CLINICAL Cochlear Implants in Infants and Toddlers

REVIEW
Indexing Metadata/Description
› Device/equipment: Cochlear Implants in Infants and Toddlers
› Synonyms: Bionic ear; assistive listening device; implants, cochlear in infants and
toddlers; auditory prosthesis in infants and toddlers; prosthesis, auditory in infants and
toddlers; cochlear prosthesis in infants and toddlers; prosthesis, cochlear in infants and
toddlers
› Area(s) of specialty: Hearing Impairment
› Description/use: A cochlear implant (CI) is a small, partially implanted electronic device
that provides a person with a profound hearing loss a representation of sound from the
environment.(1) A CI contains components that are located outside of a person’s body
(external portion) as well as parts that are implanted (implanted portion). The external
portion includes a microphone, a sound processor, and a transmitter system, which
transmits speech signals to the receiver-stimulator. The external portion is removable and
is powered by batteries, much like traditional hearing aids. The implanted portion includes
a receiver-stimulator, which converts information from the transmitter into electric
impulses, and an electrode system. The electrode system, which is threaded through the
cochlea, transports the electrical impulses to the auditory nerve. The external and internal
systems are held next to each other by an implanted magnet which works through the
person’s skin(1,2,3)
› Indications: Children who are permanently profoundly deaf or have severe, bilateral
hearing impairment are typically good candidates for CIs; however, hearing threshold is
only one factor when considering a child’s candidacy for a CI(1,4,61)
• Although the United States Food and Drug Administration (FDA) has approved
multichannel CIs for implantation in children as young as 12 months of age, many
children younger than 12 months have received CIs off-protocol(5,6)
–Authors of a review of the literature found that evidence of the auditory and linguistic
benefits of CI implantation outweigh the risks in children under age 12 months with an
experienced surgeon and pediatric anesthesiologist(7)
Author –In a retrospective chart review study conducted in Australia, researchers found that
Natasha Kanapathy, MA, CCC-SLP better communication development was associated with early implantation. Subjects in
Cinahl Information Systems, Glendale, CA the study were 35 children implanted between 6 and 12 months of age and 85 children
implanted between 13 and 24 months of age. Outcome measures of language, speech
Reviewers production, and speech perception were taken at 1, 2, 3, and 5 years post implantation;
Amory Cable, PhD, CCC-SLP
American Speech-Language-Hearing
subjects who had been implanted prior to 12 months of age performed significantly
Association (ASHA) better than those who received the CI after 12 months of age(43)
Rehabilitation Operations Council –Implantation after 12 months of age is common among children with progressive
Glendale Adventist Medical Center,
Glendale, CA
hearing loss because they often are not candidates for CI at the time their hearing
impairment initially is diagnosed. Children with known progressive hearing loss
Editor should be monitored frequently to determine when they are appropriate candidates for
Sharon Richman, MSPT implantation(56)
Cinahl Information Systems, Glendale, CA
• Children with the following diagnoses might be candidates for a CI:
– Sensorineural hearing loss(3)
November 2, 2018 – Auditory neuropathy(3)

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professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 –Meningitis followed by hearing loss(3)
–Otosclerosis(3)
–Inner ear malformations(3)
• Authors of a systematic review of the literature on cochlear implantation for children with unilateral hearing loss published
in 2016 reported that CIs for these children might be an effective treatment for improving quality of life and speech
perception; however, they were unable to draw firm conclusions due to the variability in study methodologies and the
heterogeneity of study findings and outcome measures. There were only 5 articles that met criteria for this systematic
review and the studies had small sample sizes(59)
• The following risks are associated with CIs
–Risks associated with receiving general anesthesia(2)
–Facial nerve could become damaged during surgical implantation(2)
–Meningitis could occur (especially in individuals with inner ears that are abnormally formed)(2)
–Cerebrospinal fluid could leak(2)
–Perilymph fluid could leak(2)
–Skin wound could become infected(2)
–Blood or fluid could collect at the site of surgery(2)
–Dizziness or vertigo could develop(2)
–Tinnitus(2)
–Taste sensation could be disturbed(2)
–The ear could become numb(2)
–The body could reject the implant, leading to localized inflammation and a reparative granuloma (localized inflammation
that occurs if the body rejects the implant)(2)
–Sounds might be perceived differently than prior to surgery(2)
–Residual hearing will be lost(2)
–Long-term effects are unknown and uncertain(2)
–Hearing abilities following surgery vary among patients; results might be disappointing(2)
–Language comprehension following surgery varies among patients; results might be disappointing(2)
–Certain medical procedures cannot be performed following CI:
- MRI (an MRI can dislodge the CI or cause the internal magnet to demagnetize; however, two multichannel CIs exist that
can undergo 1.5 Tesla MRI imaging in certain conditions)(2,6)
- Neurostimulation(2)
- Electrical surgery(2)
- Electroconvulsive therapy(2)
- Ionic radiation therapy(2)
–CI might need to be removed if infection occurs(2)
–CI could fail(2)
–As CI technology improves, the patient might not be able to upgrade to new CI if new external parts are not compatible
with existing internal portion(2)
–CI is dependent upon batteries to function(2)
–There is a risk of damaging the CI (e.g., external portions might be damaged if they become wet)(2)
–Patient might need to make lifestyle changes(2)
–Skin might become irritated due to placement of external portions(2)
–Strange sounds might be heard when in the presence of magnetic fields (e.g., near airport passenger screening
machines)(2)
 –There is a large amount of opposition to CI use in the Deaf community. Many members of this community believe that CI
use is not culturally responsive in that it prevents CI users from being complete members of the community, implies that
deafness is a disability (a belief that the Deaf community adamantly opposes), and implies that Deaf persons are of lesser
worth(46,47)
› CPT codes
• 92601 cochlear implant follow-up exam (under age 7)
• 92602 reprogramming of cochlear implant (under age 7)
• 92507 aural rehabilitation
› ICD-10 codes
• Z96.21 cochlear implant status
(ICD codes are provided for the reader’s reference, not for billing purposes)
› G-Codes
• Spoken Language Comprehension G-code set
–G9159, Spoken language comprehension functional limitation, current status at therapy episode outset and at reporting
intervals
–G9160, Spoken language comprehension functional limitation, projected goal status at therapy episode outset, at reporting
intervals, and at discharge or to end reporting
–G9161 Spoken language comprehension functional limitation, discharge status at discharge from therapy or to end
reporting
• Spoken Language Expressive G-code set
–G9162, Spoken language expression functional limitation, current status at therapy episode outset and at reporting
intervals
–G9163, Spoken language expression functional limitation, projected goal status at therapy episode outset, at reporting
intervals, and at discharge or to end reporting
–G9164, spoken language expression functional limitation, discharge status at discharge from therapy or to end reporting
› Reimbursement: CIs are now recognized as standard treatment for severe-to-profound sensorineural hearing impairment,
and most insurance companies cover the cost of implantation(2)
• As of 2004, Medicare, Medicaid, the Veterans Benefits Administration (see http://www.benefits.va.gov/benefits/), and over
90% of all commercial health plans cover CIs in the United States(2)
• CI centers will often take the responsibility of obtaining authorization from the patient’s insurance company prior to
proceeding with surgery(2)

