The Newborn Hearing Screening Programme is one of the highest-impact public health programmes the NHS runs. Before its rollout in 2005, most children with permanent hearing impairment were not picked up until age 2 or 3 — by which time spoken language was already lagging behind. Now most are identified within the first weeks of life, when intervention can keep language development on track.
The test is quick, painless, runs while the baby is sleepy, and gives a result there and then. A 'refer' is not a verdict — it just means the response wasn't clear enough on this attempt and the baby needs another look.
Healthbooq keeps records of all the routine newborn checks in one place.
What the Test Is Actually Doing
Two automated technologies are used.
AOAE (Automated Otoacoustic Emissions) — the first test for most well term babies. A small soft-tipped probe is placed gently in the ear canal and plays a series of clicks. A healthy cochlea responds by sending tiny echoes back out — the otoacoustic emissions. The probe records them. Each ear takes a minute or two; the baby just needs to be reasonably quiet.
If AOAE doesn't give a clear response after two attempts, the baby moves to the second test.
AABR (Automated Auditory Brainstem Response) — small adhesive electrodes go on the forehead, shoulder, and behind one ear. Sounds are delivered through small earphones, and the electrodes pick up the electrical response from the auditory nerve and brainstem. This tests the whole hearing pathway, not just the cochlea.
AABR is used:
- As the second test after AOAE refers
- As the first test for any baby who has spent over 48 hours in NICU. NICU babies have a higher rate of auditory neuropathy spectrum disorder, where the cochlea works but the auditory nerve doesn't transmit signals properly. AOAE alone would miss this.
Neither test is painful or invasive. Both can be done on a sleeping baby.
What 'Clear' Means and What 'Refer' Means
Clear (also called 'pass'): the response was detected normally. The baby's hearing is normal at this point, in this frequency range, on this day. It does not rule out:- Hearing loss that develops later (around half of childhood hearing loss is acquired or progressive)
- Mild hearing loss
- Auditory neuropathy not picked up by AOAE alone
- Hearing loss in a frequency range outside what was tested
If you ever feel your baby isn't responding to sounds normally — not startling at loud noises, not turning to your voice by 4 months, not babbling by 9 months, language behind by 18 months — bring it up regardless of the screen result. The screen is a snapshot.
Refer: the test could not detect a clear response. About 1 in 30 babies refer on the first round. The most common reasons are not hearing loss:
- Vernix or amniotic fluid still in the ear canal — usually clears within days
- The baby was unsettled, crying, or moving
- Background noise during the test
- Middle ear fluid (very common in the first days)
- Equipment contact issue
Most referred babies are followed up and confirmed to have normal hearing.
What Happens After a Refer
The next step depends on which test was used and where the screen was done.
If AOAE alone refers, the baby has AABR before leaving hospital or at a community follow-up appointment within 1–2 weeks. If AABR also refers, the baby is referred for a full audiological assessment at the local audiology department, ideally completed by 4 weeks of age and certainly by 3 months.
The diagnostic assessment uses:
- ABR (auditory brainstem response) — the same principle as AABR but tested across multiple frequencies and intensities, giving a hearing threshold per ear
- Tympanometry — measures middle ear function and helps distinguish conductive (middle ear) from sensorineural (cochlea/nerve) hearing loss
- OAE testing — confirms cochlear function
- Visual reinforcement audiometry — used in older infants
If permanent hearing impairment is confirmed, a multidisciplinary pathway begins promptly: paediatric audiologist, paediatrician, teacher of the deaf, speech and language therapist. Hearing aids can be fitted from around 4 weeks of age. Cochlear implant assessment for severe-to-profound sensorineural loss usually begins by 6 months, with surgery around 9–12 months.
The 1-3-6 framework — identified by 1 month, diagnosed by 3 months, intervention by 6 months — is the international standard, and the UK programme is built around it.
Permanent Childhood Hearing Impairment in Numbers
- 1–2 per 1,000 newborns have permanent bilateral hearing loss
- About half is congenital (present at or near birth); the other half is acquired or progressive in childhood
- ~840 babies a year in England identified through NHSP
Common causes of congenital hearing loss:
- Genetic — about half of congenital cases. GJB2 mutations affecting connexin 26 are the single most common cause; usually autosomal recessive. Other syndromic and non-syndromic genetic causes exist.
- Congenital cytomegalovirus (cCMV). The single most common non-genetic cause of congenital hearing loss. cCMV is caught in pregnancy, usually asymptomatic. Targeted antiviral treatment if diagnosed in the first weeks can reduce the risk of progressive loss.
- Prematurity — babies born under 32 weeks are at higher risk; routine AABR for NICU graduates targets this.
- Hyperbilirubinaemia at levels needing exchange transfusion.
- Bacterial meningitis — postnatal cause, accounts for some childhood-onset loss.
- Intrauterine infection — toxoplasmosis, rubella, syphilis (rare with modern antenatal screening).
- Family history.
What Parents Can Do
Take the screen. It happens in 5 minutes, and it is the most cost-effective hearing intervention in childhood.
If a refer comes back, do not panic — but do not ignore it either. The diagnostic appointment matters and should be kept. Most referred babies turn out to be fine. The ones who don't, do dramatically better with early intervention.
Watch your baby's responses to sound across the first year, even if the screen was clear:
- Newborn: should startle at sudden loud sounds, quieten to familiar voices
- 3–4 months: turns head towards sounds, recognises parents' voices
- 6 months: babbles using a range of sounds, responds to their name
- 9 months: distinguishes parents from strangers by voice, turns towards sounds in another room
- 12 months: responds to simple instructions, babbles with intonation
- 18 months: a few clear words
Concerns at any stage are worth raising with the GP or health visitor. Glue ear is very common (peaks at 2–5 years) and causes fluctuating conductive loss that can be confused with developmental delay.
Key Takeaways
Every baby in the UK gets a hearing screen, usually before they leave the maternity unit. Two technologies are used. AOAE (a soft probe in the ear) is the first-line test for healthy term babies and takes a few minutes. AABR (small electrodes on the head) is used for NICU graduates and as a follow-up if AOAE doesn't give a clear response. A 'refer' result is not a diagnosis — most referred babies turn out to have normal hearing once fluid clears or background noise is reduced. Around 1–2 in 1,000 babies have permanent hearing loss; identifying it before 3 months and starting hearing aids by 6 months changes language outcomes substantially.
