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

Cochlear Implant Infections

Cochlear implants (CIs) are associated with a range of infections. These infections present unique considerations because of their position relative to the respiratory tract and the central nervous system, as well as the propensity for biofilms to form on CIs. This article reviews infections related to CIs, including otitis media, mastoiditis, meningitis, and deep CI infection. High-quality evidence on the prevention and management of CI infections is lacking; however, best practices regarding prevention and management are provided.

Mandarin-speaking Children With Cochlear Implants Face Challenges in Using F0 Expansion to Express Contrastive Focus

OBJECTIVES

Children with cochlear implants (CIs) face challenges in perceiving fundamental frequency (F0) information because CIs do not transmit F0 effectively. In Mandarin, F0 can contrast meanings at the word level, that is, via lexical tones with distinct F0 contours, and signal contrastive relations between words at the utterance-level, that is, via contrastive focus with expanded F0 range and longer duration. Mandarin-speaking children with CIs have been reported to face challenges in producing distinct F0 contours across tones, but early implantation facilitates tonal acquisition. However, it is still unclear if utterance-level prosody, such as contrastive focus, is also challenging for these children, and if early implantation also offers benefits for focus production. Therefore, this study asked how accurately children with CIs can produce contrastive focus, and if early implantation leads to more accurate focus production, with acoustic patterns approaching that of children with typical hearing (TH).

DESIGN

Participants included 55 Mandarin-speaking children (3 to 7 years) with CIs and 55 age-matched children with TH. Children produced noun phrases with and without contrastive focus, such as RED-COLORED cat versus red-colored cat . Three adult native listeners perceptually scored the productions as correct or incorrect. The "correct" productions were then acoustically analyzed in terms of F0 range and duration.

RESULTS

Based on the perceptual scores, children with CIs produced focus with significantly lower accuracy (38%) than their TH peers (84%). The acoustic analysis on their "correct" productions showed that children with TH used both F0 and duration to mark focus, producing focal syllables with an expanded F0 range and long duration, and postfocal syllables with a reduced F0 range and short duration. However, children with CIs differed from children with TH in that they produced focal syllables with long duration but not an expanded F0 range, although they produced postfocal syllables with a reduced F0 range and short duration like their TH peers. In addition, early implantation correlated with the percept of more accurate focus productions and better use of F0 range in focal marking.

CONCLUSIONS

This study finds that Mandarin-speaking children with CIs are still learning to apply appropriate acoustic cues to contrastive focus. The challenge appears to lie in the use of an expanded F0 range to mark focus, probably related to the limited transmission of F0 information through the CI devices. These findings thus have implications for parents and those working with children with CIs, showing that utterance-level prosody also requires speech remediation, and underscores the critical role of identifying problems early in the acquisition of F0 functions in Mandarin, not only at the word level but also at the utterance-level.

Childhood Listening and Associated Cognitive Difficulties Persist Into Adolescence

OBJECTIVE

Listening difficulty (LiD) refers to the challenges individuals face when trying to hear and comprehend speech and other sounds. LiD can arise from various sources, such as hearing sensitivity, language comprehension, cognitive function, or auditory processing. Although some children with LiD have hearing loss, many have clinically normal audiometric thresholds. To determine the impact of hearing and cognitive factors on LiD in children with a clinically normal audiogram, we conducted a longitudinal study. The Evaluation of Children's Listening & Processing Skills (ECLiPS), a validated and standardized caregiver evaluation tool, was used to group participants as either LiD or typically developing (TD). Our previous study aimed to characterize LiD in 6- to 13-year-old children during the project's baseline, cross-sectional phase. We found that children with LiD needed a higher signal-to-noise ratio during speech-in-speech tests and scored lower on all assessed components of the NIH Cognition Toolbox than TD children. The primary goal of this study was to examine if the differences between LiD and TD groups are temporary or enduring throughout childhood.

DESIGN

This longitudinal study had three data collection waves for children with LiD and TD aged 6 to 13 years at Wave 1, followed by assessments at 2-year (Wave 2) and 4-year (Wave 3) intervals. Primary analysis focused on data from Waves 1 and 2. Secondary analysis encompassed all three waves despite high attrition at Wave 3. Caregivers completed the ECLiPS, while participants completed the Listening in Spatialized Noise-Sentences (LiSN-S) test and the NIH-Toolbox Cognition Battery during each wave. The analysis consisted of (1) examining longitudinal differences between TD and LiD groups in demographics, listening, auditory, and cognitive function; (2) identifying functional domains contributing to LiD; and (3) test-retest reliability of measures across waves. Mixed-effect models were employed to analyze longitudinal data.

RESULTS

The study enrolled 169 participants, with 147, 100, and 31 children completing the required testing during Waves 1, 2, and 3, respectively. The mean ages at these waves were 9.5, 12.0, and 14.0 years. On average, children with LiD consistently underperformed TD children in auditory and cognitive tasks across all waves. Maternal education, auditory, and cognitive abilities independently predicted caregiver-reported listening skills. Significant correlations between Waves 1 and 2 confirmed high, long-term reliability. Secondary analysis of Wave 3 was consistent with the primary analyses of Waves 1 and 2, reinforcing the enduring nature of listening difficulties.

CONCLUSION

Children with LiD and clinically normal audiograms experience persistent auditory, listening, and cognitive challenges through at least adolescence. The degree of LiD can be independently predicted by maternal education, cognitive processing, and spatial listening skills. This study underscores the importance of early detection and intervention for childhood LiD and highlights the role of socioeconomic factors as contributors to these challenges.

The roles of language and executive function in Mandarin-speaking children's theory of mind development

Introduction

Research has indicated that language and executive function relate closely to first-order false belief reasoning, yet their roles in second-order false belief reasoning are under-explored, and their interplay in theory of mind development remains obscure.

Methods

This study assessed 160 Mandarin-speaking preschoolers' and early primary schoolers' language, executive function, and theory of mind abilities to examine the unique roles and interplay of language and executive function in first-order and second-order false belief reasoning.

Results

Results showed that language significantly uniquely predicted the children's first-order as well as second-order false belief reasoning when controlling for the effects of age and executive function. Although executive function significantly predicted first-order FB reasoning when controlling for age, it was no longer a significant predictor of first-order FB reasoning when language was included in the model. However, executive function played a significant unique role in second-order FB reasoning when controlling for the effects of age and language.

Discussion

The current findings suggest that language plays a greater role than executive function in Mandarin-speaking children's theory of mind development and the contributors to theory of mind development vary in different levels of false belief reasoning.

SLPs' perceptions of language learning myths about children who are DHH

This article reports on speech-language pathologists' (SLPs') knowledge related to myths about spoken language learning of children who are deaf and hard of hearing (DHH). The broader study was designed as a step toward narrowing the research-practice gap and providing effective, evidence-based language services to children. In the broader study, SLPs (n = 106) reported their agreement/disagreement with myth statements and true statements (n = 52) about 7 clinical topics related to speech and language development. For the current report, participant responses to 7 statements within the DHH topic were analyzed. Participants exhibited a relative strength in bilingualism knowledge for spoken languages and a relative weakness in audiovisual integration knowledge. Much individual variation was observed. Participants' responses were more likely to align with current evidence about bilingualism if the participants had less experience as an SLP. The findings provide guidance on prioritizing topics for speech-language pathology preservice and professional development.

Production of nouns and adjectives of children with cochlear implants and of children with typical hearing

This analytical cross-sectional study aimed to investigate the production of nouns and adjectives in 62 children between the ages 5 and 7, with 31 children having Cochlear Implants (CIs) and 31 children having Typical Hearing (TH). The study compaired their performance in a picture naming test of nouns and adjectives. Poisson regression models were fitted to compare the responses of both groups of children, and intra-subject differences between responses to the noun and adjective naming tasks were also analyzed. The results showed that both groups of children produced the same number of non-responses of nouns and of adjectives and a higher number of correct productions of nouns than of adjectives. However, children with CIs produced more errors when naming adjectives than when naming nouns, while this difference is not observed in children with TH. The comparative analysis between both groups of children indicates that children with CIs produced a higher proportion of non-responses when naming nouns, but the same proportion as children with TH when naming adjectives. Children with CIs also produced fewer correct nouns and adjectives and more errors than children with TH. Vocabulary expansion and repair of production errors in children with CIs should be targeted by speech-language pathologists in intervention programs.

