Chapter 1 24 (implant) loss through both trauma and failed osseointegration, have been demonstrated to be higher in paediatric populations [117,118]. Skin reactions require special consideration in the paediatric population. Pubertal hormonal changes result in sebaceous hypertrophy and an associated skin overgrowth which may require a longer abutment and attention to the soft tissues [119]. As the population of implanted paediatric patients is heterogeneous and often accompanied by systemic co-morbidities as well as additional childcare needs from a medical, learning, and social aspect, the burden of care for percutaneous implants may be a limiting factor. Unlike in the adult population where hearing rehabilitation options are offered based on audiological test results, undertaking these tests in children poses additional challenges. The validity of subjective hearing tests such as play audiometry, VRA or PTA in young children requires conditioning of a child to provide a response to indicate hearing thresholds. Speech assessments and hearing in noise tests require patient to repeat sentences or words and is dependent on the child’s age and ability to understand and repeat a complex sequence of instruction in an unfamiliar and noisy environment. Many children who require audiological rehabilitation are too young, restricted by co-morbidities or have additional learning needs to gain any meaningful results from many of these tests and so their application is limited. Auditory Brainstem response test (ABR) thresholds can be utilised to guide implantation. However, in the paediatric population parental/carer and patient reported outcome measures bare far more weight in assessing the effectiveness of a BCHD. If an observed improvement is reported during the trial period, this can provide sufficient evidence to offer formal implantation for the patient. In many cases, such a device trial may take months or even years before the decision to move to implantation is taken. To aid clinical decision-making, validated health benefit questionnaires are applied to provide objective evidence of any observed improvement. The Glasgow Children’s Benefit Inventory (GCBI) [120] and an additional visual analogue scale (VAS) are often applied, and many other scoring systems have been proposed [121]. The responses from these can be subdivided to provide assessment relating to emotion, physical health, learning and vitality. This information is easier for parents/careers to relate to in terms of benefits to their child rather than just hearing thresholds and this helps guide them in making the decision to undertake implantation. Transcutaneous implant systems reduce potential for skin complications traditionally associated with percutaneous implants. Such implant systems produce excellent audiological outcomes but still require the surgical implantation of either an osseointegrated fixture and/or
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