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

The Role of Diet in Tympanostomy Tube Otorrhea

OBJECTIVE

The objective of this study was to evaluate the role of diet quality in children with tympanostomy tube placement (TTP) complicated by tympanostomy tube otorrhea (TTO).

STUDY DESIGN

Three-day 24-hour diet recall.

SETTING

Tertiary care medical center.

METHODS

Children between the ages of 2 to 6 years old with TTP performed 6 months to 2 years prior to enrollment were included. Children with a history of Down syndrome, cleft palate, craniofacial syndromes, known immunodeficiency, g-tube dependent, or a non-English speaking family were excluded. The primary outcome variable was TTO. The primary predictor was total caloric intake measured by percent estimated energy rate (%EER).

RESULTS

A total of 120 families completed the 3-day diet recall. The median age was 27 months (interquartile range: 7.9-68.5), with 57% male sex. Most children reported dietary intake within the recommended range percent intake for carbohydrates and fat and less than recommended range for percent vitamin D. Within this cohort 63 (52.5%) participants had >1 TTO episode and 57 (47.5%)≤ 1 TTO episode. Children with an EER% that was average or high were at higher odds of >1 TTO episodes compared to participants with a low EER% with ORs of 4.6 (95% confidence interval [CI]: 1.4, 15.6) and 5.7 (95% CI: 1.5, 22.1) respectively.

CONCLUSION

Children with a typical or high total daily caloric intake are approximately 5 to 6 times more likely to have multiple TTO episodes compared to those with low intake.

Associated factors for parent-reported otitis media in 12-month-old infants

OBJECTIVE

To report host-related and environmental factors associated with otitis media (OM), and compare the prevalence of OM in 12-month-old infants reported by parents with that predicted from audiological assessment results.

DESIGN

A non-randomised, cross-sectional design was used. Data were collected via a parental questionnaire during children's audiology appointment at 12 months of age. Audiological assessments were performed on all participants.

STUDY SAMPLE

Participants were 237 infants whose parents had completed a questionnaire at the audiology appointment.

RESULTS

The results of the logistic regressions with univariate model showed that attendance at day-care centres, upper respiratory tract infections (URTI) and siblings' history of OM were statistically significant variables with an odds ratio of 1.91, 2.87 and 3.56, respectively. The results of the multivariate logistic regression highlighted siblings' history of OM as the significant associated factor. The prevalence of parent-reported OM was 22.3% whereas the prevalence predicted from audiological findings was at least 39.7%.

CONCLUSIONS

The present study identified three associated factors for OM: day-care attendance, frequent URTI and siblings' history of OM in infants. The prevalence of OM predicted from audiologic measures was about twice of that reported by parents. Preventive measures to mitigate the effects of OM have been suggested.

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.

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.

Multi-institutional Assessment of Otitis Media Epidemiology Using Real-world Data

OBJECTIVES

To determine rates and risk factors of pediatric otitis media (OM) using real-world electronic health record (PEDSnet) data from January 2009 through May 2021.

STUDY DESIGN

Retrospective cohort study.

SETTING

Seven pediatric academic health systems that participate in PEDSnet.

METHODS

Children <6 months-old at time of first outpatient, Emergency Department, or inpatient visit were included and followed longitudinally. A time-to-event analysis was performed using a Cox proportional hazards model to estimate hazard ratios for OM incidence based on sociodemographic factors and specific health conditions.

RESULTS

The PEDSnet cohort included 910,265 children, 54.3% male, mean age (months) 1.3 [standard deviation (SD) 1.6] and mean follow up (years) 4.3 (SD 3.2). By age 3 years, 39.6% of children had evidence of one OM episode. OM rates decreased following pneumococcal-13 vaccination (PCV-13) and the COVID-19 pandemic. Along with young age, non-Hispanic Black/African American or Hispanic race/ethnicity, public insurance, higher family income, and male sex had higher incidence rates. Health conditions that increased OM risk included cleft palate [adjusted hazard ratio (aHR) 4.0 [95% confidence interval (CI) 3.9-4.2], primary ciliary dyskinesia [aHR 2.5 (95% CI 1.8-3.5)], trisomy 21 [aHR 2.0 (95% CI 1.9-2.1)], atopic dermatitis [aHR 1.4 (95% CI 1.4-1.4)], and gastroesophageal reflux [aHR1.5 (95% CI 1.5-1.5)].

