Effect of otitis media on development: a community-based study

Does otitis media in early childhood affect later behavioural development? Results from the Western Australian Pregnancy Cohort (Raine) Study

OBJECTIVES

To examine the relationship between early life episodes of otitis media and later behavioural development with adjustment for confounders.

DESIGN

Longitudinal cohort study.

SETTING

The Western Australian Pregnancy Cohort (Raine) Study recruited 2900 pregnant women from King Edward Memorial Hospital (KEMH) in Perth, Western Australia, between 1989 and 1991.

PARTICIPANTS

Data from the children born were collected at both the Year 3 and Year 5 follow-up. At Year 3, n = 611 were diagnosed with recurrent otitis media through parent-report and clinical examination. At Year 5, n = 299 were considered exposed to otitis media based upon tympanometry results.

MAIN OUTCOME MEASURES

Performance in the Child Behaviour Checklist (CBCL), a questionnaire completed by the primary caregiver at Year 10.

RESULTS

Significant associations were found between recurrent otitis media at Year 3 and internalising behaviours (P = .011), and the somatic (P = .011), withdrawn (P = .014), attention (P = .003) and thought problems domains (P = .021), and the total CBCL score (P = .010). A significant association was also found between exposure to otitis media at Year 5 and externalising behaviours (P = .026).

CONCLUSIONS

A modest association was seen between recurrent otitis media at Year 3 and exposure to otitis media at Year 5 and a number of behaviour domains at Year 10.

Prevalence and risk factors for parent-reported recurrent otitis media during early childhood in the Western Australian Pregnancy Cohort (Raine) Study

AIM

To describe the prevalence and risk factors of recurrent otitis media (rOM) in an urban Australian population at 3 years of age.

METHODS

Cross-sectional examination of prevalence and risk factors of rOM in 2280 participants from the Raine Study enrolled from public and private hospitals in Perth, Western Australia, between 1989 and 1991. Parental report questionnaires at 3 years of age were used for rOM identification, with secondary confirmation by otoscopic examination at 1, 2 or 3 years of age.

RESULTS

The prevalence of parent-reported rOM was 26.8% (611/2280) and 5.5% (125/2280) for severe rOM in the Study. Independent associations were found between rOM and the presence of older siblings, attendance at day care and the introduction of other milk products at ≤4 months of age. Independent associations for severe rOM were the presence of allergies and attendance at day care.

CONCLUSIONS

Prevalence rates of rOM within the Raine Study children are similar to a number of other known cohorts. Parity, presence of allergies, attendance at day care and introduction of other milk products at ≤4 months are highlighted as specific risk factors for rOM in this population and presence of allergies and attendance at day care being risk factors for severe rOM. Diagnosis of rOM by parent report and the delay between data collection and reporting are limitations of this study. However, as there is very limited data on OM in urban, non-Indigenous Australian children, this study improves our understanding of OM for this group.

Prevalence and risk factors of otitis media with effusion in school children in Eastern Anatolia

OBJECTIVE

To investigate the prevalence and demographic, environmental and child associated risk factors of OME in schoolchildren in Eastern Anatolia, Turkey, and analyze the results with reference to the review of the literature.

METHODS

A total of 2355 children who were attending two different primary schools, one located in low, and the other located in a high socioeconomic district of city of Van were screened and 2320 children who met the inclusion criteria were enrolled to study. Standardized questionnaires that include nine questions for determination of risk factors were delivered to the parents to be filled before examination of each child. All of the children underwent both otoscopic examination and tympanometric evaluation to provide high accuracy on the diagnosis of OME. The association between children diagnosed as OME and the answers to the questionnaires were evaluated. Also, teachers of the children were asked to complete a questionnaire evaluating child's level of school success, and the success levels of children with or without OME were compared.

RESULTS

The prevalence of OME was found to be 10.43%. Second-hand smoking (p<0.0001), low socioeconomic status (p<0.001), living in a crowded house (p<0.001), presence of atopy (p<0.01), lack of breast-feeding (p<0.05), presence of URTI (p<0.0001), young age (p<0.001) and snoring (p<0.0001) were found to be associated with prevalence of OME. No significance was found for duration of breast-feeding, gender, birth history and previous otolaryngological operations. Also, children with OME were tended to be less successful in terms of school success.

