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Communication Development in Children

Who Receive the Cochlear Implant Younger
than 12 Months: Risks versus...

Article in Ear and Hearing · May 2007

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 Communication Development in Children Who
Receive the Cochlear Implant Younger than
12 Months: Risks versus Benefits
Shani J. Dettman, Darren Pinder, Robert J. S. Briggs,
Richard C. Dowell, and Jaime R. Leigh
Background: The advent of universal neonatal
hearing screening in some countries and the avail-
ability of screening programs for at-risk infants in
other countries has facilitated earlier referral, di-
agnosis, and intervention for infants with hearing
loss. Improvements in device technology, two de-
cades of pediatric clinical experience, a growing
recognition of the efficacy of cochlear implants for
young children, and the recent change in the U.S.
Food and Drug Administration’s age criteria to in-
clude children as young as 12 mo has led to increas-
ing numbers of young children receiving cochlear
implants. Evidence to support provision for infants
younger than 12 mo is extrapolated from physiolog-
ical studies, studies of children using hearing aids,
and studies of children older than 12 mo of age with
implants. To date, however, there are few published
research findings regarding communication devel-
opment in children between 6 and 12 mo of age who
receive implants. The current study hypothesized
that earlier implantation would lead to increased
rates of language acquisition as the children were
still in the critical period for their development.
Method: A retrospective review was completed for
19 infants (mean age at implantation, 0.88 yr; range,
0.61–1.07, SD 0.15) and 87 toddlers (mean age at
implantation, 1.60 yr; range, 1.13–2.00, SD 0.24) who
received the multichannel implant in Melbourne,
Australia. Preimplantation audiological assess-
ments for these children included aided and un-
aided audiograms, auditory brain stem response,
auditory steady state response (ASSR), and oto-
acoustic emission and indicated profound to total
bilateral hearing loss in all cases. Communication
assessment included completion of the Rossetti In-
fant-Toddler Language Scale and educational psy-
chologists’ cognitive and motor assessment. Com-
puted tomography scan, magnetic resonance
imaging, and surgical records for all cases were
reviewed. Postimplantation language assessments
were reported in terms of the rate of growth over
The University of Melbourne (S.J.D., R.J.S.B., R.C.D.), Parkville,
Australia; The Cooperative Research Centre for Cochlear Im-
plant and Hearing Aid Innovation (S.J.D., R.J.S.B., R.C.D.,
J.R.L.), East Melbourne, Victoria, Australia; Cochlear Implant
Clinic (S.J.D., R.J.S.B., R.C.D., J.R.L.), Royal Victorian Eye and
Ear Hospital, East Melbourne, Victoria, Australia; Radcliffe In-
firmary (P.D.), Oxford, UK.
0196/0202/07/282 Supplement-0011S/0 • Ear & Hearing • Copyright © 2007 by Lippincott Williams & Wilkins • Printed in the U.S.A.
11S
time on the language comprehension and language
expression subscales of the Rossetti Infant-Toddler
Language Scale.
Results: Results demonstrated that cochlear im-
plantation may be performed safely in very young
children with excellent language outcomes. The
mean rates of receptive (1.12) and expressive (1.01)
language growth for children receiving implants
before the age of 12 mo were significantly greater
than the rates achieved by children receiving im-
plants between 12 and 24 mo, and matched growth
rates achieved by normally hearing peers. These pre-
liminary results support the provision of cochlear
implants for children younger than 12 mo of age
within experienced pediatric implantation centers.
(Ear & Hearing 2007;28;11S–18S)
Widespread universal newborn hearing screening
programs and increased general awareness of co-
chlear implants have resulted in increasing num-
bers of children younger than 12 mo of age being
diagnosed and referred to implantation centers. The
“earlier is better” argument as it relates to cochlear
implants is supported by evidence from physiologi-
cal studies and from studies of children using hear-
ing aids. A younger age at implantation is also
associated with optimum communication outcomes
for children with cochlear implants.
PHYSIOLOGICAL STUDIES
Auditory perception, that is, learning to listen, in
hearing children as well as children with hearing loss,
is associated with the regular occurrence of speech
events coupled with the features of attention, memory,
and meaning. If listening is not developed during the
critical language learning years, a child’s potential to
use speech input is likely to deteriorate. The key
feature of the developing auditory system is plasticity,
which is present at birth and decreases with age
(Ruben & Rapin, 1980). Evidence suggests that the
myelination occurs early in life and enables stable
neural connections to form so that memory and learn-
ing can develop (Ryugo, Limb, & Redd, 2000). The
earlier that a child receives the cochlear implant, the
12S
greater is the child’s potential to benefit from these
critical periods of neural development.