MMP-9 plasma level as biomarker of cochlear implantation outcome in cohort study of deaf children

PURPOSE

If before cochlear implantation it was possible to assay biomarkers of neuroplasticity, we might be able to identify those children with congenital deafness who, later on, were at risk of poor speech and language rehabilitation outcomes.

METHODS

A group of 40 children aged up to 2 years with DFNB1-related congenital deafness was observed in this prospective cohort study over three follow-up intervals (0, 8, and 18 months) after cochlear implant (CI) activation. Children were assessed for auditory development using the LittlEARS Questionnaire (LEAQ) score, and at the same time, measurements were made of matrix metalloproteinase-9 (MMP-9) plasma levels.

RESULTS

There were significant negative correlations between plasma levels of MMP-9 at 8-month follow-up and LEAQ score at cochlear implantation (p = 0.04) and LEAQ score at 18-month follow-up (p = 0.02) and between MMP-9 plasma levels at 18-month follow-up and LEAQ score at cochlear implantation (p = 0.04). As already reported, we confirmed a significant negative correlation between MMP-9 plasma level at cochlear implantation and LEAQ score at 18-month follow-up (p = 0.005). Based on this latter correlation, two clusters of good and poor CI performers could be isolated.

CONCLUSIONS

The study shows that children born deaf who have an MMP-9 plasma level of less than 150 ng/ml at cochlear implantation have a good chance of attaining a high LEAQ score after 18 months of speech and language rehabilitation. This indicates that MMP-9 plasma level at cochlear implantation is a good prognostic marker for CI outcome.

Two-Year Outcomes of Cochlear Implant Use for Children With Unilateral Hearing Loss: Benefits and Comparison to Children With Normal Hearing

OBJECTIVES

Children with severe-to-profound unilateral hearing loss, including cases of single-sided deafness (SSD), lack access to binaural cues that support spatial hearing, such as recognizing speech in complex multisource environments and sound source localization. Listening in a monaural condition negatively impacts communication, learning, and quality of life for children with SSD. Cochlear implant (CI) use may restore binaural hearing abilities and improve outcomes as compared to alternative treatments or no treatment. This study investigated performance over 24 months of CI use in young children with SSD as compared to the better hearing ear alone and to children with bilateral normal hearing (NH).

DESIGN

Eighteen children with SSD who received a CI between the ages of 3.5 and 6.5 years as part of a prospective clinical trial completed assessments of word recognition in quiet, masked sentence recognition, and sound source localization at regular intervals out to 24-month postactivation. Eighteen peers with bilateral NH, matched by age at the group level, completed the same test battery. Performance at 24-month postactivation for the SSD group was compared to the performance of the NH group.

RESULTS

Children with SSD have significantly poorer speech recognition in quiet, masked sentence recognition, and localization both with and without the use of the CI than their peers with NH. The SSD group experienced significant benefits with the CI+NH versus the NH ear alone on measures of isolated word recognition, masked sentence recognition, and localization. These benefits were realized within the first 3 months of use and were maintained through the 24-month postactivation interval.

CONCLUSIONS

Young children with SSD who use a CI experience significant isolated word recognition and bilateral spatial hearing benefits, although their performance remains poorer than their peers with NH.

Evolution of Feeding and Developmental Outcomes in Infants With Moderate Hypoxic-Ischemic Encephalopathy: A Pilot Study

The purpose of the study was to describe the evolution of outcomes among full-term infants with moderate hypoxic-ischemic encephalopathy (HIE); from their early swallowing and feeding abilities during hospitalization, to their later developmental outcomes at 6 and 12 months. Four participants with moderate HIE were recruited. Early feeding and swallowing were assessed using the Neonatal Feeding Assessment Scale and video fluoroscopic swallow studies. Developmental assessments were conducted at 6 and 12 months using the Rossetti Infant-Toddler Language Scale and Vineland-3 Scale. All participants displayed atypical outcomes throughout the study, including oropharyngeal dysphagia initially during hospitalization. All participants were discharged on oral feeds but some breastfeeding difficulties persisted. Variable but pervasive developmental delays were found among all participants at 6 and 12 months. This study emphasizes the need for consistent early intervention from the neonatal period onward, for all infants with moderate HIE. Future studies should use larger cohorts, longer follow-up, and correlational designs.

Quality Standard for Rehabilitation of Young Deaf Children Receiving Cochlear Implants

Background and objectives: More and more children with severe-to-profound hearing loss are receiving cochlear implants (CIs) at an early age to improve their hearing and listening abilities, speech recognition, speech intelligibility, and other aspects of spoken language development. Despite this, the rehabilitation outcomes can be very heterogeneous in this population, not only because of issues related to surgery and fitting or the specific characteristics of the child with his/her additional disabilities but also because of huge differences in the quality of the support and rehabilitation offered by the therapist and the family. These quality standards for the rehabilitation of young deaf children receiving CIs are developed within the European KA202 Erasmus+ project "VOICE"-vocational education and training for speech and language therapists and parents for the rehabilitation of children with CIs, Ref. No.: 2020-1-RO01-KA202-080059. Material and methods: To develop these quality standards, we used the input from the face-to-face interviews of 11 local rehabilitation experts in CIs from the four partner countries of the project and the outcomes of the bibliographic analysis of 848 publications retrieved from six databases: Pub Med, Psych Info, CINAHL, Scopus, Eric, and Cochrane. Based on all this information, we created a first set of 32 quality standards over four domains: general, fitting, rehabilitation, and for professionals. Further on, the Delphi method was used by 18 international rehabilitation experts to discuss and agree on these standards. Results: The results from the literature analysis and the interviews show us that more than 90% of the consulted international experts agreed on 29 quality standards. They focus on different aspects of rehabilitation: the multidisciplinary team, their expertise and knowledge, important rehabilitation topics to focus on, and programming issues related to rehabilitation. Conclusions: These quality standards aim to optimize the activity of speech rehabilitation specialists so that they reach the optimal level of expertise. Also presented is the necessary equipment for the IC team to carry out the rehabilitation sessions in good conditions. This set of quality standards can be useful to ensure the appropriate postoperative care of these children. As a result, the rehabilitation process will be more relaxed, and therapists will have the opportunity to focus more on the specific needs of each child, with the provision of quality services, which will result in better results. This theme is particularly complex and dependent on multifactorial aspects of medicine, education, speech therapy, social work, and psychology that are very intricate and interdependent.

Cochlear implants: the effects of age on outcomes

INTRODUCTION

Cochlear implants (CIs) provide access to sound for children and adults who do not receive adequate benefit from hearing aids. Age at implantation is known to affect outcomes across the lifespan.

AREAS COVERED

The effects of age on CI outcomes are examined for infants, children, adolescents, and older adults. A variety of outcome measures are considered, including speech perception, language, cognition, and quality of life measures.

EXPERT OPINION/COMMENTARY

For those meeting candidacy criteria, CIs are beneficial at any age. In general, younger age is related to greater benefit when considering pre-lingual deafness. Other factors such as additional disabilities, may mitigate this effect. Post-lingually deafened adults demonstrate similar benefit regardless of age, though the oldest individuals (80+) may see smaller degrees of improvement from preoperative scores. Benefit can be measured in many ways, and the areas of greatest benefit may vary based on age: young children appear to see the greatest effects of age at implantation on language measures, whereas scores on cognitive measures appear to be most impacted for the oldest population. Future research should consider implantation at extreme ages (5-9 months or > 90 years), unconventional measures of CI benefit including qualitative assessments, and longitudinal designs.

Language and academic outcomes of children with cochlear implants in an inclusive setting: Evidence from 18 years of data

OBJECTIVE

This study examined outcomes in core and pragmatic language, receptive vocabulary, and academic skills in children with cochlear implants (CIs) enrolled in an inclusive educational setting.

METHODS

Eighty-eight children with CIs were included in the analyses. Data was collected over an 18-year period, at six-month intervals for core language, vocabulary, and pragmatic skills and in kindergarten and second grade for academic skills. Kaplan-Meier analyses were used to estimate the median time to achieve age-appropriate scores.

