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Objectives To identify risk factors associated with hearing loss in low-birth-weight neonates admitted to the National Neonatology Unit of Hospital Roosevelt, Guatemala.Methods An analytical cross-sectional case-control study was conducted. Cases included 63 low-birth-weight neonates (1.5–2.4 kg) who did not pass neonatal hearing screening with otoacoustic emissions in two consecutive evaluations. Controls were 63 low-birth-weight neonates who passed the screening. The study was carried out between January 2022 and December 2023. Clinical and perinatal data were collected from medical records and analyzed using Microsoft Excel and Epi Info.Results Among cases, 60.3% were male. Most were late preterm (73%) and 93.6% had low birth weight. The most frequent clinical conditions were prematurity (25.4%), perinatal asphyxia (15.9%), neonatal respiratory distress syndrome type I (15.9%), neonatal pneumonia (14.3%), and neonatal jaundice (11.1%). No statistically significant associations were identified (p>0.05). However, clinically relevant trends were observed with Apgar score <4 (OR = 1.71), aminoglycoside exposure (OR = 1.56), and neonatal jaundice (OR = 1.28).Conclusions These findings highlight the importance of systematic neonatal hearing screening programs and early follow-up in vulnerable neonatal populations, as they enable timely detection and intervention to improve long-term outcomes.