Most parents first notice that something is wrong when their child does not respond to sound, does not babble as expected, or is slow to speak. Often, by the time the problem is recognized, the child has already lost months, and sometimes years, of the listening experience that language development depends on. In Pakistan, this pattern is common, and it is largely preventable. The tools to identify hearing loss in the first days of life exist. The challenge is to put them into every hospital, connect every positive result to a diagnosis, and connect every diagnosis to treatment.

This article looks at why early hearing detection matters, what the evidence says about newborn screening in Pakistan, where the system is failing families, and what a workable national approach could look like. It is written for parents, clinicians, hospital managers, and policymakers, because the solution depends on all of them.

Why Hearing Matters So Early

Hearing is the foundation of spoken language. Babies learn to recognize their mother’s voice before birth and begin to discriminate between sounds within the first months of life. Through babbling, imitation, and conversation, they practise the sounds, rhythm, and meaning of the language around them. When a baby cannot hear speech clearly, this process is disrupted. The effect is not limited to speech. Language is the tool we use to think, to reason, to read, and to form relationships, so a delay in language can ripple into learning, behaviour, and social participation for years.

Hearing loss in children ranges from mild to profound, and it can be present at birth or develop later. Congenital hearing loss is among the more common birth conditions. Estimates of permanent sensorineural hearing loss in newborns are often placed at roughly one to three per 1,000 births, and the rate is higher among babies admitted to neonatal intensive care, those with a family history of hearing loss, and those exposed to certain infections or medications before or after birth. Many children with hearing loss also have no other obvious health problem, which is why screening, rather than waiting for symptoms, is so important.

The Global Picture

The World Health Organization’s first World Report on Hearing, published in 2021, estimated that more than 1.5 billion people worldwide live with some degree of hearing loss, and that around 430 million have hearing loss of moderate or greater severity in the better ear. The report also projected that by 2050 almost one in four people could be living with some degree of hearing loss. It emphasized that a large share of hearing loss, particularly in children, is due to causes that can be prevented or treated, and it called for early identification as a first step in any effective response.

The same report noted that most of the world’s people with disabling hearing loss live in low- and middle-income countries, where access to hearing care is often limited. Pakistan is one of those countries. Its health system faces many pressures at once, and hearing care is still too often treated as a specialist service that only reaches large urban centres. For children, this means that the gap between when hearing loss could be detected and when it actually is detected can be very wide.

Why Timing Is Everything

The brain’s auditory pathways are highly responsive in early life. Research over several decades has shown that children who receive appropriate amplification or intervention early tend to develop speech and language more closely in line with their hearing peers than children who are identified later. The benefit is greatest when the intervention begins in the first months of life, although the evidence also shows that older children still benefit from timely support. Waiting does not make a loss go away. It usually means the child has fewer opportunities to catch up.

International professional guidance reflects this understanding. The Joint Committee on Infant Hearing (JCIH), whose 2019 position statement is widely used as a reference, recommends a “1-3-6” model. Every baby should be screened for hearing by one month of age. Any baby who does not pass should have a diagnostic audiological evaluation by three months of age. If a hearing loss is confirmed, intervention, which may include hearing aids, cochlear implant assessment, and early language support, should begin by six months of age. The model is not a rigid rule for every case, but it sets a clear and ambitious target, and it treats the entire sequence, from screening to treatment, as one pathway rather than three separate events.

How Newborn Screening Works

Newborn hearing screening is quick, painless, and non-invasive. The two methods most commonly used are otoacoustic emissions (OAE) testing and automated auditory brainstem response (AABR) testing. OAE testing measures faint sounds produced by the inner ear in response to a click or tone played into the ear canal. A healthy cochlea normally produces these emissions, so their absence suggests a problem in the inner ear. AABR testing measures the electrical activity of the auditory nerve and brainstem in response to sound, and is often used when a baby does not pass the OAE screen or in babies at higher risk. Many programs use a two-stage approach, in which babies who do not pass the first screen are tested again, usually before they leave the hospital or within a few weeks.

It is important to understand what a screening result means. A pass indicates that the baby responded as expected on the day of testing, not that the child will never develop hearing loss. Some losses appear later, and some mild losses may be missed even when screening is performed. A refer result does not mean the baby has a hearing loss. Many babies who are referred turn out to have normal hearing, often because of fluid, debris, or the conditions of the test. However, every referred baby needs a timely diagnostic evaluation, because the only way to know is to test again. This is why the follow-up pathway is as important as the screening itself.