RESULTS

Results indicated the median time to obtain age-appropriate skills for children with CIs enrolled in our program was less than three years for core language and pragmatic skills and less than two years for vocabulary. Over 90% of the sample had academic skills in the average range in both kindergarten and second grade.

DISCUSSION

This study shares outcomes of children with CIs who received consistent and intensive transdisciplinary intervention in an inclusive educational setting, revealing the trajectory required to obtain age-appropriate skills, when compared to normative data.

CONCLUSION

Results were favorable, indicating that children with CIs in an inclusive program, with intensive intervention and strong language and social models, can develop skills commensurate with typically developing peers across a variety of core skills.

Dichotic listening deficits in children with hearing loss

PURPOSE

This correlational study compared dichotic listening among children with significant hearing loss to typically developing children and children clinically assessed for auditory processing disorder.

METHOD

Recorded versions of two dichotic tests were delivered under earphones or in the sound field for children using amplification. Individual ear scores and interaural asymmetry were compared to normative data. Matched deficit patterns from both tests were identified, ranked for severity of deficit, and compared across groups. Relationships between dichotic scores and factors related to amplification were investigated in the children with hearing loss.

RESULTS

Dichotic scores were significantly poorer among children with hearing loss without the large interaural asymmetries seen in children assessed clinically for auditory processing problems. Device type and age of implantation had no effect on scores; non-dominant ear scores on the digits test were significantly correlated to age of device use in the left ear and duration of device use in the right ear. Non-dominant ear scores with digits were also significantly correlated with bilateral word recognition.

CONCLUSIONS

Poor dichotic perception in children with significant hearing losses may be related to the use of recorded test materials, immature skills in attention and working memory, or other factors that contribute to development of vocabulary and language. These weaknesses may interfere with successful mainstream educational placement in these children. Assessment of dichotic performance in this population could lead to deficit-specific interventions that may improve outcomes and enhance educational opportunities for children with hearing loss.

Does the duration matter? Effect of cochlear implantation on language development in Mandarin-speaking children with hearing loss

OBJECTIVE

Several studies have shown that cochlear implantation (CI) can influence language development in children with severe-to-profound hearing loss. However, whether the age of implantation and duration of CI use influence language development remains unclear, particularly in Mandarin-speaking children with hearing loss. Therefore, this study investigated the effects of CI-related variables on language development in these children.

METHODS

The present study recruited 133 Mandarin-speaking children with hearing loss, aged between 36 and 71 months chronologically, from a nonprofit organisation in Taiwan. The Revised Preschool Language Assessment (RPLA) was used to evaluate the children's language performance.

RESULTS

Children with hearing loss demonstrated delayed language comprehension and oral expression. Among them, 34% achieved age-appropriate language development. The duration of CI use had a significant direct effect on language-related abilities. Conversely, the age of implantation did not have a significant direct effect. Furthermore, the age of initial interventions (auditory-oral) had a significant direct effect only on language comprehension. Compared with the age of implantation, the duration of CI use was a significant mediator of language-related abilities.

CONCLUSION

In Mandarin-speaking children with late CIs, the duration of CI use is a more effective mediator of language development than the age of implantation.

Acoustic change complex for assessing speech discrimination in normal-hearing and hearing-impaired infants

OBJECTIVE

This study examined (1) the utility of a clinical system to record acoustic change complex (ACC, an event-related potential recorded by electroencephalography) for assessing speech discrimination in infants, and (2) the relationship between ACC and functional performance in real life.

METHODS

Participants included 115 infants (43 normal-hearing, 72 hearing-impaired), aged 3-12 months. ACCs were recorded using [szs], [uiu], and a spectral rippled noise high-pass filtered at 2 kHz as stimuli. Assessments were conducted at age 3-6 months and at 7-12 months. Functional performance was evaluated using a parent-report questionnaire, and correlations with ACC were examined.

RESULTS

The rates of onset and ACC responses of normal-hearing infants were not significantly different from those of aided infants with mild or moderate hearing loss but were significantly higher than those with severe loss. On average, response rates measured at 3-6 months were not significantly different from those at 7-12 months. Higher rates of ACC responses were significantly associated with better functional performance.

CONCLUSIONS

ACCs demonstrated auditory capacity for discrimination in infants by 3-6 months. This capacity was positively related to real-life functional performance.

SIGNIFICANCE

ACCs can be used to evaluate the effectiveness of amplification and monitor development in aided hearing-impaired infants.

The feasibility of cochlear implantation in early infancy

OBJECTIVES

To determine the key image anatomical parameters that are relevant to cochlear implantation (CI) using temporal bone high-resolution computed tomography (HRCT) scans and to identify age group differences in order to provide image anatomical support for early CI.

METHODS

The data of 346 temporal bone HRCTs of 173 children from 5 months to 18 years of age were retrospectively selected and reviewed. Parameters of the human temporal bone that are relevant to CI key surgical steps include mastoid thickness (MT), the facial recess width (FRW), and an angle representing the round window visibility. All measurements are performed on axial images.

RESULTS

There was no significant difference in the above morphological values by gender (p > 0,05). Two-sided FRW was not significantly different (p > 0,05), but MT and angle A were significantly different (p < 0,001). FRW and angle were independent of age (p > 0,05). However, MT had been found to exhibit postnatal development. The linear function of MT were calculated as y = 2463 × group(s) + 20,574 (p < 0,001).

CONCLUSIONS

Based on preoperative imaging analysis at different ages, middle ear development was stable at 5 months of age, allowing early CI in infancy with severe to severe hearing loss at this age. These data must be considered exploratory and more extensive clinical studies are needed.

The 100 Most-Cited Manuscripts in Hearing Implants: A Bibliometrics Analysis

The aim of the study was to characterise the most frequently cited articles on the topic of hearing implants. A systematic search was carried out using the Thomson Reuters Web of Science Core Collection database. Eligibility criteria restricted the results to primary studies and reviews published from 1970 to 2022 in English dealing primarily with hearing implants. Data including the authors, year of publication, journal, country of origin, number of citations and average number of citations per year were extracted, as well as the impact factors and five-year impact factor of journals publishing the articles. The top 100 papers were published across 23 journals and were cited 23,139 times. The most-cited and influential article describes the first use of the continuous interleaved sampling (CIS) strategy utilised in all modern cochlear implants. More than half of the studies on the list were produced by authors from the United States, and the Ear and Hearing journal had both the greatest number of articles and the greatest number of total citations. To conclude, this research serves as a guide to the most influential articles on the topic of hearing implants, although bibliometric analyses mainly focus on citations. The most-cited article was an influential description of CIS.

Is Early Cochlear Implantation Leads to Better Speech and Language Outcomes?

A cochlear implant is an electronic sensory system that converts mechanical energy into coded electrical signals that directly activate the auditory nerve fibers. Present review article investigates the findings of previous research papers which have assessed speech and language outcome in children who underwent early cochlear implantation. Several databases, including PubMed, Google, Google Scholar, and Medline, were investigated for research papers on the speech and language outcomes of children who had early-life implants. According to previous research, early detection and intervention of hearing loss are critical for the growth of speech and language skills. The effect of early detection of hearing loss and early cochlear implantation on a child's overall speech-language and auditory growth is highlighted in this article.

Auditory, Speech and Language Development in Cochlear Implant Children: A One Year Longitudinal Study

The advent of Cochlear Implants (CI) has bought with it, the goal of spoken language performance for severe-profound sensori-neural hearing loss (SNHL) as par with the normal hearing listeners. The aim of this study was to evaluate the outcome of paediatric cochlear implantation in auditory and speech skills below the age of 5 years. The present study consisted of 50 childrens. Auditory skills were assessed in terms of audiometric thresholds and localization abilities. Speech - Language skills were measured using; Categories of Auditory Performance -CAP; Meaningful Use of Speech Scale - MUSS; Meaningful Auditory Integration Scale - MAIS and Speech intelligibility Rating - SIR. Hearing thresholds obtained from all the subjects for pre implant and post implant conditions of 3rd, 6th, 9th, 12th month conditions, evidenced a high significant (p < 0.001) improvement across all test frequencies 500, 1000, 2000 and 4000 Hz. There was also a statistically significant difference across successive measurements of auditory and speech skills, as determined by ANOVA (F (4, 245) = 151.33, p < 0.001 for CAP; F (4, 245) = 89.636, p < 0.001 for SIR; F (4, 245) = 812.282 p < 0.001 for MAIS and F(4, 245) = 435.677 p < 0.001 for MUSS). Auditory localization abilities were also improved considerably over a period of one year. The present study added the evidence to the literature that cochlear implants significantly improved the hearing ability of children with severe-to-profound hearing loss. This study also demonstrated that, children were better able to make use of the auditory information perceived through the implant.

