Evaluation of the effect of passive smoking on otitis media in children by an objective method: urinary cotinine analysis

Prenatal Exposure to Tobacco and Alcohol Alters Development of the Neonatal Auditory System

Prenatal exposures to alcohol (PAE) and tobacco (PTE) are known to produce adverse neonatal and childhood outcomes including damage to the developing auditory system. Knowledge of the timing, extent, and combinations of these exposures on effects on the developing system is limited. As part of the physiological measurements from the Safe Passage Study, Auditory Brainstem Responses (ABRs) and Transient Otoacoustic Emissions (TEOAEs) were acquired on infants at birth and one-month of age. Research sites were in South Africa and the Northern Plains of the U.S. Prenatal information on alcohol and tobacco exposure was gathered prospectively on mother/infant dyads. Cluster analysis was used to characterize three levels of PAE and three levels of PTE. Repeated-measures ANOVAs were conducted for newborn and one-month-old infants for ABR peak latencies and amplitudes and TEOAE levels and signal-to-noise ratios. Analyses controlled for hours of life at test, gestational age at birth, sex, site, and other exposure. Significant main effects of PTE included reduced newborn ABR latencies from both ears. PTE also resulted in a significant reduction of ABR peak amplitudes elicited in infants at 1-month of age. PAE led to a reduction of TEOAE amplitude for 1-month-old infants but only in the left ear. Results indicate that PAE and PTE lead to early disruption of peripheral, brainstem, and cortical development and neuronal pathways of the auditory system, including the olivocochlear pathway.

Cigarette smoke exposure effects on the brainstem expression of nicotinic acetylcholine receptors (nAChRs), and on cardiac, respiratory and sleep physiologies

Cigarette smoking during pregnancy is the largest modifiable risk factor for adverse outcomes in the infant. Investigations have focused on the psychoactive component of cigarettes, nicotine. One proposed mechanism leading to adverse effects is the interaction between nicotine and its nicotinic acetylcholine receptors (nAChRs). Much data has been generated over the past three decades on the effects of cigarette smoke exposure (CSE) on the expression of the nAChRs in the brainstem and physiological parameters related to cardiac, respiration and sleep, in the offspring of smoking mothers and animal models of nicotine exposure. This review summarises this data and discusses the main findings, highlighting that findings in animal models closely correlate with those from human studies, and that the major brainstem sites where the expression level for the nAChRs are consistently affected include those that play vital roles in cardiorespiration (hypoglossal nucleus, dorsal motor nucleus of the vagus, nucleus of the solitary tract), chemosensation (nucleus of the solitary tract, arcuate nucleus) and arousal (rostral mesopontine sites such as the locus coeruleus and nucleus pontis oralis). These findings provide evidence for the adverse effects of CSE during and after pregnancy to the infant and the need to continue with the health campaign advising against CSE.

American pediatric society's 2017 John Howland award acceptance lecture: a tale of two toxicants: childhood exposure to lead and tobacco

This article summarizes the presentation of the 2017 Howland Award to Michael Weitzman, MD, at the Annual Pediatric Academic Society Meetings. It summarizes the remarkable advances in understanding the effects and pathways of exposure of the two most common and pernicious of our nation's child environmental exposures, namely lead and tobacco. It also summarizes the profound effect of the translation of these findings into prudent and effective clinical and public health policies such that exposure to both has dramatically decreased over the past 40 years due to the tenacious activities of pediatricians, other child-related professionals, government agencies at all levels, and the American Academy of Pediatrics. Research and clinical activities, although essential, were not sufficient to produce these successes, but required extensive mentoring to produce a generation of academic pediatricians capable of conducting the requisite research, and extensive advocacy by pediatricians and others to overcome the formidable inertia and outright opposition to efforts to protect our children from these exposures. Moreover, the article highlights that both of these environmental exposures have roots in social and environmental injustice and neither is solved, and that there is no safe level of exposure to either of these toxicants.

Salivary cotinine levels in children with otolaryngological disorders

OBJECTIVE

To determine if salivary cotinine, a biomarker for tobacco smoke exposure, is elevated more often or to a higher degree in children meeting criteria for tonsillectomy or tympanostomy tube insertion.

METHODS

Saliva samples were obtained from 3 groups of children for salivary cotinine measurement. Group 1 served as healthy controls. Group 2 consisted of subjects meeting tympanostomy tube criteria. Group 3 consisted of patients meeting tonsillectomy criteria. Environmental tobacco smoke (ETS) exposure was defined as a salivary cotinine concentration ≥1.0 ng/mL. Demographic data, smoke exposure history, and co-morbidities were also determined.

RESULTS

331 patients were included, with 112 in Group 1, 111 in Group 2, and 108 in Group 3. No differences were encountered for smoke exposure by history or smoker's identity, salivary cotinine level, or frequency of positive cotinine results. 42.6% of Group 1 had positive salivary cotinine compared to 51.8% of Group 2 and 47.7% of Group 3. Group 1 had a mean salivary cotinine level of 2.42 ng/mL compared to 2.54 ng/mL in Group 2 and 2.60 ng/mL in Group 3. The frequency of positive cotinine levels was higher than expected based on parental history. Among subjects with positive cotinine levels, 93 had no ETS exposure, and 64 had ETS exposure by history.

CONCLUSION

Approximately 50% of children who undergo tonsillectomy and tympanostomy tube insertion have objective evidence of ETS exposure. Parental history underestimates passive smoke exposure, which can impact perioperative care.

The Impact of Smoking on Ossiculoplasty Outcomes

OBJECTIVES

To assess the impact of tobacco smoking on outcomes after ossiculoplasty.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

PATIENTS

Adult patients (16-88 yr of age) undergoing ossiculoplasty with cartilage tympanoplasty.

OUTCOME MEASURES

Patients were classified as smokers (TOB) or nonsmokers (TOB). Comparisons were then made between these two groups with regard to early and late audiometric outcomes, rate of cure of conductive hearing loss, rate of successful graft healing, and incidence of complications after surgery.

RESULTS

There was no significant difference between the two groups with regard to postoperative ΔPTA-ABG (change in pure-tone average air-bone gap) (-14.4 dB vs. -14.6 dB for TOB vs. TOB, respectively, p = 0.946) or final audiometric outcome (ΔPTA-ABGfinal) (-13.6 dB vs. -11.7 dB for TOB vs. TOB, respectively, p = 0.315), cure of conductive hearing loss, defined as closure of the PTA-ABG to ≤20 dB HL, at postoperative audiometry (75.0% [129/172] for the TOB group vs. 69.3% [52/75] for the TOB group, p = 0.355), late audiometry (71.4% [105/147] for the TOB group vs. 66.7% [44/66] for the TOB group, p = 0.483), or successful graft healing (99.4% in the TOB group vs. 98.7% in the TOB group, p = 0.544). However, complications were observed significantly (p = 0.0003) more often in the TOB group (34.7% [26/75]) than the TOB group (14.5% [25/172]).

CONCLUSION

Smoking is not a significant risk factor for anatomic failure of cartilage tympanic membrane graft or worsened audiometric outcome after ossiculoplasty. However, complications were significantly more common in smokers, supporting the practice of primary tympanostomy tube placement at the time of ossiculoplasty.

