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Doctor, is my child’s hearing alright? How can I tell?

Hello and TGIF! Welcome to Dr Euan's ENT blog!

Today's blogpost is about pediatric hearing assessments, and is also specially written by guest writer Audiologist Ms Jennifer Lee who we work closely with, from Audiology Centre Hearing Partners.

So let's see what advice she has for us about hearing tests for children, shall we?

Ms Jennifer Lee:

There are many types of hearing assessment available for the pediatric population, as we need to tailor the assessment to the child's developmental milestones. When a child's participation is not feasible, there are also objective hearing assessments that can be used to estimate the child's auditory pathway integrity and hearing ability.

We will explore the different types of hearing assessment, the preparations required, and what to expect during an appointment below.

Types of Pediatric Hearing Assessment

Universal Newborn Hearing Screening (UNHS)

The UNHS was first implemented in Singapore in 2002 – and eventually introduced as a national program in 2003 – for the early detection and intervention of hearing impairments in newborns. Although the UNHS is an optional assessment, it is now part of the standard practice in government-restructured and private hospitals with delivery facilities[1].

There are two screening methods:

- Otoacoustic Emissions (OAE)

- Automated Auditory Brainstem Response (AABR).

Both are quick and non-invasive.

The differences between the respective screening methods are as follows:


Preparation - Minimal or no preparation required

Fundamental principal - Assess function of the hearing organ; may not detect neural defects

Duration - 15 minutes

Relative cost - $


Preparation- Skin preparation is required for the adhesion of electrodes

Fundamental principal - Assess the integrity of the auditory pathway, up to the lower brainstem

Duration - 45 minutes

Relative cost - $$

Behavioural Hearing Assessment

For children above the age of 6 months with age-appropriate development, behavioral hearing assessment can be attempted. The above hearing screening methods only provide information on the physiological functions of the ear and auditory pathway, whereas behavioral hearing assessment helps establish the child's hearing thresholds across different frequencies. These are important for medical management, and the child’s speech and language development.

Visual Reinforcement Audiometry (VRA) and Play Audiometry are the two most common behavioral hearing assessments, each for a different age group.

Visual Reinforcement Audiometry (VRA)

VRA utilizes the concept of behavioral conditioning to observe toddlers’ responses to sounds.

This behavioral hearing assessment is suitable for children aged 6 months to 2.5 years as they would already have good neck support and environmental awareness.

Most children with age-appropriate development can associate sounds with the reinforcers (e.g., toys or screens) at the side of the room; so, when a sound is heard, a distinct head turn from the child to look at the reinforcer is expected and used as a reliable indicator of a true-positive response.

Picture 1: Child turning to the TV screen at the side during VRA.

Play Audiometry

This behavioral hearing assessment is suitable for children aged 2 to 5 years who can understand and follow simple instructions.

Conditioning will be done to help the child learn to execute a developmentally-appropriate task (e.g., putting cars into a box, stacking blocks and piecing a puzzle) whenever a sound is heard.

There will be times when some children rush to perform the task before any sound is heard or they appear uncertain about the task; the audiologist should have the skills and experience to spot these false responses and reinstruct/reassure the child. It may take a few attempts and/or retests to establish reliable results.

Picture 2: Child executing a play task during play audiometry.

How to prepare the kids for the visit

For infants (<6 months old) scheduled for UNHS, please ensure that they are well-fed and sleepy for the session – naptime would be the best time – as the hearing screening will yield the most reliable results when they are asleep and quiet.

For toddlers, let them know that they will be getting their ears checked and that they will be playing a game with the audiologist. Showing them the clinic setup to familiarize them beforehand, and pretending to check their favorite doll/superhero’s ears would help to ease any anxiety about new procedures.

Pictures 3 and 4: Clinic front and test room at Hearing Partners Novena.

Depending on the hearing assessment, headphones, ear tips and/or headbands may be used to obtain ear-specific results; hence, parents can introduce these tools to their children at home to reduce the chance of rejection during assessment. Finally, on the day of the assessment, ensure that they are rested, happy and well. Feel free to bring along your child’s favorite toy, book or snack as a reward!

Photo 5: Transducers used in hearing assessments (from top left in clockwise direction) – in-ear probe, headphones, insert earphones and bone conductor.

What to expect during the appointment


Bring along your child’s health booklet to provide the audiologist with some birth information and to update the UNHS results upon completion. The audiologist may also ask questions regarding the pregnancy, birth, and family history of childhood hearing loss.

The room would be dimmed and white noise can be utilized to provide a soothing environment for the infant to fall/stay asleep. Milk can be offered to the infant, if necessary. Once ready to begin the hearing screening, the environment must be kept as quiet as possible.

Other pediatric hearing assessments

The session starts with warming up the child to the audiologist and environment. Following this, simple history taking would be conducted. This can include, but is not limited to, the main purpose of the hearing assessment, child’s listening and speech development at home and/or in school, and history of ear infection and flu etc.

The audiologist may take a quick look into the child’s ear to check on ear wax and ear drum conditions prior to the hearing assessment.

Photo 6: Child getting his ear checked by the audiologist.

During the hearing assessment, the audiologist may seek parents’ participation in keeping the child still and/or playing with the child to help the child feel comfortable and confident throughout the session. The child can either be seated on a chair independently or seated in the parent’s lap. Timely praises and rewards would serve as a great motivation but be cautious not to give hints or cues that could affect the child’s responses to sounds.

The process of the assessment is highly dependent on the child’s interest, attention and cooperation; alternative or additional hearing assessment may be required if the ordered test(s) cannot be completed. There is also a chance that no conclusive results are obtained on the same day; in such cases, the assessment would be split into a few sessions.

At the end of the assessment, the audiologist would provide a brief explanation of the results obtained and recommend a management plan for hearing monitoring purposes; further medical intervention, if any, is to be advised by the pediatrician or ENT doctor.

You may discuss with the doctor to request for other objective hearing assessments – Auditory Brainstem Response (ABR) and Auditory Steady State Response (ASSR) – if there is an urgency to establish hearing thresholds but behavioral hearing assessments are not feasible for your child.

Thank you once again to Ms Jennifer Lee & Hearing Partners for their helpful advice! You can find Hearing Partners at if you would like to try a hearing assessment for you or your child. Hearing Partners Novena is located at Royal Square Novena at address 103 Irrawaddy Rd, #01-02, Singapore 329566 and you can call them at 6238 8832 .

Thank you for reading! We wish you a blessed Friday!

If you would like to consult an ENT Specialist about you or your child's hearing capabilities, please feel free to Contact Us at Euan's ENT Surgery & Clinic to make an appointment.

Telephone No.: 6694 4282

References: [1] V.S. Rajadurai, W.Y. Yip, J.S.C. Lim5, et al. Evolution and expansion of newborn screening programmes in Singapore. Singapore Med J 2021; 62(1 Suppl): S26-S35. doi: 10.11622/smedj.2021073


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