Last updated 2026-07-09
TL;DR
If a toddler shows a speech delay, get a hearing test before anything else. About 2 to 3 in every 1,000 children are born with hearing loss, and mild or fluctuating loss from ear infections can quietly stall language for months without anyone noticing. The test itself is painless, often free through your pediatrician, and the results shape every decision that follows.
Speech and hearing are tangled together in a way that's easy to underestimate. A child learns words by hearing them hundreds of times, in dozens of different situations. Take away even a little of that hearing and the input a child gets turns thin and distorted, which slows language down or stalls it altogether.
This isn't rare. The Centers for Disease Control and Prevention estimates that about 2 to 3 per 1,000 children in the United States are born with detectable hearing loss, and that number climbs once you count toddlers who develop hearing problems later from chronic ear infections or other causes [1]. The American Academy of Pediatrics states directly that "hearing loss is one of the most common conditions present at birth" and calls routine screening "essential" [2].
Hearing comes before nearly every other evaluation for a good reason: if a child can't hear well, speech therapy won't work the way it's supposed to. A speech-language pathologist can't tell you a child's real language ceiling until someone has answered the more basic question of what that child can actually hear. Yet plenty of parents spend months in speech therapy before anyone thinks to recheck hearing after a run of ear infections. It's a common pattern and a frustrating one. Push for the hearing test first, or at least alongside any other referral.
Which milestones mean it's time for a hearing test
The American Academy of Pediatrics and the American Speech-Language-Hearing Association publish the milestones pediatricians use as checkpoints, and missing even one is reason enough to act rather than wait [2][3].
| Age | Typical milestone | Red flag |
|---|---|---|
| 6 months | Turns toward sounds; babbles with consonants | No reaction to loud sounds; no babbling |
| 12 months | Says 1-2 words; responds to own name | No words; doesn't look when called |
| 18 months | 10-20 words; follows simple directions | Fewer than 6-10 words; doesn't point |
| 24 months | 50+ words; 2-word phrases | Fewer than 50 words; no 2-word combinations |
| 36 months | 3-word sentences; strangers understand ~75% | Speech mostly unintelligible; fewer than 200 words |
You don't need a stack of warning signs before asking for an evaluation. One missed checkpoint is enough on its own.
Ear infections make this trickier to spot. A child can pass a newborn hearing screen and then develop conductive hearing loss months later from fluid in the middle ear (otitis media with effusion). This kind of loss is often mild and comes and goes, which is exactly why it gets missed: the child hears fine some days and poorly on others. Parents often read this as the child being selective about listening. Usually that's not what's happening.
The different tests toddlers actually get
Not every test suits every age. Audiologists pick a method based on what a child can reliably do at that stage. Here's what you'll likely run into.
Otoacoustic Emissions (OAE). A tiny probe sits in the ear canal, plays a soft sound, and measures whether the inner ear (cochlea) sends an echo back. No cooperation needed from the child, which is why it's often the first screen used, even with newborns. It checks cochlear function but not the full pathway to the brain [4].
Auditory Brainstem Response (ABR). Electrodes go on the scalp and behind the ears while clicks or tones play, and the brain's electrical response gets measured. It can be done while a child sleeps naturally or under sedation, and because it needs no behavioral response, it's the most accurate option for young children [4].
Visual Reinforcement Audiometry (VRA). Used roughly from 6 months to 2.5 years. The child learns to turn toward a sound, and a lit-up toy or animated figure rewards the turn. Most toddlers enjoy it, and it can map hearing thresholds across different frequencies.
Conditioned Play Audiometry (CPA). Used from about 2.5 to 5 years. The child drops a block in a bucket or puts a peg in a board every time they hear a tone, turning the test into a game. It's about as close as you get to a standard adult audiogram for this age group.
Tympanometry. Not a hearing test exactly, but it's almost always paired with one. A probe measures how the eardrum moves with changes in air pressure, and it's the most reliable way to catch fluid in the middle ear, the leading cause of fluctuating conductive hearing loss in toddlers.