What the Evidence From Pakistan Shows

Pakistani researchers have been studying newborn hearing for more than a decade, and their work shows both that screening is feasible and that the system around it is not yet strong enough. A 2013 study conducted at Fatima Memorial Hospital in Shadman, Lahore, examined 100 high-risk neonates using two rounds of OAE testing, followed by brainstem evoked response audiometry and an ENT consultation for babies who were referred. The authors found that about 6 per cent of these high-risk babies had bilateral hearing impairment confirmed by diagnostic testing. They concluded that tertiary care hospitals should screen every newborn where possible, and at minimum screen high-risk infants.

A more recent prospective study conducted at Liaquat National Hospital in Karachi, published in the Journal of the Pakistan Medical Association in 2023, screened 267 newborns between November 2020 and April 2021 using OAE testing. Of these, 249 babies, or 93.3 per cent, passed the first screen. Of the 18 babies who did not pass, eight passed on the second screen. The remaining 10 were asked to return for follow-up after three weeks, and only three came back. In other words, seven of these 10 infants, or 70 per cent, did not attend the follow-up appointment that was needed to determine whether they had a hearing loss. The authors concluded that a comprehensive neonatal hearing screening programme is needed, and this finding is among the clearest warnings in the local literature: a screening test without a reliable follow-up system cannot protect children.

Evidence also comes from older children. A 2023 study published in the Eastern Mediterranean Health Journal, which examined the impact of hearing impairment on children and their parents in Pakistan, reported that a previously published study from one region of the country found a prevalence of 7.9 per cent in school children. The same paper noted that the absence of neonatal screening contributes to late identification of hearing impairment in developing countries, including Pakistan, and that financial constraints and limited reliable data hinder the development of neonatal screening. Its findings on social life are equally important. Among the parents surveyed, many reported that their children faced difficulties in joining community activities because of their hearing, and a significant share of families reported financial strain.

Parents’ understanding is another part of the picture. A cross-sectional study conducted in Rawalpindi and published in BMC Pediatrics in 2024 found that about two-thirds of the parents surveyed (67.3 per cent) demonstrated good knowledge of childhood hearing loss. However, the same study identified gaps in knowledge about preventable causes and about newborn screening itself. Parents in the study generally held positive attitudes towards children with hearing loss, which is encouraging, but good attitudes do not replace the practical information a family needs in order to act early.

Where the System Breaks Down

The obstacles to universal newborn screening in Pakistan are practical rather than mysterious. The first is equipment. OAE devices and AABR systems are not expensive compared with many other hospital technologies, but they must be purchased, calibrated, maintained, and replaced. In facilities without a dedicated budget for audiology, screening equipment can be unavailable or out of service for long periods. The second is trained personnel. Screening must be carried out by people who understand the protocol, know how to get reliable results from a noisy newborn, and can explain a refer result to a parent without causing unnecessary alarm. In many hospitals, these tasks are not formally assigned to anyone.

The third barrier is follow-up, and it is the one the Karachi study illustrates so clearly. A referral that is not booked, tracked, and reminded is a child who may slip out of the system. Families may live far from the diagnostic centre, may be unable to afford the travel or the consultation, may not understand why a second test is needed, or may simply assume that the baby is fine. Without a named person responsible for following the case, the referral often ends at the hospital exit.

The fourth barrier is what happens after diagnosis. Even when a hearing loss is confirmed, families may face long waits or high costs for hearing aids, cochlear implant assessment, speech and language therapy, or early education support. Hearing aids are not a single purchase in isolation. They must be fitted, verified, adjusted, and followed up over time, and the child needs support to use them effectively. Where these services are missing, the screening programme delivers information without delivering help.

Finally, there is the question of data. Without a national register of screened and referred babies, it is difficult to know how many children are being tested, how many are lost to follow-up, how many are diagnosed, and how many receive treatment. The lack of reliable epidemiological data is repeatedly cited in the Pakistani literature as a barrier. A programme that cannot measure itself cannot improve.