Studies regarding the human fetus’ ability to detect
sound, neonates’ preferences for their native language,
fundamental frequency and prosodic cues (of the pri-
mary caregiver), coupled with a curtailing of percep-
tual discrimination skills toward the end of the first 12
mo suggest a phonological critical period from the 6th
mo of fetal life to 12 mo chronological age (Ruben,
1997). So, from a neurolinguistic perspective, it ap-
pears possible that if phonological distinctions are not
made in the first year post-implantation, long-term
language processing difficulties will result. Ruben
(1997) suggested “insufficient early phonological input
results in flawed semantic and syntactic capacities” (p.
204).
There is also evidence from animal models and
investigations of brain plasticity that suggests that
auditory stimulation can facilitate preservation of au-
ditory structures and reverse the effects of auditory
deprivation (Matsushima, Shepherd, Seldon, Xu, &
Clark, 1991; Shepherd, Hartmann, Heid, Hardie, &
Klinke, 1997).
CHILDREN YOUNGER THAN 6 MO USING
HEARING AIDS
For children using hearing aids, many of the nega-
tive effects of hearing loss on communication develop-
ment can be prevented, or at least substantially min-
imized, if intervention and training are initiated early
in life (Hayes & Northern, 1997; Yoshinaga-Itano,
Sedey, Coulter, & Mehl, 1998). Studies have shown
that early diagnosis and appropriate intervention for
infants with hearing aids is associated with improve-
ments in receptive and expressive language skills
(Apuzzo & Yoshinaga-Itano, 1995; Markides, 1986;
Robinshaw, 1995; White & White, 1987; Yoshinaga-
Itano et al., 1998). Apuzzo and Yoshinaga-Itano (1995)
demonstrated that children who were identified and
aided in the first 2 mo of life had significantly better
language development than children identified between
3 and 12 mo of age, despite significant hearing loss.
CHILDREN USING COCHLEAR IMPLANTS
For children using cochlear implants, a younger age
at surgery is associated with optimum speech percep-
tion, speech intelligibility (Dowell, Blamey, & Clark,
1995; Nikolopoulos, O’Donoghue, & Archbold, 1999;
Waltzman & Cohen, 1998) and language outcomes
(Hammes, Novak, Rotz, Wills, Edmondson, & Thomas,
2002; Kirk, Miyamoto, Lento, Ying, O’Neill, & Fears,
2002; Svirsky, Teoh, & Neuburger, 2004).
EAR & HEARING / APRIL 2007
RISKS VERSUS BENEFITS
Cochlear implants for infants younger than 12 mo
should only be considered if the potential benefits
outweigh the potential risks of the procedure. Objec-
tions to elective surgery in very young infants are
sometimes raised with regard to the safety of gen-
eral anesthesia in this age group. Outpatient anes-
thetic studies reported mortality rates of zero in
healthy children for ophthalmological surgery
(Petruscak, Smith, & Breslin, 1973; Romano, 1981);
however, other studies reported that the risk of cardiac
arrest increased with decreasing age (Cohen, Cameron,
& Duncan, 1990; Tiret, Nivoche, Hatton, Desmonts, &
Vourc’h, 1988). A history of anesthesia, emergency
procedures, and/or fasting of less than 8 hr were risk
factors for anesthetic complications (Tiret, Nivoche,
Hatton, Desmonts, & Vourc’h, 1988). Initial findings of
the Pediatric Perioperative Cardiac Arrest Registry*
suggested that, of all cardiac arrests, 55% occurred in
infants younger than 12 mo, and 43% occurred in
infants younger than 5 mo. When data were analyzed
according to the American Society of Anesthesiologist’s
physical status classification system, it was found that
emergency procedures, not age alone, were predictive
of infant mortality (Morray et al., 2000). Pediatric
anesthesiologist’s expertise was suggested as a possi-
ble factor in the incidence of critical pediatric periop-
erative events (Keenan, Shapiro, & Dawson, 1991),
but the Pediatric Perioperative Cardiac Arrest Regis-
try data, being from larger university-based and chil-
dren’s hospitals, not smaller and community hospitals,
did not add support to this finding.
Waltzman and Cohen (1998) reported on the safe
implantation of children between the ages of 12 and 24
mo. No additional surgical risk was reported for the
younger children. The authors, however, acknowl-
edged the difficulties inherent in documenting speech
perception improvement with this young group due to
the nature of the assessment materials. It was not
possible to make valid comparisons with older children
due to the differences in linguistic knowledge. Nikolo-
poulos et al. (1999) stated the need for long-term
follow-up as children who were older at implantation
initially performed tests better due to advanced cogni-
tive skills, longer exposure to language, and greater
familiarity with test conditions. This advantage grad-
ually diminished over time as the children who were
younger at implantation gradually overtook and out-
performed them. Lesinski-Schiedat, Illg, Heermann,
Bertram, and Lenarz (2004) reported there was no
higher incidence of surgical complications, and higher
*
The Pediatric Perioperative Cardiac Arrest Registry is an
U.S.-based registry that was established to collect data regarding
pediatric cardiac arrests and deaths in the perioperative and