Association of outdoor air pollution and indoor renovation with early childhood ear infection in China

BACKGROUND

Otitis media (OM) is a common infection in early childhood with repeated attacks that lead to long-term complications and sequelae, but its risk factors still remain unclear.

OBJECTIVE

To examine the risk of childhood OM for different indoor and outdoor air pollutants during different timing windows, with a purpose to identify critical windows of exposure and key components of air pollution in the development of OM.

METHODS

We conducted a retrospective cohort study of 1617 children aged 3-4 years in Changsha, China (2011-2012). Children's life-time prevalence of OM and exposure to indoor air pollution related to home renovation activities were surveyed by a questionnaire administered by the parents. Children's exposure to outdoor air pollution, including nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and particulate matter with an aerodynamic diameter ≤ 10 μm (PM₁₀), was estimated using the measured concentrations at municipal monitoring stations. The odds ratio (OR) and 95% confidence interval (CI) of childhood OM for prenatal and postnatal exposure to indoor and outdoor air pollution were examined by using logistic regression model.

RESULTS

Life-time prevalence of OM in preschool children (7.3%) was associated not only with prenatal exposure to industrial air pollutant with adjusted OR (95% CI) = 1.44 (1.09-1.88) for a 27 μg/m³ increase in SO₂ but also with postnatal exposure to indoor renovations with OR (95% CI) = 1.62 (1.05-2.49) for new furniture and 1.81 (1.12-2.91) for redecoration, particularly in girls. Combined exposure to outdoor SO₂ and indoor renovation significantly increased OM risk. Furthermore, we found that exposure to outdoor SO₂ and indoor renovation were significantly associated with the onset but not repeated attacks of OM.

CONCLUSION

Prenatal exposure to outdoor industrial air pollution and postnatal exposure to indoor renovation are independently associated with early childhood OM in China and may cause the OM onset.

Impact of environmental tobacco smoke exposure on anaesthetic and surgical outcomes in children: a systematic review and meta-analysis

BACKGROUND

Tobacco smoke exposure in adults is linked to adverse anaesthetic and surgical outcomes. Environmental tobacco smoke (ETS) exposure, including passive smoking, causes a number of known harms in children, but there is no established evidence review on its impact on intraoperative and postoperative outcomes.

OBJECTIVES

To undertake a systematic review of the impact of ETS on the paediatric surgical pathway and to establish if there is evidence of anaesthetic, intraoperative and postoperative harm.

ELIGIBILITY CRITERIA PARTICIPANTS

Children aged 0-18 years undergoing anaesthetic or surgical procedures, any country, English language papers.

EXPOSURE

ETS exposure assessed via questioning, observation or biological marker.

OUTCOME MEASURES

Frequency of respiratory and other adverse events during anaesthesia, surgery and recovery, and longer term surgical outcomes.

RESULTS

28 relevant studies were identified; 15 considered anaesthetic outcomes, 12 surgical outcomes, and 1 a secondary outcome. There was sufficient evidence to demonstrate that environmental smoke exposure significantly increased risk of perianaesthetic respiratory adverse events (Pooled risk ratio 2.52 CI 95% 1.68 to 3.77), and some evidence that ear and sinus surgery outcomes were poorer for children exposed to ETS.

CONCLUSIONS

ETS exposure increases the risk of anaesthetic complications and some negative surgical outcomes in children, and this should be considered when planning surgery. Research is required to demonstrate whether changes in household smoking behaviour prior to surgery reduces risk of adverse outcomes, and to close the evidence gap around other outcomes such as wound healing and respiratory infections.

TRIAL REGISTRATION NUMBER

Review registration number 42014014557.

The Difference a Decade Makes: Smoking Cessation Counseling and Screening at Pediatric Visits

INTRODUCTION

There has been a sharp decline in adolescents who smoke cigarettes but no national-level study evaluating the impact of smoking cessation counseling by pediatricians or other clinicians who care for children.

METHODS

Combined data from ambulatory portions of the National Hospital Ambulatory Care Survey and National Ambulatory Medical Care Survey from 1997-1999 and 2009-2011 were analyzed to determine changes in the frequency of pediatric visits that included clinician-reported tobacco counseling and how such counseling varied by child, family, and clinician characteristics.

RESULTS

In 1997-1999, 1.5% of all medical visits for children aged below 19 years included tobacco counseling; this increased to 3.8% in 2009-2011 (P < .001). A marked increase from 4.1% to 11.1% was noted at well-child visits (P < .001). There were significant increases in counseling by pediatricians but not mid-level providers or general/family physicians. Provision of counseling did not result in greater visit length during either time point. During 2009-2011, visits with a diagnosis of asthma were four times as likely (OR 4.2, 95% CI 2.8-6.2) and visits for otitis media two times as likely (OR 2.1, 95% CI 1.2-3.7) to include smoking cessation counseling than sick visits for all other diagnoses.

CONCLUSION

These results demonstrate a significant increase in tobacco counseling by pediatric providers within the last decade, especially at well-child visits. However, the American Academy of Pediatrics' recommendation that pediatricians counsel about the harms of tobacco use and secondhand smoke exposure has not yet been exhaustively implemented.

IMPLICATIONS

A significant increase in smoking cessation counseling at pediatric medical appointments, especially at well-child visits, occurred from 2009-2011 compared with 1997-1999, paralleling a large decrease in smoking prevalence. These improvements in counseling rates have been predominantly noted for pediatricians but not mid-level providers or general practitioners. Counseling was not associated with increased visit lengths. Although improved counseling practices by pediatricians have been demonstrated, there is still room for improvement.

The 100 Most Cited Turkish Papers in the Otorhinolaryngology Journals of Web of Science

Objective

The aim of the study was to analyze the 100 most cited publications with Turkish origin in the Web of Science Otorhinolaryngology (ORL) journals.

Methods

The Web of Science database was searched in terms of citations for publications originating from Turkey in ORL journals since 1983. After the identification of the 100 most cited articles, analysis was performed for the first author, institution, city, publication type, subject related to subspecialty, and journals having the most cited articles. Moreover, the number of ORL publications and citations of countries was determined in descending order using the same database.

Results

A total of 3948 ORL articles with Turkish origin was identified. The number of citations was 181 for the first and 28 for the last in the 100 most cited articles. As there was more than one article with 28 citations, 101 articles were analyzed. The number of the articles was 76, 22, and 3 for the university, education/research, and state hospitals, respectively. Hacettepe University, Ankara Numune Hospital, and Gazi University were the three leading institutions having the most cited articles, and Ankara was the first city. While 98 of 101 articles were original research, the number of case reports and review articles were 2 and 1, respectively. Thirty-five articles were related to otology, 23 to pediatric ORL, 20 to rhinology and head and neck surgery, and 3 to facial plastic surgery. Laryngoscope, Otolaryngology-Head and Neck Surgery, and International Journal of Pediatric Otorhinolaryngology were the leading 3 journals with the most cited articles coming from Turkey. The evaluation of countries revealed that Turkey was among the first 10 countries in terms of number of ORL articles but fell behind for the number of citations.