Younger Age at Cochlear Implant Activation Results in Improved Auditory Skill Development for Children With Congenital Deafness

PURPOSE

The U.S. Food and Drug Administration indications for cochlear implantation in children is currently 9 months of age and older for children with bilateral profound sensorineural hearing loss (SNHL). Studies have shown that earlier activation of a cochlear implant (CI) can lead to better spoken language outcomes. As auditory skills are a precursor to the development of spoken language, this study was developed to investigate the influence of age at CI activation on auditory skill acquisition in young children. A secondary aim was to describe the auditory skills of children implanted prior to 9 months of age as compared to children with older ages of activation.

METHOD

Functional Listening Index (FLI) scores obtained during routine clinical visits were reviewed for 78 pediatric CI recipients with congenital bilateral profound hearing loss who were activated before 2 years of age. A linear mixed-effects model assessed the effect of age at CI activation on cumulative FLI scores over time.

RESULTS

There was a significant interaction between age at activation and chronological age at the time of evaluation, indicating that children with earlier access to sound achieved a greater number of auditory skills than those with later CI activations when measured at the same chronological age. Children activated before the age of 9 months approximated scores expected of children with typical hearing, whereas children activated between 9 and 24 months of age did not.

CONCLUSIONS

Younger age at CI activation is associated with increased auditory skills over time. Children who undergo cochlear implantation and CI activation before 9 months achieve more auditory skills by 4 years of age than children who are activated at later ages. These data suggest that reducing the approved age at cochlear implantation for children with congenital bilateral profound SNHL may support optimal auditory skill acquisition.

A global survey of healthcare professionals undertaking MRI of patients with cochlear implants: a heterogeneity of practice and opinions

OBJECTIVE

To capture practice and opinions around the current clinical use of MRI in patients with cochlear implants (CIs), and to characterise patient progression from referral to image reporting.

METHODS

An online survey recruited 237 healthcare professionals between 9 December 2019 and 9 September 2020. Descriptive statistics and informal thematic analyses were conducted.

RESULTS

Respondents estimated that approximately 75% of CI users referred for an MRI proceeded to image acquisition, of which ~70% of cases comprised image acquisition on the head and the remaining cases on another area. They estimated that the proportion of these images that were usable was 93 and 99%, respectively. Confidence in most processes was high, with at least two-thirds of respondents reporting to be very or somewhat confident in obtaining consent and acquiring images. Conversely, fewer than half the respondents had the same confidence when splinting and bandaging the implant and troubleshooting any issues arising. Patient safety was rated of paramount importance, with patient comfort a clear second and image quality third.

CONCLUSION

These findings highlight the need for consistent publication of clear, succinct, and standardised operating procedures for scanning patients with CIs and the requirement for regular training of radiographic and radiological healthcare professionals to address the heterogeneity of devices available.

ADVANCES IN KNOWLEDGE

There is a need to improve the communication to radiography and radiology personnel regarding the nature of CIs, the heterogeneity of devices in existence, and the key differences between them. CI users risk being underserved by diagnostic medical imaging.

A Retrospective Evaluation to Assess Reliability of Electrophysiological Methods for Diagnosis of Hearing Loss in Infants

Background: An electrophysiological investigation with auditory brainstem response (ABR), round window electrocochleography (RW-ECoG), and electrical-ABR (E-ABR) was performed in children with suspected hearing loss with the purpose of early diagnosis and treatment. The effectiveness of the electrophysiological measures as diagnostic tools was assessed in this study. Methods: In this retrospective case series with chart review, 790 children below 3 years of age with suspected profound hearing loss were tested with impedance audiometry and underwent electrophysiological investigation (ABR, RW-ECoG, and E-ABR). All implanted cases underwent pure-tone audiometry (PTA) of the non-implanted ear at least 5 years after surgery for a long-term assessment of the reliability of the protocol. Results: Two hundred and fourteen children showed bilateral severe-to-profound hearing loss. In 56 children with either ABR thresholds between 70 and 90 dB nHL or no response, RW-ECoG showed thresholds below 70 dB nHL. In the 21 infants with bilateral profound sensorineural hearing loss receiving a unilateral cochlear implant, no statistically significant differences were found in auditory thresholds in the non-implanted ear between electrophysiological measures and PTA at the last follow-up (p > 0.05). Eight implanted children showed residual hearing below 2000 Hz worse than 100 dB nHL and 2 children showed pantonal residual hearing worse than 100 dB nHL (p > 0.05). Conclusion: The audiological evaluation of infants with a comprehensive protocol is highly reliable. RW-ECoG provided a better definition of hearing thresholds, while E-ABR added useful information in cases of auditory nerve deficiency.

Investigating the association of electrically-evoked compound action potential thresholds with inner-ear dimensions in pediatric cochlear implantation

OBJECTIVES

A narrow bony cochlear nerve canal (BCNC), as well as a hypoplastic and aplastic cochlear nerve (CN) have been associated with increased electrically-evoked compound action potential (eCAP) thresholds in some studies, suggesting poorer neural excitability in cochlear implantation. Also, in large cochleae the extent of activated spiral ganglion neurons with electrical stimulation is less than in smaller ones. However, a detailed description of the relationship between eCAP thresholds for a lateral-wall electrode array and dimensions of the inner-ear structures and internal auditory canal (IAC) is missing.

DESIGN

The study subjects were 52 pediatric patients with congenital severe-to-profound hearing loss (27 females and 25 males; ages 0.7-2.0 years; 1.0 ± 0.3 years, mean ± SD) implanted bilaterally with Cochlear Nucleus CI422, CI522, or CI622 implants with full insertion of the Slim Straight electrode array. Diameters of the cochlea and the BCNC as well as the widths and heights of the IAC and the CN were evaluated from preoperative computed tomography and magnetic resonance images. These anatomical dimensions were compared with each other and with the patients' intraoperative eCAP thresholds.

RESULTS

The eCAP thresholds increased from the apical to basal direction (r = 0.89, p < 0.001). After sorting the cochleae into four size categories, higher eCAP thresholds were found in larger than in smaller cochleae (p < 0.001). With similar categorization, the eCAP thresholds were higher in cochleae with a larger BCNC than in cochleae with a smaller BCNC (p < 0.001). Neither IAC nor CN cross-sectional areas affected the eCAP thresholds. Correlations were found between cochlea and BCNC diameters and between IAC and CN cross-sectional areas (r = 0.39 and r = 0.48, respectively, p < 0.001 for both).

CONCLUSIONS

In the basal part of the electrode array, higher stimulation levels to elicit measurable neural responses (eCAP thresholds) were required than in the apical part. Increased eCAP thresholds associated with a larger cochlear diameter, but contrary to the earlier studies, not with a small size of the BCNC or the CN. Instead, the BCNC diameter correlated significantly with the cochlea diameter.

Examination of Language, Behavioral, Academic, and Social Skills of Cochlear Implant Users in Early Primary Education

BACKGROUND

 Cochlear implants (CIs) improve spoken language skills as well as social and academic performance in children with severe and profound sensorineural hearing loss.

PURPOSE

 We compare the social skills, academic competence, and problem behaviors in children with CIs and their typical-hearing peers and investigate the relationship between language skills and social skills, academic competence, and problem behaviors in children with CIs.

RESEARCH DESIGN

 Thirty-two children with CIs were divided into two groups according to implantation age: early (n = 17) and late-implanted group (n = 15). The control group was formed by the inclusion of five same-sex classmates of each implanted child selected by the teachers of the children with CIs. Thus, 160 typical-hearing children were included in the control group.

STUDY SAMPLE

 Thirty-two children with CIs and 160 typical-hearing children participated in this study.

DATA COLLECTION AND ANALYSIS

 Primary school teachers rated the children's social skills, academic competence, and problem behaviors using the Social Skills Rating System (SSRS). The language skills of the children with CIs were assessed with the Turkish Expressive and Receptive Language Test (TIFALDI).