.
G-code Modifier Impairment Limitation Restriction
CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent impaired, limited or
restricted
CJ At least 20 percent but less than 40 percent impaired, limited
or restricted
CK At least 40 percent but less than 60 percent impaired, limited
or restricted
CL At least 60 percent but less than 80 percent impaired, limited
or restricted
CM At least 80 percent but less than 100 percent impaired, limited
or restricted
CN 100 percent impaired, limited or restricted
Source: http://www.cms.gov

.
Indications for device/equipment
› Children who are profoundly deaf, have a significant, permanent hearing loss, or have another type of hearing disorder (as
listed above) are candidates for a CI(1,3,5)
• Although children with cognitive impairment and developmental disabilities can benefit from a CI, it is more difficult to
anticipate outcomes and there might be significantly greater risks associated with surgery for these children(8,45,60)
› According to current FDA guidelines, in order to receive a CI a child must have a significant hearing loss, display a lack of
auditory development even when using hearing aids, and be medically fit for surgery(9)
• 95% of deaf children are born to parents with normal hearing; CI implantation can improve parent-child bonding between
parents with normal hearing and their hearing-impaired infants(7)
› Prior to being approved for a CI, a child must undergo audiological, otologic, ophthalmologic, physical, auditory skill, and
language assessments(4,5)
› Prior to receiving a CI, the expectations of the child’s family should be evaluated to confirm that they are realistic.
Additionally, prior to implantation, the family should receive information on the requirements for programming and aural
rehabilitation following implantation. Characteristics displayed by family members that may hinder progress following
implantation should be identified and addressed if necessary(4)

Guidelines for use of device/equipment

› The FDA regulates the development and manufacturing of CIs available in the United States. CIs must be deemed safe and
effective prior to FDA approval(2)
› Typically, a child’s family/caregiver and surgeon work collaboratively to determine which type of CI best meets the patient’s
needs(5)
› A CI can be implanted unilaterally or bilaterally; however, a growing body of evidence regarding CI implantation supports
early, bilateral implantation of CIs in congenitally deaf children in order to achieve the best auditory and linguistic
outcomes.(10,11,12,54) In children with asymmetrical hearing loss, unilateral implantation might be performed initially
with a hearing aid used on the less impaired ear.(51) In some cases, the unilateral CI is sufficient, but a second CI might be
necessary in cases in which optimal outcomes are not achieved or hearing in the better ear worsens over time(51)
• Despite the fact that evidence supports early implantation, there are sometimes barriers to early implantation of CI in
children with hearing loss. Researchers in Australia found that, in a sample of 417 children who received a CI before the
age of 3, children with stable (nonprogressive) hearing losses, higher socioeconomic status, and those who had been fitted
for hearing aids earlier in life were more likely to have cochlear implantation at an earlier age compared to children without
these characteristics(58)

Contraindications/Precautions to device/equipment
› There are two primary questions that must be addressed when considering cochlear implantation in a child: 1) Do the
benefits of a CI outweigh the risks associated with this type of intervention? 2) Will CIs provide greater benefit to the child
and facilitate communication significantly more than traditional amplification (e.g., hearing aids)?(4)
› A child’s family must make an ongoing commitment of time and resources following implantation. Is the child’s family able
to make this commitment?(4)
› In order to determine whether a child is a good candidate for a CI, input from professionals in several fields is required.
An audiologist and CI surgeon will be the primary professionals involved in the decision-making process; however,
speech-languagepathologists (SLPs), aural rehabilitation specialists, psychologists, social workers, occupational therapists,
and/or early intervention specialists are often among the professionals involved in preimplantation assessment as well(5,9)
› Cochlear nerve deficiency (seen on MRI) is a marker of very poor outcomes with CI(13)
› There is an increased, life-threatening risk of bacterial meningitis in patients with CIs; the U.S. Centers for Disease Control
and Prevention (CDC) and FDA recommend fully immunizing persons who receive CIs against bacterial meningitis(2)
• Children implanted with CIs that have a positioner were at greatest risk; however, the only model with a positioner was
withdrawn from the market in 2002(2)
› The SLP should carefully review all audiological and medical records before evaluating or treating a child at any stage in the
implantation process (i.e., before or after implantation)
› A child and family’s cultural and linguistic background should be considered to determine the appropriateness of
examination and therapy materials