For most toddlers being evaluated for a speech delay, the audiologist runs OAE, tympanometry, and either VRA or ABR, depending on age and how cooperative the child is that day.
A screening isn't the same as a full evaluation
A screening is pass or fail. A full evaluation gives you actual numbers, and that gap matters more than most parents realize.
The screening done at birth, or in some pediatric offices, is built to catch kids who obviously need more testing. It isn't designed to catch mild or fluctuating losses, and it won't tell you the thresholds: exactly how quiet a sound can get before a child stops hearing it.
A full audiological evaluation, done by an audiologist rather than a nurse, is what you want once a speech delay is on the table. It maps the specific frequencies and decibel levels a child can hear, tests each ear on its own, includes tympanometry, and gives you a real picture of what sound that child is working with.
ASHA recommends a full audiological evaluation, not just a screening, for any child with a suspected speech or language delay [3]. So if your pediatrician's office runs a quick in-office screen, says the child passed, but the speech delay is still there, ask for the full evaluation anyway. A mild high-frequency loss can wreck a child's perception of consonants (the sounds that carry most of the meaning in speech) while still sailing right through a basic screen.
The referral path usually goes like this: the pediatrician hears the concern, refers to audiology for a full evaluation, and refers to a speech-language pathologist around the same time. In practice these referrals sometimes happen out of order or just stall. Worth knowing: in most states you can self-refer to an audiologist without a doctor's order.
What it costs, and who pays
A hearing screening at a well-child visit is usually free. A full audiological evaluation without insurance runs about $200 to $500, and the coverage picture breaks down as follows.
Under the Affordable Care Act, hearing screening for children counts as a preventive service, so most insurance plans have to cover it with no cost-sharing when it happens at a well-child visit [5]. The Bright Futures schedule, maintained by the AAP and followed by most insurers, includes hearing screening at multiple well-child visits through age 21 [2].
A full audiological evaluation falls under a different billing category. It's usually covered as a medical benefit rather than a preventive one, and it needs a diagnosis code behind it, such as a speech delay or a physician referral. Without insurance, a full pediatric audiological evaluation typically costs $200 to $500 depending on the clinic and region.
Children on Medicaid or CHIP (Children's Health Insurance Program) generally have hearing evaluations covered, often with no copay. The Early Hearing Detection and Intervention (EHDI) program, run through the CDC and state health departments, connects families to low-cost or free evaluation resources [1].
If cost is standing in the way, reach out to your state's EHDI program or your school district's child find office. Under the Individuals with Disabilities Education Act (IDEA), Part C, states are required to provide free evaluation for children under 3 who are suspected of having a disability affecting development, and hearing loss qualifies [6]. For children 3 and older, school-based audiological evaluations fall under IDEA Part B and are also provided at no cost to the family [6].
