Cochlear Implants
by Cochlear Guest Author

Journal Club: Pediatric cochlear implant wear time and early language development

December 16, 2019
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By Amy Donaldson, Professional Education Manager, Cochlear Americas

Gagnon, Erika B., Eskridge, Hannah, Brown, Kevin D.

Pediatric cochlear implant wear time and early language development

Sep 29, 2019:1-6

Cochlear Implants Journal

In today’s busy clinical environment, clinicians who value research-based practice often struggle to keep up with current literature.  To help, we’re excited to offer a new ProNews Blog monthly feature – Journal Club!  Each month, rotating guest authors will present a current journal article summary.

This month’s Journal Club explores a recent study by the team at the University of North Carolina published in September 2019, Pediatric Cochlear Implant Wear Time and Early Language Development. This article may be especially useful for those clinics working with pediatric recipients as a resource for counseling on device use.

What did the study investigate?

This study was designed to examine the relationship between device wear time in pediatric recipients and their language development. 

For children with hearing loss, consistent access to auditory information with either hearing aids or cochlear implants is associated with better speech and language development.1,2,3,4 Unfortunately, clinicians can’t always rely on parental report of device use – some studies have shown that they overestimate device use by an average of 2.6 hours per day.5 

Modern cochlear implant systems now have datalogging available to help clinicians objectively track device use, but it can be unclear how these results should be interpreted or what is the impact of differences in wearing time.  If a one-year-old uses their device seven hours per day, is that enough to provide access to spoken language?  What about the same use per day for a five-year-old?  This study attempted to answer these questions.

How did they do it?

The authors utilized datalogging in the Nucleus® sound processor and applied a measurement called “Hearing Hour Percentage” or HHP to track the amount of device use: 

HHP = total wear time/median awake time * 100

This measurement provides more information than just hours per day since it considers the waking hours of each day for children of different ages.  For example, according to the American Academy of Sleep Medicine6 the average median awake time for a one-year-old is 11.5 hours; for a five-year-old, it’s 12.5 hours.  That makes sense – younger children sleep more.  So seven hours of device use for the one-year-old is 61% of their awake day; but for the five-year-old, it is only 56%.  See table below:

Here are the key features of the study:

  • 37 children implanted prior to age 5
  • Average age of implantation: 1.97 years
  • Followed for the first year of device use
  • All using Nucleus 6 technology or later
  • Language tests: The Preschool Language Scale: Fifth Edition (PLS-5) or Oral and Written Language Scales: Second Edition (OWLS-II)

Results

The study found HHP of the 37 children ranged from 18% to 117% with an average of 63%.  More than half of the group achieved an HHP of over 60% by the end of their first year of device use.  This is interesting since many professionals would recommend device use during “all waking hours” but this study demonstrated that average usage of cochlear implants in children may only be about 60% of waking hours. 

The study found a positive correlation between HHP and receptive language abilities – the more recipients used their device, the better their receptive language – although the correlation was not significant for expressive language abilities.  This may have been because they only followed the children for one year after device use and expressive language development lags behind receptive language development.  Device use accounted for 40% of the variability in receptive language for the children confirming that while device use is important, it is still only one variable in outcomes for children.

Discussion

The results of this study support the importance of consistent device use for language development in children and highlight device datalogging as a critical tool in measuring progress.  The findings may also encourage professionals to consider how they counsel parents of young children who are using cochlear implants.  Combining datalogging with information about average awake time allows clinicians to determine the HHP for an individual child.  Counseling a parent to have their child use the device “all waking hours” may be helpful, but it might be even more useful to encourage use for a percentage of the child’s awake time and measure their progress by increasing that percentage. 

Pediatric clinicians encourage families to achieve “full time” device use.  This study helps define what that number should look like for children of different ages and gives parents and caregivers specific goals.  While datalogging can help clinicians track progress during clinic visits, Hearing Tracker is now available for parents to use between visits.  Hearing Tracker is available for the Nucleus 7 sound processor in the Nucleus Smart App, and is available in both iOS and Android™ devices. 

With Hearing Tracker, datalogging and device use information is not just available to clinicians but can be seen real-time by parents and caregivers, supporting device use and helping to support language development in children who use cochlear implants. 

Learn  more about this exciting clinical strategy by accessing the publication here and stay tuned for next month’s edition of Journal Club!

About our guest author:

Amy Donaldson is an Audiologist and Professional Education Manager for Cochlear Americas.  She received her Master’s Degree in Audiology from the State University of New York at Buffalo and her AuD from the University of Florida.  She was privileged to begin her career as a pediatric audiologist and gain extensive clinical experience in implantable hearing devices at the University of Michigan in Ann Arbor and at the Manchester Cochlear Implant Programme in the United Kingdom.  After working for several years as an Educational Audiologist and Technical Support Audiologist in the hearing aid industry, she returned to hearing implants and Cochlear in 2011. 