Examination
› Contraindications/precautions to examination
• Assessments conducted prior to implantation should be conducted by SLPs who have experience in postimplantation
management and rehabilitation(4)
• During a preimplantation assessment, the family should be presented with alternative rehabilitative options (e.g., use of
hearing aids or signed languages)(4)
• When assessing a young child, both prior to cochlear implantation and following implantation, developmentally
appropriate practices must be used. This may include dividing assessment time into multiple sessions and relying heavily
on parental report for an accurate picture of the child’s skills(4,14)
• SLPs must review all medical and audiological evaluation reports prior to conducting a speech-language assessment
• During a speech-language evaluation, it is of utmost importance to be aware of and sensitive to a child’s level of frustration
• Prior to surgery, the child’s family/caregivers should receive counseling on the potential risks and benefits of
implantation(5)
• Prior to surgery, the patient’s family/caregivers should be educated on the components of a CI and the daily responsibilities
of CI use(5)
• Prior to surgery, the SLP should discuss the range of possible speech and language outcomes with the child’s family/
caregivers(5)
› History
• History of present illness/injury
–Mechanism of injury or etiology of illness: Document the etiology and history of the patient’s hearing loss.(5) In cases
with congenital absence of neural foramina and acoustic tumors, auditory nerve innervation may not be possible and
thus a CI is inappropriate. In cases of hearing loss resulting from structural abnormalities, if a CI is determined to be
appropriate electrode placement must be carefully considered and/or adjusted.(4) Decisions such as these will be made by
the CI surgeon
–Course of treatment: A trial period with a hearing aid is highly recommended; the child’s response to the hearing aid
during this period will help to determine whether the child is a good candidate for CI. A child’s willingness to tolerate
wearing a hearing aid could indicate a likelihood of success in wearing of external CI components. However, a child who
is unwilling to wear a hearing aid could still be appropriate for a CI in order to access auditory information(4)
- Medical management: Document previous use of hearing aids and/or other amplification devices (e.g., FM systems)
and examine audiograms (if available) that illustrate the patient’s pure tone thresholds with and without the use of
amplification
- Medications for current illness/injury: Determine what medications (if any) physician has prescribed; are they being
taken?
–Diagnostic tests completed: Usual tests to determine candidacy for a CI are described below. In addition, a child’s
speech, language, and auditory skills should be assessed regularly following implantation to determine if the child is
meeting developmental benchmarks(9)
- High-resolution computerized tomography (HRCT), CT, and/or MRI should be conducted by the appropriate medical
professional in order to evaluate accessibility of the cochlea, identify or rule out any structural abnormalities of the inner
ear, assess the temporal bone, and assess cochlear nerve integrity(2,5,6)
- Audiologic evaluation to determine:
- Presence and degree of hearing loss
- Preoperative hearing status, including a complete audiogram, air and bone conduction thresholds, and speech
perception testing (when age appropriate)(2,5)
- Patient’s previous use of amplification systems, such as hearing aids, and results of amplification use(5)
- Need for trial period of a less permanent type of amplification (i.e., hearing aids) in patients who have not previously
used amplification(5)
 - Physical examination to determine:
- State of general physical health(4,5)
- Ability to tolerate general anesthesia(2,4,5)
- Ability to participate in postimplantation training(5)
- Physical state of the patient’s cochlea and inner ear(2,5)
- Visual skills/acuity: can the child use vision to support language development as his or her auditory skills develop?
Does the child display visual abnormalities associated with congenital sensorineural deafness (e.g., strabismus)?
Does the child have visual symptoms that are associated with other conditions (e.g., Usher syndrome, rubella
retinopathy)?(4)
- Psychological evaluation to assess:
- Parental expectations regarding outcomes following implantation(4)
- Patient and family/caregiver’s ability to cope with having a CI(2)
- Patient and family/caregiver’s ability to complete needed follow-upcare(5)
- Patient and family/caregiver’s ability to incorporate CI into daily living(5)
- General eligibility considerations:
- Patient has been identified with a severe-to-profound sensorineural hearing loss in both ears(3)
- Patient receives limited benefit from hearing aids and expectations are that communication would benefit from a CI(3,5)
- No medical or radiological contraindications exist(3,5)
- Patient’s family/caregivers are highly motivated to attend programming and rehabilitation appointments(3)
- Patient’s family/caregivers display appropriate expectations regarding potential outcomes(3)
- Patient’s family/caregivers have or can develop necessary support networks to use a CI on a daily basis(5)
–Previous therapy: Document whether patient has had speech therapy, occupational therapy, physical therapy, or other
early intervention services for this or other conditions and what specific treatments were helpful or not helpful
–Psychosocial status: Communication is a significant aspect of psychosocial development in children with hearing
impairment(15)
- In a study conducted in Denmark, researchers reported that children with hearing impairment who had access to early
sign language or oral communication did not have an increased prevalence of psychosocial difficulties when compared
to normal-hearing peers(15)
- Additionally, the researchers found increased psychosocial difficulties in children who had other disabilities in addition
to the hearing loss(15)
- In a 5-year prospective follow-up study conducted in Finland with 18 unilaterally implanted children, parents reported
a major increase in spoken language and socioemotional development 1–2 years after implantation; by 5 years
postimplantation, two thirds of the parents reported that they perceived their children to be as independent as their
normal-hearingpeers(16)
- Parents of children with profound hearing loss can experience grief and depression(11)
- Document information related to psychosocial status. Inquire about symptoms of depression and anxiety in the child,
parents, and caregiver(s) and refer to psychiatric professional for intervention as appropriate(11)
–Barriers to learning
- Are there any barriers to learning? Yes__ No__
- If Yes, describe _________________________
• Medical history
–Past medical history: Obtain a complete medical history (including information on mother’s pregnancy and child’s birth)
as well as a complete developmental history
- Previous history of same/similar diagnosis: Document etiology of hearing loss, history of hearing loss, and history
of amplification use.(5) Document developmental delays in the areas of speech, language, gross motor skills, fine motor
skills, and cognition
- Comorbid diagnoses: Ask patient’s family/caregivers about other problems the patient is experiencing, including visual
deficits, developmental delays, and other diagnoses that might affect communication
 - Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including OTC drugs)
- Other symptoms: Ask patient’s family/caregivers about other symptoms the patient is experiencing
• Social/occupational history
–Patient’s goals: Document what the family/caregivers hope to accomplish in speech therapy
–Vocation/avocation and associated repetitive behaviors, if any: Will the patient and parent/caregiver be able to attend
follow-up appointments to complete CI programming and aural rehabilitation? Does the patient participate in recreational/
social activities? Does the patient attend daycare or preschool? Does the patient receive early intervention services?
–Functional limitations: Patient’s family/caregivers must be aware of potential for CI to interact with electronics in the
environment (e.g., various types of security systems, cellular phones, computer systems).(2) Do the family/caregivers
understand functional limitations associated with having a CI? For example:
- Patient must avoid static electricity(2)
- Patient/family/caregiver must remove external components before swimming or bathing(2)
–Living environment: With whom does patient live (e.g., caregivers, siblings)? Who will participate in aural rehabilitation
program with the patient? Does patient and patient’s family/caregiver have access to transportation for follow-up care?
What language(s) are used in the home, daycare, and community? What communication method is used in the home (e.g.,
oral communication, sign language)? Is the communication method used in the home the same as the method used in the
child’s therapy and/or school setting? What is the noise level in the child’s living environment? Children with CIs have
considerable difficulty with speech perception tasks in the presence of background noise(42)
• Communication history: Assess patient’s history of hearing loss and use of hearing aids and/or other amplification. Did
the child’s hearing loss occur before or after he or she acquired some language? Determine what type of communication
system patient and family/caregivers primarily use (e.g., oral, total communication, signed languages)
› Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting.) The following areas should be tested/measured
prior to implantation in order to establish a child’s baseline skills and then on a regular basis following implantation in order
to monitor the child’s progress(9)
• Assistive and adaptive devices
–Note patient’s previous use of amplification and its effect on patient’s ability to hear and communicate. Determine if
both ears have received previous amplification and/or if one ear was more consistently amplified. Ears that have received