CONCLUSIONS

Approximately 20% of children by age 1 and 40% of children by age 3 years will have experienced an OM episode. OM rates decreased after PCV-13 and COVID-19. Children with abnormal ciliary function or craniofacial conditions, specifically cleft palate, carry the highest risk of OM.

Impact of ventilation tube insertion on long-term language outcomes at 6 and 10 years of age: A prospective pregnancy cohort study

OBJECTIVE

Investigating the impact of early childhood ventilation tube insertion (VTI) on long-term language outcomes.

DESIGN

Longitudinal cohort study.

SETTING

A total of 2900 pregnant women participated in the Raine Study between 1989 and 1991 in Western Australia, and 2868 children have been followed up.

PARTICIPANTS

Based on parental reports, 314 children had a history of recurrent otitis media but did not undergo VTI (rOM group); another 94 received VTI (VTI group); while 1735 had no history of rOM (reference group) in the first 3 years of childhood. Children with data on outcomes and confounders were included in analyses of PPVT-R at ages 6 (n = 1567) and 10 years (n = 1313) and CELF-III at 10 years (n = 1410) (approximately 5% in the VTI group and 15% in the rOM group).

MAIN OUTCOME MEASURES

Peabody Picture Vocabulary Test-Revised edition and Clinical Evaluation of Language Fundamentals® Preschool-3.

RESULTS

At 6 years, mean PPVT-R scores were significantly lower in the VTI group than the reference group (β = -3.3; 95% CI [-6.5 to -0.04], p = .047). At 10 years, while the difference between the VTI and reference groups was less pronounced for PPVT-R scores, there was a small but consistent trend of lower measures, on average, across CELF-III scores (expressive: β = -3.4 [-7.1 to 0.27], p = .069; receptive: β = -4.1 [-7.9 to -0.34], p = .033; total: β = -3.9 [-7.5 to -0.21], p = .038). There was no evidence to suggest that language outcomes in the rOM group differed from the reference group.

CONCLUSION

Lower scores of language outcomes in school-aged children who received VTI in early childhood may suggest a long-term risk which should be considered alongside the potential benefits of VTI.

Risk Factors for Chronic and Recurrent Otitis Media in Children: A Review Article

Otitis media is an inflammation of the mucous membrane of the middle ear, which includes mastoid air cells, the middle ear cavity, the Eustachian tube, and the mastoid antrum. Otitis media can be either acute, less than six weeks, or chronic, which lasts for more than six weeks. Recurrent otitis media refers to three episodes of the disease occurring within six months or four episodes within one year. There are many risk factors for otitis media among children; however, some of such factors may vary based on the type of otitis media. To highlight the risk factors of chronic and recurrent otitis media in pediatrics. Scientific databases were used to search for articles related to our objective. Various terms were used for the search process. The types of articles included in our review were original articles, review articles, meta-analyses, and systematic reviews written in the English language and concerned with our subject. The topic was discussed under four main titles; the first overviewed the prevalence and risk factors of otitis media, the second title discussed chronic otitis media and its risk factors, the third title discussed recurrent otitis media and its risk factors, and the last title discussed the risk factors of both chronic and recurrent otitis media. There are various risk factors for chronic and recurrent otitis media, and they include allergy, passive smoking, male gender, and snoring. Also, genetics may have a common role, but this needs further investigation.

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 Impact of Waiting Times on Behavioral Outcomes for Children with Otitis Media: Results from an Urban Ear, Nose, and Throat Telehealth Service

Aim

Children with otitis media (OM) experience long waiting times to access Australia's public hospitals due to limited capacity. The aim of this article is to utilize an Ear, Nose, and Throat (ENT) telehealth service (the Ear Portal) to examine whether delayed access to specialist care is associated with poorer behavioral outcomes for children with OM.

