Communication development in children who receive the cochlear implant younger than 12 months: risks versus benefits

Spoken language benefits of extending cochlear implant candidacy below 12 months of age

OBJECTIVE

To test the hypothesis that cochlear implantation surgery before 12 months of age yields better spoken language results than surgery between 12 and 18 months of age.

STUDY DESIGN

Language testing administered to children at 4.5 years of age (± 2 mo).

SETTING

Schools, speech-language therapy offices, and cochlear implant (CI) centers in the United States and Canada.

PARTICIPANTS

Sixty-nine children who received a cochlear implant between ages 6 and 18 months of age. All children were learning to communicate via listening and spoken language in English-speaking families.

MAIN OUTCOME MEASURE

Standard scores on receptive vocabulary, expressive, and receptive language (includes grammar).

RESULTS

Children with CI surgery at 6 to 11 months (n = 27) achieved higher scores on all measures as compared with those with surgery at 12 to 18 months (n = 42). Regression analysis revealed a linear relationship between age of implantation and language outcomes throughout the 6- to 18-month surgery-age range.

CONCLUSION

For children in intervention programs emphasizing listening and spoken language, cochlear implantation before 12 months of age seems to provide a significant advantage for spoken language achievement observed at 4.5 years of age.

Enduring advantages of early cochlear implantation for spoken language development

PURPOSE

In this article, the authors sought to determine whether the precise age of implantation (AOI) remains an important predictor of spoken language outcomes in later childhood for those who received a cochlear implant (CI) between 12 and 38 months of age. Relative advantages of receiving a bilateral CI after age 4.5 years, better pre-CI-aided hearing, and longer CI experience were also examined.

METHOD

Sixty children participated in a prospective longitudinal study of outcomes at 4.5 and 10.5 years of age. Twenty-nine children received a sequential second CI. Test scores were compared with normative samples of hearing age mates, and predictors of outcomes were identified.

RESULTS

Standard scores on language tests at 10.5 years of age remained significantly correlated with age of first cochlear implantation. Scores were not associated with receipt of a second, sequentially acquired CI. Significantly higher scores were achieved for vocabulary as compared with overall language, a finding not evident when the children were tested at younger ages.

CONCLUSION

Age-appropriate spoken language skills continued to be more likely with younger AOI, even after an average of 8.6 years of additional CI use. Receipt of a second implant between ages 4 and 10 years and longer duration of device use did not provide significant added benefit.

Developmental effects of family environment on outcomes in pediatric cochlear implant recipients

OBJECTIVE

To examine and compare the family environment of preschool- and school-age children with cochlear implants and assess its influence on children's executive function and spoken language skills.

STUDY DESIGN

Retrospective between-subjects design.

SETTING

Outpatient research laboratory.

PATIENTS

Prelingually deaf children with cochlear implants and no additional disabilities and their families.

INTERVENTION(S)

Cochlear implantation and speech-language therapy.

MAIN OUTCOME MEASURES

Parents completed the Family Environment Scale and the Behavior Rating Inventory of Executive Function (or the preschool version). Children were tested using the Peabody Picture Vocabulary Test-4 and either the Preschool Language Scales-4 or the Clinical Evaluation of Language Fundamentals-4.

RESULTS

The family environments of children with cochlear implants differed from normative data obtained from hearing children, but average scores were within 1 standard deviation of norms on all subscales. Families of school-age children reported higher levels of control than those of preschool-age children. Preschool-age children had fewer problems with emotional control when families reported higher levels of support and lower levels of conflict. School-age children had fewer problems with inhibition but more problems with shifting of attention when families reported lower levels of conflict. School-age children's receptive vocabularies were enhanced by families with lower levels of control and higher levels of organization.

CONCLUSION

Family environment and its relation to language skills and executive function development differed across the age groups in this sample of children with cochlear implants. Because family dynamics is one developmental/environmental factor that can be altered with therapy and education, the present results have important clinical implications for family-based interventions for deaf children with cochlear implants.

Performance of Indian Children with Cochlear Implant on PEACH Scale

This study compares the functional language performance of Tamil-speaking children (n = 30) who received a cochlear implant (CI) before 2 years of age (earlier implanted group: EIG) and between 3 and 4 years of age (later implanted group: LIG). Everyday functional language of children was evaluated by interviewing parents using the adapted Parents' Evaluation of Aural/Oral Performance of Children (PEACH) Questionnaire in Tamil language. On average, both groups of children had difficulties in everyday language functioning. However, functional results of EIG were better than those of LIG. In addition significant correlations were found between age at intervention and PEACH score. The evidence lends support to early intervention increasing the functional performance of the children fitted with CI. PEACH can be a clinically feasible evaluation tool to implement in practice for clinicians to obtain meaningful information regarding children's auditory performance in real life at childhood.

A case study assessing the auditory and speech development of four children implanted with cochlear implants by the chronological age of 12 months

Children with severe hearing loss most likely receive the greatest benefit from a cochlear implant (CI) when implanted at less than 2 years of age. Children with a hearing loss may also benefit greater from binaural sensory stimulation. Four children who received their first CI under 12 months of age were included in this study. Effects on auditory development were determined using the German LittlEARS Auditory Questionnaire, closed- and open-set monosyllabic word tests, aided free-field, the Mainzer and Göttinger speech discrimination tests, Monosyllabic-Trochee-Polysyllabic (MTP), and Listening Progress Profile (LiP). Speech production and grammar development were evaluated using a German language speech development test (SETK), reception of grammar test (TROG-D) and active vocabulary test (AWST-R). The data showed that children implanted under 12 months of age reached open-set monosyllabic word discrimination at an age of 24 months. LiP results improved over time, and children recognized 100% of words in the MTP test after 12 months. All children performed as well as or better than their hearing peers in speech production and grammar development. SETK showed that the speech development of these children was in general age appropriate. The data suggests that early hearing loss intervention benefits speech and language development and supports the trend towards early cochlear implantation. Furthermore, the data emphasizes the potential benefits associated with bilateral implantation.

Categories of auditory performance and speech intelligibility ratings of early-implanted children without speech training

OBJECTIVE

To assess whether speech therapy can lead to better results for early cochlear implantation (CI) children.

PATIENTS

A cohort of thirty-four congenitally profoundly deaf children who underwent CI before the age of 18 months at the Sixth Hospital affiliated with Shanghai Jiaotong University from January 2005 to July 2008 were included. Nineteen children received speech therapy in rehabilitation centers (ST), whereas the remaining fifteen cases did not (NST), but were exposed to the real world, as are normal hearing children.

