International Congress Series 1273 (2004) 368 – 371

www.ics-elsevier.com

Age at implantation and communicative outcome

in pediatric cochlear implant users:
Is younger always better?
Rachael Frush Holt*, Mario A. Svirsky, Heidi Neuburger,
Richard T. Miyamoto
DeVault Otologic Research Laboratory, Department of Otolaryngology/Head and Neck Surgery, Indiana
University School of Medicine, Riley Research Wing Room 044, 699 West Drive,
Indianapolis, IN 46202, United States

Abstract. As with any surgery requiring anesthesia, cochlear implantation in the first few years of
life carries potential risks, which makes it especially important to assess potential benefits. In this
study, we compared speech perception outcomes in children who received cochlear implants in the
first, second, third, or fourth year of life. Among the latter three groups of age at implantation, it was
found that earlier implantation resulted in spoken word recognition advantages. Speech perception
performance of children implanted during the first year of life was similar to that of the children
implanted in the second year of life. D 2004 Elsevier B.V. All rights reserved.

Keywords: Cochlear implant; Implantation age; Outcome; Speech perception; Congenitally deaf children

1. Introduction
One factor reported to influence benefit from cochlear implantation in congenitally deaf
children is the age at which the child receives the device [1,2]. Specifically, evidence
suggests that children who receive a cochlear implant between 2 and 5 years of age tend to
have better speech perception than children who receive one after 5 years of age [1].
Therefore, it might stand to reason that for optimal communication outcomes, cochlear
implantation should take place as early in life as possible in children for whom
implantation is indicated. This begs the question, how early is appropriate?

* Corresponding author. Tel.: +1 317 274 4931; fax: +1 317 274 4949.
E-mail address: raholt@indiana.edu (R.F. Holt).

0531-5131/ D 2004 Elsevier B.V. All rights reserved.

doi:10.1016/j.ics.2004.08.043
 R.F. Holt et al. / International Congress Series 1273 (2004) 368–371 369

As with any surgery in very young children, early cochlear implantation may carry
significant additional risks related to anesthetic complications [3]. For example, there was a
higher incidence of bradycardia in infants undergoing noncardiac surgery younger than 12
months of age (1.3%) than in children in the second, third, and fourth years of life (0.98%,
0.65%, and 0.16%, respectively) [4]. Many factors influence surgical risk in very young
children, such as whether the surgery is elective, the length of the procedure, whether
anesthesia is administered by a pediatric anesthesiologist, and whether the child is otherwise
healthy. Because cochlear implantation is an elective surgery, typically lasts fewer than 4 h,
and is usually performed on otherwise healthy patients, the average risks are less than in the
study described above. However, even though the risks of anesthesia are low, there is a
possibility that cochlear implantation under 12 months of age may carry additional risks.
Therefore, it is especially important to evaluate the potential benefits of very early cochlear
implantation.
The purposes of this study were to compare speech perception of congenitally deaf
children who received cochlear implants in the first, second, third, or fourth year of life,
and to examine whether children implanted in the first year of life demonstrate improved
speech perception over children implanted at later intervals.

2. Method
2.1. Participants
Children were recruited from the clinical population at the Indiana University Medical
Center. All were implanted with current devices before the age of 5 years, used the SPEAK
or CIS stimulation strategies since their initial stimulation, and had no handicapping
conditions other than congenital, profound deafness bilaterally. Children were stratified by
age at implantation: Group 1 was implanted between 7 and 12 months of age; Group 2
between 13 and 24 months; Group 3 between 25 and 36 months; and Group 4 between 37
and 48 months. Table 1 displays the number of children, mean age at initial stimulation,
mean best-ear unaided pure tone average (PTA), and the percent using oral communication
(in which no supplemental signing is used) for each group.
2.2. Procedure
Children were administered the Mr. Potato Head Task [5] prior to cochlear implantation
and at approximately regular 6-month intervals after implantation. Some children were not
tested at every interval due to missed appointments or fatigue. The Mr. Potato Head Task is
a modified open-set test of spoken word recognition (involving perception and