consistent amplification are associated with better outcomes upon receiving a CI; therefore, if only one ear has received
auditory input over time, the cochlear implant surgeon may prefer to implant that ear(5)
–Note if patient uses positioning devices (e.g., for sitting, standing), augmentative and assistive communication (AAC)
devices, glasses, or any other type of assistive or adaptive device
• Audiological testing
–All audiological testing must be done by a certified and licensed audiologist. Specific testing will vary according to
the age of the child
–Infant hearing screening: Infants in the United States are commonly screened for hearing loss shortly after birth (before
leaving the hospital or birthing center). An infant’s hearing can be assessed using otoacoustic emissions testing (OAE)
and/or auditory brainstem response testing (ABR)(17)
- Infant hearing screenings can ensure early cochlear implantation. Authors of a retrospective data review study conducted
in New Zealand with 123 children who received a CI between March 2003 and August 2014 reported that the median
age of implantation for infants who had received a hearing screening shortly after birth was 13 months. The median age
of implantation for the children who did not undergo an infant hearing screening was 24 months(55)
–Toddler/preschool screenings: If hearing is not screened at birth, the child should be screened at 3 months of age. If
a child is at high risk for developing hearing loss (e.g., family history of childhood hearing loss, history of recurrent
otitis media), he or she should be rescreened at 6-month intervals until the age of 3 even if no hearing loss is initially
identified(17)
–Otoscopic examination: Visual examination of the ear canal and tympanic membrane (eardrum)(9,17)
–Tympanograms: Measurement of tympanic membrane mobility(9,17)
–Static acoustic measures: Measures the volume of air in the ear canal (can be used to identify perforated eardrums or
blocks in the ventilation of the ear)(17)
 –Acoustic reflexes: Measures the responses of tiny ear muscles when presented with sound at varying intensities(17)
–OAE (otoacoustic emissions): OAEs measure the cochlea’s response to sound stimulation. OAEs can identify blockages
in the outer ear canals, fluid in the middle ear, and damage to the cochlea’s outer hair cells(18)
–ABR (auditory brainstem response): During ABR testing, electrodes are placed on an infant’s head while sound is
presented to his or her ears. The electrodes record the brain’s response (or lack of response) to these sounds. ABRs can be
used to identify damage to the cochlea, auditory nerve, and auditory pathways in the brainstem(17)
–Pure-tone and speech reception thresholds: A patient’s ability to hear calibrated pure tones and recognize the
presence of speech is measured.(18) This may be done using visual reinforcement audiometry (VRA) or conditioned play
audiometry (CPA).(9) VRA is primarily used to test children between the ages of 6 months and 2 years. In VRA, children
are trained to look towards lights or toys when they hear a sound presented by the audiologist. After training, when the
child looks up upon hearing a sound, he or she is rewarded by the presentation of lights or a moving toy. CPA is primarily
used on children between the ages of 2 and 3 years and involves training a child to perform an activity (e.g., placing a
block in a box) when hearing a sound(17)
–Speech perception tests (word and sentence recognition): Speech perception testing will depend upon the age of the
child but may include open-set word and sentence recognition or closed-set tasks involving the identification of prosodic
features and word identification.(5,9) If age appropriate, speech perception measures should be taken for each ear
- Ina study conducted in Taiwan with Mandarin-speaking children with CIs, researchers found that although there
were far fewer tones than speech sounds in Mandarin, tone perception was significantly poorer than speech-sound
perception(19)
–Evaluation of current amplification: Does the child currently use hearing aids or another form of amplification? How
has the patient benefitted from his or her current amplification?(5)
–Trial use of amplification, if appropriate: If the patient has not previously used amplification, a 3- to 6-month trial
period might be recommended(5)
• Auditory skills assessment: Prior to receiving the CI, a child should use his or her hearing aids during auditory skills
assessment. Assess the child’s ability to 1) pay attention to speech and environmental sounds, 2) integrate auditory
perception and speech production (i.e., is the child able to imitate sounds that he or she hears?), 3) assign meaning to the
sounds he or she hears, and 4) use hearing to engage in communication exchanges.(4) Examples of auditory skill measures
include 9)
–Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS):(20) Results are based upon parent/caregiver report. For
use with infants and toddlers. The IT-MAIS assesses the following three areas:
- Vocalization behavior
- Alerting to sound
- Deriving meaning from sound
• Speech and language examination
–Speech: Complete a phonetic inventory in order to determine which sounds the child is producing and/or administer an
articulation test to identify or rule out articulation errors(9,21)
- Stark Assessment of Early Vocal Development–Revised (SAEVD-R): Instrument used to track vocal development in
infants and toddlers from birth to 20 months of age. Includes five hierarchical levels of vocalizations(48)
- Many children with early implantation of a CI will progress through articulation and phonological development in the
same manner as their normal-hearing peers.(22) Children with severe-to-profound hearing loss who have early cochlear
implantation are able to obtain phonological awareness abilities (which are essential in order to learn to read) similar to
those of children with typical hearing abilities(53)
- In a study conducted in the United States with CI implant users aged 9 to 36 months, researchers found that the children
developed intonation over a similar amount of time and with a similar pattern to typically developing infants based on
the length of hearing experience (i.e., an 18-month-oldchild who has had a CI for 9 months would be expected to have
intonation patterns similar to those of a typically developing 9-month-old infant). For children who were slightly older
when receiving their CI (> 25 months), intonation development was more rapid than expected (i.e., a 36-month-oldchild
with 3 months of CI use might achieve the same intonation developmental level as a typically developing infant does
over 6 months of time)(23)
 - In a study conducted in Poland of severely, prelingually deaf children under the age of 2 years, researchers found that
prosodic development was significantly better in children who used CIs than in those who used hearing aids(24)
–Language: Assess the child’s ability to express thoughts, wants, and needs vocally, verbally, gesturally, and/or using
signed language. Following implantation, it is important to carefully monitor the child’s vocabulary development.(62)
Even with early cochlear implantation, children with CI have increased risk of vocabulary delays compared to typically
developing peers.(62) A child’s language can be assessed through standardized testing or through the collection of
language samples.(9) Language assessments that are appropriate for children from birth to age 3 years include:
- Communication and Symbolic Behavior Scales:(25) Assesses prelinguistic skills such as communicative functions, use
of gestures, reciprocity, and eye gaze. For use with children from birth through age 4 years
- Rossetti Infant-Toddler Language Scale:(26) Parent report, observation, and elicited behavior are used to assess a child’s
communication skills. For use with children from birth to age 3 years or birth through preschool
- MacArthur Index of Communicative Development:(27) Parent report is used to assess language and communication
skills in infants and toddlers. For children aged 8–37months
–Fluency: Informally assess fluency of speech in order to rule out or identify any atypical disfluencies(9)
–Voice: Informally assess voice quality in order to rule out or identify any voice disturbances(9)
- Children with CIs have difficulty controlling pitch and loudness of sustained phonation(28)
• Oral mechanism exam and related tests: Complete an oral motor assessment in order to rule out or identify any oral
mechanism dysfunction
• Parent-child communication: Many parents who are considering a CI for their child may be experiencing feelings of
grief, depression, fear, anger, and/or stress due to their child’s hearing loss diagnosis.(14,29) Evidence exists to suggest that
maternal stress and depression can negatively impact a child’s linguistic, emotional, and behavioral development.(29,30)
Additionally, the communication interactions between hearing mothers and their deaf children contain significant
disruptions (more maternal control, more rigidity, less joint attention) and lead to poorer communication skills in deaf
children.(30) Therefore, it is critical to monitor parent-child interaction styles and refer a family to social work and/or
psychology when signs of stress or depression are present
• Setting the cochlear implant processor (programming): A patient who receives a CI is not able to hear immediately
following surgery. Three to 5 weeks after surgery (when the physical healing has taken place), the patient receives
the external components of the CI. At that time, the external processor is programmed by the patient’s audiologist.
Programming might require several visits to complete, and reprogramming is sometimes necessary if the patient
experiences changes in his or her ability to hear over time. Electrodes are assigned specific sound frequencies. During
programming, each electrode is programmed for a threshold level (the lowest level at which the patient responds to a sound
sensation 100% of the time) and for the most comfortable level of loudness. Other parameters that can be adjusted during
programming include global loudness levels and speed of transmission(5)