METHODS

All children were assessed before surgery and at 6, 12, and 24 months after surgery with the Categories of Auditory Performance test (CAP) and the Speech Intelligibility Rating (SIR). Each assessment was given by the same therapist who was blind to the situation of the child at each observation interval. CAP and SIR scores of the groups were compared at each time point.

RESULTS

Our study showed that the auditory performance and speech intelligibility of trained children were almost the same as to those of untrained children with early implantation. The CAP and SIR scores of both groups increased with increased time of implant use during the follow-up period, and at each time point, the median scores of the two groups were about equal.

CONCLUSIONS

These results indicate that great communication benefits are achieved by early implantation (<18 months) without routine speech therapy. The results exemplify the importance of enhanced social environments provided by everyday life experience for human brain development and reassure parents considering cochlear implants where speech training is unavailable.

Auditory and oral language abilities in children with cochlear implants: a case study

The cochlear implant (CI) represents the most important advance in the treatment of individuals with severe to profound bilateral hearing loss who do not benefit from hearing aids. Children who receive the CI during the critical period of neuroplasticity of the auditory system, when combined with speech therapy, have the chance to develop the auditory and linguistic skills similarly to their normal hearing peers. Two cases of implanted children are presented in this study, and one of them was not enrolled in a formal aurioral therapeutic program since the implantation surgery. At the moment of language and auditory assessment, the children were 2 years and 5 months old, and the CI had been used for 11 months. According to the results presented, it was observed that the child enrolled in rehabilitation program had better auditory and language performance when compared to the other child. Despite the remarkable benefits that the CI provides to children with hearing impairment, the device itself only provides the child with the audibility of environmental sounds and speech signal. For the auditory and language development to happen, it is necessary, among other factors, a speech-language intervention, with partnership between professionals and parents.

Age or experience? The influence of age at implantation and social and linguistic environment on language development in children with cochlear implants

PURPOSE

The authors investigated the influence of social environmental variables and age at implantation on language development in children with cochlear implants.

METHOD

Participants were 25 children with cochlear implants and their parents. Age at implantation ranged from 6 months to 42 months ( M (age) = 20.4 months, SD = 22.0 months). Linguistic progress was assessed at 12, 18, 24, and 30 months after implantation. At each data point, language measures were based on parental questionnaire and 45-min spontaneous speech samples. Children's language and parents' child-directed language were analyzed.

RESULTS

On all language measures, children displayed considerable vocabulary and grammatical growth over time. Although there was no overall effect of age at implantation, younger and older children had different growth patterns. Children implanted by age 24 months made the most marked progress earlier on, whereas children implanted thereafter did so later on. Higher levels of maternal education were associated with faster linguistic progress; age at implantation was not. Properties of maternal language input, mean length of utterance, and expansions were associated with children's linguistic progress independently of age at implantation.

CONCLUSIONS

In children implanted within the sensitive period for language learning, children's home language environment contributes more crucially to their linguistic progress than does age at implantation.

The impact of blood loss during cochlear implantation in very young children

The aim of this study was to investigate if the intraoperative bleeding during cochlear implantation in very young children had any clinical importance and if it should influence the clinical management of such cases. A retrospective chart review of the pre- and postoperative hemoglobin concentration was performed on 14 implantations in children aged 16 months or younger at the time of surgery (11 males and 3 females). A postoperative decrease of the hemoglobin value was noted in 13 cases (93 %), with a mean difference between pre- and postoperative measurement of -1.9 g/dl. The most remarkable case was that of a 2-month-old newborn with a bilateral profound hearing loss caused by bacterial meningitis. In the course of the asynchronous bilateral cochlear implantation and due to a remarkable bleeding, a transfusion of packed red blood cells was performed. The increased loss of blood was reported at the time of detaching and lifting up the muscle-periosteal-flap from the mastoid bone as well as at the time of the mastoidectomy. The special physiological properties of this age can contribute to a rapid cardiovascular decompensation in the case of increased blood loss. The consideration of these aspects is of great importance in the stage of planning the cochlear implantation, which in this group of patients should include the requirement of banked human blood. In addition, the intraoperative bleeding should be taken into account during the decision for a simultaneous bilateral implantation.

Language and behavioral outcomes in children with developmental disabilities using cochlear implants

OBJECTIVE

Over the past decade, the number of deaf children with developmental disabilities receiving cochlear implants has increased dramatically. However, little is known about the developmental outcomes of these children post-implantation. The current study evaluated oral language and behavioral outcomes over 3 years after implantation in a sample of typically developing deaf children and children with developmental disabilities.

STUDY DESIGN

A three year longitudinal study of the effects of cochlear implantation on language and behavioral outcomes in children with and without additional disabilities.

SETTING

Six cochlear implant centers in the United States.

PATIENTS

The study cohort consisted of 188 deaf children. Eighty-five percent of the sample (n = 157) had a single diagnosis of severe to profound hearing loss and 15% (n = 31) had an additional disability.

MAIN OUTCOME MEASURES

Oral language was assessed using the Reynell Developmental Language Scales, and behavioral outcomes were assessed using the Child Behavior Checklist.

RESULTS

Results using multilevel modeling indicated that deaf children with and without additional disabilities improved significantly in oral language skills post-implantation. However, children with additional disabilities made slower progress. In terms of specific diagnoses, children with developmental disorders, such as autism, made the slowest progress over time. In addition, behavior problems increased significantly in this group, whereas behavior problems decreased over 3 years in the typically developing deaf sample.

CONCLUSION

Overall, given the improvements in expressive and receptive language skills documented over 3 years, these findings support the use of cochlear implants for deaf children with developmental disabilities.

Identification of effective strategies to promote language in deaf children with cochlear implants

Parental involvement and communication are essential for language development in young children. However, hearing parents of deaf children face challenges in providing language input to their children. This study utilized the largest national sample of deaf children receiving cochlear implants, with the aim of identifying effective facilitative language techniques. Ninety-three deaf children (≤ 2 years) were assessed at 6 implant centers prior to and for 3 years following implantation. All parent-child interactions were videotaped, transcribed, and coded at each assessment. Analyses using bivariate latent difference score modeling indicated that higher versus lower level strategies predicted growth in expressive language and word types predicted growth in receptive language over time. These effective, higher level strategies could be used in early intervention programs.

Validation of a new TEOAE-AABR device for newborn hearing screening

OBJECTIVE

Because newborn hearing screening (NHS) programs are currently implemented in an increasing number of countries, physiological NHS technologies have to be continuously optimized. This study validates a new TEOAE-AABR screening device.

