issue with hearing aids is feedback, which occurs when sound leaks out of the ear and is re-amplified by the hearing aids, creating a whistling sound. This can happen when the ear molds are not inserted properly, if they fit poorly, or if there is excessive wax in the ears. Your audiologist will also give you instructions about basic troubleshooting of the hearing aids, including performing a listening check.
Until your child is old enough to be able to reliably report to you what they are hearing, it is critical that you regularly listen to the hearing aids to ensure they are working properly. Additionally, you should inspect your child’s ears to ensure that there are no sore spots or pressure points created by the ear molds.
Promoting Successful Adoption and Use
The absolute most important thing to ensure success with hearing aids for kids is wear time. The general rule is “eyes open, ears on.” Children should be wearing their hearing aids for all waking hours to maximize the amount of language, both passive and active, that they are hearing.
By the age of three, children need to hear approximately 30,000 words each day in order to develop the language needed for success in school. Consider that if your child only wears their hearing aids four hours a day, it will take them six years to hear what a normal hearing kid hears in one year.
This “eyes open, ears on” mantra can seem daunting in the beginning. As a parent myself who sometimes struggles to keep socks on my children or a ponytail in their hair, I can say you will certainly face your kid pulling their hearing aids out. It will be challenging and frustrating. That said, habits are created relatively quickly in children. You will be amazed how soon your child will make the connection between having their hearing aids and hearing sound.
Children like hearing sound- your voice, their voice, music, noise from outdoors. There will be rough patches of constant removal, but if you can power through them like so many other difficult phases and behaviors with kids, it will really pay off. If you are facing a time when it is challenging to keep the hearing aids on, try to associate the hearing aids with something positive that the child really loves, like a music class, snack time, or TV show. Make the hearing aids a positive, not a punishment.
How should I educate my child about their hearing aids?
Depending on the age your child is, when they are fit with hearing aids, they may not grow up knowing any differently. There are a lot of resources out there to explain hearing loss and hearing aids to children. Books such as A Button in Her Ear, Freddie and the Fairy, and Lucy are great options for younger kids, and El Deafo and Rally Caps are great for adolescents.
It is important to emphasize to your child that hearing loss is simply one part of them, and that all people have to seek help for certain things. Some kids wear glasses; some need reading support, and others have difficulty climbing ropes or playing sports. Hearing aids for kids are incredible technology and they can be something to show off rather than something to hide.
It is really important that you involve your child in the hearing aid color choice if they are at an age where it is appropriate. This helps children to take ownership of their hearing aids and to make them feel proud and confident to wear their devices. We want kids to advocate for themselves, and there should not be any part of them that feels shame or embarrassment for wearing hearing aids. Some children may very well want devices that blend into their skin or hair, but it should be their choice.
There are also all kinds of stickers and jewelry to decorate the hearing aids for kids, so even if you choose a neutral color, you can mix it up regularly with accessories that are relatively inexpensive and easy to use. There is a popular brand of sticker called SkinIts, and a whole market of hearing aid products and accessories on Etsy. Any pattern, character, or sports team your child can dream up is out there.
This is a great way for them to feel ownership and pride over their devices. As they get older, they may also be able to teach their peers about the fun features of their hearing aids, like rechargeability, waterproof capabilities, and Bluetooth streaming.
How should I care for my child’s hearing aids?
The BTE hearing aids for kids themselves should be relatively low maintenance, though your audiologist will likely provide you with a drying kit of some sort to remove moisture from the devices and extend their life. Sometimes, these are simple jars with beads that remove moisture; there are also electric dehumidifying driers that can be used if you live in a particularly hot or humid climate.
You can check the ingress protection (IP) rating of the hearing aids; many of them have a 68 rating, meaning that they are waterproof and dustproof. These are particularly advantageous for those humid climates or children prone to getting dirty and sweaty!
The ear mold is the portion that will require more maintenance. When you remove the hearing aids for the day, always check if there is wax or other debris in the opening or anywhere along the tubing. Additionally, you should check to ensure the tubing is soft and supple- if it becomes hard or discolored, it’s time to have it changed by your audiologist. Some earmolds also include a vent or a small hole through the mold that should remain clear for comfort and ventilation.
The earmold should be wiped with a soft cloth or tissue when you remove the hearing aids. Try to avoid using alcohol or other chemicals which may break down the material. Once your child is old enough, you can start to pass the responsibility for care and maintenance onto them to encourage ownership of their hearing loss and their devices.
