12Paediatric candidacy

FTA different problem

Adult candidacy rests on a number the patient can give you — a best-aided sentence score. A young child cannot, so paediatric candidacy relies on objective measures, behavioural observation over time, and the child's developmental responseto sound. The question shifts from “what does the test score?” to “is this child using sound to learn?”[2009]

CThe paediatric pathway

The path begins with newborn screening, which flags loss in the first weeks, and proceeds to diagnosis by ABR and behavioural audiometry. When an infant cannot respond behaviourally, electrophysiologic testing (including electrically-evoked responses) can help confirm both the loss and the integrity of the auditory nerve. Auditory-skills, language and developmental assessment then judge whether the child is making use of sound at all.

CThe hearing-aid trial

The traditional cornerstone of paediatric candidacy is the fitted hearing-aid trial. A child's acquiescenceto wearing the aid is itself informative, and the development of aided listening and speech skills over a period of observation is the clearest gauge of benefit. Rejection of amplification, or a failure to progress, flags that the aid is not enough — a signal for implantation. The caution is not to prolong a fruitless trial that merely lengthens deprivation when an implant is otherwise indicated.

TRacing the clock

What makes paediatric candidacy urgent is the sensitive period (Chapter 3). The whole purpose of providing a child with access to sound as early as possible is to exploit the critical windows for speech and language. So the assessment is built for speed and certainty in the very young: confirm the loss, gauge the aid, and — if it falls short — implant early. In children, candidacy and timing are almost the same question.

TCFunctional measures and the age floor

Without a sentence score, paediatric candidacy leans on validated functional questionnaires — IT-MAIS/MAIS, the Auditory Skills Checklist, LittlEARS, FAPCI — that gauge real-world listening, and on a “month-for-month” rule: during the aided trial a child should gain at least a month of auditory and language age for each month elapsed. Falling behind despite full-time amplification and early intervention triggers candidacy (confirmed with serial speech-language evaluations).

The trend is to lower the age floor. The FDA approves implantation from 12 months, but combined behavioural and physiologic measures now give reliable thresholds earlier, and the developmental case for the first year is strong — earlier access yields better word and language acquisition.[2008][2010] The brake is anaesthetic: infants under a year historically carried higher anaesthetic morbidity, so very early implantation belongs in centres with paediatric anaesthesia and minimised operative time. And children with additional handicaps (over 30% of deaf children — CMV, cerebral palsy, autism, CHARGE) should not be denied an implant; their goals are individualised, sometimes environmental awareness rather than open-set speech.