DESIGN

TEOAE and AABR screenings were performed in 299 ears with both the new NHS device and a well-established and validated one. Furthermore, 49 ears, suspected of having a hearing loss, underwent the screenings and an additional diagnostic ABR.

STUDY SAMPLE

One hundred and fifty newborns and infants were included in the study (median age 1.0 months, range 0-54 months; among them 39 babies from neonatal intensive care units).

RESULTS

Screening with both devices resulted in a concordance of κ =.98 for TEAOE measurements and .96 for AABR measurements. The mean measurement durations were significantly shorter for the new device than for the established one for both TEOAE (15.4 vs. 17.2 s) and AABR (26.6 vs. 32.7 s).

CONCLUSIONS

The algorithm of the new screening device is as valid as that for the established one. The shorter test durations with the new device facilitate hearing screenings and allow for a higher number of valid measurements in restless children than with former comparable procedures.

The impact of early identification of permanent childhood hearing impairment on speech and language outcomes

It is well established that permanent childhood hearing impairment (PCHI) has a detrimental impact on speech and language development. The past two decades have seen the gradual introduction of universal newborn hearing screening (UNHS) programmes coupled with early intervention programmes. We review studies that have capitalised on the advent of newborn hearing screening to assess the impact of early identification of PCHI on language outcomes in deaf children. The research supports the conclusion that, in children with PCHI, newborn hearing screening and early identification lead to beneficial effects on language development, with the most consistent evidence provided for links between early identification of PCHI and positive language outcomes. Future research needs to encompass a wider range of outcomes and to assess the impact of UNHS in adolescents and young adults.

Targeted surveillance for postnatal hearing loss: a program evaluation

OBJECTIVE

The importance of monitoring hearing throughout early childhood cannot be understated. However, there is a lack of evidence available regarding the most effective method of monitoring hearing following the newborn screen. The goal of this study was to describe a targeted surveillance program using a risk factor registry to identify children with a postnatal hearing loss.

METHODS

All children who were born in Queensland, Australia between September 2004 and December 2009, received a bilateral 'pass' on newborn hearing screening, and had at least one risk factor, were referred for targeted surveillance and were included in this study. The cohort was assessed throughout early childhood in accordance with Queensland's diagnostic assessment protocols.

RESULTS

During the study period, 7320 (2.8% of 261,328) children were referred for targeted surveillance, of which 56 were identified with a postnatal hearing loss (0.77%). Of these, half (50.0%) were identified with a mild hearing loss, and 64.3% were identified with a sensorineural hearing loss. In regards to risk factors, syndrome, craniofacial anomalies, and severe asphyxia had the highest yield of positive cases of postnatal hearing loss for children referred for targeted surveillance, whereas, low birth weight, bacterial meningitis, and professional concern had a particularly low yield. Limitations of the targeted surveillance program were noted and include: (1) a lost contact rate of 32.4%; (2) delays in first surveillance assessment; (3) a large number of children who required on-going monitoring; and (4) extensive diagnostic assessments were completed on children with normal hearing. Examination of the lost contact rate revealed indigenous children were more likely to be documented as lost contact. In addition, children with one risk factor only were significantly more likely to not attend a surveillance appointment.

CONCLUSIONS

Positive cases of postnatal hearing loss were detected through the targeted surveillance program. However, the limitations of the program question the usefulness of this service delivery model. For targeted surveillance to continue, time frames for assessment, assessments performed, and discharge criteria need to be revisited. The contribution of individual and combined risk factors in detecting postnatal hearing loss should also be examined in more detail.

Early intervention and assessment of speech and language development in young children with cochlear implants

OBJECTIVE

Age is one of the most important determinants of the benefit achieved in the cochlear implantation of pre-lingually deafened children. Earlier age at implantation increases the exposure of children with a hearing impairment to auditory stimuli. Earlier auditory stimulation enables children to better understand spoken language and to use spoken language themselves. Furthermore, there appears to be critical period under 2 years of age during which access to spoken language is essential in order for language development to proceed appropriately. The present study aimed to assess the impact of cochlear implantation under 2 years of age on subsequent speech and language development.

METHODS

28 children implanted with a cochlear implant prior to 2 years of age were included in this study and the effects of age at implantation were determined using a reception of grammar test, active vocabulary test and speech development test. Demographic features were described using descriptive statistics and data were compared to the normative values (T-values) of their hearing peers by t-test or Mann-Whitney U-test.

RESULTS

The present data indicates that overall children with a hearing impairment implanted at less than 2 years of age perform as well as or better than their hearing peers in speech and grammar development. Word Comprehension was significantly greater in children with a cochlear implant compared to their normative peers (p=0.003), whereas Phonological Working Memory for Nonsense Words was poorer (p=0.031). An effect of age on grammatical and speech development could be found for younger implanted children (<12 months), who reached higher scores than children implanted after 12 months of age.

CONCLUSIONS

The data suggests that early hearing loss intervention via cochlear implantation in children benefits the speech and language development of children. A potential sensitive period exists for implantation before 12 months of age. These outcomes support the recent trend toward early cochlear implantation in pre-lingually deaf children.

Determining early speech development in children with cochlear implants using the ELFRA-2 parental questionnaire

OBJECTIVES

Increased early identification of hearing loss has led to infants younger than 24 months of age being implanted with cochlear implants. The objective of this study was to assess early speech development in children implanted with a cochlear implant before 24 months of age using the German questionnaire Elternfragebogen für Risikokinder 2 (ELFRA-2), and to compare these results to normative data of the ELFRA-2 in order to determine any performance differences.

METHODS

Two groups of children were included in this study. The first group included 6 children with a mean age at implantation of 11 months (range: 8-14 months). These children were tested by their parents or caretakers with the ELFRA-2 at the chronological age of 24 months. The second group included 9 children with a mean age at implantation of 13 months (range: 6-20 months) who were tested with the ELFRA-2 after 24 months of cochlear implant use.

RESULTS

Comparison analyses of children tested with the ELFRA-2 demonstrated a statistically significant difference in all ELFRA-2 scales between children with cochlear implants (CIs) at the chronological age of 24 months and the norm group (productive vocabulary: p=0.002; syntax: p=0.003; and morphology: p<0.001), and no significant difference between children with CIs at 24 months of device use and the norm group in all scales (productive vocabulary: p=0.335; syntax: p=0.965; and morphology: p=0.304).

CONCLUSION

Children implanted before 24 months of age reach a speech production level after 24 months of device use that is comparable to that of their normal hearing peers.