Parents often assume that once a baby passes the newborn hearing screen, hearing is off the list of possible explanations for a speech delay. That assumption can cost months. The most common cause of hearing loss that shows up later in toddlers is otitis media with effusion, the fluid that lingers in the middle ear after a bacterial infection clears. It can stick around for weeks or months, and since the eardrum can't vibrate properly against fluid, sound arrives muffled. A toddler who gets this repeatedly during the first two years may be hearing inconsistently right when language is developing fastest. Other causes include cytomegalovirus (CMV), whether congenital or picked up shortly after birth: it's the leading nongenetic cause of childhood sensorineural hearing loss, and the damage can progress after birth[7]. Meningitis and other serious infections can damage the cochlea. Ototoxic medications (some antibiotics, chemotherapy drugs given during illness) are another cause, as is head trauma. And some genetic conditions cause hearing loss that shows up gradually, so a child can hear normally at 12 months and have significant loss by 24 months. That last possibility is exactly why the one-time newborn screen doesn't close the book. Both ASHA and AAP recommend ongoing audiological monitoring for any child with a speech delay, not a single test and done. A normal hearing test is good news, but it doesn't explain the delay, it just rules out one cause and points you toward the next question: a full speech and language evaluation by a licensed speech-language pathologist. The SLP looks at what the child understands, what they produce, articulation, and social communication, and that gives you a baseline and a diagnosis if one applies. A few outcomes show up often. Some kids have a language delay with no clear cause, sometimes called a "late talker" presentation. Many late talkers with normal hearing do catch up, but the research isn't fully reassuring: a review by Rescorla in Developmental Disabilities Research Reviews found that children identified as late talkers at 24 months had higher rates of language difficulty at school age than peers, even when they seemed to catch up in preschool[8]. Others turn out to have apraxia of speech, a motor planning disorder where the brain has trouble coordinating the movements speech requires (separate from hearing and language, and treated differently). Sometimes the delay fits a broader autism spectrum profile, and sometimes it's developmental language disorder (DLD), where language itself is affected without an identifiable cause. If hearing checks out normal and a delay is confirmed, early intervention is the step backed by the strongest evidence. In the US, children under 3 qualify for free Part C evaluation and services if they meet their state's criteria, and that window closes at age 3, so it pays to move quickly. Once a child turns 3, the school district takes over evaluation and services through the IEP process under IDEA Part B[6]. Some families go through school-based speech therapy, others use private SLP services, and plenty use both. Whether hearing loss itself is temporary or lasting depends on the type. Conductive loss, usually caused by middle ear fluid, often clears up: many cases resolve on their own within 3 months, and pediatricians or ENTs may recommend watching and waiting, or placing pressure equalization tubes to drain fluid and keep the ear ventilated. Decongestants don't have good evidence behind them for this. Hearing typically returns to normal once the fluid issue is treated. Sensorineural loss, involving the cochlea or auditory nerve, is usually permanent, and the degree changes everything about the plan. Mild loss (26-40 dB) means a child misses soft speech and some consonant sounds, and hearing aids usually help a great deal. Moderate loss (41-55 dB) makes normal conversational speech hard to catch without aids. Severe loss (71-90 dB) means only very loud sounds come through unaided, and with profound loss (91+ dB), cochlear implants often become the option on the table; the FDA has approved them for children as young as 9 months[9]. Any confirmed sensorineural loss should lead to a referral to otolaryngology and a hearing aid specialist. Fitting hearing aids early is strongly linked to better language outcomes down the line. The EHDI program's benchmark, known as "1-3-6," calls for identification by 1 month, diagnosis by 3 months, and intervention started by 6 months[1]. Speech therapy should start alongside hearing technology rather than waiting for it: an SLP experienced with hearing loss can work with a child wearing hearing aids or using a cochlear implant, and that combination outperforms either one on its own. Pediatricians are usually receptive to a parent's concern, but visits are short, so be direct and specific. Ask for a "full audiological evaluation," not a screening, and not "let's watch and wait." Something like: "I'm concerned about [child's name]'s speech development. I'd like a referral for a full audiological evaluation and a speech-language pathology evaluation" works better than "she's behind." Specifics help too: "At 18 months she has about 4 words and doesn't point" tells a doctor far more than a general worry. If you've tracked milestones with the AAP Bright Futures tools or the CDC's Milestone Tracker app, bring that along[2][10]. If a pediatrician suggests waiting a few more months, it's fair to push back: ask what would actually change in that time, and what the downside of evaluating now would be. There isn't a real downside to early evaluation, but there's a real cost to delay, since the window for maximum neurological plasticity