immediate postoperative period and analyze causal relationships.
EAR & HEARING, VOL. 28 NO. 2 SUPPLEMENT
mean speech perception scores for 27 children who
were implanted under 12 months compared to 89
children implanted between 12 and 24 months (both
group being tested at 2½ yr of age). The problem with
reporting results in this way is that the younger group
had, on average, 18 to 24 mo of device experience,
whereas the older group had, on average, less than 12
mo and in some cases only 6 mo of device experience.
Cochlear implantation was reported to be safe and
facilitated normalization of babbling in 10 infants who
underwent implantation before 12 mo (Colletti,
Carner, Miorelli, Guida, Colletti, & Fiorino, 2005). Full
insertions without perioperative or immediate postop-
erative surgical complications, and the development of
auditory perception (Infant-Toddler Meaningful Audi-
tory Integration Scale, open-set words and sentences)
was reported for 18 children who received implants
before 12 mo of age (Waltzman & Roland, 2005). One
child underwent successful reimplantation after
wound breakdown (thought to be due to eyeglass
frame irritation) after 12 mo of device use. Anecdotal
reports from parents and teachers indicated good
development of speech production and language
skill, but formal tests of language were not yet
reported for this group.
LANGUAGE OUTCOMES
For children who were old enough to complete
formal test procedures, language data are customarily
reported in terms of the difference between the child’s
chronological and equivalent language age, gap index
(El-Hakim, Levasseur, Blake, Papsin, Panesar,
Mount, Steven, & Harrison, 2001), rate of growth over
time, and/or developmental trajectory (Svirsky, Teoh,
& Neuburger, 2004). Studies suggest that for children
receiving cochlear implants during the critical lan-
guage period, deficits associated with profound hear-
ing loss may be minimized (Bollard, Shute, Popp, &
Parisier, 1999; El-Hakim, Levasseur, Blake, Papsin,
Panesar, Mount, Steven, & Harrison, 2001; Novak,
Firszt, Rotz, Hammes, Reeder, & Willis, 2000; Rob-
bins, Bollard, & Green, 1999; Robbins, Svirsky, &
Kirk, 1997; Svirsky, Teoh, & Neuburger, 2004; Truy,
Lina-Granade, Jonas, Martinon, Maison, Girard, Porot,
& Morgon, 1998). Language outcomes for children
with cochlear implants, however, vary considerably,
and there are complex interactions between preex-
isting child and family characteristics, child intelli-
gence, hearing thresholds, device used, mode of commu-
nication, and age (Connor, Hieber, Arts, & Zwolan,
2000; Dowell, Dettman, Blamey, Barker, & Clark,
2002; Geers, Nicholas, & Sedey, 2003; Musselman,
Lindsay, & Wilson, 1988).
Studies examining the impact of the cochlear
implant on language development need to select
13S
appropriate early indicators of language progress,
rather than wait for the child to perform formal test
procedures. Nott, Cowan, Brown and Wigglesworth
(2003) used the Rossetti Infant-Toddler Language
Scale (RI-TLS) (Rossetti, 1990) in addition to the
MacArthur Communicative Developmental Invento-
ries and parental diary entries to chart early lexical
development in young children with profound hear-
ing loss using cochlear implants and/or hearing aids.
Good correlations were found between the diary
entries, RI-TLS, and the Communicative Develop-
mental Inventories.
RATIONALE
The aim of the present study was to examine the
receptive and expressive language growth of chil-
dren who received implants before 12 mo of age
compared to children who received them between 12
and 24 mo of age and to determine the prevalence of
surgical and/or anesthetic complications. As most
cochlear implantation centers do not routinely pro-
ceed with children younger than 6 mo, it is not yet
possible to replicate the studies by Apuzzo and
Yoshinaga-Itano (1995) or Yoshinaga-Itano et al.
(1998), but it is possible to examine children using
cochlear implants from 6 mo onward. Accurate
records regarding prevalence of mapping and/or
device problems are required as preverbal children
may be unable to report changes in their hearing.
Given potentially greater surgical and anesthetic
risks in those younger than 12 mo of age, improved
dissemination of appropriate evidence is required
for parents trying to decide whether to proceed with
cochlear implantation.
METHOD
There were 106 children who received the Co-
chlear Ltd. multichannel implant at the Melbourne
Cochlear Implant Clinic before the age of 24 mo.
Each had profound bilateral sensorineural hearing
loss, used the ACE or SPEAK speech-processing
strategy with SPrint, ESPrit 3G, or Freedom speech
processors, and used a range of communication
modes. There were 19 children in group 1 (mean age
at implantation, 0.88 yr; range, 0.61–1.07; SD 0.15)
and 87 toddlers in group 2 (mean age at implanta-
tion, 1.60 yr; range, 1.13–2.00; SD 0.24). Individual
demographic and developmental features for the 19
children who underwent implantation at younger
than 12 mo of age are given in Table 1. Statistical
comparisons between groups 1 and 2 for hearing
level and cognitive status are given in Table 2.
14S EAR & HEARING / APRIL 2007

