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Primary ear & hearing care

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By the end of this module the learner should be able to:

  • List the common milestones for hearing in babies and children
  • Suspect hearing loss in children and adults
  • Perform different tests (without equipment) depending upon the age of the individual
  • Use hearWHOpro or similar tests
  • Understand when a person should be referred for further testing
  • Explain the tests that will be done at a medical facility for different ages





–– Automated auditory brainstem response (AABR) test
–– Conditioned play audiometry
–– Distraction test of hearing
–– Hearing-related milestones
–– hearWHO app and hearWHOpro app
–– Landmarks for hearing
–– Otoacoustic emissions (OAE) test
–– Smartphone app
–– Whispered voice test


Identifying hearing impairment in a timely manner is very important to make sure that people can get the treatment or rehabilitation they need. As a health worker, you will be the first person a family may come to for advice if they notice any problems, either in children or in adults. Since the ways and means for checking hearing varies according to the age group of the person to be tested, this module is divided into three sections, according to age groups.

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Hearing loss in babies and toddlers.mp4
Hearing loss in babies and toddlers

Video used (with permission) from 

This non-commercial website has been established to increase public awareness of hearing loss and is an excellent resource for further reading.



In order to assess hearing loss in babies and children, you must check to see if they are reaching specific hearing, understanding, and talking benchmarks, which are listed below. These benchmarks are indicators of healthy hearing and talking, and their absence may indicate hearing loss.



Hearing impairment may not be easily suspected or recognized in babies and young children. Any child could have hearing loss, and as a health worker you should know when to suspect hearing loss and perform further tests or refer.

*Adapted from the American Speech-Language-Hearing Association’s guidelines for healthy speech, language, and hearing development in youths.


a) There has been a problem during pregnancy or birth, such as:

  • Infection in the mother while she was pregnant with the baby. The mother may give history of having had fever or rashes.
  • Receiving medicines during pregnancy that can affect hearing. Such medicines are often prescribed for treatment of infections, malaria and TB (refer page …)
  • Lack of oxygen at time of birth: parent may inform that the labour was long and difficult or that the child had a cord around its neck or was blue at birth.
  • Low birth weight baby: if the baby had a birth weight of below 1500gms.
  • Jaundice: if the child had high levels of jaundice, parents may inform you that the child had turned very yellow in the days after birth or had to be given light therapy or a blood (exchange) transfusion.
  • Prolonged stay in the Intensive care unit.
  • Family history of deafness in the family
  • Any visible abnormalities of the head and neck e.g. small ear, recessed jaw, different colours of eyes.
  • History of ear discharge: at times the child may develop an ear infection very early in life and the parents may bring him to you saying that the ear is discharging.

b) Child has delayed development of hearing-related milestones: most children will follow a similar pattern of responding to sounds around them and starting to use sounds and words as they grow. However if a child is born deaf or develops hearing loss she would not respond to sounds or start speaking in a manner which is common for children of her age.

Common hearing-related milestones in children during first few years of life are as outlined in Table7a. This information is available in the form of Community resource 2 on early identification of hearing loss in children, which can be shared with parents.

If a child does not achieve these common milestones, you should suspect hearing loss and check for it.


Try to check the hearing of all babies you see and most especially those that have any risk factor or delay in reaching the common hearing milestones. The section below tells you how this can be done.

Depending upon the age of the child, you can perform different tests:

a) 0-6 months:

It is very difficult to test the hearing without equipment in such a small baby. You should try to observe the child’s response to sounds e.g. if the child wakes up or startles when there is a loud sounds and if she responds to her mother’s voice.

It is very important that even moderate hearing loss be identified very early in children. If they get rehabilitation in the first few months of life, they can learn language much better than if they are identified later. For this reason, in some countries every child has a test of their hearing when they are born.
If the child has not had such a test because it is not available or the child was ‘missed’ and there is any suspicion of hearing loss, please REFER the child for a hearing test to a nearby health facility.

b) 6 months-3 years:

The simplest test of hearing in babies once they are 6 months of age or older is the Distraction test of hearing. It uses a rattle or the spoken voice or to see if the child turns to the sound.