doesn't stay open forever. You can also self-refer: most audiology clinics accept this, and ASHA's Find a Professional tool helps you locate audiologists nearby[11]. Calling a clinic directly is sometimes faster than waiting on a pediatrician's office to process a referral, and if you're already working with an SLP, ask them for the audiology referral too. They do this all the time and often know faster pathways than a pediatrician's office does. Hearing loss and autism can absolutely occur together, and it gets missed more often than it should. They co-occur more than chance would predict, though solid data on the exact rate is still thin. Hearing loss can mask autism features, autism can make hearing tests harder to interpret, and both can genuinely be present at once, so an audiologist experienced with neurodivergent children matters here. Children with Down syndrome have a very high rate of chronic middle ear problems and elevated risk for both conductive and sensorineural loss, and the same holds for children with cleft palate. If your child has either diagnosis, regular audiological monitoring should already be built into their care, though it's worth double-checking that it actually is. When autism is suspected alongside a speech delay, the workup should include an audiological component alongside an assessment from a developmental pediatrician or psychologist, run in parallel rather than one after another. Things like echolalia or absent joint attention aren't caused by hearing loss, but hearing loss can make autistic communication harder to support, so getting both answers at once lets you build a plan around the full picture. If a child with suspected autism ends up needing augmentative and alternative communication, hearing status matters for choosing the right approach, since AAC devices built for speech output assume a child can hear that output clearly enough for it to reinforce learning. For families juggling all this and looking for a structured way to build language practice at home between sessions, Little Words (littlewords.ai) offers an AI-powered speech companion built for neurodivergent kids, including those with hearing differences. The quiz at /start can help you see if it's a fit.What should parents do at home while waiting for evaluation appointments?
Waiting for appointments when you're worried about your child is hard. Here's what actually helps in the meantime.
Keep talking. Research on language input consistently shows that the amount and quality of child-directed speech matters for language development. Even if your child isn't responding the way you expect, keep narrating what you're doing, naming objects, and commenting on what they're looking at. This is called following the child's lead, and it's one of the foundational techniques in naturalistic language intervention [12].
Notice and record what your child does respond to. Does she startle at loud sounds? Does he turn toward music but not voices? These observations matter for the audiologist and make the evaluation more productive.
Cut background noise when you talk to your child. If there's any question about hearing, competing sound from TVs, music, and siblings makes it harder for a child to process what you're saying. One-on-one conversation in a quieter room is worth practicing.
Don't try to "test" your child's hearing at home by making loud sounds and watching for a startle. That's not reliable, and it tells you nothing about mild or high-frequency losses.
Document milestones. Use the CDC's free Milestone Tracker app, or just write down the dates when you see new words, new behaviors, or regressions [10].
Contact your state's early intervention program now, even before you have any results. You can request an early intervention evaluation without a physician referral in most states. The process takes time, so starting sooner is always better. Find your state's program through the Center for Parent Information and Resources [6].
What does the research say about outcomes when hearing loss is caught and treated early?
The data here is encouraging. Earlier identification means better language outcomes, and the effect is large enough to have reshaped policy across the country.
A 1998 study by Yoshinaga-Itano and colleagues, published in Pediatrics, found that children with hearing loss who were identified and enrolled in intervention before 6 months of age had significantly better language outcomes than those identified later, even when degree of hearing loss was controlled for [13]. That finding has been replicated and extended since, and it's the scientific foundation for universal newborn hearing screening in every US state.
For children with conductive hearing loss from middle ear fluid, research supports that treating persistent fluid (particularly with PE tubes when indicated) improves hearing thresholds and can support language development, though the link between short-term ear infections and long-term language outcomes is messier and still being studied.
The EHDI program's "1-3-6" goal (screen by 1 month, diagnose by 3 months, enroll in intervention by 6 months) exists because the data shows each month of delayed intervention has measurable consequences for language [1].
None of this means a child diagnosed at 18 or 24 months is out of options. The brain stays highly plastic through the early childhood years, and children who get appropriate hearing technology and speech-language support after later identification can still make big gains. But earlier is genuinely better, which is why pushing for fast evaluation when you have a concern is the right call.
Frequently asked questions
At what age can a toddler be tested for hearing?