TABLE 1. Individual demographic and audiological data for group 1 (N ⴝ 19)

Onset of Age at Age at Duration

L PTA R PTA profound hearing implantation of profound Comm Cognitive
Case Sex unaided unaided Etiology loss (yr) aid (yr) (yr) loss (yr) mode† status‡
1 M 100** 100* Unknown 0 0.50 0.61 0.61 5 0
2 M 113* 115 Connexion 26 0 0.33 0.64 0.64 5 1
3 M 100 100* Family history 0 0.33 0.65 0.65 2 1
4 M 120 120* Unknown 0.08 0.25 0.75 0.67 5 1
5 F 110* 110** Family history 0 0.50 0.75 0.75 5 1
6 M 110* 110 Unknown 0 0.58 0.81 0.81 5 1
7 M 115* 115 Family history 0 0.17 0.84 0.84 5 1
8 F 120 123* Unknown 0 0.25 0.85 0.85 5 1
9 M 118* 115 Neonatal O2/gentamicin 0 0.25 0.86 0.86 5 1
10 F 113 110* Connexion 26 0 0.17 0.90 0.90 5 1
11 F 125* 125 Unknown 0 0.50 0.97 0.97 Spec 2
12 M 105* 105 Unknown 0 0.21 0.97 0.97 5 1
13 M 120* 115 Connexion 26 0 0.33 1.00 1.00 5 0
14 F 120** 120* Unknown 0.66 0.75 1.01 0.35 5 1
15 M 125* 125 Meningitis 0.5 0.66 1.04 0.54 Spec 5
16 F 125* 125 Unknown 0 0.25 1.05 1.05 5 1
17 M 117* 107 Unknown 0 0.83 1.05 1.05 5 1
18 F 110* 110 Unknown 0 0.75 1.06 1.05 2 1
19 F 120* 120 Connexion 26 0 0.25 1.07 1.07 5 1
Mean 113.25 115.92 0.07 0.41 0.88 0.82
Min 100.00 105.00 0.00 0.17 0.61 0.35
Max 120.00 125.00 0.66 0.83 1.07 1.07
SD 9.43 6.79 0.18 0.21 0.15 0.20