There are a variety of retention options to keep the devices on your child’s ears and minimize the risk of loss and damage. For example, there are plastic retention rings that function like a sort of rubber band around the hearing aid and the ear, and there are small bands that attach to the hearing aids and then to a wire clipped onto your kid’s clothing.
Wig tape (double-sided tape) is another option that some parents find effective for keeping the hearing aids on a child. Crucially, the ear mold must have a good fit, and the ear hook and tubing must be the correct size and length.
Many hearing aids for kids are now rechargeable, but if your child’s hearing aids take disposable batteries, you want to be very careful to keep them out of reach and use the tamperproof battery door. The batteries are small and a definite choking hazard.
Supporting Your Kid’s Communication and Development
How should I communicate effectively with my child with hearing loss?
“Your kid may not be listening to you, but it does not mean they are not hearing you.“
Making eye contact with your child when you are talking with them is critical. You may also have to educate other family members and friends about communicating with a child with hearing loss. Hearing aids for kids are not a miracle cure; remember that even people with normal hearing struggle to hear in certain environments.
Listening and hearing are not the same: listening is a complex skill that involves different layers of behavior and comprehension. Your kid may not be listening to you, but it does not mean they are not hearing you. Regular troubleshooting and listening checks of the hearing aids can help you to distinguish between the two.
As your kid enters school age, it is more than likely that some form of assistive technology, in addition to hearing aids, will be recommended. Most classrooms are noisy, distracting places. An FM system improves the signal-to-noise ratio for kids with hearing loss by placing a microphone on the teacher and sending their voice directly to your child’s hearing aids. This is something that is usually coordinated by the educational audiologist if your child attends public school.
Your kid will probably be on an individualized education plan (IEP) to monitor them throughout school and ensure they have the resources and support needed to be successful. They may or may not continue to receive services from a speech-language pathologist to ensure appropriate speech and language development.
Dealing with Challenges and Seeking Support
It is never easy to see your kid struggle, and the journey of hearing loss will change as they get older. As babies, your biggest challenge might be keeping the hearing aids on their little ears. As they get older, it might be preventing them from getting lost or broken when they insist on wrestling with a sibling. Moving into middle school, it could be the social and emotional challenge of your child feeling different from other kids.
All of these are very real obstacles, but keeping wear time and continued progress as the north star can help you get through it. If you feel shame or embarrassment about your child’s hearing loss, they will feel it. Parenting is hard even in the most straightforward of circumstances; try to make their hearing loss and hearing aids just a basic part of their everyday day, neither hiding it nor drawing unnecessary attention towards it.
As your kid enters school, they will need either an IEP or a 504 plan. Both are outlines for supporting a child’s success in school, but there is a subtle difference. Kids with an IEP require specialized instruction, whereas kids with a 504 plan have accessibility requirements but can be in mainstream classrooms. These plans are updated annually, and it is possible that a child can transition out of an IEP into a 504.
This legislation, part of the Individuals with Disabilities Education Act (IDEA), protects children and guarantees them access to services and equipment, such as FM systems, in the classroom. Your pediatric audiologist and educational audiologist are great resources for guiding you through this process, as are your kid’s teacher and principal.
Hearing Aids for Kids Conclusion
There’s a whole host of virtual and in person support groups for individuals with hearing loss. Communicating with other parents of children with hearing loss and presenting an opportunity for your child to connect with others who use hearing aids for kids or cochlear implants can be invaluable.
Good places to start are the Hearing Loss Association of America (HLAA), the Alexander Graham Bell Association, and Hands and Voices. You can also check with your pediatric audiologist to see if there are other local groups. Sometimes, audiologists are able to connect you with another family who has been through the process before. Many parents are happy to serve as mentors and make connections with others going through a similar journey.
The most important thing to remember is that you are doing the right thing for your child. Hearing loss has been identified, and if your goal is for your kid to develop spoken language, hearing aids for kids are the next step. If your child has developed hearing loss later in life, fitting them with hearing aids for kids will offer opportunities for continued success in school.
There are a lot of resources and support available for you and your kid as you go through this process. Surely, many new challenges and questions will come up along the way, but soon enough, your kid’s hearing aids will be a part of them, and you will be the expert on your child’s hearing loss.
We hope this comprehensive guide to hearing aids for kids provided the information you need to help your child hear better!
Erin Edwards received her Doctor of Audiology degree from Towson University in 2015 and her Ph.D. in Education and Leadership from Pacific University in 2022. She has worked with patients of all ages in a variety of settings and has a specific interest in cochlear implants, the relationship of hearing loss and dementia, and interdisciplinary healthcare.