Conclusion

This bibliometric study is the first one regarding the contribution of Turkish authors and institutions to ORL literature. Similar studies might be periodically repeated to determine national development in the field of ORL and place of Turkey in the world.

Prevalence and risk factors of chronic otitis media: the Korean National Health and Nutrition Examination Survey 2010-2012

Background

The performance of nationwide studies of chronic otitis media (COM) in adults has been insufficient in Korea. We evaluated the prevalence and risk factors of COM in Korea.

Methods

This study was conducted using data from the fifth Korean National Health and Nutrition Examination Survey (n = 23,621). After excluding the subjects under 20 year old and suffered from cancers, 16,063 patients were evaluated for COM. Participants underwent a medical interview, physical examination, endoscopic examination, and blood and urine test. COM was diagnosed by trained residents in the Department of Otorhinolaryngology using an ear, nose, and throat questionnaire and otoendoscopy findings. Data on the presence and absence of COM were collected. Multivariate logistic regression analyses were performed to identify its risk factors.

Results

Of the 16,063 participants aged above 20 year old, the weighted prevalence of COM was 3.8%. In the multivariate analyses, the following factors showed high odds ratios (ORs) for COM: pulmonary tuberculosis (adjusted OR, 1.78; 95% confidence interval [CI], 1.06-3.01), chronic rhinosinusitis (adjusted OR, 1.87; 95% CI, 1.17-2.98), mild hearing impairment (adjusted OR, 1.95; 95% CI, 1.34-2.85), moderate hearing impairment (adjusted OR, 4.00; 95% CI, 2.21-7.22), tinnitus (adjusted OR, 1.82; 95% CI, 1.34-2.49), increased hearing thresholds in pure tone audiometry in the right ear (adjusted OR, 1.02; 95% CI, 1.01-1.03), and left ear (adjusted OR, 1.03; 95% CI, 1.02-1.04). The following factors showed low odds ratios for COM: hepatitis B (adjusted OR, 0.28; 95% CI, 0.08-0.94) and rhinitis (adjusted OR, 0.60; 95% CI, 0.42-0.88). In addition, high levels of vitamin D, lead, and cadmium, EQ-5D index; and low red blood cell counts were associated with development of COM (Student’s t-test, P < 0.01).

Conclusions

Our population-based study showed that COM is not rare in Korea, and its development may be associated with various host and environmental factors. Further research on its relationships and the pathogenesis are needed.

Physical, behavioral, and cognitive effects of prenatal tobacco and postnatal secondhand smoke exposure

The purpose of this review is to examine the rapidly expanding literature regarding the effects of prenatal tobacco and postnatal secondhand smoke (SHS) exposure on child health and development. Mechanisms of SHS exposure are reviewed, including critical periods during which exposure to tobacco products appears to be particularly harmful to the developing fetus and child. The biological, biochemical, and neurologic effects of the small fraction of identified components of SHS are described. Research describing these adverse effects of both in utero and childhood exposure is reviewed, including findings from both animal models and humans. The following adverse physical outcomes are discussed: sudden infant death syndrome, low birth weight, decreased head circumference, respiratory infections, otitis media, asthma, childhood cancer, hearing loss, dental caries, and the metabolic syndrome. In addition, the association between the following adverse cognitive and behavioral outcomes and such exposures is described: conduct disorder, attention-deficit/hyperactivity disorder, poor academic achievement, and cognitive impairment. The evidence supporting the adverse effects of SHS exposure is extensive yet rapidly expanding due to improving technology and increased awareness of this profound public health problem. The growing use of alternative tobacco products, such as hookahs (a.k.a. waterpipes), and the scant literature on possible effects from prenatal and secondhand smoke exposure from these products are also discussed. A review of the current knowledge of this important subject has implications for future research as well as public policy and clinical practice.

Risk factors for chronic and recurrent otitis media-a meta-analysis

Risk factors associated with chronic otitis media (COM) and recurrent otitis media (ROM) have been investigated in previous studies. The objective of this study was to integrate the findings and determine the possible risk factors for COM/ROM based on our meta-analysis. A comprehensive search of electronic bibliographic databases (PubMed, Embase, CNKI and Wanfang database) from 1964 to Dec 2012, as well as a manual search of references of articles, was performed. A total of 2971 articles were searched, and 198 full-text articles were assessed for eligibility; 24 studies were eligible for this meta-analysis. Regarding risk factors for COM/ROM, there were two to nine different studies from which the odds ratios (ORs) could be pooled. The presence of allergy or atopy increased the risk of COM/ROM (OR, 1.36; 95% CI, 1.13–1.64; P = 0.001). An upper respiratory tract infection (URTI) significantly increased the risk of COM/ROM (OR, 6.59; 95% CI, 3.13–13.89; P<0.00001). Snoring appeared to be a significant risk factor for COM/ROM (OR, 1.96; 95% CI, 1.78–2.16; P<0.00001). A patient history of acute otitis media (AOM)/ROM increased the risk of COM/ROM (OR, 11.13; 95% CI, 1.06–116.44; P = 0.04). Passive smoke significantly increased the risk of COM/ROM (OR, 1.39; 95% CI, 1.02–1.89 P = 0.04). Low social status appeared to be a risk factor for COM/ROM (OR, 3.82; 95% CI, 1.11–13.15; P = 0.03). Our meta-analysis identified reliable conclusions that allergy/atopy, URTI, snoring, previous history of AOM/ROM, Second-hand smoke and low social status are important risk factors for COM/ROM. Other unidentified risk factors need to be identified in further studies with critical criteria.

Otitis media with effusion: an effort to understand and clarify the uncertainties

Otitis media with effusion--defined as the accumulation of middle-ear effusion behind an intact tympanic membrane without signs or symptoms of acute infection--is one of the most common causes of hearing loss in children in developed countries, potentially leading to language deficits. Although treatment of chronic or relapsing otitis media with effusion is considered imperative, none of the preventative or nonsurgical management measures currently available have proven effective. Tympanostomy tube placement remains the recommended treatment option for high-risk children or for cases of unresponsive otitis media with effusion. This can be attributed to the uncertainties surrounding its pathogenesis. Multiple factors and several possible pathogenetic models have been proposed to explain the production and persistence of middle-ear effusion; only a few of them are supported by sufficient evidence. In this review, the authors will present current knowledge on the pathogenesis, consequences, diagnosis and management of otitis media with effusion. An effort will be made to clarify those aspects sufficiently supported by evidence-based studies, and to underline those that remain unfounded.

Otitis media in Indigenous Australian children: review of epidemiology and risk factors

Background:

Otitis media represents a major health concern in Australian Indigenous children (‘Indigenous children’), which has persisted, despite public health measures, for over 30 years.

Methods:

Global searches were performed to retrieve peer-reviewed and ‘grey’ literature investigating the epidemiology of and risk factors for otitis media in Indigenous children, published between 1985 and 2012.