CONCLUSIONS

The potential of OME to cause serious sequelae and complications that may affect children's life long-term, makes the disease an important health problem. Environmental, epidemiologic and familial factors play an important role in pathogenesis of OME. Caretakers must be informed about these highly modifiable risk factors, by this way the development or delayed diagnosis of the disease that may cause serious consequences can be prevented.

Prevalence and risk factors for persistent otitis media with effusion in primary school children in Istanbul, Turkey

OBJECTIVE

To determine the impact of environmental, epidemiologic and familial factors in the development of persistent otitis media with effusion (OME-OME treated with antibiotics and followed additional 12 weeks) in primary school children in Istanbul.

MATERIALS AND METHODS

A total of 1800 children who were attending 4 different primary schools in Sisli and Beyoglu districts of Istanbul were screened and 1740 children who met the inclusion criteria were enrolled into this study. Questionnaires prepared in the Otorhinolaryngology Clinics of Taksim Research and Training Hospital and the forms were delivered to the parents to be filled the day before examination of each child. The forms were collected during the otoscopic examinations. Pure tone audiometry and tympanometry tests and pneumatic otoscopy were performed on the children who were diagnosed as OME by otoscopic examination. The association between the children diagnosed as OME and the answers to the questionnaires was evaluated.

RESULTS

The prevalence of persistent OME in this paper was 8.7% (152/1740). Frequency of smoking in both parents (p<0.01) and mothers alone (p<0.0001), the frequency of acute otitis media (AOM) and upper respiratory tract infection (URTI) in past 1 year (p<0.0001), incidence of attending day care centers and crèches (p<0.0001), allergy history (p<0.05), the number of siblings (p<0.0001) and poor educational status of the parents (p<0001) were statistically significant factors among children with OME compared to normal children. Sex factors (p>0.05), mothers smoke history during pregnancy (p>0.05), relative marriage (p>0.05), smoking history of the fathers (p>0.05) and duration of breastfeeding (p>0.05) were not statistically significant.

CONCLUSION

Environmental, epidemiologic and familial factors in the etiology of OME are important. The parents must be informed about the risk factors and symptoms of OME and by this way, the development or delayed diagnosis of the disease that may lead to permanent hearing loss may be prevented.

Breastfeeding and infant illness in low-income, minority women: a prospective cohort study of the dose-response relationship

The authors' objective was to determine whether cumulative weekly breastfeeding duration by 13 weeks was associated with infant otitis media, respiratory and gastrointestinal illness, and total illness visits up to 12 months. The authors performed a secondary analysis of data from a randomized clinical trial of low-income, primarily Hispanic and Black women enrolled from 2 medical center affiliated clinics. "Breastfeeding sensitive" (BFS) outpatient and emergency room (ER) visit data for the above illnesses were obtained for 255 mother/infant dyads. Outcome measures were unadjusted and adjusted rates of outpatient and ER visits with sick and BFS diagnoses. The authors found no significant associations between breastfeeding intensity and infant visits for otitis media, respiratory and gastrointestinal illness, or total illness visits. In this low-income, multiethnic sample, breastfeeding intensity was not associated with infant health service use, in contrast to other evidence-based reports. Low exclusive breastfeeding rates and lack of coverage for health visits may be reasons for this finding.

Risk factors for otitis media with effusion in Chinese schoolchildren: a nested case-control study and review of the literature

OBJECTIVE

To identify the risk factors for otitis media with effusion (OME) in Chinese schoolchildren and analyse the results with reference to the review of the literature.

METHODS

The study subjects were 6-7-year-old children drawn from a school-screening program for OME in Hong Kong. Both positive and negative screens attended a hospital clinic for further assessment with repeated otoscopic examination and tympanometry as well as pure tone audiometry within 3 weeks after the initial school-screening. During the visit, parents were interviewed to provide information with regard to the children's birth history, neonatal history, socio-economic background, otological history, past health, and medical history. These data formed the basis in the estimation of potential risk factors for OME.

