International Journal of Pediatric Otorhinolaryngology 155 (2022) 111086

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Delayed cochlear implantation in congenitally deaf children—identifying

barriers for targeted interventions
Steven A. Gordon, Susan B. Waltzman, David R. Friedmann *
Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: Age of cochlear implantation (CI) is an important predictor of language development in those with
Delayed cochlear implantation congenital sensorineural hearing loss. Despite universal newborn hearing screening initiatives and the known
Early implantation benefits of early CI, a subset of congenitally deaf children continue to be evaluated for cochlear implants later in
Universal newborn hearing screening
childhood. This study aims to identify the barriers to early cochlear implantation in these children.
Barriers to care
Barriers to cochlear implantation
Methods: A retrospective review was conducted for all pediatric cochlear implants aged 3 years or older per­
formed at a single academic institution between 2013 and 2017. Children implanted before the age three, those
with a prior unilateral cochlear implant, and those with progressive or sudden hearing loss were excluded.
Variables included newborn hearing screen results, age at hearing loss diagnosis, time of initiation and docu­
mented benefit of hearing aids, age of implantation, pre/post-implantation evaluation scores, and reason for
delayed referral for cochlear implantation.
Results: Thirty-one patients were identified meeting these inclusion criteria. Twenty-one children were subject to
UNBS in the U.S. Fourteen of those children failed their newborn hearing screening. Average age at implantation
was 6.2 years. Four reasons were identified for increased age at cochlear implantation. Two categories represent
delays related to (1) Amplification continually prescribed even though the range of hearing loss and speech
development assessment suggests CI may have been more appropriate well before referral (N = 13) (2) Patients
were not subject to newborn hearing screening and/or timely diagnosis of their hearing loss (N = 8). In other
cases, patients were appropriately fit with hearing aids until evidence that they derived limited benefit and then
referred for CI (N = 8). Lastly, in a few cases, records were indeterminate with regards to the timing and
appropriate diagnosis of their hearing loss (N = 2).
Conclusion: Understanding the reasons for delayed cochlear implantation in congenitally deaf children might
allow the development of targeted interventions to improve outcomes. Specifically, those children who were not
referred before age 3 despite use of amplification with limited benefit offer one potential target population for
earlier CI.

1. Introduction child’s success with cochlear implantation, this delay in access to

Cochlear implantation for children with congenital severe-profound
sensorineural hearing loss can facilitate the development of oral speech
and language. Factors associated with improved speech perception
outcomes for children after cochlear implantation (CI) have been well
studied [1–3] and include age at implantation [4–7]. Studies [8–14]
describe a “sensitive period” of maximal neuroplasticity of the central
auditory system [15–17] that occurs early in life with closure of the
neural gate around three years of life. While many factors contribute to a
auditory input can contribute to worse oral language outcomes, and
negatively influence other domains including long-term academic per­
formance, social interaction [18], employment, and quality of life [19].
Despite this knowledge, many children are still implanted after the
age of 3. There are a number of possible contributing factors, perhaps
the most obvious of which is a delay in diagnosis such that children with
hearing loss are not identified until speech milestones are missed. To
address this, a number of countries including the United States have
implemented universal newborn hearing screening (UNBHS) to

* Corresponding author. Division of Otology, Neurotology and Skull Base Surgery Department of Otolaryngology – Head and Neck Surgery, New York University
Grossman School of Medicine, 530 First Avenue, Suite 7Q, New York City, NY, 10016, USA.
E-mail address: david.friedmann@nyulangone.org (D.R. Friedmann).

https://doi.org/10.1016/j.ijporl.2022.111086
Received 29 September 2021; Received in revised form 1 February 2022; Accepted 15 February 2022
Available online 22 February 2022
0165-5876/© 2022 Elsevier B.V. All rights reserved.
S.A. Gordon et al. International Journal of Pediatric Otorhinolaryngology 155 (2022) 111086

facilitate earlier age at diagnosis and treatment of hearing loss. These

programs, mandated nationally but implemented on the state level over
the last 20 years, have demonstrated improved rates of detection and
early referral for audiological assessment, enrollment into early inter­
vention (EI) programs, and treatment [20–22]. While these programs
have helped children receive implants earlier in life, the average age of
CI in the United States for children is 3 years of age [23].
It is unknown which factors account for the observed variability in
age at implantation of children with severe-profound hearing loss. The
current study was undertaken to understand reasons for late-
implantation in children from a referral Cochlear Implant Center. The
longer-term goal of this work is to assist in identifying targeted in­
terventions for modifiable barriers.