Any age, including right after birth. Newborns are usually screened with OAE or ABR before they leave the hospital. Toddlers between 6 months and 2.5 years are typically tested with Visual Reinforcement Audiometry, and kids from about 2.5 to 5 can usually manage Conditioned Play Audiometry. If you're worried, there's no age that's too young for an audiological evaluation.
What counts as a normal hearing test result for a toddler?
Audiologists generally consider thresholds of 15 dB HL or better across the speech frequencies (500 Hz to 4000 Hz) to be normal hearing, with mild hearing loss falling between 16 and 40 dB HL. After testing, you'll get an audiogram: a report showing the softest sound your child could hear at each frequency, in each ear.
My toddler passed the newborn hearing screen. Can they still have a hearing problem?
Yes. Newborn screens catch most hearing loss but not all of it, and some types show up later. Conductive loss from chronic ear infections is common in toddlers and wouldn't have been caught at birth, and progressive sensorineural hearing loss can also develop in the first few years. Passing the newborn screen doesn't rule out hearing loss as a factor in a current speech delay.
How long does a pediatric hearing test take?
Plan for 45 to 90 minutes for a full evaluation. The audiologist needs time to build rapport with your child and run several tests (OAE, tympanometry, and VRA or CPA), then interpret the results. Some toddlers need a second appointment if they're not cooperating the first time around. ABR under sedation takes longer and usually means coordinating with a hospital or clinic anesthesia team.
What is glue ear, and how does it affect speech?
Glue ear (otitis media with effusion) is fluid sitting in the middle ear without an active infection. It's extremely common under age 4, with some estimates suggesting up to 80% of kids will have at least one episode by then. The fluid dampens how the eardrum vibrates, causing mild to moderate hearing loss that comes and goes. Because this happens during a sensitive window for language learning, the inconsistent sound input can meaningfully slow vocabulary and speech growth.
Can ear infections cause permanent speech delay?
The infections themselves cause temporary hearing loss that clears once the infection and any leftover fluid resolve. The real concern is fluid that lingers for months at a stretch during the toddler years, cutting down on language input during a key learning period. Research on the long-term language effects of recurrent otitis media is mixed, but if your child has chronic middle ear fluid alongside a speech delay, that combination deserves close monitoring and early speech-language support regardless of which one is causing the other.
Will insurance cover a hearing test for my toddler?
Most plans cover hearing screening at well-child visits at no cost, under the ACA's preventive services mandate. A full evaluation ordered because of a speech delay is usually covered as a medical benefit once you have a physician referral and diagnosis code. Medicaid and CHIP cover hearing evaluations for kids, and under IDEA Part C, children under 3 are entitled to a free evaluation if there's a developmental concern, insurance or not.
What if my toddler won't cooperate during the test?
Just tell the audiologist ahead of time. This isn't unusual, and experienced pediatric audiologists plan for it. They'll often start with OAE and tympanometry, which need no cooperation at all, then move to VRA using toys as reinforcement. Some kids need two or three sessions before results are complete. If behavioral testing genuinely can't happen, ABR (done during natural sleep or under brief sedation) is the fallback for young or uncooperative toddlers.
Should I see an audiologist or an ENT?
Start with an audiologist for the hearing evaluation itself, since that's their specific training. ENTs are surgeons and physicians who treat the medical or structural causes behind hearing loss. If the audiologist finds something, they'll usually refer you to ENT for management, so you may end up seeing both, but the evaluation should start with audiology.
How do I find an audiologist who works with toddlers?
ASHA's Find a Professional tool at asha.org lets you search for pediatric audiologists, or you can contact your state's EHDI (Early Hearing Detection and Intervention) program, which keeps referral lists for families. Children's hospitals with audiology departments are another solid option. When you call, ask specifically for someone who does VRA or behavioral testing with toddlers.
My toddler has a speech delay and normal hearing. What comes next?