References:

  1. Weisman KB, Warner-Czyz AD (2018) Inconsistent device use in pediatric cochlear implant users; Prevalence and risk factors. Cochlear Implants International, 19, 131-141.
  2. Toblin, JB, Harrison, M, Ambrose, S, Walker EA, Oleson, JJ, Moeller MP. (2015) Language outcomes in young children with mild to severe hearing loss. Ear and Hearing, 36(Suppl 1):76S-91S.
  3. Easwar V, Sanfilippo J, Papsin, B, Gordon, K. (2018) Impact of consistency in daily device use on speech perception abilities in children with cochlear implants: datalogging evidence. Journal of the American Academy of Audiology, 29:835-846.
  4. Guerzoni L, Cuda D (2017) Speech processor datalogging helps in predicting early linguistic outcomes in implanted children. International Journal of Pediatric Otorhinolaryngology, 101:81-86.
  5. Walker EA, Spratford M, Moeller MP, Oleson J, Hua O, Roush P, Jacobs S. (2013) Predictors of hearing aid use time in children with mild-to-severe hearing loss. Language, Speech & Hearing Services in the Schools, 44(1):73-88.
  6. Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA et al (2016) Recommended amount of sleep for pediatric populations: A consensus statement of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine, 12(6):785-786.

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The Cochlear Nucleus Smart App is available on App Store and Google Play. For complete smartphone compatibility information, please visit www.cochlear.com/compatibility.




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Cochlear Guest Author

In an effort to keep our content fresh and reflective of a diverse industry, Cochlear Americas features a mix of employees and professional partners to contribute to Cochlear ProNews as Guest Authors.

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Custom Sound Pro

Use of Global Adjustments for cochlear implant fittings

October 5, 2021

By Kyle Longwell, Product Manager – Software and Clinical Care

With the introduction of Custom Sound® Pro fitting software, Cochlear embraces new advances in fitting practice while maintaining support for historical fitting methodologies.

By leveraging ongoing developments in implant technology and clinical data available after 40 years of experience, Cochlear is utilizing data-driven design and automation with an increased focus on the use of Global Adjustments. This contrasts with historical fitting practices, which often focused on per- channel fitting methodologies which can be time-consuming and require sustained recipient attention.

These new fitting approaches are supported by the introduction of new screens and a default workflow in Custom Sound Pro software. These advances also prepare you and Cochlear for the future of ongoing advances in programming and digital healthcare.

What are Global Adjustments?

Global Adjustments are changes to MAP settings which are applied across the entire MAP profile at the same time, rather than on a channel-by-channel basis.

Global Adjustments have been used within Custom Sound software for many years. For example, Global Adjustments have been a key part of the streamlined programming flow (i.e., Shift and Tilt in live stimulation mode) for at least 15 years. These adjustments are typically made in live speech, allowing for patient judgement of MAP comfort and sound quality and are ideal to use as a part of routine programming or for patient control of MAP comfort outside the clinic. However, access to Global Adjustment may be conditional upon the patient’s MAP or implant type.

Let’s take a quick look at the Global Adjustments used within Custom Sound Pro fitting software:

Master volume

Applies a global shift of the entire T and/or C level MAP profile during live speech and is used to set or modify the overall loudness or comfort of a MAP. This saves measurement time and is less taxing for patients than individual channel measurements. The Master Volume level is the average of all C levels for active electrodes in the MAP. Adjustments can be applied to C profiles only, T profiles only, or both T and C profiles. If Thresholds were measured prior, only the C level profile will be adjusted to preserve behavioral T levels.

Bass and treble

Applies a combination of tilt and curvature across the MAP profile in the presence of live speech. Bass adjusts low frequency volume and Treble adjusts high frequency volume and is used to balance sound quality of a MAP in response to patient feedback. Adjustments start at zero and are applied in a gentle curve starting from the most central channel (maximum range -30 to +30 CLs).

Why program using Global Adjustments vs. individual electrodes?

Individual channel measurements are sometimes necessary to obtain quality hearing outcomes, however, with technological advances the need for per-channel measurements across the entire array has reduced.

Some patient factors such as tinnitus, poor concentration, unreliable responses, young age, etc. may restrict a clinician’s capability to perform individual channel measurements in a reliable manner. Additionally, stimulating on single electrodes does not consider loudness summation when all channels are activated in a MAP. After individually measuring C levels, many clinicians globally reduce C levels before going live to compensate for expected loudness summation and as a result, setting loudness globally with live audio may better reflect daily use conditions.