2. Methods

A retrospective review was performed of all children who underwent

cochlear implantation at a single academic institution between the years
2013–2017 (N = 650). Based on age at implantation, we excluded all
children implanted before the age of three years, the defined critical
period for intervention for congenital hearing loss in children [4,6,7,17,
24]. For those children implanted after this critical period (n = 111),
individual chart abstraction was performed. Additional exclusion
criteria were those patients who underwent sequential CI older than 3
years but received their first implant before this age. Also excluded were
those with documented progressive or sudden hearing loss, who were
appropriately evaluated for implantation based on the timing of these
changes in their hearing (n = 81). The remaining cohort were implanted
between 3 and 14 years of age (n = 31).
Demographic information as well as audiometric data were recorded
including age at diagnosis, age at implantation, pre-implantation and
post-implantation speech perception scores using age-appropriate
speech perception testing including, Phonetically Balanced Kinder­
garten Test (PBK) [25]; Glendonald Auditory Screening Procedure
(GASP) [26]; Multisyllabic Lexical Neighborhood Test (MLNT) [27];
Lexical Neighborhood Test (LNT) [27]; AzBio [28]; The Hearing in Noise
Testing in Children (HINT C) [29]; The Infant-Toddler Meaningful
Auditory Integration Scale (IT-MAIS) [30]; and The Early Speech
Perception (ESP) test [31]. If available, information related to UNBHS
outcomes were included. Age at hearing aid fitting were also noted.
Detailed discussion with the audiologists involved in the care of these
patients elucidated the explicit factors related to the timing of
implantation.
Fig. 1. Flow diagram of patient selection.
(1) Children were appropriately fit with hearing aids until evidence
that they derived limited benefit and then referred for CI (N = 8).
These children were implanted at an average age of 6.5 years
(range 3.5–12).
2) Amplification was continually prescribed even though the range
of HL and speech development assessment suggests CI may have
been more appropriate well before referral (N = 13). This may
have been related to patient, family or provider factors as
detailed below. The average age of cochlear implantation for this
group was 6.3 (range 3.4–12.5).
(3) Patients not subjected to newborn hearing screening and/or
timely diagnosis of their hearing loss (N = 8) often because they
had emigrated from somewhere where this testing was not
available. The average age of at implantation was 5.5 years
(range 3.2–10.3 years).
(4) Records were indeterminate with regards to the timing and
appropriate diagnosis of their hearing loss (N = 2). The two
children were implanted at ages of nearly 6 and 9 years old.