RESULTS

In the univariate analysis of 127 cases and 173 controls, significantly elevated odds ratios (OR) for OME were detected on the symptoms of atopy (OR = 2.21, p = 0.04), hearing loss (OR = 4.13, p = 0.001), nasal obstruction (OR = 1.94, p = 0.005), rhinorrhoea (OR = 1.61, p = 0.04), tonsillitis in the past 12 months (OR = 1.82, p = 0.02), and previous history of acute otitis media (OR = 6.89, p < 0.001). However, only three of them were found to be significant in the multivariate logistic regression model: nasal obstruction (OR = 1.67, 95% CI: 1.01-2.75); acute tonsillitis (OR = 1.68, 95% CI: 1.00-2.80), and previous acute otitis media episodes (OR = 5.75, 95% CI: 2.60-12.69).

CONCLUSIONS

Risk factors identified in the Chinese schoolchildren for OME were comparable with previous western reports. A previous attack of acute otitis media was a major determinant for middle ear effusion.

Randomized, controlled trial of a prenatal and postnatal lactation consultant intervention on duration and intensity of breastfeeding up to 12 months

OBJECTIVE

To determine whether an individualized, prenatal and postnatal, lactation consultant intervention resulted in increased cumulative intensity of breastfeeding up to 52 weeks.

DESIGN

The randomized, nonblinded, controlled trial recruited women from prenatal care. Baseline prenatal interviews covered demographic data and breastfeeding experience, intention, and knowledge. Interviews at 1, 2, 3, 4, 6, 8, 10, and 12 months after birth collected data on weekly feeding patterns, infant illness, and infant health care use.

SETTING

Two community health centers serving low-income, primarily Hispanic and/or black women.

PARTICIPANTS

The analytic sample included 304 women (intervention: n = 145; control: n = 159) with > or = 1 postnatal interview.

INTERVENTION

Study lactation consultants attempted 2 prenatal meetings, a postpartum hospital visit, and/or home visits and telephone calls. Control subjects received the standard of care.

OUTCOME MEASURES

Cumulative breastfeeding intensity at 13 and 52 weeks, based on self-reports of weekly feeding, on a 7-level scale.

RESULTS

The intervention group was more likely to breastfeed through week 20 (53.0% vs 39.3%). Exclusive breastfeeding rates were low and did not differ according to group. In multivariate analyses, control subjects had lower breastfeeding intensity at 13 weeks (odds ratio [OR]: 1.90; 95% confidence interval [CI]: 1.13-3.20) and 52 weeks (OR: 2.50; 95% CI: 1.48-4.21). US-born control subjects had lowest breastfeeding intensity at 13 weeks (OR: 5.22; 95% CI: 2.43-11.22) and 52 weeks (OR: 5.25; 95% CI: 2.44-11.29). There were no significant differences in breastfeeding intensity among the US-born intervention, foreign-born intervention, and foreign-born control groups.

CONCLUSIONS

This "best-practices" intervention was effective in increasing breastfeeding duration and intensity. Breastfeeding promotion should focus on US-born women and exclusive breastfeeding.

Parent-reported language skills in relation to otitis media during the first 3 years of life

As part of a larger study of the potential impact of early-life otitis media (OM) on speech, language, cognition, and behavior, we studied the degree of association between parent-reported language scores at ages 1, 2, and 3 years and the cumulative duration of middle-ear effusion (MEE) during the first 3 years of life in a demographically diverse sample of 621 children. We estimated the cumulative percentage of days with MEE from prospective monthly observations of middle-ear status and interpolations for periods between visits. For each child, parents completed the appropriate inventory of the MacArthur Communicative Development Inventories (CDI; L. Fenson et al., 1993) at ages 1, 2, and 3 years. We also evaluated the contribution of maternal education, as a proxy for socioeconomic status, to scores on the parent reports. Scores on the new CDI-III (B. Oliver et al., in press) varied positively with sociodemographic variables and were significantly correlated with scores from the CDI used when the children were younger. Unadjusted correlations between scores at ages 1 and 2 years and the percentages of days with MEE in the respective antecedent periods were statistically nonsignificant or of questionable clinical importance. The correlations between parent-reported scores at age 3 years and children's cumulative percentage of days with MEE in Years 1, 2, and 3 combined ranged from -.187 to -.248 (all p values < .001). The percentage of days with MEE and maternal education each contributed independently to scores at age 3 years. In the light of other findings from the larger study, we think it likely that the negative associations between language measures and MEE reflect confounding factors that contribute, on the one hand, to the duration of OM in young children and, on the other hand, to slow development of their language skills.