* Implanted ear, ** Second implanted ear.

†
Comm (communication) mode (1– 6) as defined by Geers and Brenner (2003).
‡
Cognitive status: 0 ⫽ accelerated, 1 ⫽ normal, 2 ⫽ borderline cognitive delay, 3 ⫽ mild, 4 ⫽ moderate, 5 ⫽ severe global delay.
L PTA, left pure-tone average; R PTA, right pure-tone average; Spec, specialized early intervention.

Cognitive Assessment achieved. All six subscales including Interaction-At-

All children completed a standardized psychologi-
cal, cognitive, and motor evaluation by an educational
psychologist, using a range of assessment materials
suitable for the age and developmental level of each
child. There was one group 1 child with severe global
delay (after meningitis), and eight group 2 children
who had mild, moderate, or severe cognitive delay.
tachment, Pragmatics, Gesture, Play, Language Com-
prehension (LC), and Language Expression (LE) were
administered. Results are reported for 11 group 1
children and 36 group 2 children who completed two or
more RI-TLS over time. The slope of the linear regres-
sion lines through the available data points for the
subscales LC and LE were derived.

Language Assessment Surgical

The RI-TLS (Rossetti, 1990) uses a combination of
author observations, developmental hierarchies, and
behaviors recognized by leading authorities in the field
of infant/toddler assessment to assess the language
skills of children from birth to 36 mo of age. The
RI-TLS differs from other rating scales as it is appro-
priate for use from birth through to 3 yr of age and
examines mastery or emergence of important aspects of
preverbal and verbal interaction such as interaction-
attachment, pragmatics, gesture, and play, in addition to
76 language comprehension and 93 language expression
milestones. These milestones may be observed, elicited,
or reported by the clinician and/or the primary caregiver
within an interview/play interaction session.
It was desirable to obtain at least one test admin-
istration of the RI-TLS pre-implantation and at yearly
intervals post-implantation, but this was not always
Computed tomography, magnetic resonance imag-
ing, anesthetic, and surgical records for all 106 chil-
dren were reviewed. In all cases, a minimally invasive
surgical approach was used similar to that described
by O’Donoghue and Nikolopoulos (2003). Before rever-
sal of anesthesia, a plain radiograph of the mastoid
was taken to check the position of the electrode. The
functional status of the implant was tested with im-
pedance and neural response telemetry. A head ban-
dage was applied.
RESULTS
Rate of Language Growth
For the 11 group 1 subjects, the individual rates
of growth for LC and LE are given in Figures 1 and
EAR & HEARING, VOL. 28 NO. 2 SUPPLEMENT 15S