RESULTS

 A statistically significant difference was found between the SSRS scores of the study and control groups, which was mostly due to lower social skills, and academic competence, and higher problem behavior ratings in the late-implanted group. In the study group, there was a statistically significant correlation between TIFALDI and SSRS scores.

CONCLUSION

 Early cochlear implantation provides advantages in social skills and vocabulary for children with profound congenital hearing loss. Late-implanted children need special support in different developmental areas despite attending mainstream education.

Cochlear Implants for Deaf Children With Early Developmental Impairment

BACKGROUND AND OBJECTIVES

Infants with profound hearing loss are typically considered for cochlear implantation. Many insurance providers deny implantation to children with developmental impairments because they have limited potential to acquire verbal communication. We took advantage of differing insurance coverage restrictions to compare outcomes after cochlear implantation or continued hearing aid use.

METHODS

Young children with deafness were identified prospectively from 2 different states, Texas and California, and followed longitudinally for an average of 2 years. Children in cohort 1 (n = 138) had normal cognition and adaptive behavior and underwent cochlear implantation. Children in cohorts 2 (n = 37) and 3 (n = 29) had low cognition and low adaptive behavior. Those in cohort 2 underwent cochlear implantation, whereas those in cohort 3 were treated with hearing aids.

RESULTS

Cohorts did not substantially differ in demographic characteristics. Using cohort 2 as the reference, children in cohort 1 showed more rapid gains in cognitive, adaptive function, language, and auditory skills (estimated coefficients, 0.166 to 0.403; P ≤ .001), whereas children in cohort 3 showed slower gains (-0.119 to -0.243; P ≤ .04). Children in cohort 3 also had greater increases in stress within the parent-child system (1.328; P = .02), whereas cohorts 1 and 2 were not different.

CONCLUSIONS

Cochlear implantation benefits children with deafness and developmental delays. This finding has health policy implications not only for private insurers but also for large, statewide, publicly administered programs. Cognitive and adaptive skills should not be used as a "litmus test" for pediatric cochlear implantation.

Delayed cochlear implantation in congenitally deaf children-identifying barriers for targeted interventions

OBJECTIVES

Age of cochlear implantation (CI) is an important predictor of language development in those with congenital sensorineural hearing loss. Despite universal newborn hearing screening initiatives and the known benefits of early CI, a subset of congenitally deaf children continue to be evaluated for cochlear implants later in childhood. This study aims to identify the barriers to early cochlear implantation in these children.

METHODS

A retrospective review was conducted for all pediatric cochlear implants aged 3 years or older performed at a single academic institution between 2013 and 2017. Children implanted before the age three, those with a prior unilateral cochlear implant, and those with progressive or sudden hearing loss were excluded. Variables included newborn hearing screen results, age at hearing loss diagnosis, time of initiation and documented benefit of hearing aids, age of implantation, pre/post-implantation evaluation scores, and reason for delayed referral for cochlear implantation.

RESULTS

Thirty-one patients were identified meeting these inclusion criteria. Twenty-one children were subject to UNBS in the U.S. Fourteen of those children failed their newborn hearing screening. Average age at implantation was 6.2 years. Four reasons were identified for increased age at cochlear implantation. Two categories represent delays related to (1) Amplification continually prescribed even though the range of hearing loss and speech development assessment suggests CI may have been more appropriate well before referral (N = 13) (2) Patients were not subject to newborn hearing screening and/or timely diagnosis of their hearing loss (N = 8). In other cases, patients were appropriately fit with hearing aids until evidence that they derived limited benefit and then referred for CI (N = 8). Lastly, in a few cases, records were indeterminate with regards to the timing and appropriate diagnosis of their hearing loss (N = 2).

CONCLUSION

Understanding the reasons for delayed cochlear implantation in congenitally deaf children might allow the development of targeted interventions to improve outcomes. Specifically, those children who were not referred before age 3 despite use of amplification with limited benefit offer one potential target population for earlier CI.

Multidimensional Family-Centred Early Intervention in Children with Hearing Loss: A Conceptual Model

At least two per thousand newborns are affected by hearing loss, with up to 40% with an additional disability. Early identification by universal newborn hearing screening and early intervention services are available in many countries around the world, with limited data on their effectiveness and a lack of knowledge about specific intervention-related determinants of child and family outcomes. This concept paper aimed to better understand the mechanisms by which multi-dimensional family-centred early intervention influences child outcomes, through parent behaviour, targeted by intervention by a review of the literature, primarily in the field of childhood hearing loss, supplemented by research findings on physiological and atypical child development. We present a conceptual model of influences of multi-disciplinary family-centred early intervention on family coping/functioning and parent–child interaction, with effects on child psycho-social and cognitive outcomes. Social communication and language skills are postulated as mediators between parent–child interaction and non-verbal child outcomes. Multi-disciplinary networks of professionals trained in family-centred practice and the evaluation of existing services, with respect to best practice guidelines for family-centred early intervention, are recommended. There is a need for longitudinal epidemiological studies, including specific intervention measures, family behaviours and multidimensional child outcomes.

American Cochlear Implant Alliance Task Force Guidelines for Determining Cochlear Implant Candidacy in Children

This article summarizes the available evidence on pediatric cochlear implantation to provide current guidelines for clinical protocols and candidacy recommendations in the United States. Candidacy determination involves specification of audiologic and medical criteria per guidelines of the Food and Drug Administration. However, recommendations for a cochlear implant evaluation also should maintain flexibility and consider a child’s skill progression (i.e., month-for-month progress in speech, language, and auditory development) and quality of life with appropriately fit hearing aids. Moreover, evidence supports medical and clinical decisions based on other factors, including (a) ear-specific performance, which affords inclusion of children with asymmetric hearing loss and single-sided deafness as implant candidates; (b) ear-specific residual hearing, which influences surgical technique and device selection to optimize hearing; and (c) early intervention to minimize negative long-term effects on communication and quality of life related to delayed identification of implant candidacy, later age at implantation, and/or limited commitment to an audiologic rehabilitation program. These evidence-based guidelines for current clinical protocols in determining pediatric cochlear implant candidacy encourage a team-based approach focused on the whole child and the family system.

The development of auditory temporal processing during the first year of life

OBJECTIVES

The processing of auditory temporal information is important for the extraction of voice pitch, linguistic information, as well as the overall temporal structure of speech. However, many aspects of its early development remain poorly understood. This paper reviews the development of auditory temporal processing during the first year of life when infants are acquiring their native language.

METHODS

First, potential mechanisms of neural immaturity are discussed in the context of neurophysiological studies. Next, what is known about infant auditory capabilities is considered with a focus on psychophysical studies involving non-speech stimuli to investigate the perception of temporal fine structure and envelope cues. This is followed by a review of studies involving speech stimuli, including those that present vocoded signals as a method of degrading the spectro-temporal information available to infant listeners.

RESULTS/CONCLUSION

This review suggests that temporal resolution may be well developed in the first postnatal months, but that the ability to use and process the temporal information in an efficient way along the entire auditory pathway is longer to develop. Those findings have crucial implications for the development of language abilities, especially for infants with hearing impairment who are using cochlear implants.

Language-Independent Hearing Screening - Increasing the Feasibility of a Hearing Screening Self-Test at School-Entry

A tablet-based language-independent self-test involving the recognition of ecological sounds in background noise, the Sound Ear Check (SEC), was adapted to make it feasible for young children. Two experiments were conducted. The first experiment investigated the SEC's feasibility, as well as its sensitivity and specificity for detecting childhood hearing loss with a monaural adaptive test procedure. In the second experiment, the SEC sounds, noise, and test format were adapted based on the findings of the first experiment. The adaptations were combined with three test procedures, one similar to the one used in Experiment 1, one presenting the sounds dichotically in diotic noise, and one presenting all the sounds with a fixed signal-to-noise ratio and a stopping rule. Results in young children show high sensitivity and specificity to detect different grades of conductive and sensorineural hearing loss (70-90%). When using an adaptive, monaural procedure, the test duration was approximately 6 min, and 17% of the results obtained were unreliable. Adaptive staircase analyses showed that the unreliable results probably occur due to attention/motivation loss. The test duration could be reduced to 3-4 min with adapted test formats without decreasing the test-retest reliability. The unreliable test results could be reduced from 17% to as low as 5%. However, dichotic presentation requires longer training, reducing the dichotic test format's feasibility.