Warning Signs and Myths for Parents

Parents are not expected to diagnose hearing loss themselves, but they play an essential role in noticing when something may be wrong. Some signs deserve prompt attention at any age. A baby who does not startle or turn toward loud sounds, a toddler who does not respond to their name, a child who speaks very few words for their age, or a child who often asks people to repeat themselves, or who seems to watch faces closely rather than listen, should be assessed by a professional. A family history of childhood hearing loss, a stay in neonatal intensive care, or an infection during pregnancy are reasons to raise the question even if the child seems to be developing normally.

Several common beliefs can delay care. One is that a quiet baby is simply a calm baby. Another is that a child who is slow to talk will catch up on their own, or that boys always speak later than girls. A third is that a hearing test is only necessary if the child is already obviously deaf. In fact, mild or moderate hearing loss can significantly affect speech and learning, and it often goes unnoticed for years. If a concern is raised by a parent, teacher, or doctor, it is worth a proper hearing assessment, and the result, whatever it is, is far more useful than uncertainty.

A Practical Framework for Pakistan

Pakistan does not need to build a perfect programme overnight, but it does need a clear and sequenced direction. A workable national approach would combine universal screening with a reliable pathway from screening to treatment. The following elements would form the core of such a system.

• Screening at birth in every delivery unit. Hospitals, maternity units, and neonatal units should screen all newborns, beginning with tertiary and large district hospitals and extending to smaller facilities as capacity grows. High-risk babies should be prioritized where full coverage cannot yet be achieved.
• A referral tracking system. Every referred infant should have a booked diagnostic appointment before discharge or within a defined time, and a named person should be responsible for following up when the family does not attend. Simple tools, such as a referral register, mobile reminders, and home visits by community health workers, can make a large difference.
• Standardized protocols and training. Screening procedures, pass and refer criteria, and counselling messages should be consistent across facilities. Nurses, technicians, and paediatric staff should receive structured training, and audiologists should provide supervision and quality assurance.
• Clear pathways from diagnosis to intervention. Confirmed hearing losses should lead to a defined set of services, including amplification, cochlear implant assessment where indicated, early intervention, and educational support. Families should know who to contact and what to expect.
• Public awareness campaigns. Messages should explain what newborn screening is, why a pass does not rule out later problems, why a refer result requires a second test, and why concerns about speech or responsiveness deserve attention at any age. Health workers, religious leaders, and community organizations can help spread these messages.
• Financial protection. Screening itself should be free or low-cost for families, and diagnostic and intervention services should be affordable through public programmes, insurance, or targeted support, so that cost does not decide whether a child is treated.
• National data collection. A simple register of screened, referred, diagnosed, and treated children would allow policymakers to see where services are reaching families and where they are not, and would help measure progress against national and global targets.

Telehealth, district-level partnerships with tertiary centres, and the training of audiology technicians may help extend services to regions where specialists are scarce. These approaches should be supported by clear standards and supervision, so that expansion of access does not come at the expense of quality.

Shared Responsibility

No single group can deliver universal newborn hearing screening alone. Parents should ask whether their newborn has been screened, keep their appointments, and raise concerns about hearing or speech without waiting for them to resolve on their own. Obstetricians, midwives, and paediatricians should make screening a routine part of birth care and should explain results clearly. Audiologists should lead on testing, diagnosis, and rehabilitation, and should communicate with families in plain language. Hospital administrators should budget for equipment, staff, and follow-up, and provincial health departments should integrate screening into their maternal and child health plans. Regulators should set standards for hearing services and ensure that professional titles and claims are accurate. Policymakers should make newborn hearing screening a national priority, with defined targets, funding, and accountability for results.

Conclusion: A Child’s First Sounds Should Not Be Left to Chance

Newborn hearing screening is one of the most effective and evidence-based steps available for protecting children’s communication, learning, and social development. It is quick, low-risk, and inexpensive compared with the lifelong costs of unidentified hearing loss. Pakistan already has the researchers, the clinicians, and the evidence needed to act. What it needs is a system that makes sure every newborn is screened, every referral is followed through, and every confirmed loss leads to care.

Every child deserves the opportunity to hear the world, to learn to speak and read, to succeed in school, and to take a full part in family and community life. That opportunity begins with a simple test in the first days of life and a system that ensures the test is not the end of the story. The question is not whether we can afford to screen our newborns. It is whether we can afford not to.

The views expressed in this article are solely those of the author and do not necessarily reflect the views of The Opinion Desk.