3. Results
Thirty-one children implanted after the age of 3 met our inclusion
criteria and were included for analysis (see Fig. 1). The individual pa­
tient demographics and outcomes are described in Table 1. Fourteen of
the twenty-one children subject to UNBS reportedly failed their newborn
hearing screening. Overall, 6 children were found to have cochlear
malformations—3 with Mondini malformation and an enlarged vestib­
ular aqueduct and 3 with cochlear nerve dysplasia. Nine children
received simultaneous bilateral implantation and another five under­
went bilateral implantation in a sequential manner. For those obtaining
a single implant, there were 9 children with right-sided CI and 8
receiving a left. Twenty-two of the thirty-one implants were Cochlear
brand, 8 Advanced Bionic, and 1 Med-El. Mean age at first hearing aid
was 2.8 years old (range 4 months–6 years). Overall, the mean age at
cochlear implantation in this cohort was 6.2 years old (range 3.1–13.5
years).
Individual chart abstraction was performed to determine what fac­
tors impacted on the age at implantation. In doing so, 4 themes were
identified:
3.1. Delayed referral (GROUP 2)
Based on individual chart abstraction and discussion with the
treating audiologists, the children with delayed CI referral despite
limited demonstrable benefit from amplification was inferred to occur
related to three underlying factors—1) those related to family dynamics;
2) structural/socioeconomic; and 3) inadequate guidance from prior
providers.
3.2. Patient/family factors
In this cohort, the majority (7/13) of delays in cochlear implantation
were a result of family hesitancy. For example, Patients 3 and 17 grew
up in conservative Middle Eastern and East Asian families. Parents
initially denied their child’s diagnosis, contributing to the delayed im­
plantation. Specifically, Patient 3 failed her newborn hearing screening
and the family waited nearly two years before following up. She has
three older siblings with hearing loss that were similarly delayed in
treatment. The family reported they were worried about the cultural
stigma associated with a diagnosis of hearing loss and ultimately
required multiple referrals for cochlear implantation.

2
 Table 1

S.A. Gordon et al.

Individual Preoperative and Postoperative Assessment for Children with Delayed Cochlear Implantation After Age 3.
# Age Aided Age Implanted Laterality Abnormal Newborn Cata Preoperative Speech Testingc Post Operative Speech Post Operative Speech Testingc Post Operative Speech Testingc
(years) (years) Anatomyb Screen Testingc 1 year 2 years
3 months

1 4.5 5.0 BIL none 3 Severe to Profound Loss BIL mild HL, moved out of
state
2 4.5 6.2 BIL none 3 ESPT unable to complete past IT-MAIS 25/40
training
3 2 13.5 L then R fail 2 PBK words: CNC words:
R HA- 24%, L HA- 8%, B/L- 20% R CI-66%, L CI-60%, B/l-80%
HINT C SENT (noise) AZ BIO (quiet)
R HA- 36%, L HA- 0%, B/L- 34% R CI-94%, L CI-86%, B/l-98%
AZ BIO(noise)
R CI-81%, L CI-68%, B/l-79%
4 2.5 3.7 R none 3 GASP words: PBK-1/2 list:
R HA- 0%, L HA- 83% R CI - 48%, L HA- 56%,
MLNT words: B/l-74%
R HA: DNT, L HA- 76%, B/l- 87%
5 0.5 4.9 R fail 2 LNT words: LNT words: HINT C Sentences (quiet):
R HA-0% Bilateral- 84% R CI-80% Bilateral- R CI-94% Bilateral- 100%
84% HINT C Sentences (noise):
R CI-93% Bilateral- 94%
6 5.5 6.1 BIL EVA, Cochlear N unknown 3 could not perform the training ESPT: Cat 3 8/17
Deficiency subtest correct
7 6 6.1 R then L pass 4 LNT words: LNT words: CNC words:
(2017) Bilateral: 56% CI-64% Bilateral: 84% R CI-96%, L CI-88%, B/l-96%
HINT sent (quiet)
R CI-90%, L CI-96%, B/l-100%
HINT sent (noise)
3

R CI-94%, L CI-92%, B/l-96%

8 4 7.9 R pass 1 PBK words: PBK words Able to repeat LING sounds
R HA: 4%, L HA 32%, B/l- 52% R CI 0% “mom notes improvement and
HINT C (quiet) HINT-C (quiet) hearing from the CI time"
R HA: 0%, L HA 83%, B/l- 79% R CI 0%
9 3 8.2 R Mondini, EVA BIL fail 2 AZ BIO Quiet: AZ BIO Quiet:
R HA-0%, L HA-92%, B/l-88% R CI-83%, L HA-94%,