Assessment/Plan of Care
› Contraindications/precautions
• Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patient’s physician. The summary
below is meant to serve as a guide, not to replace orders from a physician or a clinic’s specific protocols
• Once a CI has been implanted, the patient, with the aid of family/caregivers, must heed the following precautions:
–Avoid static electricity(2)
–Remove external components before swimming or bathing(2)
• Be aware of the potential for the CI to interact with electronics in the environment (e.g., various types of security systems,
cellular phones, computer systems)(2)
› Diagnosis/need for device/equipment: An infant or toddler’s family/caregivers work in collaboration with a cochlear
implant team to determine the appropriateness of a CI on an individual basis. Team members working with infant and
toddler patients might include the CI surgeon, an otologist or otolaryngologist, an audiologist, an SLP, a family counselor/
psychologist, an aural rehabilitation specialist, a social worker, an occupational therapist, and/or an early intervention
specialist(5,9)
› Prognosis
• Outcomes following a CI are highly variable and a child’s family/caregiver should receive pre-implant counseling to
explain this fact and to establish appropriate expectations regarding speech, language, and auditory outcomes(31)
• Factors influencing outcome include the following:(2)
–Child variables
- Length of time that the child has been deaf (shorter periods of deafness lead to more positive outcomes)(2,5,32)
- Age at time of deafness/hearing loss (children who became deaf at later ages typically have more positive
outcomes)(2,5,32)
- Age at implantation (children who undergo implantation at younger ages typically have more favorable
outcomes)(2,32,33,44,57)
- Early implantation (at ages 1–2 years) does not necessarily result in normal language development(34)
- In a study conducted in the United States of infants with CIs, researchers found that infants with CIs transition from
precanonical vocalizations to speech-like babbling rapidly despite initial auditory deprivation prior to receiving a
CI. Findings of this study showed a significant decrease in precanonical vocalizations and increase in speech-like
babbling after 1 year of CI use(35)
- Being cognitively, socially, and motorically mature at the time of implantation (compared with a hearing newborn) can
contribute to a rapid pace of vocal development(49)
- Length of time using implant: children who used a CI for longer periods of time during infancy and very early childhood
had more favorable spoken language outcomes(2,32,33,36)
- In a study conducted in the United States, researchers compared outcomes in 9 English-speaking children who received
CIs before 30 months of age at 3, 4, and 5 years postimplantation(41)
- 9 typically developing peers were used as control subjects
- Outcome measure was the use of correct tense marking in a story retell task
- The percent of correct tense marking increased significantly over time for both groups of children (those with CIs and
those who were typically developing)
- As a group, the children with CIs at 3 years postimplantation had similar accuracy of tense marking compared with
typically developing children; however, accuracy was significantly lower for the children with CIs at 4 and 5 years
postimplantation.(41) There was considerable individual variability among the children with CIs throughout the study;
some of the children with CIs performed similarly to typically developing peers at all testing points(41)
- Patient’s learning aptitude/nonverbal intelligence(2,32,57)
- Health and structure of the patient’s cochlea(2)
- Patient’s amount of residual hearing pre-implant(5)
- Patient’s lip-reading ability(5)
–Implant variables
- Type of speech processor(2,32)
- Larger numbers of active electrodes in the CI map lead to better outcomes(2,32)
- A precise and accurate map is associated with more positive outcomes(32)
- Bilateral or unilateral implantation
- Bilateral implantation is associated with better sound localization and speech recognition in noise(54,57)
- In a study conducted in the United States with 36 children who had been implanted either bilaterally or unilaterally at
some point between ages 10 and 23 months, researchers found that at 12 months postimplantation, overall vocabulary
size did not differ between children with unilateral versus bilateral CIs. The children with bilateral CIs had much
more sensitive word-level statistical patterns of spoken language (e.g., words with rare sound sequences and dense
neighborhoods) than did those with a unilateral CI. The sensitivity of the children with bilateral CIs was close to that
of a child with normal hearing. Because sensitivity to these patterns is associated with the ability to learn new sounds,
vocabulary, and sentence structures, researchers concluded that future acquisition of spoken language is likely to be
stronger in the children with bilateral CIs(52)
 –Rehabilitation program variables
- Mode of communication used in the child’s educational setting(32)
- Enrollment in an oral education program leads to more positive outcomes in auditory and speech skill development(32)
- High level of parental involvement(37,38)
- Parental use of spoken language at home(38)
• It is critical that a child use his or her CI full-time (i.e., during all waking hours except when in water) in order to get the
full benefit from the device(14)
• In a longitudinal research study involving 13 children who received CIs prior to 36 months of age and 11 typically hearing
children, researchers compared the vocal development of the two groups. Typically hearing children were assessed at 6,
9, and 12months of age. Children with CIs were assessed at 2, 3, 6, 9, and 12 months post CI activation. Following the
conclusion of this study, researchers reported that following implantation young CI users used fewer non-speech-like
vocalizations more quickly than typically hearing children and they began to use basic canonical syllables more quickly
than younger, typically hearing children. The authors of this study suggest that this rapid development in older children
with CIs might be due to motor, cognitive, neurological, and social maturity at time of implantation (when compared to
typically developing infants)(50)
• Following study of 12 young children who had received CIs prior to age 3 years and 11 typically developing children,
researchers concluded that during the second year of CI use vocal development in CI users continues to occur at a faster
rate than in younger, typically developing children(49)
› Referral to other disciplines: Patient should be referred to audiology if patient, patient’s family, the SLP, or aural
rehabilitation specialist notices changes in hearing levels following implantation and programming(5)
› Treatment summary
• Twelve guiding principles have been suggested based upon research findings and clinical experience(37)
–The infant or toddler with a CI must learn to attach meaning to what is heard through his or her CI(37)
–The ultimate goal for children with CIs is that they become competent communicators(37)
–Skills learned in a therapy setting must be transferred into the classroom, home, and other natural settings(37)
–Rehabilitation sessions should integrate goals of speech, language, auditory perception, and pragmatics within an
environment that has appropriate social/emotional context(37)
–Almost all children with CIs require a combination of direct teaching of specific auditory skills and incidental learning to
acquire spoken language(37)
–A diagnostic teaching approach to CI therapy yields the most benefit. This approach determines what a child can currently
do and then challenges the child to perform at the next level of difficulty while identifying factors that facilitate or hinder
performance(37)
–Material from the child’s educational program should be used during rehabilitation/therapy sessions(37)
–Music should be integrated into rehabilitation sessions since music perception is closely related to speech and other
auditory perception(37)
- In a study conducted in Taiwan, researchers found that music training helped improve pitch perception in children with
CIs who were prelingually deaf(39)
–Infants and toddlers with CIs have unique needs that differ from the needs of older children with CIs(37)
–Established auditory milestones can be used as “red flags” to identify children who are progressing at slower than
expected rates.(40) These red flags include:(14)
- Child is not using his or her CI full-time (i.e., all waking hours except when in water) 1 month after initial
stimulation(14)
- Child does not display a change in the quality or quantity of his or her vocalizations after 3 months of CI use(14)
- Child displays skills during audiological testing that he or she does not display in everyday situations(14)
- Child is not spontaneously alerting to his or her name after 6 months of CI use(14)
- Child is not responding to environmental sounds after 6 months of CI use(14)
- Child does not display evidence that he or she is deriving meaning from sound after 12 months of device use(14)
 –Formal assessment tools might not adequately capture a child’s difficulties in the areas of inference, problem solving, and
topic shifts; therefore, they should not be used in isolation(37)
• Parent/caregiver training
–Since parents/caregivers play a critical role in fostering the speech and language development in infants and toddlers with
CIs, aural rehabilitation for this age group should involve the family as a whole(37,40)
–SLPs and/or aural rehabilitation specialists must be able to identify and describe a young child’s communication
behaviors to the parent/caregiver(40)
–Parents/caregivers should be taught methods for stimulating developmentally appropriate communication behaviors while
they interact with their child(40)
• Considerations for working with infants and toddlers with CIs
–When working with infants and toddlers, it is critical that therapy activities are centered around the whole family rather
than the individual child(14)
–Therapy materials and procedures must be developmentally appropriate for infants and toddlers (e.g., use of real
objects rather than pictures of objects during therapy sessions, use of vocabulary and syntax that a young child would
understand)(14)
–Infants and toddlers present with behavior and compliance issues not seen in older children(14)
–Therapy sessions should focus on incidental learning rather than didactic instruction(14)
–The home is recognized as the primary language learning environment(14)
–When working with infants it is critical to emphasize the prosody and suprasegmental aspects of speech (e.g., pitch,
speech rate, varying loudness levels) rather than focusing on vocabulary or grammar development. The social and
emotional content of language is conveyed through prosody and is considered to be the most important linguistic
information for an infant to learn(14,37)
–Therapy activities should be play-based and focus on helping parents foster functional communication in everyday
situations(37)
• Communication mode: Families with infants and toddlers with CIs will need to decide on a mode of communication to
use with their child. Typically, communication modes used with children with CIs are either oral communication (OC) or
total communication (TC)
–Oral communication: OC focuses on using speech and audition to communicate. Auditory input is used to monitor
the accuracy of an individual’s own speech production and to understand spoken language. OC methods exist along a
continuum with varying emphasis placed on the use of auditory versus visual channels to receive spoken information.
For example, when using a cued speech mode of communication, a child gains valuable information from hand positions
used in conjunction with lip-reading; however, when using an auditory-verbalapproach, a child is encouraged to rely
exclusively on auditory information(32)
–Total communication: TC methods incorporate the use of both signed language and the development of speech and
auditory skills. TC methods vary in the extent to which English grammar is emphasized as well in the extent to which
speech, audition, and lip-reading skills are emphasized(32)
• Short periods of prelinguistic input (SPPI) (40)
–The goal of SPPI is to assist children as they progress from precanonical to canonical and postcanonical levels of
babbling. It is hoped that the establishment of these early developing phonetic skills will support the development of
phonological and lexical skills(40)
–Parents/caregivers/SLP begin by modeling vocalizations that the child is currently able to produce and then model more
complex forms of babbling
–Parent/caregiver models target vocalizations for 1-minute periods 5 times per day, repeating the vocalization once every 5
seconds(40)
–SPPI is performed as vocal play during interactions that should be enjoyable to both the child and parent/caregiver(40)
–SPPI is intended to be used as a strategy in conjunction with interventions focusing on developing meaningful speech and
language skills(40)
 –Although the effectiveness of SPPI has not yet been researched, the use of modeling is an accepted method of teaching
speech and language to young children. Additionally, SPPI provides a systematic way to encourage early speech
development(40)

