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 wk after surgery. A number of children had a preimplantation 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 explantation: 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 reviews.
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, developmental stage, and response state of the child. Maximum comfort levels were obtained using language that was appropriate for each child's comprehension 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).
This study demonstrated that children who received the cochlear implant who were younger than the age of 12 mo could demonstrate language comprehension and expressive development comparable to that of their hearing peers. The rate of growth was significantly better than the rate of comprehension 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 suggests 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 cognitive delays could potentially reduce the average rate of growth for the group 2 children, the language data from children who demonstrated mild, moderate, 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 significantly 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 development 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 decreasing 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 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, receive hearing aids late/undergo implantation early, and receive hearing aids late/undergo implantation late to examine the relative influence of these variables. 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 publications.
These preliminary comprehension and expression results obtained from this group of children, coupled with the absence of anesthetic and/or surgical complications, 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 implantation 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.
The authors acknowledge the Speech Pathologists and Audiologists at the Cochlear Implant Clinic, Royal Victorian Eye and Ear Hospital, Melbourne, Australia.
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