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Updated: Mar 24, 2026
Systematic Hearing Performance Evaluation Process for Adolescents with Cochlear Implantation at Early Ages
Published on: March 24, 2023
Pediatric CI 3-60 Guideline: When to Refer Children for a Cochlear Implant Candidacy Evaluation
Jourdan T Holder1,2, Andrea D Warner-Czyz2,3,4, Lisa R Park2,5
1Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Insights
New guidelines for pediatric cochlear implant (CI) evaluation, called CI 3-60, use unaided thresholds, aided speech intelligibility index (SII), and word recognition scores (WRS) to identify children who may benefit from this hearing technology.
Area of Science:
- Audiology
- Otolaryngology
- Biomedical Engineering
Background:
- Cochlear implants (CIs) significantly improve sound access for children with severe-to-profound hearing loss.
- Underutilization of CIs in pediatric populations is partly due to uncertainty in referral timing for candidacy evaluation.
- Current pediatric CI referral guidelines need updating to reflect current clinical practices and outcomes.
Purpose of the Study:
- To analyze hearing evaluations from pediatric CI centers to develop updated referral guidelines.
- To establish evidence-based criteria for referring children for cochlear implant candidacy evaluation.
Main Methods:
- Retrospective analysis of hearing evaluations for 1179 children under 14 with known hearing loss across three major CI centers.
- Data collected included hearing device configuration, age, referral recommendations, audiogram thresholds (4-frequency pure-tone average, 4FPTA), unaided/aided word recognition scores (WRS), and unaided/aided speech intelligibility index (SII).
- Evaluations spanned January 2020 to December 2021.
Main Results:
- Of 348 children referred for CI evaluation, 84% were recommended for implantation.
- Nearly all ears recommended for implantation had 4FPTA thresholds ≥60 dB HL (96%), aided SII ≤0.60 (94%), or WRS ≤60% correct (96%).
- Only 23% of children could complete aided open-set speech recognition testing, emphasizing reliance on objective measures like aided SII.
Conclusions:
- A holistic approach incorporating age-appropriate testing limitations is crucial for pediatric CI candidacy.
- The proposed CI 3-60 guideline (unaided 4FPTA ≥60 dB HL, aided SII ≤0.60, or WRS ≤60%) aids in identifying suitable candidates.
- These guidelines align with adult criteria and enhance the continuum of hearing technology options for children with hearing loss.
Objectives:
Despite the success of cochlear implants (CIs) in providing access to sound for children with significant hearing loss, only approximately 50% of children with severe-to-profound sensorineural hearing loss in the United States receive this treatment option. One contributing factor to this underutilization is uncertainty surrounding the appropriate time to refer for a CI candidacy evaluation. The purpose of this study was to analyze hearing evaluations captured from children with known hearing losses at three progressive, major CI centers to develop updated guidelines for referral to pediatric CI evaluation.
Design:
Retrospective data were collected at the three participating centers. The most recent hearing evaluation for 1179 children younger than 14 yrs of age with known hearing losses was captured during a 2-yr period (January 2020-December 2021). Hearing evaluations included standard hearing evaluations to monitor hearing loss of all degrees, as well as CI candidacy evaluations. The following data points were collected: hearing device configuration, age, referral recommendation for CI evaluation, CI recommendation, audiogram thresholds (four-frequency pure-tone average, 4FPTA), unaided and aided word recognition scores (WRS), and unaided and aided speech intelligibility index (SII).
Results:
Of the 348 children (531 ears) referred for CI candidacy evaluation, a CI was recommended for 84% of them. Nearly half of the ears recommended for implantation attained a 4FPTA better than 90 dB HL with 96% of them having a 4FPTA of 60 dB HL or greater. When evaluating aided SII (252 ears), 94% of the ears recommended for implantation had an SII ≤0.60. For those with aided WRS available (99 ears), 96% had WRS scores ≤60% correct. Only 23% of children (22% of ears) undergoing CI evaluation could complete aided open-set speech recognition testing, highlighting the need to rely on objective measures such as aided SII to determine CI candidacy in children. Overall, 94% of ears met at least one of the following criteria: unaided 4FPTA thresholds ≥60 dB HL, aided SII ≤0.60, or WRS ≤60% correct. Note that 36% of children recommended to receive a CI did not meet U.S. Food and Drug Administration criteria (i.e., asymmetric hearing loss, better than severe-to-profound hearing loss, WRS >30%, or younger than the age limit).
Conclusions:
Pediatric CI candidacy considerations require a holistic approach that incorporates evidence-informed decision-making to accommodate age-related limitations in behavioral testing. These data-driven recommendations support a three-faceted referral guideline for CI evaluation, called CI 3-60: unaided 4FPTA ≥60 dB HL, aided SII ≤0.60, or WRS ≤60% correct (when available) in the ear to be implanted. This pediatric referral recommendation is consistent with current adult CI candidacy evaluation referral guidelines but adds consideration of aided SII to compensate for pediatric limitations in completing open-set speech recognition tasks. While not all children referred for an evaluation ultimately undergo implantation, these guidelines (a) capture a high proportion who would benefit more from a CI than hearing aids, and (b) frame CIs as part of a continuum of hearing technology for children who are deaf or hard of hearing.