TABLE 2. Comparison of groups 1 and 2

Group 1, Group 2,
Variable CI ⬍12 mo CI 12–24 mo Two-sample t-test
No. of children 19 87
Age at hearing aid (yr)
Mean 0.41 0.92 t ⫽ ⫺8.11, p ⬍ 0.000
SD 0.21 0.36
Age at implantation (yr)
Mean 0.88 1.60
Range 0.61–1.07 1.13–2.00
SD 0.15 0.24
No. children with cognitive delay 1 8
Degree of cognitive delay
Mean 1.16 1.27 t ⫽ ⫺0.45, p ⬍ 0.658, ns
SD 1.01 0.85
3 Freq PTA dB (best ear)
Mean 113.95 114.03 t ⫽ ⫺0.04, p ⬍ 0.966, ns
SD 7.81 9.34
No. of children completed ⱖ2 RI-TLS 11 36
Age at hearing aid (yr)
Mean 0.42 0.91 t ⫽ ⫺5.55, p ⬍ 0.000
SD 0.23 0.34
Age at implantation (yr)
Mean 0.89 1.56
Range 0.61–1.07 1.15–2.00
SD 0.15 0.25
3 Freq PTA dB (better ear)
Mean 111.5 113.0 t ⫽ ⫺0.55, p ⬍ 0.584, ns
SD 6.58 10.8
No. of children with cognitive delay 0 6
Degree of cognitive delay
Mean 0.82 1.40 t ⫽ ⫺3.14, p ⬍ 0.003
SD 0.41 0.84
LC growth
Mean 1.12 0.71 t ⫽ 3.50, p ⬍ 0.001
Range 0.78 –1.62 0.0 –2.00
SD 0.265 0.514
LE growth
Mean 1.01 0.68 t ⫽ 3.38, p ⬍ 0.002
Range 0.73–1.45 0.00 –1.56
SD 0.215 0.436
No. of children (mild, moderate, severe cognitive delay removed) 11 30
Degree of cognitive delay
Mean 0.818 1.050 t ⫽ ⫺1.82, p ⬍ 0.096, ns
SD 0.405 0.201
LC growth
Mean 1.12 0.78 t ⫽ 2.71, p ⬍ 0.011
Range 0.78 –1.62 0.0 –2.00
SD 0.265 0.521
LE growth
Mean 1.01 0.73 t ⫽ 2.67, p ⬍ 0.011
Range 0.73–1.45 0.00 –1.56
SD 0.215 0.443

CI, cochlear implant; PTA, pure-tone average; RI-TLS, Rossetti Infant-Toddler Language Scale; LC, language comprehension; LE, language expression.