.
Problem Goal Intervention Expected Progression Home Program
Delayed auditory and Support parent/family/ Parent/caregiver Parent/caregiver Parent/caregiver will
language development caregiver’s ability training will learn strategies use these strategies
due to hearing loss to facilitate child’s •Structure therapy to facilitate child’s across communication
auditory and language sessions to involve the auditory and language environments
development whole family rather development
than the individual
infant/toddler only(37)
•SLP will identify
and describe child’s
communication to
parent/caregiver(40)
•SLP will teach parent/
caregiver strategies
to foster language
development,(40)
such as following
the child’s lead;
emphasizing rhythm,
pitch contours, and
“motherese”; creating
communication
temptations for the
child(37)
Poor development
of prelinguistic vocalizations
vocalizations due to
hearing loss
Improve prelinguistic Short periods of Infant/toddler will Parent/caregiver will
prelinguistic input produce more complex model babble targets
(SPPI) (40) forms of vocal babble during play-based
•Parents/caregivers/ activities throughout
SLP begin by the day
modeling vocalizations
that the child is
currently able to
produce and then more
complex forms of
babbling(40)
•Parent/caregiver
models target
vocalizations for 1-
minute periods 5 times
per day, repeating
the vocalization once
every 5 seconds(40)
•SPPI is performed
as vocal play during
interactions that
should be enjoyable
to both the child and
parent/caregiver(40)
•SPPI is intended to
be used as a strategy
in conjunction with
interventions focusing
on developing
meaningful speech and
language skills(40)