Using Global Adjustments and the default Custom Sound Pro workflow at activation can:

  • Achieve a quick first fit MAP which can be refined later
  • Achieve an easier patient interaction as they acclimate to electrical stimulation
  • Place the focus on achieving MAP audibility and comfort
  • Serve young or less cooperative patients
  • Help avoid over or under-fitting with onscreen guidance provided

After activation, the literature confirms that MAP levels typically stabilize within the first-year post-implant and remain stable over time for both adults and children1-4, so it may not be necessary to re-measure at every follow-up appointment.

This doesn’t mean that C and T levels are not important – there will be times when it is clinically indicated to measure T and C levels during follow up appointments, but the need for frequent re-measurement may therefore be reduced.

Conversely, using Global Adjustments at follow up appointments offers a comfortable and easy task for many patients to perform a quick MAP check to monitor stability. It can also allow focus to be directed towards non-MAPping activities during follow-up sessions.

There will always be some instances when individual channel measurements are clinically indicated and should be performed to ensure optimal outcomes, but clinicians are encouraged, where possible, to start with Global Adjustments and then continue with per-electrode adjustments as needed. Consider Global Adjustments at follow up appointments for:

  • Routine fittings when setting audibility and establishing comfort
  • Optimizing whole MAP sound quality
  • Follow-up MAP checks
  • Serving patients who are uncooperative or unable to reliably perform psychophysics

Learn more about Custom Sound Pro here!

References:

1. Henkin Y, et al. Int. J. Pediatr. Otorhinolaryngol. (2003); Aug 1;67(8):873-80.

2. Gajadeera EA, et al. Ear Hear. (2017); Nov 1;38(6):736-45.

3. Hughes ML, et al. Ear Hear. (2001); Dec 1;22(6):471-86.

4. Incerti PV, et al. Int. J. Audiol. (2018); Mar 23;57(sup2):S27-40.

Jolie Fainberg, AuD

How upgrade technology can lead to better hearing

January 12, 2021

By Jolie Fainberg, AuD, Cochlear Implant Program Director at Atlanta Institute for ENT

With 34 years of cochlear implant experience, Dr. Fainberg discusses upgrading patients to the latest Nucleus® Sound Processors.

What is your current role and what do you love about it?

I am an audiologist at a busy private ENT clinic in Atlanta, Georgia. We have a pediatric ENT, four adult ENTs and we just hired a neurotologist. I love my job because in the 29 years I have worked in Atlanta, I have watched hundreds of cochlear implant (CI) kids grow up. I get to follow them through their journey to develop hearing, speech and language – I become part of their family! Cochlear implants are the most exciting technology. There have been so many changes in this industry and it only gets better.

What do you consider the biggest changes in sound processor technology affecting your Cochlear™ Nucleus upgrade patients and why?

The addition of Bluetooth® streaming technology has had the biggest impact. Everyone loves to stream their music and have the convenience of using the phone directly to their CI. Nucleus Smart App is also a great addition. Patients have more control over their sound processor overall. They can make their own adjustments as needed and change programs more easily. Next, the Hearing Tracker and Find My Processor features have been lifesavers for many patients, particularly parents of young children.  Parents have found their kid’s CI in some pretty amusing places!

How has counseling your upgrade patients evolved with today’s sound processors?

I counsel my patients to really evaluate the benefits of a new sound processor prior to upgrading, as insurance companies have specific guidelines about approving upgrade. Insurance companies can be stricter about approving upgrades. Many require that the current sound processor is not functioning before they will approve the upgrade. This is challenging as I don’t want my patients to be without sound while we wait for approval.

The technology continues to improve in leaps and bounds. Although an upgrade to new sound processor can provide a smaller device, new technology options, etc., the real benefit is the improvement in hearing. I could be the best MAPping audiologist in the world, but there are limitations to technology that cannot be changed with MAPping. When new devices are released, the better sound quality and offer of better hearing transcends any MAPping changes I can make on old technology. I wish the insurance companies understood the hearing benefit our patients get when they upgrade. They might make it easier for patients to get new technology.

What features of the new sound processors do you feel improve hearing outcomes?

Here are a few features:

  • SCAN* (the industry’s first automatic scene classifier) has been beneficial to many of my CI users. For long term recipients, it takes a week or two for them to get used to it. After a period of adjustment, SCAN helps with changes in the hearing environment without having to adjust their CI.
  • Many of my patients have liked ForwardFocus** for restaurants and one-on-one conversations. 
  • I recommend the Mini Microphone 2+ for all my patients. It helps in so many situations such as the car, restaurants and college classes.
  • The Aqua+ wear options~ have been fun for many of my patients who have never been able to hear while swimming or playing in the water.