2, respectively. There was a significant difference
between the average rate of growth for LC for group
1 (1.12) and group 2 (0.71) (t ⫽ 3.50, p ⬍ 0.001)
(Table 2). There was also a significant difference
between the rate of growth for LE for group 1 (1.01)
and group 2 (0.68) (t ⫽ 3.38, p ⬍ 0.002) (Table 2).
When data from all children with cognitive delay
were removed from the analysis, the difference be-
tween the rates of growth remained statistically
significant (Table 2).
Surgical and Programming Considerations
Most children were discharged from the hospital
1 d after surgery and reviewed in the clinic after 1
wk. Activation of the device usually took place 2 to 3
16S
Fig. 1. Individual growth rates for Language Comprehension
(LC) subscale of the Rossetti Infant-Toddler Language Scale
(RI-TLS); group 1 (n ⴝ 11).
wk after surgery. A number of children had a pre-
implantation history of ear infections that required
careful management. One group 1 child presented
with mastoiditis 6 d after discharge that resolved
after readmission for intravenous antibiotics. There
were three group 2 children who underwent explan-
tation: one for infection after trauma (fall from a
child’s seat) at 4 mo post-implantation, one due to an
unknown cause of device failure at 9 mo post-
implantation, and one due to device failure (after a
blow to the head) at 3 yr post-implantation. All three
children underwent successful reimplantation and
attended regular otological and audiological re-
views.
Appropriate threshold levels were obtained for all
children using visual reinforcement audiometry
(Moore, Thompson, & Thompson, 1975; Moore &
Wilson, 1978) and/or play audiometry (Wilson &
Thompson, 1984) depending on the age, develop-
mental stage, and response state of the child. Max-
imum comfort levels were obtained using language
that was appropriate for each child’s comprehension
Fig. 2. Individual growth rates for Language Expression (LE)
subscale of Rossetti Infant-Toddler Language Scale (RI-TLS);
group 1 (n ⴝ 11).
EAR & HEARING / APRIL 2007
and were checked by eliciting an auropalpebral
reflex (eye blink in response to a loudness discomfort
level) and subsequently reducing levels by 30%
(Rance & Dowell, 1997).
DISCUSSION
This study demonstrated that children who re-
ceived the cochlear implant who were younger than
the age of 12 mo could demonstrate language com-
prehension and expressive development comparable
to that of their hearing peers. The rate of growth
was significantly better than the rate of comprehen-
sion and expressive growth demonstrated by a group
of children who received the implant between 12 and
24 mo of age.
The relationship between cognitive status and
communication outcomes in previous literature sug-
gests that children with cochlear implants who also
demonstrate cognitive delays tend to progress more
slowly than other children in the areas of speech
perception (Dowell, Dettman, Blamey, Barker, &
Clark, 2002; Isaacson, Hasenstab, Wohl, & Williams,
1996; Pyman, Blamey, Lacy, Clark, & Dowell, 2000;
Tomov, Dettman, Barker, Dowell, Williams, &
Hughes, 2002; Waltzman, Scalchunes, & Cohen,
2000) and language (Dettman, Tomov, Dowell,
Barker, Hughes, Williams, & Saldic, 2003). As cog-
nitive delays could potentially reduce the average
rate of growth for the group 2 children, the language
data from children who demonstrated mild, moder-
ate, or severe delay were removed from the analysis.
This had the effect of improving the group 2 mean
rate of LC from 0.71 to 0.78 and LE from 0.68 to
0.73, but these rates were still statistically signifi-
cantly poorer than the rates demonstrated by group
1 children. The poorest group 1 rates of development
of LC (case 18, 0.78) and LE (case 4, 0.73) were
coincidentally the same as the average group 2 rates
(LC ⫽ 0.78, LE ⫽ 0.73).
Reporting of the language results in terms of the
slope of the child’s receptive and expressive devel-
opment over a consistent time interval proved useful
in this study. Making comparisons with normalized
data for hearing children then enables clinicians to
determine whether the gap between the children’s
chronological and equivalent language age is de-
creasing or increasing over time.
The finding that children who receive a cochlear
implant at a younger age demonstrate better
postimplantation language outcomes is consistent
with previous research (Brackett & Zara, 1998;
Hammes et al., 2002; Miyamoto, Houston, Kirk,
Perdew, & Svirsky, 2003; Robbins, 2000; Yoshinaga-
Itano et al., 1998). It must be noted that the average
age at hearing aid fitting was also significantly
EAR & HEARING, VOL. 28 NO. 2 SUPPLEMENT
different for group 1 (0.41 yr) and group 2 (0.92).
Future research may consider cohorts of children
matched for cognitive status, who variously receive
hearing aids early/undergo implantation early, re-
ceive hearing aids late/undergo implantation early,
and receive hearing aids late/undergo implantation
late to examine the relative influence of these vari-
ables. It was not within the scope of this article to
report on speech perception outcomes for this group
of children; speech perception and emerging babble
production will be the focus of subsequent publica-
tions.
CONCLUSIONS
These preliminary comprehension and expression
results obtained from this group of children, coupled
with the absence of anesthetic and/or surgical com-
plications, provides support for the consideration of
cochlear implants for children younger than 12 mo
of age. The children who underwent implantation at
younger than 12 mo of age achieved mean rates of
receptive (1.12) and expressive (1.01) language
growth that were comparable to their normally
hearing peers and were significantly greater than
the rates achieved by children who underwent im-
plantation between 12 and 24 mo of age. If normal
rates of language acquisition can be maintained in
this group, earlier cochlear implantation represents
a cost benefit to the community due to improved
employment opportunities and reduced reliance on
specialized psychosocial and educational support.
ACKNOWLEDGMENTS
The authors acknowledge the Speech Pathologists and Audiolo-
gists at the Cochlear Implant Clinic, Royal Victorian Eye and Ear
Hospital, Melbourne, Australia.
Address for correspondence: Dr. Shani Dettman, Cochlear Im-
plant Clinic, The Royal Victorian Eye and Ear Hospital, 32
Gisborne Street, East Melbourne, 8002, Victoria, Australia.
E-mail: sdettman@bionicear.org.
Received December 15, 2005; accepted May 17, 2006.
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