Auditory Sensory Gating in Children With Cochlear Implants: A P50-N100-P200 Study

Background: While a cochlear implant (CI) can restore access to audibility in deaf children, implanted children may still have difficulty in concentrating. Previous studies have revealed a close relationship between sensory gating and attention. However, whether CI children have deficient auditory sensory gating remains unclear.

Methods: To address this issue, we measured the event-related potentials (ERPs), including P50, N100, and P200, evoked by paired tone bursts (S1 and S2) in CI children and normal-hearing (NH) controls. Suppressed amplitudes for S2 compared with S1 in these three ERPs reflected sensory gating during early and later phases, respectively. A Swanson, Nolan, and Pelham IV (SNAP-IV) scale was performed to assess the attentional performance.

Results: Significant amplitude differences between S1 and S2 in N100 and P200 were observed in both NH and CI children, indicating the presence of sensory gating in the two groups. However, the P50 suppression was only found in NH children and not in CI children. Furthermore, the duration of deafness was significantly positively correlated with the score of inattention in CI children.

Conclusion: Auditory sensory gating can develop but is deficient during the early phase in CI children. Long-term auditory deprivation has a negative effect on sensory gating and attentional performance.

Differences in picture naming between children with cochlear implants and children with typical hearing

Increase in the auditory abilities of children with cochlear implants (CIs) has led to an improvement in naming tasks, although divergent results are still being reported; this strongly suggests that further studies are needed. The study aims to compare the responses in a picture-naming activity between the complete population of children aged 5 to 7 with cochlear implants in Catalonia -Spain- (N = 31), without developmental problems, and a matched sample of 31 children with typical hearing. A picture-naming task was used to assess their lexical naming abilities. The results show that children with CIs provide more non-responses, they produce fewer words correctly, they require a longer reaction time and they commit more picture-naming errors than children with typical hearing. The auditory age does significantly affect the results, but not the type of implant. In spite of the hearing gain achieved with the cochlear implant and the listening experience progressively achieved in distinct contexts, further explicit work on lexical naming in speech-therapy intervention is clearly required.

The Limitations of FDA Criteria: Inconsistencies with Clinical Practice, Findings, and Adult Criteria as a Barrier to Pediatric Implantation

Children require greater access to sound than adults as they are learning to communicate using hearing and spoken language. Yet when it comes to cochlear implant candidacy, currently approved Food and Drug Administration (FDA) criteria for adults are much less restrictive than those for children, allowing for greater levels of residual hearing and aided speech recognition in adults. Cochlear implant guidelines for children have changed very little in the 30 years since cochlear implants have been approved for pediatrics, and this lack of change has proven to be a barrier to implantation. Using evidence-based practice, centers have been providing off-label implantation for children who fall outside of current FDA criteria, including children with more residual hearing, children with single-side deafness younger than 5 years, and infants with bilateral profound loss younger than 9 months. The purpose of this article is to outline how these restrictions impede access to implants for children and describe the evidence supporting cochlear implantation in children who fall outside of current criteria.

Do Acoustic Environment Characteristics Affect the Lexical Development of Children With Cochlear Implants? A Longitudinal Study Before and After Cochlear Implant Activation

Purpose This study investigates the acoustic environment of children with cochlear implants (CIs) and the relationship between exposure to speech, in noise and in quiet, and the children's lexical production up to 1 year after CI activation, while controlling for the effect of early individual differences in receptive vocabulary growth. Method Eighteen children with CIs were observed at 3, 6, and 12 months after CI activation. Children's spontaneous word production during interaction with their mothers (types and tokens) and their expressive and receptive vocabulary size were considered. The characteristics of the acoustic environments in terms of acoustic scenes (speech in noise or in quiet, quiet, noise, music, and other) and of loudness ranges were assessed using data logging of the children's devices. Results Data analysis showed that both the number of tokens and the number of types produced 1 year after CI activation were affected by the children's exposure to speech in quiet with a loudness range between 40 and 69 dB. Expressive vocabulary size and types were affected by the receptive vocabulary knowledge that the children achieved over the first 3 months after CI activation. Conclusions Our data support the role of speech environment and individual differences in early comprehension on lexical production. The importance of exposure to speech with particular characteristics for the lexical development of children with CIs and the implications for clinical practice are discussed.

Cochlear Implant Behavioral Outcomes for Children With Auditory Neuropathy Spectrum Disorder: A Mini-Systematic Review

Objective The aim of this mini-systematic review was to evaluate the evidence reporting speech, language, and auditory behavioral outcome measures for children with a diagnosis of auditory neuropathy spectrum disorder (ANSD) who received cochlear implants (CIs) prior to 3 years of age. Method A mini-systematic review of the literature supporting evidence-based practices was performed. Two databases were searched utilizing a search strategy derived from the PICO (patient, intervention, comparison, outcome) framework. Peer-reviewed articles published between 2009 and 2019 evaluating children with a diagnosis of ANSD who were implanted prior to 3 years of age with a range of speech, language, and auditory behavioral outcomes were included. Four articles meeting inclusion criteria were critically appraised for reputable research design and risks of bias. Each of the four studies was assigned a level of evidence for effectiveness and quality assessment rating. Results Evidence supports cochlear implantation as an appropriate intervention for children with ANSD. Improvements in outcome performance were observed in all the included studies. Children with ANSD fit with CIs can achieve outcomes similar to children with sensorineural hearing loss and CIs, despite the heterogeneity of ANSD. Conclusion These findings have implications for clinical practice and for future research with current CI technology for facilitating parent education, counseling, and realistic expectations for children with ANSD and CIs.

Development and Implementation of a Low-Cost Tracking System after Newborn Hearing Screening in Upper Austria: Lessons Learned from the Perspective of an Early Intervention Provider

More than one decade after the introduction of newborn hearing screening in Upper Austria, most children were still older than 6 months at enrolment in early intervention. In this study, under the guidance of health authorities, a revised screening and tracking protocol was developed by a network of early intervention providers and representatives of ENT, obstetrics, and pediatrics, including screening professionals and parents of children with hearing loss. Critical process indicators following internationally recommended benchmarks were defined and collected annually by the health authorities. Due to data protection issues, the data collection system was not personalized. Regular network meetings, case-oriented meetings, and screener training sessions were held. As a result, even without additional costs and within the legal constraints related to data protection in Austria, the proportion of children enrolled in early intervention before 6 months of age was significantly increased from 26% to 81% in two representative birth cohorts before and after the introduction of the new protocol, respectively. The coverage for bilateral screening increased from 91.4 to 97.6% of the total number of births.

Children with hearing impairment and early cochlear implant: A pragmatic assessment

Extensive research has demonstrated the benefits of cochlear implants (CI) in contributing to improve the linguistic skills of children with hearing impairment; however, few studies have focused on the development of pragmatic ability and its relationship with age of implantation. Pragmatics is the ability to use language in different contexts and its development has crucial implications, e.g., social inclusion and professional attainments. In this study, we conducted a comprehensive assessment of pragmatic ability using the Language Pragmatic Abilities (APL Medea), a battery composed by five different tasks: Comprehension of Metaphors, Implicit meaning, Comics, Situations and Colors Game (a perspective taking task). Eighteen children with early CI, belonging to 3 different age groups (6; 11-7; 11, 8; 0-8; 11 and 9; 0-9; 11 years-old), and twenty-four children with typical development (Control Group) participated to the study. We also investigated how the precocity of CI, i.e., age of first implantation, may affect the pragmatic development. Globally, children with CI obtained lower scores in the APL Medea battery than typically hearing children. However, focusing on the Medea tasks separately, children with CIs differed from their hearing peers only in Comics and Colors Game tasks. Finally, age of implantation was a moderate but significant predictor of pragmatic performance.