What are the biggest differences you’ve seen in your patients after an upgrade?

First and foremost: better hearing! I have dozens of stories where patients have heard things with their new sound processors that they never heard before. One patient told me that after she got her upgraded device and was walking with her dad to their car, she asked him: “What’s that sound?” He said, “I don’t hear anything.” They continued walking and then she realized, the sound was her footsteps. She had never heard them before. Another time, a young man received an upgrade after more than eight years and tearful at how clear the sound of the new sound processor was! The newer technology offers hearing that cannot be realized no matter what we do to an older device. That’s why we upgrade our phones and computers!

Would you highlight a success story about one of your earliest implanted Cochlear Nucleus 22 patient (adult and/or child)?

One of my N22 patients who was implanted at two years of age in 1992 just graduated from nursing school and works as a nurse. Because of the COVID precautions, she wears a mask all day at work. In addition, she is a unilateral CI user, as many of our early CI kids were only implanted on one side. She successfully navigates this difficult listening situation. I have a large number of N22 patients still using their original internal device successfully. These patients are all adults now and having a CI has not stopped them from doing whatever they wanted.

How do you counsel your patients on which Nucleus Sound Processor is right for them?

I show both options to my patients and review the highlights of each device. The decision between Nucleus 7 and Kanso® 2 is highly polarizing! Patients either want one or the other. Many of my patients who received their CIs very young do not want the drastic change from behind-the-ear to single unit sound processor. Other patients are really excited about getting a single unit CI and get the sound processor off their ear!

What have your patients been most excited about with the Kanso 2 Sound Processor?

They love the convenience of no cables or other parts to worry about. They like that the sound processor is off their ear. Many male recipients find it more aesthetically pleasing and less noticeable.

What innovations do you think will drive the CI industry forward?

In a post-COVID world, I think the capability to offer remote care like more complex remote programming will be in our future. The added benefit to this is the ability to offer better hearing healthcare services to patients living far away from a CI center.

Read more about upgrade technology here and watch this AudiologyOnline course!

About the author:

Jolie Fainberg is an audiologist with 36 years of experience. Her primary interests are pediatric audiology and cochlear implants for children and adults. She received her BA in Speech and Hearing Science at the University of California, Santa Barbara, her MA in Audiology at the University of Tennessee, Knoxville and her AuD from AT Still University. She participated on the original FDA clinical trials for all three cochlear implant companies. Her research has focused on pediatric audiology, pediatric cochlear implants, cochlear implants in special populations, diagnostic techniques for difficult to test infants and children, and brain plasticity in children. In 1992, she developed and established the pediatric audiology and cochlear implant program for Egleston Children’s Hospital at Emory University (now Children’s Healthcare of Atlanta).  She is a Clinical Instructor in the Department of Otolaryngology at the Emory School of Medicine and an Adjunct Professor at A. T. Still University Post Professional Doctor of Audiology program. Currently, she works at an ENT practice doing pediatric diagnostic testing and cochlear implants in adults and children.

The Bluetooth® word mark and logos are registered trademarks owned by Bluetooth SIG, Inc. and any use of such marks by Cochlear is under license.

The Cochlear Nucleus Smart App is available on App Store and Google Play. For compatibility information visit www.cochlear.com/compatibility

*SNR-NR, WNR and SCAN are approved for use with any recipient ages six years and older, who is able to 1) complete objective speech perception testing in quiet  and in noise in order to determine and document  performance 2) report a preference for different program settings.

**ForwardFocus can only be enabled by a Hearing Implant Specialist. It should only be activated for users 12 years and older who are able to reliably provide  Feedback on sound quality and understand how to use the feature when moving to different or changing environments. It may be possible to have decreased speech understanding when using ForwardFocus in a quiet environment.

~The Nucleus 7 Sound Processor with Aqua+ is water resistant to level IP68 of the International Standard IEC60529. This water protection only applies when you use a Cochlear Standard Rechargeable Battery Module or Cochlear Compact Rechargeable Battery Module. The Kanso 2 Sound Processor is dust and water resistant to level of IP68 of the International Standard IEC60529. The Kanso 2 Sound Processor with Aqua+ is dust and water resistant to level of IP68 of the International Standard IEC60529. This water protection rating means that the sound processor with the Aqua+ can be continuously submerged under water to a depth of up to 3 meters (9 feet and 9 inches) for up to 2 hours. The Aqua+ accessory should be used when participating in prolonged water activities.

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