Results:

In Indigenous children, the prevalence of otitis media subtypes is 7.1–12.8 per cent for acute otitis media, 10.5–30.3 per cent for active chronic otitis media and 31–50 per cent for tympanic membrane perforation. The initial onset of otitis media in Indigenous children occurs earlier and persists for longer after the first year of life, compared with non-Indigenous children. Indigenous children are colonised by otopathogens more frequently, at younger ages and with a higher bacterial load. Poor community and domestic infrastructure, overcrowding and exposure to tobacco smoke increase the risk of otitis media in Indigenous children; however, the availability of swimming pools plays no role in the prevention or management of otitis media.

Conclusion:

Despite awareness of the epidemiological burden of otitis media and its risk factors in Indigenous children, studies undertaken since 1985 demonstrate that otitis media remains a significant public health concern in this population.

Effect of acrolein, a hazardous air pollutant in smoke, on human middle ear epithelial cells

OBJECTIVE

Acrolein is a hazardous air pollutant. Tobacco smoke and indoor air pollution are the main causes of human exposure. Acrolein has been shown to cause cytotoxicity in the airways and induce inflammation and mucin production in pulmonary cells. We investigated whether acrolein caused cytotoxicity, induced inflammation or increased expression of mucin in immortalized human middle ear epithelial cell lines (HMEECs).

METHODS

Cytotoxicity following acrolein treatment was investigated using the MTT assay, flow cytometry, and Hoechst 33342 staining of HMEECs. We measured expression of inflammatory cytokines tumor necrosis factor (TNF)-α and cyclo-oxygenase (COX)-2 and the mucin gene MUC5AC using semi-quantitative real-time reverse transcriptase polymerase chain reaction (RT-PCR) and Western blotting.

RESULTS

Exposure to >50 μg/mL acrolein caused a decrease in cell viability. Acrolein induced apoptosis and necrosis at 50 μg/mL. Acrolein at 5-50 μg/mL increased expression of TNF-α and COX-2, as shown by RT-PCR and Western blotting. Acrolein exposure at 5-50 μg/mL for 2-24h increased MUC5AC expression, as determined by RT-PCR.

CONCLUSION

Acrolein decreased cell viability, induced an inflammatory response, and increased mucin gene expression in HMEECs. These findings support the hypothesis that acrolein, a hazardous air pollutant in tobacco smoke and ambient air, is a risk factor for otitis media.

Housing and child health

The connection between housing and health is well established. Physical, chemical, and biological aspects of the child's home, such as cleanliness, moisture, pests, noise, accessibility, injury risks, and other forms of housing environmental quality, all have the potential to influence multiple aspects of the health and development of children. Basic sanitation, reduced household crowding, other improvements in housing and expanded, and improved housing regulations have led to advances in children's health. For example, lead poisoning prevention policies have profoundly reduced childhood lead exposure in the United States. This and many other successes highlight the health benefits for families, particularly children, by targeting interventions that reduce or eliminate harmful exposures in the home. Additionally, parental mental health problems, food insecurity, domestic violence, and the presence of guns in children's homes all are largely experienced by children in their homes, which are not as yet considered part of the Healthy Homes agenda. There is a large movement and now a regulatory structure being put in place for healthy housing, which is becoming closely wedded with environmental health, public health, and the practice of pediatrics. The importance of homes in children's lives, history of healthy homes, asthma, and exposures to lead, carbon monoxide, secondhand/thirdhand smoke, radon, allergy triggers is discussed, as well as how changes in ambient temperature, increased humidity, poor ventilation, water quality, infectious diseases, housing structure, guns, electronic media, family structure, and domestic violence all affect children's health.

Second-hand tobacco smoke and children

Cigarette smoke contains harmful chemicals with hazardous adverse effects on almost every organ in the body of smokers as well as of nonsmokers exposed to environmental tobacco smoke (ETS). There has been increasing interest in the effects of passive smoking on the health of children. In order to detect the magnitude of passive smoking in children, parental questionnaires, measuring nicotine and cotinine body levels, and evaluating expired carbon monoxide (CO) concentrations, have been used. Passive smoking causes respiratory illness, asthma, poor growth, neurological disorders, and coronary heart diseases. Herein, we focused on the deleterious influences of passive smoking on immunity and liver. Besides, its effects on the concentrations of various biomarker levels related to the oxidant/antioxidant status were considered. Understanding these effects may help clinicians to counsel parents on smoking cessation and smoke exposure elimination. It may also help to develop interventions to improve the health of children. This review potentially demonstrated some nutraceuticals with a promising role in the prevention of smoking-related diseases.

Secondhand smoke exposure and serum cytokine levels in healthy children

INTRODUCTION

Exposure to secondhand smoke (SHS) is associated with morbidity in children. Alterations in immune responses may explain this relationship, but have not been well-studied in children. Our objective was to determine the association between SHS exposure and serum cytokine levels in healthy children.

METHODS

We recruited 1-6 year old patients undergoing routine procedures. A parent interview assessed medical history and SHS exposure. Children with asthma were excluded. Blood was collected under anesthesia. We used Luminex Multiplex Assays to test for a panel of cytokines; cotinine was determined using an enzyme-linked immunosorbent assay. Children were categorized as no, intermediate, or high exposure. A mixed-effects model was fit to determine differences in cytokines by exposure level.

RESULTS

Of the 40 children recruited, 65% (N=26) had SHS exposure; 16 intermediate, and 10 high. There were no differences by demographics. In bivariate analyses, children exposed to SHS had lower concentrations of IL-1β, IL-4, IL-5, and IFN-γ than those with no exposure. In the mixed-effects model, children with any SHS exposure had significantly lower concentrations of IL-1β (0.554 pg/mL vs. 0.249 pg/mL) and IFN-γ (4.193 pg/mL vs. 0.816 pg/mL), and children with high exposure had significantly lower mean concentrations of IL-4 (8.141 pg/mL vs. 0.135 pg/mL) than children with no exposure.

CONCLUSIONS

This study suggests that SHS exposure decreases expression of some pro-inflammatory cytokines in SHS exposed children, including IFN-γ. Further research to describe the acute and chronic effects of SHS on the immune systems of children is needed.

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 of Otitis Media with Effusion among Primary School Children in Eastern Black Sea, in Turkey and the Effect of Smoking in the Development of Otitis Media with Effusion

The aim of this study was to determine the prevalence of otitis media with effusion (OME) in primary school children in Rize (Eastern Black Sea Region) and the impact of tobacco smoke exposure in the development of OME in primary school children. This study involved a total of 2960 children who appeal for ENT examination to our department at Rize Training and Research Hospital between November 2007 and April 2009. All children were evaluated with regard to OME and exposure to cigarette smoke. Pure tone audiometry and tympanometry tests and pneumatic otoscopy were performed on the children who were diagnosed with OME by otoscopic examination. The association between the children diagnosed as OME and exposure to cigarette smoke was evaluated. The prevalence of OME in this study was 9.86% (292/2960). Exposure to cigarette smoke was a statistically significant factor in development of OME (P < 0.0001). Environmental factors such as smoking are important in the development of OME. To prevent delayed diagnosis or development of this disease, parents must be informed about the preventable risk factors and symptoms for the development of OME.