Table 1
Participant demographics
Group N Mean age at initial Mean best-ear unaided Percent using oral mode
stimulation (months) PTA (dB HL) of communication
1 (7–12 months) 5 10.0 117.6 87.5
2 (13–24 months) 27 19.6 112.1 73.7
3 (25–36 months) 38 30.0 110.0 59.9
4 (37–48 months) 23 40.6 106.1 44.3
370 R.F. Holt et al. / International Congress Series 1273 (2004) 368–371

understanding). Mr. Potato Head is a children’s toy that consists of a bpotatoQ body, body
parts, and accessories. The approximately 20 body parts and accessories can be physically
manipulated and attached to the bpotatoQ body. During the task, children are given
auditory-only, live-voice, sentence-length instructions on how to assemble the toy. For
example, bGive him some green shoes.Q The number of key words (out of 20) correctly
identified is then converted into percent correct.

3. Results
Group mean percent correct on the Mr. Potato Head Task as a function of age at testing
is displayed in Fig. 1 for each experimental group, along with the average performance of
typically developing children based on data from Kirk et al. [6,7]. Each data point
represents scores from at least five children. Each curve represents data from each of the
four experimental groups and the triangles indicate the average age at implantation for
each group (see figure legend for further explanation). At least four trends are noteworthy.
First, the average performance of the latter three age-at-implant groups is well below that
of typically developing, normal-hearing children, at least through 6–7 years of age. The
children implanted in the first year of life were not yet old enough at each testing interval
to be compared to the norms for normal-hearing children. If they continue to make
improvements like those of the children implanted in the second year of life, they will
significantly lag behind their normal-hearing peers through 5–6 years of age. Second,
although absolute level varies across the groups, speech perception skills increase at
approximately the same rate following implantation. Third, the slopes of the curves tend
to increase for the latter three groups at or just after the mean age of initial stimulation,
suggesting that average performance starts improving faster shortly after device activation.

Fig. 1. Average performance on the Mr. Potato Head Task. The thin solid black line represents mean data from the
children implanted in the first year of life and the filled black triangle indicates the average age at stimulation of
this group. The dotted black line represents mean data from the children implanted in the second year of life and
the unfilled black triangle indicates the average age at stimulation of this group. The light-gray line represents the
mean data from the children implanted in the third year of life and the light-gray triangle indicates the average age
at stimulation of this group. The dark-gray line represents the mean data from the children implanted in the fourth
year of life and the dark-gray triangle indicates the average age at stimulation of this group. The thick black line
represents mean data from typically developing normal-hearing children.
 R.F. Holt et al. / International Congress Series 1273 (2004) 368–371 371

This pronounced increase in spoken word recognition following implantation is not

observed for the group of children implanted in the first year of life. Finally, speech
recognition is enhanced for children implanted at earlier ages relative to later ages.
Specifically, performance is better for children implanted in the second year of life relative
to the third and fourth years of life, and children implanted in the third year of life show
better performance than those implanted in the fourth year of life. For example, at 4 years
of age, children implanted in the second, third, or fourth year of life had average word
recognition scores of 70%, 52%, and 33%, respectively. Children implanted during the
first year of life show similar spoken word recognition skills to those implanted in the
second year of life, at least through 2 years of age.

4. Conclusions
The results from this single measure of spoken word recognition suggest that children
implanted in the second year of life quickly develop an advantage of 10–20 percentage
points over children implanted in the third year of life, and this advantage persists for more
than 3 years. Likewise, children implanted in the third year of life quickly develop a
similar advantage over those implanted in the fourth year of life. On the other hand at least
through 2 years of age there do not appear to be differences in spoken word recognition
between children implanted in the first year of life and those implanted in the second year
of life. However, this is based on a very small sample (N=5) of children implanted in the
first year of life and on a single measure of spoken word recognition. These results must
also be tempered by the limitations of the research design. This was not a randomized
double-blind study, and thus, there is the possibility that the differences among the groups
may have been influenced by factors other than age at implantation. Nevertheless, the
present results do suggest that cochlear implantation in the first 2 years of life may result in
an improved developmental trajectory of speech perception skills.

Acknowledgements
This research was supported by Training Grant T32 DC00012, Research Grants R01
DC 00064 and R01 DC00423, all from the NIH/NIDCD.

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