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The New Zealand Ministry of Health have a very interesting page on Cochlear Implants. It can be found here. It sets out some fo the basic information about Cochlear Implant provision in New Zealand.

Interestingly it has one section entitled “Why does the Ministry of Health only fund one cochlear implant?“. This is a very good question – one most parents of a child needing Cochlear Implants asks. Here is the Ministry of Health’s answer:

Firstly, one implant is highly effective in achieving the goal of ensuring a person to hear effectively, and for most children to develop their language skills at the crucial early stage.

Secondly, by choosing one implant over two, we can maximise the benefit of the available funding. In short, we can ensure that the maximum number of people who could benefit from an implant (children and adults) receive one in any year.

People who have had meningitis may have bilateral electrodes (the component that is implanted) funded when this is clinically recommended.

Some families choose to pay privately for the second implant.

There appear to be two reasons suggested (although it is a little difficult to be sure given the poor sentence construction). The first is that the Ministry of Health say that “…one implant is highly effective…”. The second reason is essentially that they can’t afford to do more than one. Let’s look at each of these in more detail.

“Highly Effective”

The Ministry of Health make the claim that a single Cochlear implant is “…highly effective in achieving the goal of ensuring a person to hear effectively…”. Let’s first leave aside the poor sentence construction. Let’s focus on whether this claim can be sustained.

When observing adults who have a single Cochlear Implant, there is no doubt that a single Cochlear Implant offers enormous benefits over very poor hearing. Adults can hear well in low noise environments and with modern processors, can even participate in more noisy environments. However many adult users recognise that they use enormous amounts of effort to listen with one Cochlear Implant, particularly in higher noise environments.

For children, particularly those who are pre-lingual, the effectiveness of their hearing is less clear. Almost without exception, children will require an FM system to enable clearer and faster development of language. They will miss large numbers of auditory experiences because they occur on the non-implanted side. They will struggle in everyday experiences of being a child, like going to school, hanging out with groups of friends and playing sports.

To put it simply, while it might, at a stretch, be argued that for an adult a single Cochlear Implant is effective in ensuring a person hears effectively, for a child, especially those children who are pre-lingual, this is not the case. While Cochlear Implants are very good, it is disingenuous to argue that a single Cochlear Implant is “highly effective” in the same way that one could argue a hearing aid is highly effective for someone with mild hearing loss.

The second part of this statement asserts that a single Cochlear Implant is “…highly effective…” “…for most children to develop their language skills at the crucial early stage.”. In 2012 Julia Sarant from Melbourne University published Cochlear Implants in Children: A Review, Hearing Loss. This was a pre-curser publication to a major study due out later this year into the effectiveness of Cochlear Implants in children. She concludes:

A unilateral cochlear implant does not guarantee the development of language, speech production, academic or social skills comparable to those of children with normal hearing. Although there are many children with a unilateral cochlear implant who are able to develop these skills at an age-appropriate rate, there also remain many who show delayed development in these areas, some of whom maintain or increase their delay through to adulthood. Given the difficulties of unilateral hearing loss, giving children bilateral cochlear implants could potentially improve outcomes.

Her research strongly suggests there are limitations with hearing with a single Cochlear Implant for children, specifically in the area of language skills.

Sarant’s research here was comparing children with Cochlear Implants to their hearing peers. A 2012 paper by Boons et al entitled Effect of Pediatric Bilateral Cochlear Implantation on Language Development directly compared children with a single (unilateral) Cochlear Implant to children with two (bilateral). Boons found for both receptive and expressive language testing that “children undergoing bilateral implantation performed significantly better than those undergoing unilateral implantation”. In short, children with a single Cochlear Implant lagged behind in language development when compared to their hearing and bilaterally implanted peers.

Boon et al’s research is the most substantial and sizable study to date. Later this year Sarant is likely to publish results from her current clinical research which draws on both Australian and New Zealand children with Cochlear Implants.

We would argue that this research shows that a single Cochlear Implant is not “highly effective” in ensuring a person hears effectively nor ensuring a child develops language skills. We would suggest that a single Cochlear Implant may be effective in providing effective hearing for an adult. We would assert that a single Cochlear Implant is less than effective in ensuring a child has effective hearing and develops language skills at the crucial  early developmental stages.

This is certainly what the United Kingdom’s National Institute for Health and Clinical Excellence concluded as far back as January 2009 when they moved to requiring all their DHB equivalents to fund simultaneous bilateral implants for all children.

Affordability

The Ministry of Health state that “by choosing one implant over two, we can maximise the benefit of the available funding.”. There is no doubt this is true for adults. There will always be more adults seeking Cochlear Implants than funding will allow. And if the funding was significantly increased, it would cause more people to seek them – including people who were previously outside the criteria.

For children however, particularly children who are pre-lingual, this is arguable. The issue is where the funds are. For a child who is identified with a severe to profound hearing loss at birth, who is bilaterally implanted at 6 months and then is given 6-12months intensive early intervention therapy, there is a strong likelihood that they will be caught up with their natural hearing peers by the time they are 12-18 months old. While they will require ongoing monitoring to ensure their language development and educational achievement progresses, there tends to be little need for further intervention and expenditure.

For a child who is implanted with a single Cochlear Implant, this is not as likely. While they may catch their hearing peers by the time they enter the school system, they are likely to need additional support during their school years. This is particularly the case as they enter higher level schooling. Such support can exceed $30,000 per year.

The issue of affordability for children is really a ‘do you pay now, or do you pay more later’ question.

We assert the affordability argument is now marginal, if not totally flawed. Doing only one Cochlear Implant costs more money.

Summary

At 2ears2hear we strongly support the introduction of publicly funded simultaneous bilateral implantation of children where it is clinically deemed to be beneficial. We are one eyed about this goal. But even recognising that bias, it is quite apparent that to claim that a single Cochlear Implant is “highly effective” is inaccurate, not supported by research and quite misleading at best. At worst it is disingenuous.

The Ministry of Health needs to correct this page immediately and present a real reason “Why does the Ministry of Health only fund one cochlear implant?” – if it can.