Production of third-person direct object clitics in children with cochlear implants speaking Italian

Previous research has shown that the production of third-person singular accusative object clitics (3DO clitics) might be taxing in Italian-speaking pre-school children with cochlear implants (CIs). We investigated this topic by assessing 3DO clitic production in 14 children with an average age of 8 years, who had received CI between age 1 and 4. The first goal of the study was to analyze whether school-aged children with CIs exhibit atypical behavior in 3DO clitic production. The second goal was to analyze whether children with CIs are prone to agreement errors in case of gender mismatch between the subject and the 3DO clitic, as has been shown for normal-hearing, typically developing children. To achieve this, we used two tasks in which subject and object clitic grammatical genders were manipulated so that they would or would not match. As for the first goal, the majority of children with CIs had good performance on the clitic tasks. However, some participants' performance was poor. The pattern of deviant responses differed among the poor performers. We believe that children with CIs showing impairments in 3DO clitic production need careful individual analysis in order to plan effective speech therapy. As for the second goal, children with CIs were more prone to agreement errors in the mismatch condition compared to the match condition; this dimension needs to be considered when assessing and eventually rehabilitating clitic production.

Early pediatric Cochlear implantation: An update

The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system. Thus, there is increasing evidence advocating for earlier implantation within a critical neuroplastic window. However, there is a lack of consensus on this optimal age of implantation. Historically, there were concerns regarding surgical feasibility and safety, anesthesia risk, and logistical considerations in very young infants <12 months. Recent literature has investigated surgical safety and anesthesia risk as well speech and language outcomes with early implantation, resulting in the long-awaited reduction in approved age by the FDA (<9 months for certain devices). This article reviews logistical considerations, surgical safety, anesthesia risk, and language developmental outcomes associated with early CI (<12 months).

Early pediatric Cochlear implantation: An update

The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system. Thus, there is increasing evidence advocating for earlier implantation within a critical neuroplastic window. However, there is a lack of consensus on this optimal age of implantation. Historically, there were concerns regarding surgical feasibility and safety, anesthesia risk, and logistical considerations in very young infants <12 months. Recent literature has investigated surgical safety and anesthesia risk as well speech and language outcomes with early implantation, resulting in the long-awaited reduction in approved age by the FDA (<9 months for certain devices). This article reviews logistical considerations, surgical safety, anesthesia risk, and language developmental outcomes associated with early CI (<12 months).

Longer Cochlear Implant Experience Leads to Better Production of Mandarin Tones for Early Implanted Children

OBJECTIVES

Children with cochlear implants (CIs) face challenges in acquiring tones, since CIs do not transmit pitch information effectively. It has been suggested that longer CI experience provides additional benefits for children implanted early, enabling them to achieve language abilities similar to that of normal-hearing (NH) children (Colletti 2009). Mandarin is a tonal language with four lexical tones and a neutral tone (T0), characterized by distinct pitch and durational patterns. It has been suggested that early implantation (i.e., before 2 years) greatly benefits the acquisition of Mandarin tones by children with CIs (Tang et al. 2019c). In this study, we extend those findings to investigate the effect of CI experience on the acquisition of Mandarin tones for children implanted early. We asked the extent to which they were able to produce distinct pitch and durational patterns of both lexical tones and T0 as a function of CI experience, and the extent to which their tonal productions were acoustically like that of NH children.

DESIGN

Forty-four NH 3-year olds and 28 children implanted with CIs between 1 and 2 years, aged 3 to 7, were recruited. The children with CIs were grouped according to the length of CI experience: 3 to 6 years, 2 to 3 years, and 1 to 2 years. Lexical tone and T0 productions were elicited using a picture-naming task. Tonal productions from the children with CIs were acoustically analyzed and compared with those from the NH children.

RESULTS

Children with 3 to 6 years of CI experience were able to produce distinct pitch and durational patterns for both lexical tones and T0, with NH-like acoustic realizations. Children with 2 to 3 years of CI experience were also able to produce the expected tonal patterns, although their productions were not yet NH-like. Those with only 1 to 2 years of CI experience, however, were not yet able to produce the distinct acoustic patterns for either lexical tones or T0.

CONCLUSIONS

These results provide acoustic evidence demonstrating that, when Mandarin-speaking children are implanted before the age of 2, only those with 3 to 6 years of experience were able to produce NH-like tones, including both lexical tone and T0. Children with shorter CI experience (less than 3 years) were unable to produce distinct acoustic patterns for the different tones. This suggests that at least 3 years of CI experience is still needed for early implanted children to acquire tonal distinctions similar to those of NH 3-year olds.

Cochlear implant indications: a review of third-party payers' policies for standard and expanded indications

As cochlear implant (CI) candidacy has expanded, commercial payers in the United States have varied in their adoption of new indications, potentially confusing providers' knowledge about appropriate patients for referral. We reviewed how third-party payers classify the medical necessity of cochlear implants for a variety of indications across the lifespan.We compared policies of the six largest commercial payers in our region, focusing on clinical scenarios for which many centers experience difficulty obtaining pre-authorization. These include: (1) CI in children under 12 months, (2) audiometric and speech perception criteria in children, (3) sequential bilateral CI, (4) electro-acoustic stimulation, (5) impending cochlear ossification, and (6) single-sided deafness (SSD).Of the more notable findings for the clinical scenarios half of commercial payers have a pediatric age requirement of greater than 12 months. Generally, audiologic and speech perception criteria are more stringent for children than adults across all policies. SSD is considered investigational by most policies.Third-party payers employ variable criteria regarding the medical necessity of CI, many of which are not contemporaneous with clinical knowledge and best practices. This may impact referral patterns among audiologists. More methodologically rigorous clinical trials may help shift such restrictive policies to benefit a greater number of patients.

Microsecond interaural time difference discrimination restored by cochlear implants after neonatal deafness

Spatial hearing in cochlear implant (CI) patients remains a major challenge, with many early deaf users reported to have no measurable sensitivity to interaural time differences (ITDs). Deprivation of binaural experience during an early critical period is often hypothesized to be the cause of this shortcoming. However, we show that neonatally deafened (ND) rats provided with precisely synchronized CI stimulation in adulthood can be trained to lateralize ITDs with essentially normal behavioral thresholds near 50 μs. Furthermore, comparable ND rats show high physiological sensitivity to ITDs immediately after binaural implantation in adulthood. Our result that ND-CI rats achieved very good behavioral ITD thresholds, while prelingually deaf human CI patients often fail to develop a useful sensitivity to ITD raises urgent questions concerning the possibility that shortcomings in technology or treatment, rather than missing input during early development, may be behind the usually poor binaural outcomes for current CI patients.

JT, Waltzman SB. Cochlear Implantation in Infants: Evidence of Safety

The aim of this study was to investigate surgical, anesthetic, and device-related complications associated with cochlear implantation (CI) in children younger than 1 year of age. This was a multicenter, retrospective chart review of all children with severe-to-profound sensorineural hearing loss who underwent cochlear implantation with a Cochlear Nucleus Implant System before 1 year of age. Endpoints included perioperative course, major and minor surgical, anesthetic and device-related complications, and 30-day readmission rates. One hundred thirty-six infants (242 ears) met criteria. The mean age at implantation was 9.4 months (standard deviation 1.8). Six-month follow-up was reported in all patients. There were no major anesthetic or device-related complications. Adverse events were reported in 34 of implanted ears (14%; 7 major, 27 minor). Sixteen adverse events occurred ≤30 days of surgery, and 18 occurred >30 days of surgery. The 30-day readmission rate was 1.5%. The rate of adverse events did not correlate with preexisting medical comorbidities or duration under anesthesia. There was no significant difference detected in complication rate for patients younger than 9 months of age versus those 9 to 11 months of age. This study demonstrates the safety of CI surgery in infants and supports reducing the indication for cochlear implantation to younger than 1 year of age for children with bilateral, profound sensorineural hearing loss obtaining a Cochlear Nucleus Implant System.

Delaying Cochlear Implantation Impacts Postoperative Speech Perception of Nontraditional Pediatric Candidates

INTRODUCTION

As pediatric cochlear implant (CI) candidacy expands, children with greater degrees of residual hearing are receiving CIs. These nontraditional candidates have audiometric thresholds that meet adult manufacturer labeling but are better than current pediatric guidelines allow. The purpose of this study was to determine the impact of delayed cochlear implantation on speech perception in nontraditional pediatric CI recipients.