The next step is a full speech and language evaluation with a licensed speech-language pathologist, who will look at receptive and expressive language, articulation, and social communication. Depending on what they find, they might diagnose a language delay, developmental language disorder, childhood apraxia of speech, or note features consistent with autism. Early intervention or private speech therapy is typically recommended from there, and it's worth starting services rather than waiting on a full diagnosis first.
What's the difference between a speech delay and a language delay?
Speech delay is about producing sounds and words clearly, the motor side of talking. Language delay is about understanding or using language itself, things like vocabulary, grammar, and meaning. A child can have either on its own or both together, and hearing loss can cause or worsen either one. An SLP evaluation sorts out which is going on, and that distinction matters because the treatments differ.
Is there a free hearing test option if I don't have insurance?
Yes. Under IDEA Part C, any child under 3 with a suspected developmental delay is entitled to a free evaluation through the state early intervention system, audiological assessment included. State EHDI programs can also connect you to low-cost or subsidized services, and some children's hospitals offer sliding-scale fees. Your state's Part C coordinator, findable through the Center for Parent Information and Resources, is the place to start.
Can a child with hearing loss still develop normal speech?
Many children with hearing loss, sensorineural included, go on to develop clear speech and strong language once they have appropriate amplification (hearing aids or cochlear implants) and speech-language therapy. How well this goes depends a lot on the degree of loss, how early it was identified, the quality of intervention, and how involved the family is. Research published in Pediatrics found that children fitted with hearing technology before 6 months of age consistently had better language outcomes than those identified later.
Sources
- CDC, Early Hearing Detection and Intervention (EHDI) Program: About 2 to 3 per 1,000 children are born with detectable hearing loss; EHDI 1-3-6 benchmark for screening, diagnosis, and intervention enrollment
- American Academy of Pediatrics, Bright Futures Program: AAP calls hearing loss one of the most common conditions present at birth and routine screening essential; Bright Futures schedule includes hearing surveillance at well-child visits
- American Speech-Language-Hearing Association (ASHA), Hearing Loss in Children: ASHA recommends a full audiological evaluation for any child with suspected speech or language delay
- ASHA, Pediatric Hearing Loss Practice Portal: OAE tests cochlear function without behavioral response; ABR measures auditory brainstem electrical response and is highly accurate for young children
- HealthCare.gov, Preventive Care Benefits for Children: Under the ACA, hearing screening for children is a covered preventive service with no cost-sharing when provided at a well-child visit
- U.S. Department of Education, IDEA Center for Parent Information and Resources: IDEA Part C provides free evaluation and early intervention services for children under 3 with suspected developmental disability including hearing loss; Part B covers ages 3 and up through school districts
- CDC, Cytomegalovirus (CMV) and Hearing Loss: CMV is the leading nongenetic cause of childhood sensorineural hearing loss, and CMV-related hearing loss can progress after birth
- Rescorla, L. (2011). Late talkers: Do good predictors of outcome exist? Developmental Disabilities Research Reviews, 17(2), 141-150: Children identified as late talkers at 24 months had higher rates of language difficulty at school age even when they appeared to catch up in preschool
- U.S. Food and Drug Administration, Cochlear Implants: The FDA has approved cochlear implants for children as young as 9 months
- CDC, Milestone Tracker App: CDC offers a free Milestone Tracker app for parents to monitor and record developmental milestones
- ASHA, Find a Professional Directory: ASHA maintains a searchable directory of audiologists and speech-language pathologists for consumer referral
- ASHA, Late Language Emergence Practice Portal: Naturalistic language intervention techniques, including following the child's lead and narration, support early language development
- Yoshinaga-Itano, C. et al. (1998). Language of Early- and Later-Identified Children With Hearing Loss. Pediatrics, 102(5), 1161-1171: Children with hearing loss identified and enrolled in intervention before 6 months of age had significantly better language outcomes than those identified later, controlling for degree of loss