Screening children in the first four years of life to undergo early treatment for otitis media with effusion

Risk factors for failing the hearing screen due to otitis media in Dutch infants

Hearing loss from otitis media (OM) can affect young children's development. Some children with persistent OM-related hearing loss and associated problems can benefit from treatment, but researchers and clinicians are still unclear on how to identify them best. The present study aims to determine which factors are most related to the hearing loss in OM, as a first step towards an effective case-finding instrument for detecting infants with persistent OM-related hearing loss. The full PEPPER ('Persistent Ear Problems, Providing Evidence for Referral') item pool includes a wide range of risk factors for OM in a single questionnaire, and is easily completed by parents or guardians. The questionnaire was sent to all children invited for the universal hearing screen at age 9 months in Limburg, The Netherlands. Repeatedly failing of the hearing screen was used as outcome marker indicative of OM-related chronic hearing loss. Univariate analyses were conducted to determine statistically significant risk factors predicting 'fail' cases at this hearing screen. Five items were found as individually predictive of hearing screen failure and subsequent referral: 'having severe cold symptoms', 'attending day care with >4 children', 'having siblings', 'severe nasal congestion' and 'male gender'. Suitably worded parental questions document risk factors for OM-related hearing loss in infants, broadly consistent with past general literature on OM risk factors, but more focused. The findings justify further optimising and evaluation of an additive or multiplicative combination of these questions as a means for selecting and routing an infant with diagnosed or suspected OM to further care.

Identification of children in the first four years of life for early treatment for otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is the most common cause of acquired hearing loss in childhood and has been associated with delayed language development and behavioural problems. This condition has a point-prevalence of about 20% at the age of two years, a time of rapid language development. It is most often asymptomatic. Effective treatment exists for clearing effusions. Some have argued, therefore, that children should be screened and treated early if found to have clinically important OME. However, there is a high rate of spontaneous resolution of effusions and, for some children, effusions may represent a physiological response that does not reduce hearing significantly or impact negatively on language development or behaviour. Previous reviews of the effect of screening and treatment have included studies using non-randomised designs.

OBJECTIVES

The aim of this review was to assess evidence from randomised controlled trials about the effect, on language and behavioural outcomes, of screening and treating children with clinically important OME in the first four years of their life. The focus was on the first four years of life because this is the time of most rapid language development. The consequences of hearing loss are likely to be most serious during this time. In addition, children of this age are least likely to be able to report or seek help for impaired hearing, particularly if these problems have a slow onset and are subtle.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2006), MEDLINE (1950 to 2006) and EMBASE (1974 to 2006) in February 2002, and again in January 2006, and the reference lists of all studies. We also contacted the first authors of the studies we included in the original review.

SELECTION CRITERIA

1. Randomised controlled trials evaluating interventions for OME among children with OME identified through screening.2. Comparison of outcomes for children randomised to be screened for OME and outcomes for children who were not randomised to be screened for OME.

DATA COLLECTION AND ANALYSIS

Four authors independently extracted data and assessed trial quality, two in the original review and two for the update.

MAIN RESULTS

We identified no trials comparing outcomes for children randomised to be screened for OME with outcomes for children who were not randomised to be screened for OME. We identified three trials evaluating interventions for OME among children with OME identified through screening, one of which generated three published studies. These were trials of treatment in children identified through screening rather than trials of treatment programs. From these trials, we found no evidence of clinically important benefit in language development from screening and treating children with clinically important OME.

AUTHORS' CONCLUSIONS

The identified randomised trials do not show an important benefit on language development and behaviour from screening of the general population of asymptomatic children in the first four years of life for OME. However, these trials were all conducted in developed countries. Evidence generated in the developed world, where children may enjoy better nutrition, better living conditions and less severe and different infections may not be applicable to children in developing countries. The screening aspect of some of these studies was aimed primarily at identifying suitable children in whom to evaluate the effects of treatment, rather than to evaluate the effects of screening programs. Younger children and children with milder disease may have been included in these treatment trials compared to children who are offered treatment in pragmatic settings.

Parental suspicion of hearing loss in children with otitis media with effusion

OBJECTIVE

This study aimed to evaluate the parental suspicion of hearing loss in children with otitis media with effusion (OME). As part of a population-based survey in a screening programme among 6- to 7-year-old Chinese children in Hong Kong, OME cases and controls were studied for the value of parental observations in the prediction of OME and hearing test results.

SUBJECTS AND METHODS

Prior to the otoscopic and tympanometric examination of the children on school premises, a self-administered binary-choice question was sent to the parents asking whether there was any suspicion of hearing impairment. Positive screens and randomly selected negative screens were seen in a hospital clinic for the confirmation of case and control status 2 to 3 weeks after the school screening. Aural examination under microscopy, repeated tympanometry and stapedial reflex testing, and pure-tone audiometry (PTA) were conducted, and 117 cases and 159 controls were included in this study.

RESULTS

The average PTA conductive threshold levels in the individual children with OME ranged from 3.8 dB to 40.0 dB with a group mean of 17.0 dB in the better-hearing ears. Parental suspicion of hearing deficit was significantly associated with OME (p<0.001) but not PTA findings (p=0.686). The sensitivity of parent-suspected hearing impairment to detect OME however was very low (19.7%).

DISCUSSION

In other words, if we had relied on parental suspicion as the first screening, at least 80% of the OME cases would have been missed. We conclude that the parental suspicion of hearing loss is inadequate for the identification of mild hearing loss as caused by OME. Health education is recommended to improve parental awareness of the disease.