Word learning in deaf children with cochlear implants: effects of early auditory experience

Word-learning skills were tested in normal-hearing 12- to 40-month-olds and in deaf 22- to 40-month-olds 12 to 18 months after cochlear implantation. Using the Intermodal Preferential Looking Paradigm (IPLP), children were tested for their ability to learn two novel-word/novel-object pairings. Normal-hearing children demonstrated learning on this task at approximately 18 months of age and older. For deaf children, performance on this task was significantly correlated with early auditory experience: Children whose cochlear implants were switched on by 14 months of age or who had relatively more hearing before implantation demonstrated learning in this task, but later implanted profoundly deaf children did not. Performance on this task also correlated with later measures of vocabulary size. Taken together, these findings suggest that early auditory experience facilitates word learning and that the IPLP may be useful for identifying children who may be at high risk for poor vocabulary development.

Cochlear implant in the second year of life: lexical and grammatical outcomes

PURPOSE

The authors studied the effect of the cochlear implant (CI) on language comprehension and production in deaf children who had received a CI in the 2nd year of life.

METHOD

The authors evaluated lexical and morphosyntactic skills in comprehension and production in 17 Italian children who are deaf (M = 54 months of age) with a CI and in 2 control groups of children with normal hearing (NH; 1 matched for chronological age and the other whose chronological age corresponded to the duration of CI activation). The authors also compared children with unilateral CI to children with bilateral CI.

RESULTS

Children with CI appeared to keep pace with NH children matched for time since CI activation in terms of language acquisition, and they were similar to same-age NH children in lexical production. However, children with CI showed difficulties in lexical comprehension when a task required phonological discrimination as well as in grammar comprehension and production. Children with bilateral CI showed better comprehension than did children with unilateral CI; the 2 groups were similar for production.

CONCLUSIONS

Activation of CI in the 2nd year of life may provide children who are deaf with a good opportunity to develop language skills, although some limitations in phonological and morphological skills are still present 3 years after auditory reafferentation.

Cochlear implants in children younger than 6 months

OBJECTIVES

(1) To determine the long-term outcomes of cochlear implantation in children implanted younger than 6 months and (2) to evaluate auditory-based performance in very young children compared with older children, all with profound sensorineural bilateral hearing loss.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

Twelve subjects aged 2 to 6 months, 9 aged 7 to 12 months, 11 aged 13 to 18 months, and 13 aged 19 to 24 months, all with profound bilateral hearing loss, were fitted with cochlear implants and followed longitudinally for 4 years. Subjects were developmentally normal with no additional disabilities (visual, motor, or cognitive). Auditory-based communication outcomes included tests for speech perception, receptive language development, receptive vocabulary, and speech production.

RESULTS

Age at cochlear implantation was a significant factor in most outcome measures, contributing significantly to speech perception, speech production, and language outcomes. There were no major complications and no significantly higher rates of minor complications in the younger children.

CONCLUSION

This article reports an uncontrolled observational study on a small group of infants fitted with cochlear implants following personal audiological criteria and, up to now, with limited literature support due to the innovative nature of the study. This study shows, for the first time, significantly improved auditory-based outcomes in children implanted younger than 6 months and without an increased rate of complications. The data from the present study must be considered as explorative, and a more extensive study is required.

Pediatric cochlear implantation: candidacy evaluation, medical and surgical considerations, and expanding criteria

Since the first cochlear implant approved by the US Food and Drug Administration in the early 1980s, great advances have occurred in cochlear implant technology. With these advances, patient selection, preoperative evaluation, and rehabilitation consideration continue to evolve. This article describes the current practice in pediatric candidacy evaluation, reviews the medical and surgical considerations in pediatric cochlear implantation, and explores the expanding criteria for cochlear implantation within the pediatric population.

Outcomes in cochlear implantation: variables affecting performance in adults and children

This article highlights variables that affect cochlear implant performance, emerging factors warranting consideration, and variables shown not to affect performance. Research on the outcomes following cochlear implantation has identified a wide spectrum of variables known to affect pos0timplantation performance. These variables relate to the device itself as well as individual patient characteristics. Factors believed to affect spiral ganglion cell survival and function have been shown to influence postoperative performance. Binaural hearing affects performance. Social and educational factors also affect postoperative performance. Novel variables capable of affecting performance continue to emerge with increased understanding of auditory pathway development and neural plasticity.

Language development in Japanese children who receive cochlear implant and/or hearing aid

OBJECTIVES

This study aimed to investigate a wide variety of factors that influence auditory, speech, and language development following pediatric cochlear implantation (CI).

STUDY DESIGN

Prospective collection of language tested data in profound hearing-impaired children.

HYPOTHESIS

Pediatric CI can potentially be effective to development of practical communication skills and early implantation is more effective.

METHODS

We proposed a set of language tests (assessment package of the language development for Japanese hearing-impaired children; ALADJIN) consisting of communication skills testing (test for question-answer interaction development; TQAID), comprehensive (Peabody Picture Vocabulary Test-Revised; PVT-R and Standardized Comprehension Test for Abstract Words; SCTAW) and productive vocabulary (Word Fluency Test; WFT), and comprehensive and productive syntax (Syntactic processing Test for Aphasia; STA). Of 638 hearing-impaired children recruited for this study, 282 (44.2%) with >70 dB hearing impairment had undergone CI. After excluding children with low birth weight (<1800 g), those with >11 points on the Pervasive Developmental Disorder ASJ Rating Scale for the test of autistic tendency, and those <2 SD on Raven's Colored Progressive Matrices for the test of non-verbal intelligence, 190 children were subjected to this set of language tests.

RESULTS

Sixty children (31.6%) were unilateral CI-only users, 128 (67.4%) were CI-hearing aid (HA) users, and 2 (1.1%) were bilateral CI users. Hearing loss level of CI users was significantly (p<0.01) worse than that of HA-only users. However, the threshold level, maximum speech discrimination score, and speech intelligibility rating in CI users were significantly (p<0.01) better than those in HA-only users. The scores for PVT-R (p<0.01), SCTAW, and WFT in CI users were better than those in HA-only users. STA and TQAID scores in CI-HA users were significantly (p<0.05) better than those in unilateral CI-only users. The high correlation (r=0.52) has been found between the age of CI and maximum speech discrimination score. The scores of speech and language tests in the implanted children before 24 months of age have been better than those in the implanted children after 24 months of age.

CONCLUSIONS

We could indicate that CI was effective for language development in Japanese hearing-impaired children and early CI was more effective for productive vocabulary and syntax.