Breast-feeding promotion interventions: good public health and economic sense

The health benefits of breast-feeding are well documented, as are the positive effects of breast-feeding promotion interventions. There is a clear dose-response relationship between breast-feeding and infant health in the first year of life, and beyond. Further, nearly all breast-feeding promotion interventions improve--at least minimally--breast-feeding initiation and duration rates. However, the extent to which the costs of such interventions might be offset by the potential health care cost savings during the infant's first year of life has not been examined. From a health policy perspective, such an economic analysis is indicated.

Does early detection of otitis media with effusion prevent delayed language development?

OBJECTIVE

To consider whether earlier detection of otitis media with effusion (OME) in asymptomatic children in the first 4 years of life prevents delayed language development.

METHODS

MEDLINE and other databases were searched and relevant references from articles reviewed. Critical appraisal and consensus development were in accordance with the methods of the Canadian Task Force on Preventive Health Care.

RESULTS

No randomised controlled trials assessing the overall screening for OME and early intervention to prevent delay in acquiring language were identified, although one trial evaluated treatment in a screened population and found no benefit. The "analytic pathway" approach was therefore used, where evidence is evaluated for individual steps in a screening process. The evidence supporting the use of tools for early detection such as tympanometry, microtympanometry, acoustic reflectometry, and pneumatic otoscopy in the first 4 years of life is unclear. Some treatments (mucolytics, antibiotics, steroids) resulted in the short term resolution of effusions as measured by tympanometry. Ventilation tubes resolved effusions and improved hearing. Ventilation tubes in children with hearing loss associated with OME benefited children in the short term, but after 18 months there was no difference in comparison with those assigned to watchful waiting. Most prospective cohort studies that evaluated the association between OME and language development lacked adequate measurement of exposure or outcome, or suffered from attrition bias. Findings with regard to the association were inconsistent.

CONCLUSIONS

There is insufficient evidence to support attempts at early detection of OME in the first 4 years of life in the asymptomatic child to prevent delayed language development.

Language, speech sound production, and cognition in three-year-old children in relation to otitis media in their first three years of life

OBJECTIVE

As part of a prospective study of possible effects of early-life otitis media on speech, language, cognitive, and psychosocial development, we tested relationships between children's cumulative duration of middle ear effusion (MEE) in their first 3 years of life and their scores on measures of language, speech sound production, and cognition at 3 years of age.

METHODS

We enrolled 6350 healthy infants by 2 months of age who presented for primary care at 1 of 2 urban hospitals or 1 of 2 small town/rural and 4 suburban private pediatric practices. We intensively monitored the children's middle ear status by pneumatic otoscopy, supplemented by tympanometry, throughout their first 3 years of life; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated children for otitis media according to specified guidelines. Children who met specified minimum criteria regarding the persistence of MEE became eligible for a clinical trial in which they were assigned randomly to undergo tympanostomy tube placement either promptly or after a defined extended period if MEE remained present. From among those remaining, we selected randomly, within sociodemographic strata, a sample of 241 children who represented a spectrum of MEE experience from having no MEE to having MEE whose cumulative duration fell just short of meeting randomization criteria. In subjects so selected, the estimated duration of MEE ranged from none to 65.6% of the first year of life and 44.8% of the first 3 years of life. In these 241 children we assessed language development, speech sound production, and cognition at 3 years of age, using both formal tests and conversational samples.

RESULTS

We found weak to moderate, statistically significant negative correlations between children's cumulative durations of MEE in their first year of life or in age periods that included their first year of life, and their scores on formal tests of receptive vocabulary and verbal aspects of cognition at 3 years of age. However, the percent of variance in these scores explained by time with MEE in the first year of life beyond that explained by sociodemographic variables ranged only from 1.2% to 2.9%, and the negative correlations were concentrated in the subgroup of children whose families had private health insurance (rather than Medicaid). We found no significant correlations in the study population as a whole or in any subgroup between time with MEE during antecedent periods and children's scores on measures of spontaneous expressive language, speech sound production, or other measured aspects of cognition. In contrast, by wide margins, scores on all measures were consistently highest among the most socioeconomically advantaged children and lowest among the most socioeconomically disadvantaged children.

