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

Risk of otitis media in offspring following maternal prenatal stress exposure

OBJECTIVES

There is limited but consistent evidence that suggests prenatal factors, including maternal stress, may contribute to susceptibility for otitis media. We aimed to determine the effect of multiple life stress events during pregnancy on risk of acute and recurrent otitis media in offspring at three and five years of age.

METHODS

Exposure data on stressful life events were collected from pregnant women in a longitudinal prospective pregnancy cohort study, at 18 and 34 weeks' gestation. We used longitudinal regression models stratified by offspring sex to examine associations between the number, type and timing of maternal prenatal stress events and the likelihood of any OM in addition to recurrent OM infection at age three and five years, adjusting for pre-specified prenatal sociodemographic and environmental confounders.

RESULTS

Each additional stressful life event in pregnancy was associated with increased risk of any OM at both ages (3 years: OR = 1.07, 95%CI = 1.02, 1.12; 5 years: OR = 1.07, 95%CI = 1.02, 1.12), with larger effect sizes for recurrent otitis media (3 years: OR = 1.11, 95%CI = 1.05, 1.17; 5 years: OR = 1.09, 95%CI = 1.04, 1.14). Risk of offspring otitis media did not differ with timing of stress nor by offspring sex. Specific types of stress (pregnancy and relationship problems, issues with other children) were each associated with increased risk of recurrent OM at age three and five years.

CONCLUSIONS

We observed a dose-response relationship between maternal stressful life events in pregnancy and the risk for offspring otitis media in the preschool years, most marked for recurrent otitis media.

The Impact of Early-Life Recurrent Otitis Media in Children on the Psychological Well-Being of Caregivers

AIM

Children with early-life recurrent otitis media (OM) will often endure pain, sleep disturbances, and other developmental setbacks that impact the surrounding family system. The aim of this study was to investigate the psychological well-being and family functioning of caregivers of children with early-life recurrent OM (rOM).

METHODS

Data from a longitudinal pregnancy cohort were used to categorize children into two groups: those with a history of recurrent OM (rOM group) and those without a history of rOM (reference group) by the age of 3 years. The psychological well-being of caregivers and the family functioning status were assessed using the Affect Balance Scale and the General Functioning Scale of the McMaster Family Assessment Device (FAD-GF), respectively, at the three-, five-, and eight-year follow-up appointments. Multiple linear regression models were used to analyze the data and were adjusted for potential confounding variables.

RESULTS

There were significant associations between having a child with an early history of rOM and the Affect Balance Scale of caregivers for the negative affects subscale at the three- (p < 0.001) and five- (p = 0.018) year follow-ups, and the Affect Balance subscale at the three-year (p = 0.007) and the five-year follow-ups (p = 0.047). There were no significant associations measured during the 8-year follow-up period for the FAD-GF.

CONCLUSION

The findings of this study further highlight the impact of caring for a child with rOM in early childhood on caregivers' psychological well-being in the first five years of a child's life. The impact, however, did not appear to influence the longer-term functioning of the family as a whole.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1445-1449, 2024.

Recurrent otitis media and behaviour problems in middle childhood: A longitudinal cohort study

AIM

To investigate the long-term effects of early-life recurrent otitis media (OM) and subsequent behavioural problems in children at the age of 10 years.

METHODS

Data from the Raine Study, a longitudinal pregnancy cohort, were used to categorise children into those with three or more episodes of OM (rOM group) and those without a history of recurrent OM in the first 3 years of life (reference group). The parent report Strengths and Difficulties Questionnaire was used to assess child behaviour at the age of 10 years. Parental questionnaires were used to report past and present diagnoses of various mental health and developmental conditions, including attention, anxiety, depression, learning, and speech-language problems. Multiple linear and logistic models were used to analyse the data and were adjusted for a fixed set of key confounding variables.

RESULTS

The linear regression analysis revealed significant, independent associations between a history of recurrent OM and higher Strengths and Difficulties Questionnaire scores, including total, internalising, externalising, emotional, attention/hyperactivity and peer problems subscales. Logistic regression analyses revealed an independent increased likelihood for children in the rOM group to have a diagnosis of attention, anxiety, learning and speech-language problems.