Instruments to assess the oral language of children fitted with a cochlear implant: a systematic review

The oral language development depends on the effective development of the hearing system. In cases of children presenting with hearing loss, a cochlear implant is an electronic device indicated to (re)habilitate the hearing function. Thus, it is of paramount importance to assess and follow the oral language development of children fitted with a cochlear implant (CI) to measure the effectiveness of the electronic device and support the therapeutic planning of these children. Questions are currently being raised about the instruments to assess the oral language of children using a CI, and, seeking the answers, this systematic review aimed at surveying these instruments. Searches were performed in three different databases utilizing six different descriptors to select articles published from 2004 to 2009 that performed an oral language assessment of children with a CI. Initially, 373 articles were found, and, after the application of inclusion criteria, 47 articles were analyzed, resulting in a survey of 74 instruments for oral language assessment, including tests, questionnaires and inventories. In analyzing the articles, it was realized that the studies included in this systematic review presented varied methodologies and low levels of evidence, with a greater concentration of instruments assessing receptive and expressive language, emphasizing the survey of the child's vocabulary and questionnaires. Thus, it can be verified that other linguistic skills, such as morphosyntactic, semantic, and narrative-pragmatic ones that are important in structuring speech and language for the effectiveness of the child's speech, are not being focused on. Just one of the instruments cited, a questionnaire, was specific for the oral language assessment of children with cochlear implants.

Cochlear implantation after bacterial meningitis in infants younger than 9 months

Objective. To describe the audiological, anesthesiological, and surgical key points of cochlear implantation after bacterial meningitis in very young infants. Material and Methods. Between 2005 and 2010, 4 patients received 7 cochlear implants before the age of 9 months (range 4-8 months) because of profound hearing loss after pneumococcal meningitis. Results. Full electrode insertions were achieved in all operated ears. The audiological and linguistic outcome varied considerably, with categories of auditory performance (CAP) scores between 3 and 6, and speech intelligibility rating (SIR) scores between 0 and 5. The audiological, anesthesiological, and surgical issues that apply in this patient group are discussed. Conclusion. Cochlear implantation in very young postmeningitic infants is challenging due to their young age, sequelae of meningitis, and the risk of cochlear obliteration. A swift diagnostic workup is essential, specific audiological, anesthesiological, and surgical considerations apply, and the outcome is variable even in successful implantations.

Soft tissue complications after pediatric cochlear implantation in children younger than 12 months

OBJECTIVES

Children are undergoing cochlear implantation younger than ever before. There has been some concern that young children may have an increased risk of soft tissue complications than older age groups. We aim to review the major and minor soft tissue complications after pediatric cochlear implantation in the age group of younger than 12 months.

STUDY DESIGN

Retrospective case review.

METHODS

Patients were identified from the cochlear implant program database of more than 1,000 children at the Hospital for Sick Children, Toronto, Canada. Demographic data, cause of hearing loss, and time of the onset of hearing loss were recorded.

RESULTS

A total of 66 patients were identified (94 implants) in the age group of younger than 12 months. Of these, there was 1 minor complication (implanted at 8 mo)-skin infection around implant 14 days later treated with antibiotics. There were no major complications.

CONCLUSION

Cochlear implantation in children younger than 12 months does not increase the risk of soft tissue complications.

Modifications of auditory brainstem responses (ABR): observations in full-term and pre-term newborns

OBJECTIVE

In this study, we have evaluated by means of auditory brainstem responses (ABR), in a population derived from a newborn hearing screening protocol, some aspects of maturation of the auditory pathways in the first months after birth, and the possible repercussions on early treatment.

MATERIALS AND METHODS

In this retrospective study newborns were recruited through our hearing screening program, and an ABR evaluation was performed on 339 newborns, that had risk factors or had failed the screening, or both. Such population was divided in two groups for statistical analysis purposes: full-term and pre-term. The initial ABR was pathological in 70 infants.

RESULTS

We observed an improvement over time of the estimated hearing threshold in follow-up ABRs in 43 newborns (26 in the full-term group, mean improvement 27.9 dB SPL, and 17 in the pre-term group, mean improvement 34.6 dB SPL); such an improvement might be related to a maturation of the auditory pathways that was not complete at birth.

CONCLUSIONS

The auditory system might not be completely developed at birth, and might require some months to complete; hence any early clinical approach should consider the possibility of an overtreatment, and any therapeutic strategy should only be considered once the diagnosis is certain and definitive.

Barriers to the early cochlear implantation of deaf children

OBJECTIVE

Identify social and health care system factors that prevent congenitally deaf children from receiving cochlear implants (CIs) in a timely fashion.

STUDY DESIGN

Retrospective chart review and parental interviews.

SETTING

University medical center hospital in a state with mandatory newborn hearing screening (NBHS).

PATIENTS

Fifty-nine congenitally deaf children who received CIs between January 1, 2002, and May 1, 2009.

INTERVENTIONS

Demographic and health care details were collected from the 59 patients.

MAIN OUTCOME MEASURE

Age at implantation.

RESULTS

Thirty-four patients received implants at or before age 2 years (average age at implant surgery, 14 mo), and 25 patients received implants after age 2 years (average age, 65 mo). The presence of NBHS (p<0.001) and type of health insurance (p=0.05) the child had at the time of CI surgery were significant predictors of age at implantation. The following factors were associated with increased risk of delayed implantation: no NBHS (risk ratio [RR]=2.63), NBHS not identifying hearing loss (RR=1.63), Medicaid insurance alone (RR=1.21) or in combination with private insurance (RR=1.79), family physician as primary care provider (RR=1.50), and audiologist (RR = 1.30) or otolaryngologist (RR=1.31) as secondary care providers (versus implant center, RR=0.23). The main reasons for delay in CI surgery after age 2 years also were identified and include slow referrals for care (n=8) and parental delays (n=5).

CONCLUSION

The data suggest placing special focus on children with associated risk factors, ensuring NBHS, and parent and primary care provider education on the importance of early intervention and referral to an implant center would likely limit delays in children receiving CIs.

New criteria of indication and selection of patients to cochlear implant

Numerous changes continue to occur in cochlear implant candidacy. In general, these have been accompanied by concomitant and satisfactory changes in surgical techniques. Together, this has advanced the utility and safety of cochlear implantation. Most devices are now approved for use in patients with severe to profound unilateral hearing loss rather then the prior requirement of a bilateral profound loss. Furthermore, studies have begun utilizing short electrode arrays for shallow insertion in patients with considerable low-frequency residual hearing. This technique will allow the recipient to continue to use acoustically amplified hearing for the low frequencies simultaneously with a cochlear implant for the high frequencies. The advances in design of, and indications for, cochlear implants have been matched by improvements in surgical techniques and decrease in complications. The resulting improvements in safety and efficacy have further encouraged the use of these devices. This paper will review the new concepts in the candidacy of cochlear implant. Medline data base was used to search articles dealing with the following topics: cochlear implant in younger children, cochlear implant and hearing preservation, cochlear implant for unilateral deafness and tinnitus, genetic hearing loss and cochlear implant, bilateral cochlear implant, neuropathy and cochlear implant and neural plasticity, and the selection of patients for cochlear implant.