CONCLUSIONS

Our findings suggest either that persistent early-life MEE actually causes later small, circumscribed impairments of receptive language and verbal aspects of cognition in certain groups of children or that unidentified, confounding factors predispose children both to early-life otitis media and to certain types of developmental impairment. Findings in the randomized clinical trial component of the larger study should help distinguish between causality and confounding as explanations for our findings.language, speech, cognition, development, otitis media, middle ear effusion.

Short-term benefits of grommet insertion in children

It is commonly acknowledged that otitis media with effusion (OME) can cause behavioural disturbances and that this can be relieved by grommet insertion. However, this widely-held perception has not been documented in the literature. In this study parents were asked to complete a short behavioural questionnaire on the day of the admission and 6 weeks later. A total of 32 children admitted to the Day Care Unit for insertion of grommets at The Royal National Throat, Nose and Ear Hospital, London, UK, were recruited. There was a significant behavioural change, evident by the difference in the scores before and after grommet insertion (P < 0.001).

Does breast feeding protect against non-gastric infections?

There is convincing evidence that breast-feeding is protective against gastro-enteritis and diarrhoea, but for other infections the situation is less clear cut. There is evidence that breast-fed infants are at increased risk of one infection (infant botulism). They are probably not significantly protected from upper respiratory tract infections (other than otitis media.), but they may be at a decreased risk of lower respiratory tract infections, particularly those associated with respiratory syncytial virus. There is strong evidence that Haemophilus influenzae B infection is more likely in the bottle-fed infant, and consistent evidence of protection of young children from chronic otitis media with prolonged breast-feeding.

Special properties of human milk

In this review, several nutritional and nonnutritive differences between mothers' milk and formula and their relationship to neonatal gastrointestinal and immune processes are discussed. The dynamic relationship of human milk as evidenced by its changing composition, unique bioactive and immunologic properties, and specialized cellular components is further delineated. The clinical significance and relevance of these findings to the clinician are then presented. Lastly, educational strategies, their effectiveness in promoting breastfeeding, and an approach that might be taken by the clinician to encourage breastfeeding are outlined.

Hearing and language in preschool very low birthweight children

To get more insight into preschool language and hearing in high-risk very low birthweight (VLBW) children, we conducted a prospective study in a cohort of 79 children. The prevalence of language impairment and hearing loss at age 3-4 years, their relationship to each other as well as to perinatal conditions, neurodevelopmental outcome and the home environment are described. Mild hearing loss was found in 26%, moderate hearing loss in 13% and severe hearing loss in 3% of the children. None of the children was deaf. Abnormal tympanometry was found in 57% of the children. Hearing loss at age 4 years was related to a less optimal neonatal condition and was not related to the obstetrical condition or to neonatal cerebral ultrasound findings. Language impairment was found in 21% of the children at age 3.6 years. Receptive and expressive language was not related to perinatal conditions. There was no relation between the language assessments and the audiological assessments. Cognition and the home environment of the child were the only independent variables in the prediction of language in preschool VLBW children.

Improving health status in extremely low birthweight children between two and five years

The 5-year outcome of 101 extremely low birthweight (ELBW, < 1000 g) children discharged from the Neonatal Intensive Care Unit was reported. Over this period, there were four post-discharge deaths. The neurodevelopmental impairment rate was 18% overall: cerebral palsy 7%, blindness 3%, deafness 3% and developmental delay 10%. Seventy-one percent of children were readmitted to hospital. The mean number of admissions was 2.4 per child and the mean duration of total hospital stay was 11.3 days per child in the 5-year period. A trend was observed in a reduction in the readmission rate and hospital days in the 2-5-year period compared to the period between discharge and 2 years, though the differences were not statistically significant. The most common reason for readmission was for surgical procedures, primarily aural ventilation tube insertion and tonsillectomy and adenoidectomy. Significant health problems included recurrent wheezing episodes, stridor and croup in the period up to 2 years and otitis media and tonsillitis between 2 and 5 years. There was some catch-up growth, especially in height, between 2 and 5 years. Children with < 800 g birthweight had similar rates of neurodevelopmental impairment and hospital readmission to those of 800-999 g birthweight. However, they experienced more otitis media and pneumonia, had more ear, nose and throat operations, and at 5 years of age, more were below the 3rd centile for weight. This study showed that the health status of ELBW children had improved between 2 and 5 years, but they continued to experience recurrent health problems and hospital readmissions which would have resulted in added financial and emotional burdens to their families.