CONCLUSION

Children at 10 years of age with an early history of recurrent OM are more likely to exhibit attentional and behavioural problems when compared to children without a history of recurrent OM. These findings highlight the association between early-life recurrent OM and later behavioural problems that may require professional allied health-care interventions.

The association between otitis media in early childhood with later behaviour and attention problems: A longitudinal pregnancy cohort

OBJECTIVES

The present study aims to investigate the association between an early history of recurrent otitis media (OM) with or without ventilation tube insertion (VTI) and later behavioural problems in childhood and adolescence.

METHODS

Parental reports in a longitudinal pregnancy cohort were used to classify children into three groups; recurrent OM without VTI (rOM group; n = 276), recurrent OM with VTI (VTI group; n = 62), and no history of early-life recurrent OM as a reference group (n = 1485). The Child Behaviour Checklist (CBCL) was administered at ages 5, 8, 10, and 13 years and data were analysed for psychological wellbeing. Mixed-effects regression modelling was used to investigate the associations between a history of rOM and CBCL T-scores across all ages for rOM and VTI groups compared to the reference group. All analyses were controlled for a wide range of confounding variables.

RESULTS

The analyses revealed a significant association between recurrent OM and behavioural problems. While there was a general decline in scores (i.e. improvement) observed over the duration of the follow-up period, children in the rOM group displayed significantly higher scores for internalising and externalising behaviours at ages five, eight and 10 years. Attention scores were significantly higher across all ages in the rOM group. A transient increase in internalising behaviour was observed in the VTI group at ages eight and 10 years. Logistic regression models showed an increased overall likelihood for the rOM group only to fall within the abnormal clinical range for internalising and externalising behaviours.

CONCLUSION

Early-life recurrent OM with and without VTI was associated with increased behavioural and attention problems in early and late childhood. This suggests that recurrent OM can have a significant impact on children's behaviour and attention that can persist into early adolescence.

Age at first exposure to antibiotics and neurodevelopmental outcomes in childhood

RATIONALE

Viral illnesses in children are common and are frequently treated with antibiotic medication. Antibiotics reduce the diversity and composition of the gut microbiota, leading to poor developmental outcomes.

OBJECTIVES

To investigate the relationship between age at first exposure to antibiotics and cognitive and behavioural development at 4.5 years while controlling for multiple confounders, including otitis media.

METHODS

Study participants were 5589 children enrolled in the broadly generalisable Growing Up in New Zealand cohort study, with antibiotic exposure data, maternal antenatal information, and age 4.5-year behaviour and cognitive outcome data. Children were categorised as first exposed to antibiotics according to the following mutually exclusive ages: 0-2 months; 3-5 months; 6-8 months; 9-11 months; 12-54 months or not exposed by 54 months. Developmental outcome measures included the Strengths and Difficulties Questionnaire, Luria hand clap task, and the Peabody Picture Vocabulary Test-III.

RESULTS

In univariate analysis, there was an evident dose-response relationship where earlier exposure to antibiotics in the first year of life was associated with behavioural difficulties, lower executive function scores, and lower receptive language ability. After adjusting for confounders, pairwise comparisons showed that first antibiotic exposure between birth and 3 months or between 6 and 9 months was associated with lower receptive vocabulary. Antibiotic exposure at any age prior to 12 months was associated with increases in behavioural difficulties scores at 4.5 years.

CONCLUSIONS

Following adjustment for socioeconomic factors and otitis media, there is evidence that antibiotic exposure during potentially sensitive windows of development is associated with receptive language and behaviour later in childhood.

Ear Portal: An urban-based ear, nose, and throat, and audiology referral telehealth portal to improve access to specialist ear-health services for children

INTRODUCTION

Shortage of ear, nose, and throat specialists in public hospitals can result in delays in the detection and management of otitis media. This study introduced a new hospital-based telehealth service, named the Ear Portal, and investigated its role in improving access to specialist care.

METHODS

The study included 87 children (aged 6 months to 6 years) referred to a tertiary children's hospital due to otitis media-related concerns. A specialist multidisciplinary team met fortnightly to review pre-recorded data and provide care plans.

RESULTS

The service resulted in a median waiting time of 28 days to receive a diagnosis and care plan by the multidisciplinary team, compared to a mean waiting time of 450 days for a reference group receiving standard healthcare services. Most children (90.3%) received bilateral ear diagnosis. Normal findings were found in 43.9%. However, the majority required further ear, nose, and throat with or without audiology face-to-face follow-up due to a diagnosis of middle-ear disease, unknown hearing status, or concerns not related to ears. The mean time required for clinical assessments completion by research assistants and multidisciplinary team review was 37.6 and 5.1 min per participant, respectively.