Cochlear implants: current status and future potential

This article reviews the current status of cochlear implantation in both adults and children, including expanding candidacy groups, bilateral implantation, advances in speech processing software, internal and external device hardware, surgical techniques and outcomes. Promising advances, novel therapies and evolving concepts are also highlighted in terms of their future impact on clinical outcomes.

Exploring factors that affect the age of cochlear implantation in children

OBJECTIVE

Early access to sound through early cochlear implantation has been widely advocated for children who do not derive sufficient benefit from acoustic amplification. Early identification through newborn hearing screening should lead to earlier intervention including earlier cochlear implantation when appropriate. Despite earlier diagnosis and the trend towards early implantation, many children are still implanted well into their preschool years. The purpose of this study was to examine the factors that affected late cochlear implantation in children with early onset permanent sensorineural hearing loss.

METHODS

Data were examined for 43 children with cochlear implants who were part of a group of 71 children with hearing loss enrolled in a Canadian outcomes study. Eighteen (41.9%) of the 43 children were identified through newborn screening and 25 (58.1%) through medical referral to audiology. Medical chart data were examined to determine age of hearing loss diagnosis, age at cochlear implant candidacy, and age at cochlear implantation. Detailed reviews were conducted to identify the factors that resulted in implantation more than 12 months after hearing loss confirmation.

RESULTS

The median age of diagnosis of hearing loss for all 43 children was 9.0 (IQR: 5.1, 15.8) months and a median of 9.1 (IQR: 5.6, 26.8) months elapsed between diagnosis and unilateral cochlear implantation. The median age at identification for the screened groups was 3.3 months (IQR: 1.4, 7.1) but age at implantation (median 15.8 months: IQR: 5.6, 37.1) was highly variable. Eighteen of 43 children (41.9%) received a cochlear implant more than 12 months after initial hearing loss diagnosis. For many children, diagnosis of hearing loss was not equivalent to the determination of cochlear implant candidacy. Detailed reviews of audiologic profiles and study data indicated that late implantation could be accounted for primarily by progressive hearing loss (11 children), complex medical conditions (4 children) and other miscellaneous factors (3 children).

CONCLUSIONS

This study suggests that a substantial number of children will continue to receive cochlear implants well beyond their first birthday primarily due to progressive hearing loss. In addition, other medical conditions may contribute to delayed decisions in pediatric cochlear implantation.

Peer interactions of preschool children with and without hearing loss

PURPOSE

Little is known about the social interaction skills of children with severe to profound hearing loss (SPHL) in terms of how they manage conversational exchanges with peers. This study compared the initiation and response skills of children with SPHL with those of children with typical hearing during group play in integrated preschool programs.

METHOD

Two groups of 12 children were matched on a number of variables and assessed for intelligence, language, speech, and social development. All initiations, responses, and resulting interactions during 20 min of group play were transcribed and coded. Outcome measures included number and type of initiation strategies, number of responses, and length of interactions.

RESULTS

Despite poorer speech, language, and social development, there were no significant differences in initiation and response skills measured between children with SPHL and their matched peers. The small sample size may have made differences difficult to detect; however, playmates initiated interactions less often with the children with SPHL and ignored their initiations more often than those of other children.

CONCLUSIONS

Preschool children with SPHL were excluded from interactions by their playmates. Having age-appropriate language skills did not ensure successful peer interactions. Inclusive preschool programs may consider offering classroom-wide social skills training to enhance interaction opportunities.

Pediatric cochlear implantation

PURPOSE OF REVIEW

To summarize the current state of cochlear implantation in children.

RECENT FINDINGS

Hearing loss profoundly impacts a child's ability to communicate and thereby affects educational and psychosocial development. The auditory cortex has sensitive periods during which it is maximally receptive to sound stimulus and consequent development. For this reason, there is impetus to implant children at a very young age, as a cochlear implant can provide auditory input during this critical window. Long-term follow-up of implanted children has shown that cochlear implants are able to provide substantial language, academic, and social benefit. The criteria for cochlear implantation have broadened, and promising outcomes are being seen in populations that were not previously considered for implantation. The best language acquisition outcomes are seen in recipients who were implanted at a younger age and are in an environment rich in oral communication. Bilateral implantation offers some acoustic advantages.

SUMMARY

Cochlear implants provide sound perception to deaf children and can mitigate, to varying extents, the effects of sound deprivation on auditory development. On the basis of our understanding of brain development and language outcomes, a wider population of children are now candidates for implantation than previously considered.

Brain-derived neurotrophic factor promotes cochlear spiral ganglion cell survival and function in deafened, developing cats

Postnatal development and survival of spiral ganglion (SG) neurons depend on both neural activity and neurotrophic support. Our previous studies showed that electrical stimulation from a cochlear implant only partially prevents SG degeneration after early deafness. Thus, neurotrophic agents that might be combined with an implant to improve neural survival are of interest. Recent studies reporting that brain-derived neurotrophic factor (BDNF) promotes SG survival after deafness have been conducted in rodents and limited to relatively short durations. Our study examined longer duration BDNF treatment in deafened cats that may better model the slow progression of SG degeneration in human cochleae, and this is the first study of BDNF in the developing auditory system. Kittens were deafened neonatally, implanted at 4-5 weeks with intracochlear electrodes containing a drug-delivery cannula, and BDNF or artificial perilymph was infused for 10 weeks from a miniosmotic pump. In BDNF-treated cochleae, SG cells grew to normal size and were significantly larger than cells on the contralateral side. However, their morphology was not completely normal, and many neurons lacked or had thinned perikaryl myelin. Unbiased stereology was employed to estimate SG cell density, independent of cell size. BDNF was effective in promoting significantly improved survival of SG neurons in these developing animals. BDNF treatment also resulted in higher density and larger size of myelinated radial nerve fibers, sprouting of fibers into the scala tympani, and improvement of electrically evoked auditory brainstem response thresholds. BDNF may have potential therapeutic value in the developing auditory system, but many serious obstacles currently preclude clinical application.

Infants versus older children fitted with cochlear implants: performance over 10 years

OBJECTIVES

To investigate the efficacy of cochlear implants (CIs) in infants versus children operated at later age in term of spoken language skills and cognitive performances.

