Cochlear implantation is being performed in increasingly younger children. We present a retrospective cohort of 19 patients with 23 ears implanted under 18 months of age. The mean age at implantation was 11.9 months, with the youngest being 6.8 months. The facial recess was narrow in nine ears (39%), including all premature infants. An inferiorly located stapedius tendon was sectioned in seven ears (30%) to facilitate round window access. Countersinking of the receiver-stimulator required dural exposure in 22 ears (96%). The receiver-stimulator was secured with sutures in 15 ears (65%) and within a tight pocket in eight ears (35%). Tympanostomy tubes were placed in 10 ears (43%). Cochlear implantation in very young children frequently necessitates modified surgical techniques.