International Journal of Pediatric Otorhinolaryngology 155 (2022) 111086

AZ BIO Noise: B/l-98%
R HA-0%, L HA-86%, B/l-87% AZ BIO Noise:
R CI-78%, L HA-91%,
B/l-99%
10 1 10.3 BIL none 3 ESPT Cat 1 ESPT: Cat 2 8/17 ESPT: Cat 2 4/12 correct
correct “Loves to wear device"
11 2.8 3.2 R none 3 IT-MAIS: 0/40 IT-MAIS: 25/40 IT-MAIS: 32/40
“always responds to name in quiet
and sometimes in noise"
12 none 3.5 BIL Mondini, EVA BIL pass 1 Unable to perform Little Ears Able to repeat LING sounds. Only
Auditory Questionnaire wearing 1.7 h on R and 1.0hrs on L
13 0.4 3.8 L fail 2 Unable to perform Little Ears ESPT: Cat 1
Auditory Questionnaire
14 3.8 4.1 L none 3 Unable to perform ESPT for pattern HINT C Sent (quiet):
perception R HA- CNT, L CI - 82%, B/L- 79%
HINT C Sent (noise):
R HA- CNT, L CI - 70%, B/L- 80%
15 3 4.7 BIL pass 2 MLNT Words: MLNT Words: HINT C SENT (quiet)
R HA- 20%, L HA- 27%, B/l- 29% R CI - 80%, L CI - 86%, B/l- 63% R CI - 92% L CI - 96%, B/L- 96%
HINT C SENT (noise)
R CI - 72%, L CI - 85%, B/L- 94%
(continued on next page)
 S.A. Gordon et al.
Table 1 (continued )
# Age Aided Age Implanted Laterality Abnormal Newborn Cata Preoperative Speech Testingc Post Operative Speech Post Operative Speech Testingc Post Operative Speech Testingc
(years) (years) Anatomyb Screen Testingc 1 year 2 years
3 months

16 4.5 4.7 BIL Born 23 wks fail 2 BIL Profound No Follow-up

17 5 5.3 L fail 2 MLNT Words: MLNT Words: LNT words:
R HA- 71, L HA- NR L CI - 67%, R HA- 84%, L CI - 88%, B/L- 96%
18 2.4 5.6 BIL pass 2 HINT C SENT (quiet) HINT C SENT (quiet) AZ-BIO (quiet)
R HA- 32%, L HA- 42%, B/L- 56% R CI - 76%, L HA- 42%, R CI - 100%, L CI - 98%, B/L- 100%
B/L- 96% AZ-BIO (noise)
R CI - 95%, L CI - 94%, B/L- 99%
19 1.7 7.3 R fail 1 HINT C SENT (quiet) HINT C SENT (quiet)
R HA- 82% L HA- 70%, B/L- 98% R CI - 94% L HA- 96%,
HINT C SENT (noise) B/L- 100%
R HA- 17%, L HA- 49%, B/L- 80% HINT C SENT (noise)
R CI - 92%, L HA- 92%,
B/L- 100%
20 3 8.8 L fail 2 AZ-Bio (quiet) AZ-Bio (quiet) AZ-Bio (quiet) AZ-Bio (quiet)
R HA- 73%, L HA- 61%, B/L- 76% R HA- 70%, L CI - 68%, R HA- 67%, L CI - 84%, B/L- 89% R HA- 73%, L CI - 84%, B/L- 92%
B/L- 88% AZ-Bio (noise) AZ-Bio (noise)
AZ-Bio (noise) R HA- 68%, L CI - 87%, B/L- 93% R HA- 29%, L CI - 68%, B/L- 65%
R HA- 58%, L CI - 65%,
B/L- 84%
21 1.8 3.7 R then L (12/ fail 2 Profound loss b/l: IT-MAIS 0/40 MLNT Words HINT C SENT (quiet)
17) R CI-66%, L HA- 0% R CI - 96%, L CI - 88%, B/L- 100%
HINT C SENT (noise)
R CI - 98%, L CI - 84%, B/L- 98%
4

22 4 7.9 L none 4 MLNT Words: LNT Words (easy):