DISCUSSION

Children in the Ear Portal service received a diagnosis and care plan in a median of 28 days, which is within the clinically recommended timeframes. With sufficient clinical information, this service can provide faster access to specialist care than the standard healthcare pathway. The service can reduce the time required by the specialist to provide a diagnosis and care plan which may help increase the specialists' capacity.

Middle ear effusion, ventilation tubes and neurological development in childhood

BACKGROUND

Otitis media with middle ear effusion (MEE) can be treated with ventilation tubes (VT) insertion, and it has been speculated that prolonged MEE in childhood can affect neurological development, which in turn may be important for later academic achievements.

OBJECTIVE

To investigate the association between middle ear effusion (MEE), treatment with ventilation tubes (VT) and childhood neurological development.

STUDY DESIGN

We examined 663 children from the Copenhagen Prospective Studies on Asthma in Childhood 2010 (COPSAC2010) unselected mother-child cohort study. Children were followed by study pediatricians with regular visits from pregnancy until 3 years of age. MEE was diagnosed using tympanometry at age 1, 2 and 3 years. Information regarding VT from age 0-3 years was obtained from national registries. We assessed age at achievement of gross motor milestones from birth, language scores at 1 and 2 years, cognitive score at 2.5 years and general development score at age 3 years using standardized quantitative tests.

RESULTS

Children with MEE had a lower 1-year word production vs. children with no disease: (median 2, IQR [0-6] vs. 4, IQR [1-7]; p = 0.017), and a lower 1-year word comprehension (median 36; IQR [21-63] vs. 47, IQR [27-84]; p = 0.03). Children with VT had a lower 2-5-year cognitive score vs. children with no disease; estimate -2.34; 95% CI [-4.56;-0.12]; p = 0.039. No differences were found between children with vs. without middle ear disease regarding age at achievement of gross motor milestones, word production at 2 years or the general developmental score at 3 years.

CONCLUSION

Our study supports the previous findings of an association between MEE and concurrent early language development, but not later neurological endpoints up to the age of 3. As VT can be a treatment of those with symptoms of delayed development, we cannot conclude whether treatment with VT had positive or negative effects on neurodevelopment.

Supporting the Social-Emotional Well-Being of Elementary School Students Who Are Deaf and Hard of Hearing: A Pilot Study

PURPOSE

Children who are Deaf and Hard of Hearing (DHH), their parents, Teachers of the Deaf, and other community stakeholders were involved in co-designing a web-based resource to support students' social-emotional well-being. The resource was designed to provide families and teachers with strategies to enhance the social and emotional well-being of Grade 4-6 students who are DHH. This study reports outcomes of a pilot study of the web-based resource intervention.

METHOD

A pre-post pilot study was conducted to quantitatively examine reported anxiety, well-being, social relationships, school experience, student-teacher relationship, and parent and teacher self-efficacy. A total of 37 students, their parents (n = 37), and their classroom teachers (n = 40) participated in the intervention program and were provided access to the resource.

RESULTS

In total, 19 students, 22 parents, and 17 teachers completed both pre- and postsurvey measures. Paired t tests revealed that there was a statistically significant increase in parents' self-efficacy scores from pre- to posttest. Multivariate analysis of covariance revealed a significant association between parent use of the website and student-reported improved peer support and reduced school loneliness. No other statistically significant differences were found.

CONCLUSIONS

The use of a web-based resource codeveloped with students who are DHH, their parents, and teachers could potentially be beneficial for the well-being of students who are DHH as well as parents' self-efficacy. Further research is needed to confirm the benefits.

