Background: Hearing impairment is a prevalent congenital anomaly, particularly in neonates in NICUs due to various risk factors. Early detection through screening programs is crucial for developmental outcomes. Methods: A prospective observational study was conducted at SDM College of Medical Sciences and Hospital, involving 425 neonates. Otoacoustic Emissions (OAE) testing was used for early detection and longitudinal outcome assessment. Results: Out of 425 neonates, 95.3% passed the initial OAE screening. However, 4.7% failed, necessitating further evaluation. Notable risk factors included neonatal jaundice and perinatal asphyxia, particularly impacting neonates with lower birth weights. Conclusion: The study underscores the importance of early and universal hearing screening in NICU settings, emphasizing the need for tailored protocols to address specific neonatal risks.