R HA- 47%, L HA- 40%, B/L- 46% R HA- 28%, L CI - 88%, B/L- 84%
23 4 10.0 L fail on L 2 AZ-BIO (quiet): AZ-BIO (quiet):
pass on R R HA-100%, L HA: 0%, B/l- 92% R HA-100%, L CI: 94%, B/l- 100%
AZ-bIO (noise): AZ-bIO (noise):
R HA-83%, L HA: 0%, B/l- 84% R HA-98%, L CI: 84%, B/l- 93%

International Journal of Pediatric Otorhinolaryngology 155 (2022) 111086

24 1.5 3.1 L pass 1 ESPT unable to complete training HINT C SENT (quiet)
Unable to consistently repeat Ling R HA- 78% L CI - 94%, B/L- 92%
speech sounds or words HINT C SENT (noise)
R HA- 74%, L CI - 98%, B/L- 94%
25 0.5 3.4 L Hypoplastic cochlea fail 2 IT-MAIS 0/40 IT-MAIS 18/40
26 0.3 3.4 BIL L: CSF leak; Mondini fail 1 IT-MAIS 9/40 MLNT Words: HINT C SENT (quiet)
R: common cavity rarely responds to name in quiet, R CI - 27%, L CI - 73%, B/L- 63% R CI - 6%, L CI - 69%, B/L- 92%
never in nopise Common Phrases (quiet) HINT C SENT (noise)
R CI - 30%, L CI - 45%, B/L- 65% R CI- DNT, L CI - 60%, B/L- 86%
27 0.4 4.0 R EVA, Mondini fail 1 LNT Words (easy): AZ-BIO (quiet):
R HA- 56% R CI - 98%
LNT Phonemes (easy) AZ-bIO (noise):
R HA- 79% R CI - 97%
28 3 5.4 R none 3 CNT PBK words or phonemes on R Left USA post op
29 4.5 5.5 R unknown 2 ESPT: CAT 3 AZ-BIO (quiet):
MLNT Words: R CI - 97%
R HA- 33%, L HA- 13%, B/L- DNT AZ-bIO (noise):
R CI - 96%
(continued on next page)
S.A. Gordon et al. International Journal of Pediatric Otorhinolaryngology 155 (2022) 111086

A similar reluctance was seen from the family of Patient 17, who had

Legend: BIL= Bilateral; EVA = Enlarged Vestibular Aqueduct; CSF= Cerebrospinal Fluid; R = Right; L = Left; HA= Hearing Aid; CI= Cochlear Implant; CAT= Category; IT-MAIS = The Infant-Toddler Meaningful Auditory
Integration Scale; GASP = Glendonald Auditory Screening Procedure; PBK= Phonetically Balanced Kindergarten Test; ESPT = The Early Speech Perception Test; LNT = Lexical Neighborhood Test; MLNT = Multisyllabic
a failed newborn hearing screening and then a subsequent ABR at 4
months indicating a profound loss in the left ear and a moderate loss in

R CI - 77%, L CI - 100%, B/L- 100%

R CI - 100%, L CI - 100%, B/L- 99%

R CI - 21%, L CI - 97%, B/L- 100%

R CI - 98%, L CI - 99%, B/L- 97%
the right ear. The parents chose not to pursue amplification for over four
Post Operative Speech Testingc years due to their perceived cultural stigma, believing hearing loss to be
an “unacceptable disability.” They eventually returned for care and
implantation after the patient began experiencing more difficulty
hearing in social and educational settings with evident speech delay.
AZ-Bio (noise)

AZ-Bio (noise)
AZ-Bio (quiet)

AZ-Bio (quiet)
Denial of a child’s diagnosis represents another explanatory theme
seen with the families of Patients 20, 21, and 29. Patient 20 failed his
2 years

newborn hearing screening, but was appropriately aided and enrolled in

Age appropriate speech testing determined by audiologist at time of preoperative and post-operative assessment. If blank, testing was not collected/performed or lost to follow up.
educational support services including speech and language therapy,
and assistive listening technology. Despite numerous early CI referrals,
he was not implanted until 8 years of age, because of the family’s belief
Post Operative Speech Testingc

that their child’s hearing would spontaneously improve. However, the

child had such a positive experience post implantation that his family
pursued early CI for their second child with profound hearing loss prior
to 12 months of age.
Similarly, patient’s 21 and 23 passed their newborn hearing
screenings, but were later diagnosed with severe to profound hearing
loss at age 12 months and 24 months respectively, when their parents
1 year

noticed they were not developing speech and language. Both patients
were immediately fit with bilateral amplification and referred for CI.
Post Operative Speech