METHOD

The present prospective cohort study focuses on 19 children fitted with CIs between 2 and 11 months (X=6.4 months; SD=2.8 months). The results were compared with two groups of children implanted at 12-23 and 24-35 months. Auditory abilities were evaluated up to 10 years of CI use with: Category of Auditory Performance (CAP); Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS); Peabody Picture Vocabulary Test (PPVT-R); Test of Reception of Grammar (TROG) and Speech Intelligibility Rating (SIR). Cognitive evaluation was performed using selected subclasses from the Griffiths Mental Development Scale (GMDS, 0-8 years of age) and Leiter International Performance Scale-Revised (LIPS-R, 8-13 years of age).

RESULTS

The infant group showed significantly better results at the CAP than the older children from 12 months to 36 months after surgery (p<.05). Infants PPVT-R outcomes did not differ significantly from normal hearing children, whereas the older age groups never reached the values of normal hearing peers even after 10 years of CI use. TROG outcomes showed that infants developed significantly better grammar skills at 5 and 10 years of follow up (p<.001). Scores for the more complex subtests of the GMDS and LIPS-R were significantly higher in youngest age group (p<.05).

CONCLUSION

This study demonstrates improved auditory, speech language and cognitive performances in children implanted below 12 months of age compared to children implanted later.

Speech perception in congenitally deaf children receiving cochlear implants in the first year of life

OBJECTIVE

To investigate whether children implanted in the first year of life show higher levels of speech perception than later-implanted children, when compared at the same ages and to investigate the time course of sensitive periods for developing speech perception skills. More specifically, to determine whether faster gains in speech perception are made by children implanted before 1 year old relative to those implanted at 2 or 3 years.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic referral center.

PATIENTS

117 children with congenital profound bilateral sensorineural hearing loss, with no additional identified disabilities.

INTERVENTION

Cochlear implantation in the first, second, or third year of life.

MAIN OUTCOME MEASURE

Development curves showing Lexical Neighborhood Test (LNT) word identification scores as a function of age.

RESULTS

Children implanted within the first year of life have a mean advantage of 8.2% LNT-easy word scores over those implanted in the second year (p < 0.001) and a 16.8% advantage in LNT-easy word scores over those implanted in the third year of life (p < 0.001). These advantages remained statistically significant after accounting for sex, residual hearing, and bilateral cochlear implant use. When speech perception scores were expressed as a function of "hearing age" rather than chronological age, however, there were no significant differences among the 3 groups.

CONCLUSION

There is a clear speech perception advantage for earlier-implanted children over later-implanted children when compared at the same age but not when compared at the same time after implantation. Thus, the sensitive period for developing word identification seems to extend at least until age 3 years.

Prevention and treatment of meningitis and acute otitis media in children with cochlear implants

OBJECTIVE

To provide recommendations for 1) prevention of acute otitis media and meningitis via immunization and 2) antimicrobial therapy of acute otitis media and meningitis in children with cochlear implants.

DATA SOURCES

Literature review and policy statement from the American Academy of Pediatrics.

CONCLUSION

1) Children who are candidates for cochlear implants or have received cochlear implants should receive all-age appropriate vaccinations, including indicated doses of 13-valent pneumococcal conjugate vaccine, Haemophilus influenzae type b conjugate vaccine, and influenza vaccine. A supplemental dose of 13-valent pneumococcal conjugate vaccine is indicated for children who have received indicated doses of 7-valent pneumococcal vaccine, but have not received 13-valent pneumococcal conjugate vaccine. In addition, children 24 months and older should receive a single dose of 23-valent pneumococcal polysaccharide vaccine. 2) Acute otitis media in children with cochlear implants should be treated with an antimicrobial. During the first 2 months after implant, initial treatment of acute otitis media with a parenteral antimicrobial, e.g., cetriaxone, is indicated. High-dose amoxicillin or amoxicillin-clavulanate is an appropriate antimicrobial choice for empiric treatment of acute otitis media occurring 2 or more months after implant. In cases of meningitis occurring during the first 2 months after implantation, broad spectrum empiric antimicrobial therapy, e.g., meropenem and vancomycin, should be initiated pending the results of CSF culture. Empiric antimicrobial therapy with ceftriaxone and vancomycin is appropriate for cases of meningitis occurring 2 or more months after implant.

Effects of early auditory experience on word learning and speech perception in deaf children with cochlear implants: implications for sensitive periods of language development

HYPOTHESIS

That early word learning and speech perception skills have different sensitive periods and that very early implantation may affect later vocabulary outcomes more than speech perception outcomes.

BACKGROUND

Several studies have found that deaf children who receive cochlear implants before 3 years of age tend to have better speech perception outcomes than children implanted later. Recent studies have not found age-at-implantation effects on speech perception or central auditory processing among children implanted younger than 2 years, suggesting that there may be a sensitive period for speech perception skills that closes by around 3 years of age. There has been very little work investigating possible sensitive periods for other language skills, such as the ability to learn words. Recent work suggests the possibility that the development of word-learning skills may have an earlier sensitive period than the development of speech perception skills.

METHODS

Assess speech perception and vocabulary outcomes in children implanted before 13 months of age and in children implanted between 16 and 23 months of age.

RESULTS

Children implanted during the first year of life had better vocabulary outcomes than children implanted during the second year of life. However, earlier implanted children did not show better speech perception outcomes than later implanted children.

CONCLUSION

There may be an earlier sensitive period for developing the ability to associate the sound patterns of words to their referents than for developing speech perception and central auditory processing skills.

Interdisciplinary approach to design, performance, and quality management in a multicenter newborn hearing screening project. Discussion of the results of newborn hearing screening in Hamburg (part II)

Previously presented results of the newborn hearing screening in Hamburg and the perspectives are subsequently discussed. Minimum standards referring a participation of 95% of the neonates and a fail rate of less than 4% hearing-impaired children at the primary screening are fulfilled in Hamburg. Systematic screening of newborn hearing by an interdisciplinary approach provides early identification and intervention for children with permanent unilateral and bilateral hearing loss. But a newborn hearing screening on a voluntary basis alone cannot be maintained in the long run. Further, an anonymous data collection is not sufficient in regard to an uninterrupted tracking of conspicuous and unscreened neonates. A lost-to-follow-up rate of 31.3% at primary screening in Hamburg is much too high and emphasizes the need for a public health approach to a population-based newborn hearing screening with an elaborate and name-based tracking system. The legislation and implementation of a nationwide newborn hearing screening program in Germany and the association of German newborn hearing screening centers are highlighting long efforts of hearing professionals. But the implementation of a newborn hearing screening only makes sense if there exists an efficient tracking system. Sad to say, we are still a long way from the implementation of such a tracking system.