Desired Outcomes/Outcome Measures

› Increased sound awareness
› Improved speech recognition
› Increased prelinguistic vocalizations/increased babbling
• Recording prelinguistic vocalizations and completing phonetic inventories can measure progress in speech development in
the early periods following implantation(40)
• Tracking changes in babbling behavior (from precanonical, canonical, or postcanonical) can confirm progress in vocal
development and indicate progress in speech perception when a child is too young to undergo formal testing(40)
› Ability to communicate orally
• Formal and informal testing measures should be completed in the areas of vocabulary, language, articulation, and auditory
comprehension 6 months after the CI is activated and then once a year(9)

Maintenance or Prevention
› In order to properly care for a CI
• Patient should have regular audiological visits to determine any change in hearing ability that would require
reprogramming
Family/Caregiver Education
› Many parents experience feelings of grief, depression, and stress once hearing loss is diagnosed in their child. Participation
in a support group may help address some of these feelings and provide the family/caregivers with additional resources(29)
› See Patient Information from the National Institute on Deafness and Other Communication Disorders at
https://www.nidcd.nih.gov/health/cochlear-implants
› See information about CIs on the American Speech-Language-Hearing Association website at
https://www.asha.org/public/hearing/cochlear-implant/
› Information for parents and support for CI users is available on the Cochlear (Australian developer and manufacturer of CIs)
website, http://www.cochlear.com/wps/wcm/connect/au/home/understand/understand