Despite a recommendation for CI, the family of patient 21 waited

another 11 months prior to evaluation citing concerns about the safety
of surgery. The family never fully accepted the child’s hearing loss and
Lexical Neighborhood Test; HINT C= The Hearing in Noise Testing in Children; CNC= The Consonant Nucleus Consonant Word Test.

continually expressed a resolve that her hearing would suddenly

3 months
Testingc

improve with time. Likewise, the family of patient 23 delayed amplifi­

cation by 6 months followed by an additional year-long delay after
amplification prior to CI evaluation despite multiple referrals. While the
parents had two previous children diagnosed and appropriately treated
B/L- 81%

B/L- 79%

B/L- 98%

B/L- 92%

for hearing loss, they were unable to process the reality of the diagnosis
Cata Preoperative Speech Testingc

of a third child with the same condition.

R HA- 59%, L HA- 59%,

R HA- 67%, L HA- 73%,

R HA- 93%, L HA- 70%,

R HA- 65%, L HA- 72%,

Socioeconomic/structural factors in the child’s environment were

the key influence in delayed implantation for Patients 16 and 23. Child
16 was born at 23 weeks and had a prolonged six month NICU stay at an
HINT C (noise)

HINT C (noise)
HINT C (quiet)

HINT C (quiet)

outside hospital contributing to his profound hearing loss. Despite this

history, he was not formally diagnosed with bilateral profound hearing
loss until nearly three years of age, he was not aided until he was four,
and then implanted at almost five years of age. Much of this delay was a
result of the child being moved between family members in different
1

cities with heavy involvement and support by social services. His follow
up is limited because he left the New York region immediately after
Newborn

implantation.
Screen

pass

A similar dynamic was seen with Patient 23 who failed her newborn
fail

hearing screening in the left ear, but passed in the right. She was born
and had all of her care at the public city hospital affiliated with our
institution. Her parents reported they had no concerns about her hearing
and didn’t follow up with ENT or audiology after her newborn screening
Anatomyb
Abnormal

Descriptive Category related to delayed implantation.

until she started Pre-K at age 4. At this point, she was formally diagnosed
with profound hearing loss in the left ear and moderate hearing loss in
the right ear and fit with a hearing aid only in the right ear. In this re­
view, she was categorized as delayed management because of the sig­
Laterality

R, then L

nificant interval prior to amplification fitting, however, she was

Anatomy considered normal if blank.

appropriately transitioned from amplification to CI.

L

3.3. Delayed referral by providers

Age Implanted

There were four children—Patients 9, 13, 15, and 25—whose

(years)

treating providers delayed referral of the child for CI long after they met
11.1

12.0
Table 1 (continued )

criteria. For instance, Child 9 was diagnosed with profound loss on the
right and moderate hearing loss on the left from an ABR at age 3 and on
Age Aided

imaging found to have bilateral enlarged vestibular aqueduct (EVA) and

(years)