METHODS

Pediatric CI recipients with a history of progressive hearing loss and a preoperative 4-frequency pure-tone average of ≤75 dB HL at the time of implantation were considered for this retrospective study. Preoperative serial audiograms and word recognition scores were reviewed, and a method was created to establish a date when each individual ear 1st met nontraditional candidacy. The length of time between the date of candidacy and implantation was calculated and defined as the "delay time." A multiple linear regression investigated delay time, age at surgery, surgery type (1st vs. 2nd side), and array type as predictive factors of maximum postoperative Consonant-Nucleus-Consonant (CNC) word scores. A one-way ANCOVA was performed comparing the postoperative CNC scores between subjects grouped by delay time.

RESULTS

A significant regression was found (F(4, 38) = 5.167, p = 0.002, R2 = 0.353). Both age at implantation (p = 0.023) and delay time (p = 0.002) predicted CNC word scores. Longer delay time was associated with poorer word recognition scores, while older age at implantation correlated with higher CNC word scores in this progressive hearing loss group. A significant difference was noted between subjects implanted with <1 year of delay and those with 3 or more years of delay (p = 0.003). All ears implanted within a year of candidacy achieved word recognition abilities that are generally accepted as above average (M = 84.91).

CONCLUSION

CI candidacy for adults has evolved to allow for greater degrees of residual hearing, while audiometric guidelines for children have not changed since 2000. Our findings suggest that delay of cochlear implantation, even for children with significant levels of residual hearing, leads to poorer outcomes. Modified candidacy guidelines for children should be established to expedite referral to multidisciplinary CI teams and minimize delays in this population.

Theory-of-Mind Development in Young Deaf Children With Early Hearing Provisions

Deaf and hard-of-hearing (DHH) children born to hearing parents have profound theory-of-mind (ToM) delays, yet little is known about how providing hearing assistance early in life, through cochlear implants and hearing aids, influences their ToM development. We thus addressed (a) whether young DHH children with early hearing provision developed ToM differently than older children did in previous research and (b) what ToM understandings characterize this understudied population. Findings from 84 three- to six-year-old DHH children primarily acquiring spoken language demonstrated that accumulated hearing experience influenced their ToM, as measured by a five-step ToM scale. Moreover, language abilities mediated this developmental relationship: Children with more advanced language abilities, because of more time using cochlear implants and hearing aids, had better ToM growth. These findings demonstrate the crucial relationships among hearing, language, and ToM for DHH children acquiring spoken language, thereby addressing theoretical and practical questions about ToM development.

Preverbal Production and Early Lexical Development in Children With Cochlear Implants: A Longitudinal Study Following Pre-implanted Children Until 12 Months After Cochlear Implant Activation

Studies have shown that children vary in the trajectories of their language development after cochlear implant (CI) activation. The aim of the present study is to assess the preverbal and lexical development of a group of 20 Italian-speaking children observed longitudinally before CI activation and at three, 6 and 12 months after CI surgery (mean age at the first session: 17.5 months; SD: 8.3; and range: 10–35). The group of children with CIs (G-CI) was compared with two groups of normally-hearing (NH) children, one age-matched (G-NHA; mean age at the first session: 17.4 months; SD: 8.0; and range: 10–34) and one language-matched (G-NHL; n = 20; mean age at the first session: 11.2 months; SD: 0.4; and range: 11–12). The spontaneous interactions between children and their mothers during free-play were transcribed. Preverbal babbling production and first words were considered for each child. Data analysis showed significant differences in babbling and word production between groups, with a lower production of words in children with CIs compared to the G-NHA group and a higher production of babbling compared to the G-NHL children. Word production 1 year after activation was significantly lower for the children with CIs than for language-matched children only when maternal education was controlled for. Furthermore, latent class growth analysis showed that children with CIs belonged mainly to classes that exhibited a low level of initial production but also progressive increases over time. Babbling production had a statistically significant effect on lexical growth but not on class membership, and only for groups showing slower and constant increases. Results highlight the importance of preverbal vocal patterns for later lexical development and may support families and speech therapists in the early identification of risk and protective factors for language delay in children with CIs.

A retrospective cohort study of adverse event assessment during anesthesia-related procedures for cochlear implant candidacy assessment and cochlear implantation in infants and toddlers

BACKGROUND

Cochlear implantation in children with sensorineural hearing loss is preferably performed at youngest age because early auditory input is essential to prevent neural plasticity decline. In contrast, the rate of anesthetic adverse events is increased during infancy. Therefore, to provide recommendations regarding an optimal pediatric implantation age, these possible anesthetic risks in infants need to be taken into account.

AIMS

This study aimed at assessing the relation between the age at cochlear implant surgery and anesthetic and surgical adverse events. Secondary aims were to evaluate anesthetic and surgical adverse events in relation to (a) the number of preoperative anesthesia-related procedures for cochlear implant candidacy assessment and (b) the anesthetic maintenance agent (total intravenous anesthesia versus inhalation anesthesia) during implantation.

METHODS

We executed a retrospective cohort study to evaluate cochlear implantation performed in infants and toddlers between January 2008 and July 2015 in a tertiary pediatric center. We compared anesthetic and surgical adverse events between age-at-implantation (0-12 and 12-24 months of age) groups. Furthermore, we assessed whether anesthetic adverse events occurred during preoperative anesthesia-related procedures for cochlear implant candidacy assessment.

RESULTS

Forty-six cochlear implantations were performed in 43 patients requiring 42 preoperative anesthesia-related procedures. Nineteen cochlear implantations (41.3%) were performed during infancy. During implantation, the maintenance agent was either sevoflurane (n = 22) or propofol (n = 24). None of the patients encountered major anesthetic adverse events, whereas minor adverse events occurred during 34 cochlear implantations. Those attributed to surgery occurred following six implantations. Neither the age at implantation nor the anesthetic maintenance agent was significantly related to the occurrence of both types of adverse events.

CONCLUSIONS

Adverse events occur independent of the age at implantation, the number of anesthetic preoperative procedures, and the type of anesthetic maintenance agent in patients who received a cochlear implant before 24 months of age.

Bhopal Technique of Cochlear Implantation: A Surgical Review of 50 Cases

Cochlear Implant is the new age treatment for profound deafness especially in children who are unable to hear since birth. This is a life changing technology where in a surgically implanted device can stimulate the auditory nerve through electrical currents enabling the generation of auditory potential. Various surgical techniques have been described in literature but debate exists over Posterior Tympanotomy and Trans-canal "Veria" technique. We are presenting our experience of 50 cases with modified trans-canal technique "The Bhopal Technique" which combines the best of both. 50 patients with bilateral profound deafness in age group 1-5 years were included in this observational study. These children underwent cochlear implantation by Bhopal Technique. The data was categorised into age, gender, certain surgical parameters like time taken; exposure and complications. In present study. The average time taken for surgery was 77.6 min, with electrode insertion in first attempt in about 43 cases. Round Window exposure was adequate in 37 cases while scala tympani was entered in 49 cases. Average time taken for cochleostomy was 44.6 s. Most common complication was wound hyperemia followed by Perilymph Gusher. Explantation was seen in 1 case. Minor complications included Vertigo and Tinnitus. There was one tympanic membrane perforation at 3 months follow up and response to AVT was excellent in 12 children at 6 month follow up. Bhopal technique is emerging as a promising technique for upcoming cochlear implant surgeons due to its low complication rate, better exposure of surgical landmarks and comparable outcomes to Veria and Posterior tympanotomy techniques.

Modelling the early expressive communicative trajectories of infants/toddlers with early cochlear implants

For children with normal hearing (NH), early communication skills predict vocabulary, a precursor to grammar. Growth in early communication skills of infants with cochlear implants (CIs) was investigated using the Early Communication Indicator (ECI), a play-based observation measure. Multilevel linear growth modelling on data from six ECI sessions held at three-monthly intervals revealed significant growth overall, with a non-significant slower growth rate than that of children with NH (comparison age centred at 18 months). Analyses of gesture use and of nonword vocalisations revealed the CI group used significantly more of each, with more rapid growth. In contrast, the CI group used significantly fewer single words and multiword utterances, and with slower growth. Maternal education and time to achieve consistent CI use impacted significantly on growth for the CI sample. The results indicate that progression to vocabulary by young CI users can be supported by encouraging their use of prelinguistic communication.