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Exposure to Spoken Communication in Children With Cochlear Implants During the COVID-19 Lockdown

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  To what extent have the coronavirus disease 2019 (COVID-19) lockdowns changed children’s access to speech?

Findings  In this cohort study of 45 children, sound environments, cataloged using machine learning in hearing prostheses (cochlear implants), were measured both before and during COVID-19 lockdowns in Ontario, Canada. The pre–COVID-19 ratio of speech:quiet (1.6:1.0) significantly reduced to 0.9:1.0 during lockdowns, particularly in school-aged children.

Meaning  School closures due to COVID-19 lockdowns may be associated with reduced exposure to spoken communication during important stages of social, language, and cognitive development.


Importance  The coronavirus disease 2019 (COVID-19) lockdowns in Ontario, Canada in the spring of 2020 created unprecedented changes in the lives of all children, including children with hearing loss.

Objective  To quantify how these lockdowns changed the spoken communication environments of children with cochlear implants by comparing the sounds they were exposed to before the Ontario provincial state of emergency in March 2020 and during the resulting closures of schools and nonessential businesses.

Design, Setting, and Participants  This experimental cohort study comprised children with hearing loss who used cochlear implants to hear. These children were chosen because (1) their devices monitor and catalog levels and types of sounds during hourly use per day (datalogs), and (2) this group is particularly vulnerable to reduced sound exposure. Children were recruited from the Cochlear Implant Program at a tertiary pediatric hospital in Ontario, Canada. Children whose cochlear implant datalogs were captured between February 1 and March 16, 2020, shortly before lockdown (pre–COVID-19), were identified. Repeated measures were collected in 45 children during initial easing of lockdown restrictions (stages 1-2 of the provincial recovery plan); resulting datalogs encompassed the lockdown period (peri–COVID-19).

Main Outcomes and Measures  Hours of sound captured by the Cochlear Nucleus datalogging system (Cochlear Corporation) in 6 categories of input levels (<40, 40-49, 50-59, 60-69, 70-79, ≥80 A-weighted dB sound pressure levels [dBA]) and 6 auditory scene categories (quiet, speech, speech-in-noise, music, noise, and other). Mixed-model regression analyses revealed main effects with post hoc adjustment of confidence intervals using the Satterthwaite method.

Results  A total of 45 children (mean [SD] age, 7.7 [5.0] years; 23 girls [51.1%]) participated in this cohort study. Results showed similar daily use of cochlear implants during the pre– and peri–COVID-19 periods (9.80 mean hours pre–COVID-19 and 9.34 mean hours peri–COVID-19). Despite consistent device use, these children experienced significant quieting of input sound levels peri–COVID-19 by 0.49 hour (95% CI, 0.21-0.80 hour) at 60 to 69 dBA and 1.70 hours (95% CI, 1.42-1.99 hours) at 70 to 79 dBA with clear reductions in speech exposure by 0.98 hour (95% CI, 0.49-1.47 hours). This outcome translated into a reduction of speech:quiet from 1.6:1.0 pre–COVID-19 to 0.9:1.0 during lockdowns. The greatest reductions in percentage of daily speech occurred in school-aged children (elementary, 12.32% [95% CI, 7.15%-17.49%]; middle school, 11.76% [95% CI, 5.00%-18.52%]; and high school, 9.60% [95% CI, 3.27%-15.93%]). Increased daily percentage of quiet (7.00% [95% CI, 4.27%-9.74%]) was most prevalent for children who had fewer numbers of people in their household (estimate [SE] = −1.12% [0.50%] per person; Cohen f = 0.31).

Conclusions and Relevance  The findings of this cohort study indicate a clear association of COVID-19 lockdowns with a reduction in children’s access to spoken communication.

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Article Information

Accepted for Publication: December 9, 2020.

Published Online: February 18, 2021. doi:10.1001/jamaoto.2020.5496

Corresponding Author: Karen A. Gordon, PhD, Department of Otolaryngology–Head & Neck Surgery, University of Toronto, The Hospital for Sick Children, 555 University Ave, Room 6D08, Toronto, ON M5G 1X8, Canada (karen.gordon@utoronto.ca).

Author Contributions: Dr Gordon had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gordon, Ganek, Papsin, Cushing.

Acquisition, analysis, or interpretation of data: Gordon, Daien, Negandhi, Blakeman, Ganek.

Drafting of the manuscript: Gordon.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Gordon, Daien.

Administrative, technical, or material support: Gordon, Negandhi, Blakeman, Ganek, Papsin.

Supervision: Gordon, Papsin, Cushing.

Collecting data: Negandhi.

Conflict of Interest Disclosures: Drs Gordon, Papsin, and Cushing reported being on the Speakers Bureau for Cochlear Corporation during the conduct of the study. Dr Cushing reported being on the Speakers Bureau for Interacoustics, receiving royalties as a Plural Publishing Editor for Balance Disorders in the Pediatric Population, and receiving grants from Cochlear Corporation during the conduct of the study. Dr Gordon reported being an adjunct faculty member at Salus University. Drs Cushing and Papsin hold patent no. 7041-0, Systems and Methods for Balance Stabilization Sponsored Research Agreement—Cochlear Americas. No other disclosures were reported.

Funding/Support: This work was supported by research endowments from the SickKids Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the families in our program who participated in this study and Daune MacGregor, MD, Department of Neurology, The Hospital for Sick Children, and Ari Bitnum, MD, MSc, Department of Infectious Diseases, The Hospital for Sick Children, for reviewing a draft of the manuscript before submission. There was no financial compensation for these contributions.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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