Effects of Active and Passive Smoking on Ear Infections

Otitis media (OM) is one of the most frequent diseases in young children, causing to visit a physician, and also the most common indication for antibiotic prescription. The peak incidence and prevalence of OM is 6 to 18 months of age. In children, second-hand smoke (SHS) exposure is associated with upper and lower respiratory tract infections, such as acute otitis media (AOM), pneumonia, and bronchitis. Despite the overwhelming evidence of the role of SHS exposure on infant health, a very high proportion of children still continue to be exposed. This important relationship between all kinds of smoking and poor health may not be appreciated universally. With this article, we aim to review tobacco smoke exposure and OM connection. How this exposure may cause OM especially in young children? What can be done to prevent and to reduce the harmfull effects of tobacco smoking?

Admission screening for secondhand tobacco smoke exposure

OBJECTIVES

Secondhand smoke (SHS) exposure is an important and preventable cause of mortality and morbidity among children; hospitalization represents a sentinel event that may offer opportunities for intervention. The goal of this study was to determine the frequency and validity of SHS exposure screenings by emergency department (ED) providers, residents, and nurses.

METHODS

A total of 140 inpatient pediatric families consented to a salivary cotinine measurement, in-person SHS exposure interview, and chart review to assess ED provider, pediatric resident, and nurse SHS exposure screenings and documentation validity.

RESULTS

ED providers documented screening for SHS exposure 46% of the time, pediatric residents 42% of the time, and nurses 79% of the time. ED providers, pediatric residents, and nurses reported 18%, 38%, and 12% of patients exposed to SHS, respectively, whereas 46% of patients were identified as smoke-exposed according to cotinine level and/or parent report. Those with SHS exposure outside the home were least likely to be identified as exposed.

CONCLUSIONS

The majority of smoke-exposed children were not identified as exposed based on documentation of admission screenings. Future research is important to identify accurate and efficient methods of screening for and identifying SHS exposure among children admitted to the hospital.

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.

The effect of passive smoking on the levels of matrix metalloproteinase 9 in nasal secretions of children

BACKGROUND

Matrix metalloproteinase (MMP) 9 is a gelatinase associated with tissue remodeling. It is thought to play a part in the pathogenesis of allergy. Increased levels of MMP-9 have been shown to increase in the acute allergic response in the nose, lungs, and skin. Exposure to passive tobacco smoke is associated with an increase in sneezing, nasal blockage, and a decreased sense of smell. The aim of this study was to study the effect of passive smoking on the levels of MMP-9 in nasal secretions of children.

METHODS

A prospective descriptive study was performed. Thirty-nine children aged between 7 and 16 years were enrolled in the study. They were selected based on attendance at the Otorhinolaryngology Outpatients Clinic with a primary complaint unrelated to the nose or paranasal sinuses. Children with allergic rhinitis, sinusitis, or a recent cold were excluded. The study was performed at a tertiary pediatric referral center. Exposure to passive smoking was determined by measuring the urinary cotinine to creatinine ratio. Nasal fluid was obtained by using a Rhino-Probe curette (Arlington Scientific, Inc., Springville, UT). The concentration of MMP-9 was determined by ELISA. MMP-9 activity was determined by gelatin zymography. Data were tabulated on Microsoft Excel (Microsoft Corp., Redmond, WA) and analyzed using SPSS (SPSS Inc., Chicago, IL).

RESULTS

Using a cutoff urinary cotinine/creatinine ratio of 0.025 ng/mg, 15 children were found to be exposed to passive smoking. Both the MMP-9 concentration and the activity were significantly higher in nasal secretions of children exposed to passive smoking. There was a distinct difference between the two cohorts with regard to the level of enzyme activity per weight of protein. The lowest level of enzyme activity recorded in the "exposed" cohort was over twice that of the level in the "not exposed" cohort.

CONCLUSION

MMP-9 activity and concentration is higher in nasal secretions of children exposed to passive smoking. This suggests that passive smoking might alter the inflammatory response within the nasal mucosa in a similar way to allergy.

The impact of smoking on oral and nasopharyngeal bacterial flora

Exposure to direct and passive tobacco smoking has significant impact on the gingival and oropharyngeal flora. The effects of exposure to smoking are evident in both children as well as adults. It increases the acquisition of periodontal pathogens and periodontal disease, colonization by respiratory pathogens, and the occurrence of upper respiratory tract infections, including otitis media. The flora of smokers contains fewer aerobic and anaerobic organisms with interfering activity against bacterial pathogens and harbors more potential pathogens as compared with the flora of non-smokers. The high number of pathogens and the low number of interfering organisms found in the nasopharynx of smokers revert to normal levels after complete cessation of smoking. Since parents who smoke harbor more potential pathogens and fewer interfering organisms, they may serve as a source of pathogens that can colonize and/or infect their children. The reduction in the number of members of the normal flora that interfere with the growth of pathogens and the greater adherence of bacterial pathogens to the oral mucosa are associated with the greater frequency of respiratory infections. Analysis of the data presented illustrates the adverse effects of direct and indirect exposure to smoking on colonization with potential pathogens.

Micronutrient levels in children exposed to secondhand tobacco smoke

INTRODUCTION

Antioxidant micronutrients are the body's primary defense against the oxidative stress of secondhand smoke (SHS). Micronutrient levels have been associated with lung function; decreased levels of vitamin C and β-carotene have been associated with SHS exposure in children. We sought to determine the association between SHS exposure and micronutrient levels in children.

METHODS

Data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) were analyzed. Serum cotinine levels were categorized into no (<0.015 ng/mL), moderate (0.015 to <2.0 ng/mL), and high (2.0-15.0 ng/mL) smoke exposure; t-tests determined associations between exposure and levels of micronutrients. Significant bivariate associations were tested further using linear regression.

RESULTS

In all, 2,218 children, aged 6-18 years, were included (response rate of 82%); 17% had no, 76% moderate, and 7% high exposure. Children with no exposure had higher levels of vitamin A, C, and E, cis- and trans-β-carotene, and folate, while levels of vitamins B(6), B(12), and D did not differ. In regression analysis, higher cotinine levels were negatively associated with levels of vitamin C (β = -.03; p < .01), cis-β-carotene (β = -.04; p < .01), trans-β-carotene (β = -.7; p < .01), folate (β = -.5; p < .001) and vitamin A (β = -.6; p < .01).

CONCLUSIONS

Children exposed to SHS have lower levels of antioxidants controlling for dietary and supplement intake. This antioxidant depletion may increase systemic inflammation and sensitivity to other oxidant stresses. Parents should be counseled on these specific risks from SHS exposure for their children, and the importance of smoking cessation and eliminating children's exposure to tobacco smoke.

Second hand smoke exposure in children: environmental factors, physiological effects, and interventions within pediatrics

BACKGROUND

Second hand smoke (SHS) exposure has long been correlated with many adverse disease processes, particularly in children. For children growing up with socioeconomic disadvantages and increased exposure to SHS, exposure can have far-reaching consequences.

OBJECTIVE

The purpose of this review was to examine the literature assessing the effects of SHS exposure in children, as well as the perspectives of both parents and providers regarding current practices in cessation counseling. The review also sought out recommendations on ways to increase the influence of pediatricians on parental smoking.

STUDY GROUP

Children under the age of 18 years.