dysmorphic cochlea. Some providers may be reluctant to refer when one

31 0.5
30 3

ear is doing well even with a “threatened contralateral ear.” Per chart
#

review and discussion with our audiologists, there was no hearing

b
a

5
S.A. Gordon et al. International Journal of Pediatric Otorhinolaryngology 155 (2022) 111086

change or identifiable event that resulted in the CI referral.
A similar delay was seen for child 15. He was born full-term and
passed a newborn hearing screening. Hearing loss was ultimately diag­
nosed between the ages of 2–3 years after two surgeries for myr­
ingotomy and tympanostomy tubes. He attained expressive language at
age 2.5 years but had continued difficulty with speech, resulting in a
formal diagnosis of hearing loss at age 3 when he was fit with amplifi­
cation bilaterally. His provider did not refer him for over 1.5 years for CI
despite meeting criteria.
Child 13 and 25 had a provider/system failure that contributed to
their delayed implantation. Both children failed their newborn hearing
screening, had subsequent ABR testing suggestive of bilateral profound
hearing loss, and were found to have congenital inner ear anomalies on
follow up CT scan. Patient 13 had marked bilateral cochlea dysplasia,
narrowed internal auditory canals, and absent semi-circular canals. This
child was not implanted until nearly four years old because she was
initially denied coverage for implantation by her insurance carrier.
Child 25’s CT scan demonstrating bilateral hypoplastic cochlear and the
family was incorrectly told by the provider that the child was not a
candidate for CI because of his anatomy.
3.3.1. Newborn hearing screening not performed (GROUP 3)
An overview of those patients not subject to infant hearing screening
because they were born outside the U.S. is described in Table 2. Five out
of eight of these patients are children that had the potential to be helped
sooner after moving to the US and implanted earlier, had they been
properly referred. The remaining three patients were appropriately
diagnosed and referred for evaluation of implant candidacy in a timely
manner and were implanted within one year of arrival to the U.S.
4. Discussion
In order to develop proper language skills, children require access to
acoustic-phonetic cues [32–36]. However, children born with severe to
profound hearing loss lack access to this information, which can limit
their communication skills and hinder their development of spoken
language [37]. Cochlear implants, when performed within the critical or
“sensitive period” for neuroplasticity—typically before age 3—can
potentially mitigate many of these adverse consequences. While the
need for early cochlear implantation in children with prelingual hearing
loss has been well established, many children are continually implanted
after this “sensitive period.” This study attempts to understand and
categorize barriers to early cochlear implantation in order to identify
targeted solutions to mitigate delayed implantation in the future.
Similar investigation into barriers to access and utilization to pedi­
atric hearing healthcare have been designed to examine the impact of
broader social disparities on the care of children with hearing loss
[38–47]. For instance, Bush et al. have identified rural zip code and
distance from cochlear implant centers as significant barriers to hearing
healthcare [38–41]. There has been conflicting data regarding insurance
status and barriers to hearing rehabilitation with a group from Case
Western showing that socioeconomic status and Medicaid insurance did
not impact age of cochlear implantation, however, they did note that
children with Medicaid insurance missed significantly more
post-operative follow up visits [42]. In contrast, a recent study analyzing
delayed cochlear implantation in the state of Florida found children with
Medicaid were significantly more likely to be implanted after the age of
2 compared to children with private insurance [44]. Moreover, this
group determined that children who identified as either Black or His­
panic were significantly more likely to have delayed implantation
compared to their White counterparts [44].
The current study takes a more in-depth examination into delayed
cochlear implantation and identified four main categories of patients
who were implanted after the age of three years, excluding those with
progressive or sudden hearing loss as mentioned above. The children
who had amplification continually prescribed even though loss range
was on the range for CI; and those patients who arrived in the US later in
life seeking medical care—not subject to infant screening and timely
diagnosis, offer opportunities for intervention. In this cohort, the ma­
jority (7/13) children had delays in care as a result of family/internal
factors. Cultural norms, family stigma, and parental acceptance of
diagnosis had major impacts in how these children and families inter­
acted with the health care system. Providers must incorporate this
knowledge and develop the necessary cultural competency to under­
stand the rationale for family resistance to implantation or denial of
diagnosis in order to help properly navigate these at-risk children
through the medical system.
Similarly, for those not subject to infant screening because they were
born outside the U.S., we lack a safety net to ensure these children are
accurately diagnosed and appropriately managed in a timely fashion. In
many cases, such children remain in the United States, and in addition to
the personal consequences on their development, there are important
downstream consequences on their educational and vocational oppor­
tunities and potential economic burden on society [48]. While the
introduction of newborn hearing screening programs has helped to
accelerate detection of children with profound bilateral SNHL, as this
review demonstrates, early treatment is hampered by the complex de­
livery of hearing health care.

