title: An exploratory look at pediatric cochlear implantation: is earliest always best?
abstract: OBJECTIVE
  Since the advent of cochlear implants, age at implantation has declined as investigators report greater benefit the younger a child is implanted. Infants younger than 12 mos currently are excluded from Food and Drug Administration clinical trials, but have been implanted with Food and Drug Administration-approved devices. With a chance that an infant without profound hearing loss could be implanted because of the limitations of the diagnostic measures used with this population and the potential for additional anesthetic risks to infants younger than 1-yr-old, it is prudent to evaluate benefit in the youngest cochlear implant recipients. The goals of this research were to investigate whether significant gains are made by children implanted before 1-yr-old relative to those implanted at later ages, while controlling for potential covariates, and whether there is behavioral evidence for sensitive periods in spoken language development. It was expected that children implanted before age 1 yr would have more advanced spoken language skills than children implanted at later ages; there would be a negative relationship between age at implantation and rate of spoken language development, allowing for an examination of the effects of sensitive periods in spoken language development; and these trends would remain despite accounting for participant characteristics and experiences that might influence spoken language outcomes.
  
  
  METHODS
  Ninety-six children with congenital profound sensorineural hearing loss bilaterally and no additional identified disabilities who were implanted before the age of 4 yrs were stratified into four groups based on age at implantation. Children's spoken language development was followed for at least 2 yrs after device activation. Spoken language scores and rate of development were evaluated along with four covariates (unaided pure-tone average, communication mode, gender, and estimated family income) as a function of age at implantation.
  
  
  RESULTS
  In general, the developmental trajectories of children implanted earlier were significantly better than those of children implanted later. However, the advantage of implanting children before 1-yr old versus waiting until the child was between 1 and 2 yrs was small and only was evident in receptive language development, not expressive language or word recognition development. Age at implantation did not significantly influence the rate of the word recognition development, but did influence the rate of both receptive and expressive language acquisition: children implanted earlier in life had faster rates of spoken language acquisition than children implanted later in life.
  
  
  CONCLUSIONS
  Although in general earlier cochlear implantation led to better outcomes, there were few differences in outcome between the small sample of six children implanted before 12 mos of age and those implanted at 13 to 24 mos. Significant performance differences remained among the other age groups despite accounting for potential confounds. Further, oral language development progressed faster in children implanted earlier rather than later in of life (up to age 4 yrs), whereas the rate of open-set speech recognition development was similar. Together, the results suggest that there is a sensitive period for spoken language during the first 4 yrs of life, but not necessarily for word recognition development during the same period.
authors.affiliation: Department of Speech and Hearing Sciences, Indiana University, Bloomington, Indiana, USA.
authors.forename: Rachael Frush
authors.initials: RF
authors.lastname: Holt
authors.forename: Mario A
authors.initials: MA
authors.lastname: Svirsky
mesh_terms: D000367:Age Factors; D001300:Audiometry, Evoked Response; D001301:Audiometry, Pure-Tone; D001309:Auditory Threshold; D002648:Child; D002675:Child, Preschool; D019929:Cochlear Implantation / Q000379:methods*; D003423:Critical Period, Psychological; D003638:Deafness / Q000175:diagnosis / Q000534:rehabilitation*; D003936:Diagnosis, Computer-Assisted; D006801:Humans; D007223:Infant; D007805:Language Development Disorders / Q000175:diagnosis / Q000534:rehabilitation; D017084:Otoacoustic Emissions, Spontaneous; D011379:Prognosis; D012680:Sensitivity and Specificity; D012984:Software; D013069:Speech Reception Threshold Test