A baby or young child should be sent to a suitable health facility for further tests if:

  • They fail the distraction test of hearing
  • They pass the distraction test, but there are still concerns from the parents about hearing

Even if it turns out that some of these babies referred by you actually have normal or good hearing, do not hesitate to refer them whenever there is a suspicion of hearing loss. This cannot be known for sure until the specialist tests are done.
When a baby passes the distraction test, give parents the hearing milestones development sheet (resource…) so that they can use this to monitor the child’s development at home. If there is any further delay in milestones, parents should take the child for a formal hearing test.

C) 3-7 years:

Though it may be possible to use a whispered voice test (Practical J) to check the hearing of a baby of this age, they are often too shy to repeat words as is required in this or may not follow the instructions well. For this reason, you can check their hearing by giving them simple instructions and looking for their response, such as:

  • ‘Touch your nose’
  • ‘Outh’
  • ‘Where is your tummy’

It is important to remember that hearing loss can develop in early childhood. You should let parents or caregivers know that they should bring their child back for testing if they are worried about hearing loss a few months or years later.


When you suspect hearing loss and refer the person for further testing, they will have to go to a hospital or clinic where audiology service is available. Depending upon the age of the child, the following tests could be performed there to diagnose hearing loss. The following tests can only be performed at medical centres with proper equipment.

0-3 years: A child below five years of age cannot be expected to respond reliably and hence hearing is tested in them by tests that do not require their response. The common tests that will be performed when you refer a baby to a specialist for hearing testing are:

  • Otoacoustic emissions (OAE) or automated auditory brainstem response (AABR) tests that can be done on babies and children up to five years of age. These tests are often carried out using a handheld device, while they child is asleep. They are quick and easy to perform. When a child fails this test repeatedly (twice), s/he should be sent for a (Photo of OAE test)
  • Auditory brainstem response test: this test is usually only available at specialized centres. This test is often carried out after sedating the baby.

A child should have repeat testing if there are concerns about hearing, even if previous results were normal.

3-5 years
The child’s hearing can be tested through:

Conditioned play audiometry: in this test sounds are presented to the child through earphones or in the environment. The child is conditioned to perform a simple activity (such as putting a block in a basket or adding a piece to a puzzle) when they hear a sound. This response is used to determine if the child has a hearing loss.


Above 5 years
Mostly, children above five years of age, hearing can be tested with the use of pure tone audiometers, as it is done for adults.



Most primary care clinics do not have equipment for testing hearing. At these clinics hearing can be screened using:

  • Voice tests
  • Smartphone applications


  • Speaks loudly or very softly. Older adults with hearing loss are likely to speak loudly and this can be an important indication of hearing loss.
  • has difficulty in hearing what is being said, especially in noisy places (e.g. restaurants)
  • has difficulty in talking to someone over phone
  • commonly asks people to repeat themselves
  • raises the volume of television or radio
  • complains of ringing sensation in the ear (tinnitus)


Though not as reliable as testing hearing with the use of proper equipment, hearing can be checked through simple tests carried out in the community or at home in adults.

1. Use of hearWHO app: launched by WHO, hearWHO is a validated option that can be used for hearing screening in the community hearWHO has two versions:

a. hearWHO for personal use: any person with an android or iOS based smartphone can download and start using the app following its instructions.

b. hearWHOpro for health workers: with the use of this app, you can screen adults within his or her community for hearing loss. You need to:

  • explain the process to the person being tested and help them take the test.
  • inform the user of the score and what it means.
  • depending on the score, you can either:

-Tell them that they have good hearing, but should maintain good ear and hearing care practices;
-Or inform the person that the low score could indicate a hearing impairment and that they should get their hearing tested.
-Inform them of what facilities closeby offer such testing.

  • download test results or save them in your records as required. The app offers the possibility to store multiple test results.


2. Whispered voice test: another option to screen for hearing loss is through the whispered voice test. A person with normal hearing should be able to hear and repeat words whispered at an arm’s length. In case this is not so, the person should be sent for a proper hearing test such as an audiometry.



Children older than 5 years and adults can have their hearing checked by a simple test, using the pure tone audiometry (PTA). In this test, sounds of different pitches are presented into each ear and the person is asked to respond when s/he can hear these. The result of an audiometry test is called an audiogram.



Activity 14



 Practical G: the distraction test of hearing

 Practical I: hearWHOpro app to check hearing

 Practical J: the whispered voice test of hearing

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