Children with Secondary Care Episodes for Otitis Media Have Poor Literacy and Numeracy Outcomes: A Data Linkage Study

We examined the association between otitis media (OM) and educational attainment in a retrospective population cohort of Western Australian children who participated in the grade 3 National Assessment Program—Literacy and Numeracy in 2012 (N = 19,262). Literacy and numeracy scores were linked to administrative hospital and emergency department data to identify secondary care episodes for OM. Results of multivariate multilevel models showed that children with OM episodes had increased odds of poor performance on literacy and numeracy tests, compared to children without OM episodes (46–79% increase in odds for Aboriginal children; 20–31% increase in odds for non-Aboriginal children). There were no significant effects found for age at the first episode, nor for OM episode frequency (all ps > 0.05). Regardless of the timing or frequency of episodes, children with OM episodes are at risk of poor literacy and numeracy attainment. Aboriginal children with OM appeared to be particularly at risk of poor literacy and numeracy achievement. Intervention to reduce the prevalence of otitis media in young children, and early treatment of OM, are important for limiting the negative effects on academic outcomes.

The reliability of video otoscopy recordings and still images in the asynchronous diagnosis of middle-ear disease

OBJECTIVE

To compare the asynchronous assessment of video otoscopic still images to recordings by an audiologist and ear, nose and throat surgeon (ENT) for diagnostic reliability and agreement in identifying middle-ear disease.

DESIGN

A prospective cross-sectional study, asynchronously assessing video otoscopy, tympanometry and case history (Dx1). A subset was re-diagnosed (Dx2).

STUDY SAMPLE

Video otoscopy and data from 146 children recruited at two public community events; a sub-set of 47 were re-assessed.

RESULTS

The intra-rater diagnostic agreement between Dx1 and Dx2 was moderate (k = 0.445-0.552) for the ENT surgeon, and almost-perfect (k = 0.928) for the audiologist, in both procedures. The agreement between the two procedures was substantial (k = 0.624) and moderate (k = 0.416) for the ENT surgeon in Dx1 and Dx2 respectively, and almost-perfect for the audiologist (k = 0.854-0.978) in both rounds. In Dx1, the inter-rater agreement between the clinicians was substantial using still images (k = 0.672) and moderate using recordings (k = 0.593); in Dx2 it was moderate using both procedures (k = 0.477-0.488).

CONCLUSION

Both video otoscopic procedures, in addition to tympanometry and case history information, can be reliably used for asynchronous diagnosis of childhood middle-ear disease. An audiologist has a potential role in triaging children with middle-ear abnormalities and, therefore, improving access to ear-health services.

Otitis media guidelines for Australian Aboriginal and Torres Strait Islander children: summary of recommendations

Introduction

The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Main recommendations

We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions.

Changes in management as a result of the guidelines

A GRADE approach is used.

Targeted recommendations for both high and low risk children.

New tympanostomy tube otorrhoea section.

New Priority 5 for health services: annual and catch‐up ear health checks for at‐risk children.

Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children.

Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration.

Concurrent audiology and surgical referrals are recommended where delays are likely.

Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis.

The use of autoinflation devices is recommended for some children with persistent otitis media with effusion.

Definitions for mild (21–30 dB) and moderate (> 30 dB) hearing impairment have been updated.

New “OMapp” enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Does Otitis Media Affect Later Language Ability? A Prospective Birth Cohort Study

Purpose The aim of the study was to examine whether otitis media (OM) in early childhood has an impact on language development in later childhood. Methods We analyzed data from 1,344 second-generation (Generation 2) participants in the Raine Study, a longitudinal pregnancy cohort established in Perth, Western Australia, between 1989 and 1991. OM was assessed clinically at 6 years of age. Language development was measured using the Peabody Picture Vocabulary Test-Revised (PPVT-R) at 6 and 10 years of age and the Clinical Evaluation of Language Fundamentals-Third Edition at 10 years of age. Logistic regression analysis accounted for a wide range of social and environmental covariates. Results There was no significant relationship between bilateral OM and language ability at 6 years of age (β = -0.56 [-3.78, 2.66], p = .732). However, while scores were within the normal range for the outcome measures at both time points, there was a significant reduction in the rate of receptive vocabulary growth at 10 years of age (PPVT-R) for children with bilateral OM at 6 years of age (β = -3.17 [-6.04, -0.31], p = .030), but not for the combined unilateral or bilateral OM group (β = -1.83 [-4.04, 0.39], p = .106). Conclusions Children with OM detected at 6 years of age in this cohort had average language development scores within the normal range at 6 and 10 years of age. However, there was a small but statistically significant reduction in the rate of receptive vocabulary growth at 10 years of age (on the PPVT-R measure only) in children who had bilateral OM at 6 years of age after adjusting for a range of sociodemographic factors.