METHODS

PubMed and MEDLINE were searched systematically. A narrative approach was used because the studies differed in methods and data.

RESULTS

The studies showed correlations between SHS exposure and sudden infant death syndrome (SIDS), asthma, altered respiratory function, infection, cardiovascular effects, behavior problems, sleep difficulties, increased cancer risk, and a higher likelihood of smoking initiation. Questionnaires of both parents and pediatricians showed that pediatricians are not consistently carrying out the recommended smoking cessation interventions, with lack of training as a primary barrier. Nevertheless, interventions targeting improved cessation training for both residents and practicing pediatricians have been studied and show promising results.

CONCLUSIONS

SHS exposure has many detrimental effects on children's health, particularly for those in low socioeconomic circumstances, for which factors in the built environment accentuated a higher baseline risk. By counseling parents, expanding residency education, and continuing advocacy work, pediatricians can have a significant positive impact on children's health as related to SHS exposure.

Cigarette smoke activates NFκB-mediated Tnf-α release from mouse middle ear cells

OBJECTIVES/HYPOTHESIS

: Cigarette smoke exposure is a significant risk factor in the development of otitis media. NF-κB is a transcription factor known to mediate cigarette smoke effects in multiple cell types. We hypothesized that stimulation of murine middle ear epithelial cells (MEEC) with cigarette smoke condensate (CSC) activates NF-κB resulting in upregulation of proinflammatory cytokines.

STUDY DESIGN

: In vitro model of cultured murine middle ear epithelial cells.

METHODS

: Time course CSC stimulation of MEEC was performed. Antibody microarrays were then utilized to simultaneously measure 40 inflammatory cytokines. Enzyme-linked immunosorbent assay (ELISA) and quantitative reverse transcriptase-polymerase chain reaction were performed to validate and further evaluate array results. Luciferase reporter assays were performed to evaluate NF-κB activation with CSC in MEEC. Chromatin immunoprecipitation (ChIP) assays were performed to determine whether CSC induces NF-κB interaction with the Tnf-α promoter.

RESULTS

: Multiple cytokines showed significant increases with CSC exposure. ELISA studies demonstrated that Tnf-α secretion increased the most. CSC stimulation likewise increased Tnf-α mRNA abundance and induced promoter activity 4.8-fold in a Tnf-α reporter plasmid. Reporter assays demonstrated 4.84-fold activation of NF-κB with CSC. ChIP assays demonstrated NF-κB binding to canonical κB sites in the Tnf-α promoter with CSC stimulation.

CONCLUSIONS

: CSC activates NF-κB in MEEC. Furthermore, this activation results in CSC induced Tnf-α promoter activation, gene expression, and levels in cell secretions. Laryngoscope, 120:2508-2515, 2010.

From the American Academy of Pediatrics: Technical report--Secondhand and prenatal tobacco smoke exposure

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.

Effects of cigarette smoking on mucin production in human middle ear epithelial cells

OBJECTIVE

Otitis media (OM) is the most common disease in preschool age children related to passive cigarette smoking as risk factor. In this study, we investigate whether the cigarette smoking can induce the inflammation in human middle ear epithelial cell, and cigarette smoke-induced inflammation can increase the expression of MUC5AC gene and protein that was known to play an important role in OM with effusion.

METHODS

After treatment of cigarette smoke solution (CSS) on immortalized human middle ear epithelial cells (HMEECs) with or without pretreatment by epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (AG1478), we observed expression of tumor necrosis factor-alpha (TNF-α), EGFR, MUC5AC mRNA by quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and EGFR, MUC5AC protein by western blotting.

RESULTS

Treatment of CSS increased expression of TNF-α mRNA dose dependently. Treatment of CSS upregulated the EGFR and MUC5AC mRNA in a time-dependent manner. CSS-induced upregulation of EGFR and MUC5AC mRNA was suppressed by the pretreatment of AG1478. EGFR and MUC5AC proteins were upregulated by the treatment of CSS and suppressed by the pretreatment of AG1478.

CONCLUSIONS

Treatment of CSS on HMEECs increased the expression of MUC5AC mRNAs and proteins which play a major role in OM with effusion.

Exhaled carbon monoxide screening for environmental tobacco smoke exposure in preanesthetic children

OBJECTIVE

Exposure to environmental tobacco smoke (ETS) is associated with an increased risk of perioperative adverse events in children. The purpose of this study was to evaluate exhaled carbon monoxide (CO) as a preoperative ETS screening tool in children.

METHODS

Five hundred and one children aged 6-15 years were enrolled. The child's guardian completed a questionnaire that surveyed environmental exposures to CO and ETS. A preoperative urine sample was obtained from children who assented and were able to void, and urine cotinine values were measured. Exhaled CO was measured using the EC50-Micro Smokerlyzer (Bedfont Scientific Ltd, UK).

RESULTS

Four hundred and fifty-one subjects completed the study, and urine samples were obtained from 83. 25% of subjects were classified as exposed to ETS based on questionnaire results. Exhaled CO values did not correlate with either the qualitative (questionnaire) or quantitative (urine cotinine) measurements of ETS exposure. Exhaled CO predicted a urine cotinine/creatinine ratio >10 with a sensitivity of 10% and a specificity of 85%.

CONCLUSION

Exhaled CO measured by this device is not a useful preoperative screening tool for ETS exposure in children. Because exhaled CO has been used successfully to monitor ETS exposure in adolescents, we believe that its failure in our population is as a result of the limited ability of small children to perform vital capacity maneuvers in order to provide an adequate endtidal sample.

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.

Recurrent Respiratory Papillomatosis: A Longitudinal Study Comparing Severity Associated With Human Papilloma Viral Types 6 and 11 and Other Risk Factors in a Large Pediatric Population

OBJECTIVES/HYPOTHESIS

A database was developed for prospective, longitudinal study of recurrent respiratory papillomatosis (RRP) in a large population of pediatric patients. Data recorded for each patient included epidemiological factors, human papilloma virus (HPV) type, clinical course, staged severity of disease at each surgical intervention, and frequency of surgical intervention. The study hypothesizes that patients with HPV type 11 (HPV-11) and patients younger than 3 years of age at diagnosis are at risk for more aggressive and extensive disease.

STUDY DESIGN

The 10-year prospective epidemiological study used disease staging for each patient with an original scoring system. Severity scores were updated at each surgical procedure.

METHODS

Parents of children with RRP referred to the authors' hospital completed a detailed epidemiological questionnaire at the initial visit or at the first return visit after the study began. At the first endoscopic debridement after study enrollment, tissue was obtained and submitted for HPV typing using polymerase chain reaction techniques and in situ hybridization. Staging of disease severity was performed in real time at each endoscopic procedure using an RRP scoring system developed by one of the authors (B.J.W.). The frequency of endoscopic operative debridement was recorded for each patient. Information in the database was analyzed to identify statistically significant relationships between extent of disease and/or HPV type, patient age at diagnosis, and selected epidemiological factors.