Language development in children after receiving bilateral cochlear implants between 5 and 18 months

OBJECTIVE

The objective of this study was to examine receptive and expressive language development in children who received simultaneous bilateral cochlear implants (CIs) between 5 and 18 months of age and to compare the results with language development in chronologically age-matched children with normal hearing.

METHODS

The study used a prospective, longitudinal matched-group design. Data were collected in a clinical setting at postoperative cochlear implant check-ups after 3, 6, 9, 12, 18, 24, 36, and 48 months of implant use. The sample included 42 children: 21 cochlear implant users and 21 with normal hearing, matched pairwise according to gender and chronological age. Communication assessments included the LittlEARS questionnaire, the Mullen Scale of Early Learning, and the Minnesota Child Development Inventory.

RESULTS

The cochlear implant users' hearing function according to LittlEARS was comparable to that of normal-hearing children within 9 months post-implantation. The mean scores after 9 and 12 months were 31 and 33, respectively in the prelingually deaf versus 31 and 34 in the normal-hearing children. The children's receptive and expressive language scores showed that after 12-48 months with cochlear implants, 81% had receptive language skills within the normative range and 57% had expressive language skills within the normative range. The number of children who scored within the normal range increased with increasing CI experience.

CONCLUSIONS

The present study showed that prelingually deaf children's ability to develop complex expressive and receptive spoken language after early bilateral implantation appears promising. The majority of the children developed language skills at a faster pace than their hearing ages would suggest and over time achieved expressive and receptive language skills within the normative range.

Evaluation of auditory development in infants and toddlers who received cochlear implants under the age of 24 months with the LittlEARS) Auditory Questionnaire

BACKGROUND AND AIMS

Newborn hearing screening and early intervention for congenital hearing loss have created a need for tools assessing the hearing development of very young children. A multidisciplinary evaluation of children's development is now becoming standard in clinical practice, though not many reliable diagnostic instruments exist. For this reason, the LittlEARS Auditory Questionnaire (LEAQ) was created to assess the auditory skills of a growing population of infants and toddlers who receive hearing instruments. The LEAQ relies on parent report, which has been shown to be a reliable way of assessing child development. Results with this tool in a group of children who received very early cochlear implantation are presented.

METHODS

The LEAQ is the first module of the LittlEARS comprehensive test battery for children under the age of two who have normal hearing (NH), cochlear implants (CIs) or hearing aids (HAs). The LEAQ is a parent questionnaire comprised of 35 "yes/no" questions which can be completed by parents in less than 10 min. Sixty-three children who received unilateral CIs at a young age were assessed longitudinally and their performance was compared to that of a NH group.

RESULTS

All CI children reached the maximum possible score on the LEAQ on average by 22 months of hearing age, i.e. 38 months of chronological age. In comparison, the NH group reached the maximum score by 24 months of age demonstrating that auditory skills of CI children often develop quicker than those of NH children. In the two comparison groups of children aged (a) younger and older than 12 months, and (b) between 6-9 and 21-24 months at first fitting, the early implanted children reached the highest scores faster than the later implanted children. Furthermore, three children with additional needs were tested. They showed slower growth over time but also received benefits from early implantation.

CONCLUSIONS

The LEAQ is a quick and effective tool for assessing auditory skills of very young children with or without hearing loss. In our study, the auditory skills of children with CI progressed very quickly after implantation and were comparable with those of NH peers.

Cochlear implantation in the very young child: issues unique to the under-1 population

Since the advent of cochlear implantation, candidacy criteria have slowly broadened to include increasingly younger patients. Spurred by evidence demonstrating both perioperative safety and significantly increased speech and language benefit with early auditory intervention, children younger than 12 months of age are now being successfully implanted at many centers. This review highlights the unique challenges involved in cochlear implantation in the very young child, specifically diagnosis and certainty of testing, anesthetic risk, surgical technique, intraoperative testing and postoperative programming, long-term safety, development of receptive and expressive language, and outcomes of speech perception. Overall, the current body of literature indicates that cochlear implantation prior to 1 year of age is both safe and efficacious.

Cochlear implants in children: surgical site infections and prevention and treatment of acute otitis media and meningitis

The use of cochlear implants is increasingly common, particularly in children younger than 3 years. Bacterial meningitis, often with associated acute otitis media, is more common in children with cochlear implants than in groups of control children. Children with profound deafness who are candidates for cochlear implants should receive all age-appropriate doses of pneumococcal conjugate and Haemophilus influenzae type b conjugate vaccines and appropriate annual immunization against influenza. In addition, starting at 24 months of age, a single dose of 23-valent pneumococcal polysaccharide vaccine should be administered. Before implant surgery, primary care providers and cochlear implant teams should ensure that immunizations are up-to-date, preferably with completion of indicated vaccines at least 2 weeks before implant surgery. Imaging of the temporal bone/inner ear should be performed before cochlear implantation in all children with congenital deafness and all patients with profound hearing impairment and a history of bacterial meningitis to identify those with inner-ear malformations/cerebrospinal fluid fistulas or ossification of the cochlea. During the initial months after cochlear implantation, the risk of complications of acute otitis media may be higher than during subsequent time periods. Therefore, it is recommended that acute otitis media diagnosed during the first 2 months after implantation be initially treated with a parenteral antibiotic (eg, ceftriaxone or cefotaxime). Episodes occurring 2 months or longer after implantation can be treated with a trial of an oral antimicrobial agent (eg, amoxicillin or amoxicillin/clavulanate at a dose of approximately 90 mg/kg per day of amoxicillin component), provided the child does not appear toxic and the implant does not have a spacer/positioner, a wedge that rests in the cochlea next to the electrodes present in certain implant models available between 1999 and 2002. "Watchful waiting" without antimicrobial therapy is inappropriate for children with implants with acute otitis media. If feasible, tympanocentesis should be performed for acute otitis media, and the material should be sent for culture, but performance of this procedure should not result in an undue delay in initiating antimicrobial therapy. For patients with suspected meningitis, cerebrospinal fluid as well as middle-ear fluid, if present, should be sent for culture. Empiric antimicrobial therapy for meningitis occurring within 2 months of implantation should include an agent with broad activity against Gram-negative bacilli (eg, meropenem) plus vancomycin. For meningitis occurring 2 months or longer after implantation, standard empiric antimicrobial therapy for meningitis (eg, ceftriaxone plus vancomycin) is indicated. For patients with meningitis, urgent evaluation by an otolaryngologist is indicated for consideration of imaging and surgical exploration.