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

References
1. Cochlear implants. National Institute on Deafness and Other Communication Disorders Web site. https://www.nidcd.nih.gov/health/cochlear-implants. Published July 21, 2011.
Accessed August 29, 2018. (GI)
2. Cochlear implants. U.S. Food and Drug Administration Web site. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/CochlearImplants/
default.htm. Published April 16, 2009. Accessed August 29, 2018. (GI)
3. Mayo Clinic Staff. Cochlear implants. Mayo Clinic Web site. http://www.mayoclinic.org/cochlear-implants/. Accessed August 29, 2018. (GI)
4. Niparko JK, Lingua C, Carpenter RM. Assessment of candidacy for cochlear implantation. In: Niparko JK, ed. Cochlear Implants: Principles & Practices. 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2009:137-146. (GI)
5. Working Group on Cochlear Implants. Cochlear implants [technical report]. American Speech-Language-Hearing Association Web site.
http://www.asha.org/policy/TR2004-00041/. Accessed August 29, 2018. (GI)
6. Tucci DL, Pilkingon TM. Medical and surgical aspects of cochlear implantation. In: Niparko JK, ed. Cochlear Implants: Principles & Practices. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2009:161-186. (GI)
7. Cosetti M, Roland JT, Jr. Cochlear implantation in the very young child: issues unique to the under-1 population. Trends Amplif. 2010;14(1):46-57. (RV)
8. Trimble K, Propst EJ, Gordon K. Cochlear implantation in children with cognitive impairments. Hear J. 2009;62(11):12, 14, 16. (X)
9. Bradham TS, Snell G, Haynes D. Current practices in pediatric cochlear implantation. Perspect Hear Hear Disord Child. 2009;19(1):32-42. (G)
10. Graham J, Vickers D, Eyles J, et al. Bilateral sequential cochlear implantation in the congenitally deaf child: evidence to support the concept of a 'critical age' after which the
second ear is less likely to provide an adequate level of speech perception on its own. Cochlear Implants Int. 2009;10(3):119-141. (R)
11. Kral A, O'Donoghue GM. Profound deafness in childhood. N Engl J Med. 2010;363(15):1438-1450. (RV)
12. Lovett RE, Kitterick PT, Hewitt CE, Summerfield AQ. Bilateral or unilateral cochlear implantation for deaf children: an observational study. Arch Dis Child. 2010;95(2):107-112.
(R)
13. Kang WS, Lee JH, Lee HN, Lee KS. Cochlear implantations in young children with cochlear nerve deficiency diagnosed by MRI. Otolaryngol Head Neck Surg.
2010;143(1):101-108. (R)
14. Robbins AM. Communication intervention for infants and toddlers with cochlear implants. Top Lang Disord. 2003;23(1):16-33. (X)
15. Dammeyer J. Psychosocial development in a Danish population of children with cochlear implants and deaf and hard-of-hearing children. J Deaf Stud Deaf Educ.
2010;15(1):50-58. (R)
16. Huttunen K, Välimaa T. Parents' views on changes in their child's communication and linguistic and socioemotional development after cochlear implantation. J Deaf Stud Deaf
Educ. 2010;15(4):383-404. (R)
17. Hearing screening and testing. American Speech-Language-Hearing Association Web site. http://www.asha.org/public/hearing/Hearing-Testing/. Accessed August 29, 2018.
(GI)
18. Working Group on Manual Pure-Tone Threshold Audiometry. Guidelines for manual pure-tone threshold audiometry. American Speech-Language-Hearing Association Web
site. http://www.asha.org/policy/GL2005-00014.htm. Accessed August 29, 2018. (G)
19. Hwang CF, Chen HC, Yang CH, Peng JP, Weng CH. Comparison of Mandarin tone and speech perception between advanced combination encoder and continuous
interleaved sampling speech-processing strategies in children. Am J Otolaryngol. 2012;33(3):338-344. doi:10.1016/j.amjoto.2011.08.011. (R)
20. Zimmerman-Phillips SZ, Osberger MJ, Robbins AM. Infant-Toddler Meaningful Auditory Integration Scale. Sylmar, CA: Advanced Bionics; 2000. (PP)
21. Warner-Czyz AD, Davis BL, MacNeilage PF. Accuracy of consonant-vowel syllables in young cochlear implant recipients and hearing children in the single-word period. J
Speech Lang Hear Res. 2010;53(1):2-17. (R)
22. Adi-Bensaid L, Ben-David A. Typical acquisition by atypical children: Initial consonant cluster acquisition by Israeli Hebrew-acquiring children with cochlear implants. Clin
Linguist Phon. 2010;24(10):771-794. (R)
23. Snow DP, Ertmer DJ. Children's development of intonation during the first year of cochlear implant experience. Clin Linguist Phon. 2012;26(1):51-70.
doi:10.3109/02699206.2011.588371. (R)
24. Liwo H. Cochlear implant as an important factor of the development of prosodic features in prelingually deaf children under 2 years of age. J Hear Sci. 2011;1(3):73-75. (R)
25. Wetherby AM. Communication and Symbolic Behavior Scales. Chicago, IL: Riverside; 1993. (PP)
26. Rossetti L. The Rossetti Infant-Toddler Language Scale: A Measure of Communication and Interaction. East Moline, IL: LinguiSystems; 1990. (PP)
27. Fenson L, Marchman VA, Thal DJ, Dale PS, Reznick JS, Bates E. MacArthur-Bates Communicative Development Inventories (CDIs). 2nd ed. Baltimore, MD: Brookes; 2006.
(PP)
28. Holler T, Campisi P, Allegro J, et al. Abnormal voicing in children using cochlear implants. Arch Otolaryngol Head Neck Surg. 2010;136(1):17-21. (R)
29. Mellon NK. Parental response to the diagnosis of hearing loss. In: Niparko JK, ed. Cochlear Implants: Principles & Practices. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2009:147-149. (GI)
30. Mellon NK. Maternal attachment and adjustment: impact on child outcomes. In: Niparko JK, ed. Cochlear Implants: Principles & Practices. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009:151-154. (GI)
31. Hull RH. 15 principles of consumer-oriented audiologic/aural rehabilitation. ASHA Lead. 2007;12(3):6-7, 16-17. (X)
32. Geers AE. Factors affecting the development of speech, language and literacy in children with early cochlear implantation. Lang Speech Hear Serv Sch. 2002;33(3):222-228.
(R)
33. Snow D, Ertmer D. The development of intonation in young children with cochlear implants: A preliminary study of the influence of age at implantation and length of implant
experience. Clin Linguist Phon. 2009;23(9):665-679. (R)
34. Duchesne L, Sutton A, Bergeron F. Language achievement in children who received cochlear implants between 1 and 2 years of age: group trends and individual patterns. J
Deaf Stud Deaf Educ. 2009;14(4):465-485. (R)
35. Ertmer DJ, Jung J. Prelinguistic vocal development in young cochlear implant recipients and typically developing infants: year 1 of robust hearing experience. J Deaf Stud Deaf
Educ. 2012;17(1):116-132. doi:10.1093/deafed/enr021. (R)
36. Nicholas JG, Geers AE. Effects of early auditory experience on the spoken language of deaf children at 3 years of age. Ear Hear. 2006;27(3):286-298. (R)
37. Percy-Smith L, Cayé-Thomasen P, Breinegaard N, Jensen JH. Parental mode of communication is essential for speech and language outcomes in cochlear implanted children.
Acta Otolaryngol. 2010;130(6):708-715. (R)
38. Robbins AM. Rehabilitation after cochlear implantation. In: Niparko JK, ed. Cochlear Implants: Principles & Practices. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2009:269-312. (X)
39. Chen JK, Chuang AYC, McMahon C, Hsieh JC, Tung TH, Li LP. Music training improves pitch perception in prelingually deafened children with cochlear implants. Pediatrics.
2010;125(4):e793-e800. (R)
40. Ertmer DJ, Young N, Grohne K, et al. Vocal development in young children with cochlear implants: profiles and implications for intervention. Lang Speech Hear Serv Sch.
2002;33(3):184-195, 222-228. (R)
41. Guo LY, Spencer LJ, Tomblin JB. Acquisition of tense marking in English-speaking children with cochlear implants: a longitudinal study. J Deaf Stud Deaf Educ.
2013;18(2):187-205. doi:10.1093/deafed/ens069. (R)
42. Caldwell A, Nittrouer S. Speech perception in noise by children with cochlear implants. J Speech Lang Hear Res. 2013;56(1):13-30. doi:10.1044/1092-4388(2012/11-0338). (R)
43. Leigh J, Dettman S, Dowell R, Briggs R. Communication development in children who receive a cochlear implant by 12 months of age. Otol Neurotol. 2013;34(3):443-450.
doi:10.1097/MAO.0b013e3182814d2c. (R)
44. Luckhurst JA, Lauback CW, Unterstein VanSkiver AP. Differences in spoken lexical skills: preschool children with cochlear implants and children with typical hearing. Volta Rev.
2013;113(1):29-42. (R)
45. Hayward DV, Ritter K, Grueber J, Howarth T. Outcomes that matter for children with severe multiple disabilities who use cochlear implants: the first step in an instrument
development process. Can J Speech Lang Pathol Audiol. 2013;37(1):58-69. (R)
46. Levy N. Reconsidering cochlear implants: the lessons of Martha’s Vineyard. Bioethics. 2002;16(2):134-153. doi:10.1111/1467-8519.00275. (X)
47. Pass L, Graber AD. Informed consent, deaf culture, and cochlear implants. J Clin Ethics. 2015;26(3):219-230. (X)
48. Nathani S, Ertmer DJ, Stark RE. Assessing vocal development in infants and toddlers. Clin Linguist Phon. July 2006;20(5):351-369. doi:10.1080/02699200500211451. (R)
49. Ertmer DJ, Jung J, Kloiber DT. Beginning to talk like an adult: Increases in speech-like utterances in young cochlear implant recipients and typically developing children. Am J
Speech Lang Pathol. 2013;22(4):591-603. doi:10.1044/1058-0360(2013/12-0058). (R)
50. Ertmer DJ, Jung J. Prelinguistic vocal development in young cochlear implant recipients and typically developing infants: Year 1 of robust hearing experience. J Deaf Stud Deaf
Educ. 2012;17(1):116-132. doi:10.1093/deafed/enr021. (R)
51. Tzifa K, Hanvey K. Cochlear implantation in asymmetrical hearing loss for children: our experience. Cochlear Implants Int. November 2013;14(Suppl 4):S56-61.
doi:10.1179/1467010013Z.000000000137. (C)
52. Guo LY, McGregor KK, Spencer LJ. Are young children with cochlear implants sensitive to the statistics of words in the ambient spoken language? J Speech Lang Hear Res.
2015;58(3):987-1000. doi:10.1044/2015_JSLHR-H-14-0135. (R)
53. Ching TYC, Cupples L. Phonological awareness at 5 years of age in children who use hearing aids or cochlear implants. Perspect Hear Hear Disord Child. 2015;25:48-59.
doi:10.1044/hhdc25.2.48. (R)
54. Asp F, Mäki-Torkko E, Karltorp E, et al. A longitudinal study of the bilateral benefit in children with bilateral cochlear implants. Int J Audiol. 2015;54(2):77-88.
doi:10.3109/14992027.2014.973536. (R)
55. Mustard J, Chinnery M, Guidera AK, Heslop N, Bird PA. An audit of paediatric referrals to the Southern Cochlear Implant Programme (2009-2014). N Z Med J. October 16,
2015;128(1423):42-49. (R)
56. Fitzpatrick EM, Ham J, Whittingham J. Pediatric cochlear implantation: Why do children receive implants late? Ear Hear. November 2015;36(6):688-694. doi:10.1097/
AUD.0000000000000184. (R)
57. Geers AE, Nicholas J, Tobey E, Davidson L. Persistent language delay versus late language emergence in children with early cochlear implantation. J Speech Lang Hear Res.
February 2016;59(1):155-170. doi:10.1044/2015_JSLHR-H-14-0173. (R)
58. Dettman S, Choo D, Dowell R. Barriers to early cochlear implantation. Int J Audiol. 2016;55(Suppl 2):S64-76. doi:10.1080/14992027.2016.1174890. (R)
59. Peters JP, Ramakers GG, Smit AL, et al. Cochlear implantation in children with unilateral hearing loss: A systematic review. Laryngoscope. 2016;126(3):713-721. doi:10.1002/
lary.25568. (SR)
60. Udholm N, Jørgensen AW, Ovesen T. Cognitive skills affect outcome of CI in children: A systematic review. Cochlear Implants International. 2017;18(2):63-75.
doi:10.1080/14670100.2016.1273434. (SR)
61. Leigh JR, Dettman SJ, Dowell RC. Evidence-based guidelines for recommending cochlear implantation for young children: Audiological criteria and optimizing age at
implantation. Int J Audiol. 2016;(55 Suppl 2):S9-S18. doi:10.3109/14992027.2016.1157268. (R)
62. Lund E. Vocabulary knowledge of children with cochlear implants: A meta-analysis. J Deaf Stud Deaf Educ. April 2016;21(2):107-21. doi:10.1093/deafed/env060. (R)