RESULTS

The study may represent the first longitudinal prospective analysis of a large pediatric RRP population. Fifty-eight of the 73 patients in the study underwent HPV typing. Patients infected with HPV-11 were significantly more likely to have higher severity scores, require more frequent surgical intervention, and require adjuvant therapy to control disease progression. In addition, patients with HPV-11 RRP were significantly more likely to develop tracheal disease, to require tracheotomy, and to develop pulmonary disease. Patients receiving a diagnosis of RRP before 3 years of age had significantly higher severity scores, higher frequencies of surgical intervention, and greater likelihood of requiring adjuvant medical therapy. Patients with Medicaid insurance had significantly higher severity scores and required more frequent surgical debridement. Birth by cesarean section appeared to be a significant risk factor for more severe disease and necessity of more frequent surgical intervention.

CONCLUSION

Statistical analysis of the relationships among epidemiological factors, HPV type, and clinical course revealed that patients with HPV-11 and patients younger than 3 years of age at RRP diagnosis are prone to develop more aggressive disease as represented by higher severity scores at endoscopic debridement, more frequent operative debridement procedures per year, a greater requirement for adjuvant therapy, and greater likelihood of tracheal disease with tracheotomy.

Tobacco use increases susceptibility to bacterial infection

Active smokers and those exposed to secondhand smoke are at increased risk of bacterial infection. Tobacco smoke exposure increases susceptibility to respiratory tract infections, including tuberculosis, pneumonia and Legionnaires disease; bacterial vaginosis and sexually transmitted diseases, such as chlamydia and gonorrhoea; Helicobacter pylori infection; periodontitis; meningitis; otitis media; and post-surgical and nosocomial infections. Tobacco smoke compromises the anti-bacterial function of leukocytes, including neutrophils, monocytes, T cells and B cells, providing a mechanistic explanation for increased infection risk. Further epidemiological, clinical and mechanistic research into this important area is warranted.

The effect of passive smoking on the risk of otitis media in Aboriginal and non-Aboriginal children in the Kalgoorlie-Boulder region of Western Australia

OBJECTIVES

To determine the risk of otitis media (OM) associated with passive smoking in young children, and any competing effect between passive smoking and childcare attendance.

DESIGN, PARTICIPANTS AND SETTING

Prospective cohort study of 100 Aboriginal and 180 non-Aboriginal children born in Kalgoorlie Regional Hospital between 1 April 1999 and 31 January 2003. These children underwent routine clinical examinations by an ear, nose and throat specialist up to three times before the age of 2 years, and tympanometry at routine field follow-up visits from the age of 4 months. Childrens' mothers were interviewed at 1-3 weeks postpartum to provide sociodemographic data.

MAIN OUTCOME MEASURES

Associations between OM and exposure to environmental tobacco smoke (ETS) and childcare attendance.

RESULTS

82 Aboriginal and 157 non-Aboriginal children attended for routine clinical examinations. OM was diagnosed at least once in 74% of Aboriginal children and 45% of non-Aboriginal children; 64% of Aboriginal children and 40% of non-Aboriginal children were exposed to ETS. Exposure to ETS increased the risk of specialist-diagnosed OM in Aboriginal children (OR, 3.54; 95% CI, 1.68-7.47); few attended childcare. Non-Aboriginal children exposed to ETS but not attending childcare were at increased risk of OM (OR, 1.91; 95% CI, 1.07-3.42) while those attending childcare had no increased smoking-related risk. Tympanometry was performed on 87 Aboriginal and 168 non-Aboriginal children; a type B tympanogram (suggesting fluid in the middle ear) was also associated with passive smoking in Aboriginal children.

CONCLUSIONS

Reducing the exposure of children to ETS is a public health priority, especially for the Aboriginal population. A smoke-free environment will help reduce the burden of OM.

Prevalence of recurrent otitis media in habitually snoring school-aged children

INTRODUCTION

The pathophysiology of obstructive sleep apnea (OSA) and recurrent otitis media (ROM) is intimately associated with the presence of adenotonsillar hypertrophy in children. However, it remains unclear whether habitually snoring children have a higher prevalence of ROM and whether they require tympanostomy tube placement more frequently.

METHODS

Questionnaires collected from parental surveys of 5- to 7-year-old children attending the public schools in Louisville, KY were retrospectively reviewed for the presence of habitual snoring (HS), ROM, and the need for tympanostomy tube insertion.

RESULTS

There were 16,321 surveys with complete datasets (51.2% boys; 18.6% African American (AA) with a mean age of 6.2+/-0.7 years). Of these children, 1844 (11.3%) were HS (53% boys; 25.9% AA); and, of these, 827 HS had also a positive history of ROM (44.8%) with a slight predominance in males (55%). In addition, 636 of these children underwent placement of tympanostomy tubes (i.e., 34.4% of all HS and 76.9% of ROM). Among the 14,477 non-snoring children (NS), ROM was reported in 4247 NS children (29.3%; p<0.000001; odds ratio [OR]: 1.95; confidence interval [CI]: 1.77-2.16) of which 57.6% were boys, and 1969 NS with ROM underwent tympanostomy tube placement (i.e., 46.3% of those with ROM and 13.6% of all non-snoring children). Thus, the risk for tympanostomy tube placement was also greater among HS compared to NS children (p<0.00001; OR: 2.19; CI: 1.98-2.43).

CONCLUSIONS

Habitual snoring is associated with a significant increase in the prevalence of recurrent otitis media and the need for tympanostomy tube placement. Further studies aiming to assess the prevalence of obstructive sleep apnea among children with ROM are needed.

Cigarette smoke activates NF kappa B and induces Muc5b expression in mouse middle ear cells

OBJECTIVES

Cigarette smoke exposure is a significant risk factor in the development of otitis media (OM). Nuclear factor kappa B (NF-kappa B) is a ubiquitous transcription factor known to mediate cigarette smoke effects on gene regulation in multiple cell types. The MUC5B mucin gene contains several putative NF-kappa B sites in its promoter and is the predominant mucin expressed in human OM. We hypothesized that in vitro stimulation of a recently developed model system, murine middle ear epithelial cells (MEEC), with cigarette smoke condensate (CSC) activates NF-kappa B and subsequently induces Muc5b gene expression.

METHODS

Luciferase reporter assays, electromobility shift assays (EMSA), and quantitative microplate transcription factor assays (TFA) were performed to evaluate NF-kappaB activation with CSC in immortalized murine MEEC (mMEEC). Reverse transcriptase polymerase chain reaction (RT-PCR) assays and quantitative real time RT-PCR were performed to determine whether time course CSC stimulation upregulates Muc5b mRNA levels in differentiated mMEEC. Luciferase reporter assays were performed to determine whether CSC activates the Muc5b promoter.

RESULTS

Reporter assays, EMSA, and TFA demonstrated three- to five-fold dose-dependent activation of NF-kappa B with CSC in mMEEC. CSC stimulation likewise increased Muc5b mRNA abundance and induced reporter activity 1.8- to 4.8-fold in plasmids containing -556 and -255 base pairs upstream of the Muc5b transcriptional start site in mMEEC.

CONCLUSIONS

CSC activates NF-kappaB in immortalized MEEC. Furthermore, this activation correlates with CSC-induced Muc5b promoter activation and gene expression. Taken together, these results hint that much as in lung cells, the activation of mucins by cigarette smoke is mediated in part by NF-kappa B.

