Hearing and speech delay
When a child is slow to start talking, hearing is the first thing we check. Not because it is the most likely cause, but because it is a cause that can be treated and, if it is missed, it costs time at an age when time matters. Hearing can be tested at any age, without your child needing to answer or cooperate.
How is hearing linked to speech?
Children learn to talk by copying what they hear. For this it is not enough to hear that someone is speaking, they need to tell the sounds of words apart clearly.
There is a misconception here that delays many diagnoses. Parents expect a child who doesn't hear well to seem as if they hear nothing at all. In practice the usual picture is much milder: the child hears the vowels and misses the consonants, because consonants sit in the high frequencies and are softer. Your child hears that you are talking to them but can't tell "fish" from "dish". They react to a loud noise but don't turn around when you call them from the next room.
When the cause is fluid behind the eardrum, hearing comes and goes: better after a good week, worse after every cold. So the child learns language from a signal that is sometimes clear and sometimes muffled, and this shows in the way they speak.
What should you expect at each age?
The milestones below are a rough guide, not a test. Children differ from one another, and a gap of a few weeks means nothing. A gap that persists, however, is worth checking.
- By 3 months: startles at loud sounds, calms down when hearing your voice
- Around 6 months: turns toward the source of a sound, babbles syllables like "ba-ba", "da-da"
- Around 12 months: responds to their name, understands "no", points with a finger, says 1 or 2 words with meaning
- Around 18 months: says several words, follows a simple instruction without being shown
- Around 2 years: puts 2 words together, like "more milk", and is understood by family
- Around 3 years: speaks in short sentences and is understood by people outside the home as well
One exception doesn't wait for any age. If your child has lost words they used to say, or has stopped responding the way they did before, this is not a delay, it is a step backward (regression), and it needs to be checked right away.
When does a child need a hearing test?
- Doesn't respond to their name or doesn't turn around when you speak from behind
- Is late to talk compared with the milestones for their age
- Talks, but is still hard to understand at an age when you would expect clearer speech
- Turns the TV up very loud or sits very close to hear
- At school, teachers say they don't pay attention, don't follow instructions or daydream
- Has frequent ear infections or has been diagnosed with fluid in the middle ear
They passed the newborn hearing screening. Do they need another test?
Newborn hearing screening is valuable and picks up hearing loss present from birth, but it only shows hearing at the moment it was done. International guidelines are clear on this: hearing and speech development should keep being monitored in all children, whatever the newborn screening result, because some types of hearing loss appear or get worse later.
Some children need closer follow-up even with a normal first test: those who spent time in a neonatal intensive care unit (NICU), those who had severe jaundice, those with a family history of hearing loss starting in childhood, those who had meningitis or an infection passed on during pregnancy, and those who received medicines that can damage hearing (ototoxic drugs).
What can cause hearing loss in a child?
The first distinction we make is whether the hearing loss is temporary or permanent, because everything else depends on it.
When it is temporary
- Fluid in the middle ear, after ear infections or viral infections. It is the most common cause of reduced hearing in childhood and it doesn't hurt, which is why it goes unnoticed.
- Large adenoids, which block the opening of the Eustachian tube and stop air from reaching the ear.
- Earwaxblocking the ear canal, which is removed at the same visit.
When it is permanent
- Genetic causes, the most common cause of permanent hearing loss in children, even when nobody else in the family is deaf.
- Infections during pregnancy, cytomegalovirus (CMV) being the best known.
- Complications around birth, such as premature birth, severe jaundice or a stay in neonatal intensive care.
- Meningitis and medicines that can damage hearing, which can affect hearing at any age.
The two groups are told apart at the same visit, by combining the tympanogram with the hearing test.
What happens at the appointment?
We start with the history, which of course comes from you: how your child communicates at home, what words they say, how they react to sounds, how many ear infections they have had, how they breathe and how they sleep. Then we look into the ears (otoscopy).
Hearing tests by age
There is no single test for all children, there is the right test for each age.
- Otoacoustic emissions (OAE): measure the response of the inner ear (cochlea) to a sound. Possible from infancy, they take a few minutes and your child can be asleep.
- Auditory brainstem response (ABR): records the response of the hearing nerve. It gives an objective result with no participation from the child and is used when the hearing threshold needs to be measured precisely.
- Visual reinforcement audiometry: for babies and toddlers. The child learns to turn toward the sound and is rewarded with something that lights up.
- Play audiometry: for preschool children. The child learns to make a movement as part of a game every time they hear the sound.
- Standard audiogram: from school age on, as in adults.
Tympanogram
It shows in seconds whether there is fluid behind the eardrum and whether the Eustachian tube is working. It is the test that separates temporary hearing loss, the kind caused by fluid that can be treated, from permanent hearing loss.
Looking behind the nose (endoscopy)
When large adenoids are suspected, their size can be seen directly with a thin, flexible camera, with no X-ray.
What happens next?
When hearing is normal
This is not a negative result, it is useful information. It rules out the cause that had to be ruled out first and lets speech therapy or a developmental assessment start without any question marks over hearing. The order matters: speech therapy on top of undiagnosed hearing loss doesn't work, however well it is done.
When there is fluid in the middle ear
It is the most common cause of reduced hearing in childhood and usually clears up on its own. It is monitored with hearing tests and, if the fluid persists beyond 3 months and affects hearing, we discuss ear tubes. σωληνάκια.
When the hearing loss is permanent
Here time matters more than anything else. The international standard is screening within the 1st month of life, diagnosis by the 3rd month and the start of support by the 6th month, because children who start early develop speech very close to children with normal hearing. Treatment is tailored to each child and includes hearing aids, speech therapy and, in severe cases, a cochlear implant.
Frequently asked questions
No. None of the tests is painful or invasive. Babies are often tested while asleep, older children do the tests like a game.
No. Hearing can be tested from the first days of life. What changes with age is the method, not whether testing is possible.
That happens too, and most children who are late to talk don't have hearing loss. We don't test because we think something is wrong, we test because it takes one visit and rules out the one thing we don't want to discover later.
The hearing test, and it can be done right away. No time is lost, because speech therapy starts straight after, with the difference that we now know what it is building on.
That is not a safe conclusion. High-frequency hearing loss lets a child hear music and loud sounds while missing the consonants of speech. That is why hearing is measured at each frequency separately.
In most cases no, as long as it is found and monitored. The concern is fluid that stays for months without anyone knowing, precisely because it doesn't hurt.
When should you not wait?
Immediately
Has lost words they used to say
A step backward in speech or in responding is checked without waiting, at any age.
Soon
Doesn't react to sounds or to their name
We don't wait for them to "grow out of it". Hearing can be tested at any age and gives an answer.
Soon
Fluid in the ear for more than 3 months
At this point an audiogram is needed, because the decision depends on how much your child hears.
Medical review: Dr. Ioannis KotrotsosENT Surgeon and Specialist in Phoniatrics and Pediatric Audiology.
Πηγές: Joint Committee on Infant Hearing, Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs · Rosenfeld RM et al., Clinical Practice Guideline: Otitis Media with Effusion (Update), AAO-HNSF, 2016.
The information on this page is for general information only and does not replace a medical examination. For diagnosis and treatment, please consult a doctor.