Table 2
Timeline of hearing healthcare interaction among children born outside the US and not subject to universal newborn screening (category 3): From birth to cochlear
implantation.
Patient # Native County Hearing Loss Newborn screen Age at Age at Diagnosis Age at Hearing Aid Age at
Arrival to US Implantation

1 Nigeria Severe to Profound Bilaterally No 4 years 2 years 4 year 5 yearsa

6 months
2 Yemen Severe to Profound Bilaterally No 1 year 4 years 4 years 6 years 2 monthsa
6 months 6 months
4 Congo Right Profound No 2 years 2 years 2 years 3 years 7 monthsb
Left Moderate 6 months
6 China Severe to Profound Bilaterally No 5 years 5 years 5 years 6 years 1 monthsa
6 months 6 months
10 Honduras Severe to Profound Bilaterally No 7 years 1 year 1 year 10 years 4monthsa
11 India Right Profound No 8 months 2 years 2 years 3 years 2 monthsb
Left Severe 8 months
14 Guyana Severe to Profound Bilaterally No 2 Years 2 years 3 years 4 years 1 monthsb
6 months 8 months
28 Canada Right Profound No 5 Years 3 years 3 years 5 years 4 monthsb
Left Severe (left only)
a
Bilateral Simultaneous Cochlear Implantation.
b
Unilateral Cochlear Implantation.

6
S.A. Gordon et al.
One consideration might include an additional screening assessment
after birth but before closure of the critical period independent of
identified delays. In addition to identifying those not subject to UNBHS,
it could be expected to also identify those who passed UNBHS but with
etiologies of progressive SNHL. Dedhia et al. described 78 patients that
initially passed their UNBHS who were later diagnosed with sensori­
neural hearing loss [49]. For our cohort, a secondary universal screening
point likely would have helped identify as many as half of the patients at
an earlier time point.
One limitation in our study design is bias in our cohort, in that it was
defined as patients implanted at our cochlear implant center. There are
likely other children worldwide who were not identified until later or
may have eventually been referred but were not deemed appropriate CI
candidates given their age at referral and potentially other factors
related to their educational setting such that a CI was not pursued. This
consideration may underestimate the scope of children who would
benefit from timelier referral to cochlear implant programs. Addition­
ally, there were some individuals with indeterminate records (Group 4)
limiting inferences about the reasons for possible delayed implantation.
Reinforcing the benefits of earlier implantation to audiologists and
providers alike working outside of specialized cochlear implant centers
are key to ensuring many of these children are targeted earlier and
earlier in order to obtain optimal benefit.
These delays might be partially due to changing standardized
guidelines and policies set by the FDA and third-party commercial
payers. Until recently, the pediatric criteria for implantation of 12
months of age or older were based on 2005 FDA guidelines. Those
guidelines have now been updated to 9+ months based on published and
unpublished data reviewed by the FDA [50]. Moreover, despite their
need for adequate audibility during oral language acquisition, the
criteria for degree of hearing loss in prelingual children undergoing
evaluation for CI is more conservative than in adults [51]. This may
contribute to confusion among community providers who may not
regularly encounter children with significant hearing loss about the
appropriateness of referrals. Consequently, hearing aids, which are less
appropriate for severe and profound hearing loss, may be continually
prescribed.
5. Conclusion
Children with prelingual severe-profound hearing loss stand to
benefit from early implantation as age at implantation is an important
predictor of language outcomes in children using cochlear implants [7].
Despite this, a significant cohort continues to be implanted later than
this critical period. There are a number of potential barriers to early
intervention and treatment and review of our experience provides some
guidance for possible solutions to consider. The potential solutions to
minimize delayed implantation vary by the etiology. Understanding
these barriers might allow the development of programs to intervene
earlier and optimize outcomes.
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