Effects of early cigarette smoke exposure on early immune development and respiratory disease

Exposure to tobacco constituents during early development remains a common but avoidable toxic exposure, which has been clearly linked with decreased lung growth and subsequent wheezing illness. There is also now emerging evidence that tobacco smoke can influence early immune function. This includes alterations in cytokine production by the fetoplacental unit, as detected ex vivo in cord blood, as well as in patterns of fetal mononuclear cell responses in vitro. Recent studies also suggest that the newborns of smoking mothers have altered signalling through Toll-like receptors (TLRs) that are essential for innate microbial responses. This may be implicated in the increased predisposition to infection in exposed infants. TLR-mediated innate response pathways are also believed to be important in promoting regulatory pathways that inhibit allergic immune responses. However, although a number of studies have documented associations between early cigarette smoke exposure and subsequent allergic disease, this remains controversial. This review explores the consequences of smoking on these important aspects of early development, including potential mechanisms, interactions with predisposing asthma genes and a potential role in epigenetic regulation. Although parental smoking may not be the primary factor in the changing prevalence of asthma and respiratory disease, we propose that it is an important contributor, with significant potential to interact with other genetic factors and environmental risk factors to influence disease propensity.

Passive smoking after tympanostomy and risk of recurrent acute otitis media

OBJECTIVE

Exposure to environmental tobacco smoke has been reported to be a risk factor for childhood otitis media. The effect of parental smoking on the risk of otitis media after the insertion of tympanostomy tubes is unknown. We evaluated the effect of parental smoking on the risk of recurrent otitis media in children who had received tympanostomy tubes.

METHODS

We enrolled 217 children aged 1-4 years who underwent insertion of tympanostomy tubes because of middle ear disease. The children were followed-up for 12 months. Otitis media episodes were recorded in patient diaries by primary care physicians. Parental smoking habits were assessed by a questionnaire at the start of the trial and after the 12 month follow-up had ended. The main outcome measure was risk of recurrent otitis media as defined by four or more otitis media episodes after tympanostomy. Altogether 198 children completed the follow-up.

RESULTS

Maternal smoking was associated with a highly increased risk of recurrent acute otitis media (OR 4.15, 95% CI 1.45-11.9) after the insertion of tympanostomy tubes.

CONCLUSION

Exposure to passive smoking is associated with four-fold risk of recurrent otitis media after tympanostomy. This finding should be used to encourage parents to stop smoking even after the insertion of tympanostomy tubes to their children.

Association of maternal smoking with increased infant oxidative stress at 3 months of age

BACKGROUND

Cigarette smoke is a major source of free radicals and oxidative stress. With a significant proportion of women still smoking during pregnancy, this common and avoidable exposure has the potential to influence infant oxidative status, which is implicated in the increased propensity for airway inflammation and asthma. The aim of this study was to examine the effects of maternal smoking on markers of infant oxidative stress.

METHODS

The level of oxidative stress (using urinary F2-isoprostanes as a marker of lipid peroxidation) was compared in infants of smokers (n = 33) and non-smokers (n = 54) at 3 months of age. These groups were balanced for maternal atopy and socioeconomic status. Infant urinary cotinine levels were also measured as an indicator of early postnatal cigarette smoke exposure.

RESULTS

Maternal smoking was associated with significantly higher infant cotinine levels, despite the fact that most smoking mothers (83.8%) claimed not to smoke near their baby. Maternal smoking was associated with significantly higher markers of oxidative stress (F2-isoprostane) at 3 months of age. There was also a positive correlation between urinary F2-isoprostanes and infant urinary cotinine levels.

CONCLUSIONS

Although this study does not separate the prenatal and postnatal effects of smoking, these findings indicate that environmental tobacco smoke in the early postnatal period adversely affects pro-oxidative/antioxidative status within weeks of life in very early infancy.

The laws of acute otitis media

One key to successfully navigating the quagmire of otitis media is to understand otitis media and share that understanding with parents. The Laws of Otitis Media can be useful in this endeavor. Another key to success is to help parents understand that they and their child's physician are partners in the goal of preventing AOM as much as possible, and treating episodes as precisely as possible when they occur. Parents need to know that AOM usually occurs at < 3 years of age and most normal children experience some AOM. The number of AOM episodes depends on a combination of inherited factors that are compounded by immature immunity and anatomy plus the degree of exposure to provoking respiratory pathogens. A firm understanding of the difference between AOM and OME makes it simpler to withhold antibiotics for OME; and understanding that infrequent AOM usually gets well without antibiotics also may reduce some of parents' anxieties. Parents of patients with frequent AOM deserve more guidance about the need for more potent antibiotics and the reduced expectations for cure despite use of appropriate antibiotics. Clinicians need to share with parents the fact that most information about antibiotics and AOM comes from studies sponsored by pharmaceutical companies, with the goal of optimizing the chance that the company's drug would appear to be a good choice. Therefore, only by understanding critical study-design characteristics that ensure fair and proper comparison, will the clinician (or parent using the Internet) be able to decide which drugs are best. Because there are so few well-designed studies, pharmacodynamics has become an alternative method to decide which drugs are best. Practitioners may need to rely on an expert to help interpret the application of pharmacodynamics to local AOM pathogens. While shorter courses of antibiotics are attractive from the compliance and perhaps even the reduction of resistance perspective, failure rates will be higher in young children with tough-to-treat AOM. Further, some of the better tasting or more convenient drugs turn out to be less effective in these same hard-to-treat patients. To further minimize parental anxiety, clinicians should share the fact that it is very rare to see severe complications or lifelong hearing problems due to AOM that is reasonably managed. This is important because the available tools to prevent AOM are limited in number and efficacy. The Laws of AOM can be a basis for busy practitioners to establish a structure for constructively sharing information and responsibility with parents concerning AOM.

Black-white differences in health care utilization among US children with frequent ear infections

OBJECTIVE

To examine differences in patterns of and barriers to health care utilization between black and white children who have frequent ear infections (FEI).

METHODS

Analysis was conducted using the 1997 and 1998 National Health Interview Survey-Sample Child Files. Data on 25 497 children under 18 years of age and 1985 who were reported by the parent/guardian to have had "3 or more ear infections during the past 12 months" were analyzed. The data were weighted and analyzed to represent all black and white children nationwide, accounting for the complex survey design.

RESULTS

Of white and black children under 18 years of age in the United States, 8.0 and 6.6%, respectively, had FEI in the past year. Among those with FEI, whites and blacks exhibited significantly different patterns in the type of health insurance they had and in the usual source of care. After accounting for sociodemographic factors, health insurance, and usual source of care, there were still significant differences in health care use between whites and blacks. The affected black children had an increased risk of getting delayed care because of transportation problems (odds ratio [OR]: 2.32) and a reduced likelihood of seeing a medical specialist (OR: 0.49) and having surgery (OR: 0.39) in comparison to white children.

CONCLUSION

Although black children with FEI were as likely as white children to be covered by health insurance and have a usual place of health care, they were significantly more likely to face barriers in obtaining the care, especially the more specialized care.