Methods

Participants in the study included 45 children who were referred to ENT specialists due to recurrent and persistent OM. Children were triaged as semiurgent with a target time-to-assessment of 90 days or nonurgent with a target time-to-assessment of 365 days. The behavioral outcomes of children were assessed using the parent report Strengths and Difficulties Questionnaire (SDQ). Descriptive statistics and adjusted multiple linear regression models were used to compare children who received access to the service within the time-to-assessment target of their triage category ("on-boundary"; n = 17) and outside the time-to-assessment target ("off-boundary"; n = 28). Spearman correlation analysis was used to explore the relationship between the internalizing, externalizing, and total SDQ scores as a function of waiting times in days.

Results

Borderline or abnormal SDQ scores ranged from 24.4% to 42.2% across the study participants. The regression analysis showed a statistically significant association between the off-boundary group and higher scores (i.e., poorer) on the peer, emotional, conduct, internalizing, and total problems subscales. Further, lengthy waiting times were significantly correlated with higher internalizing problems. These findings indicate that longer waiting times may lead to poorer behavioral outcomes for children with OM.

Clinical Trial Registration: (ACTRN1269000039189p).

Conclusion

Children with recurrent and persistent OM referred to ENT outpatient care were found to have significantly more behavioral difficulties if their waiting times exceeded the recommended timeframes for their triaged referrals. Additionally, they experienced more internalizing problems that correlated with longer waiting times. This highlights the calls for alterations in current clinical practice given the lengthy waiting times in Australia's public hospitals.

Association of Diet Patterns and Post-Operative Tympanostomy Tube Otorrhea: A Pilot Study

OBJECTIVE

The objective of this study was to explore diet patterns in children with tympanostomy tube placement (TTP) complicated by postoperative tympanostomy tube otorrhea.

STUDY DESIGN

Cross-sectional survey and retrospective cohort study.

METHODS

Caregivers of children (0-12 years old), at a tertiary-care pediatric hospital who underwent TTP within 6 months to 2 years prior to enrollment were included. Children with a history of Down syndrome, cleft palate, craniofacial syndromes, known immunodeficiency, or a non-English-speaking family were excluded. Our primary outcome variable was the number of otorrhea episodes. The primary predictor was diet patterns, particularly dessert intake, which was captured through a short food questionnaire.

RESULTS

A total of 286 participants were included in this study. The median age was 1.8 years (IQR, 1.3, 2.9). A total of 174 (61%) participants reported at least one episode of otorrhea. Children who consumed dessert at least two times per week had a higher risk of otorrhea compared to children who consumed one time per week or less (odds ratio [OR], 3.22, 95% Confidence Interval [CI]: 1.69, 6.12). The odds ratio increase continued when considering more stringent criteria for otorrhea (multiple episodes or one episode occurring 4 weeks after surgery), with a 2.33 (95% CI: 1.24, 4.39) higher odds of otorrhea in children with dessert intake at least 2 times per week.

CONCLUSIONS

Our pilot data suggest that episodes of otorrhea among children with TTP were associated with more frequent dessert intake. Future studies using prospectively administered diet questionnaires are necessary to confirm these findings.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:3575-3581, 2023.

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.

Prevalence of Gram positive bacteria in the affected individuals of Otitis media with effusion from the indigenous population of Southern Punjab, Pakistan: first report

Otitis media with effusion (OME) is a type of otitis media (OM) characterized by the presence of fluid behind intact tympanic membrane and is one of the most common diseases of early childhood. It is an infectious disease associated with the presence of many pathogenic bacteria in the middle ear of affected individuals. This study was aimed to determine the prevalence of Gram-positive bacteria from the middle ear of OME patients in the population of Southern Punjab, Pakistan. The incidence of OME under comprehensive healthcare setting was investigated in patients who consulted at the department of ear, throat and nose, Bahawal Victoria Hospital (BVH), Bahawalpur, from December, 2019 to May, 2021. Ear swabs were taken from affected and normal individuals. After culturing bacteria from the ear swabs, microscopic analysis and biochemical tests were performed to characterize the cultured Gram-positive bacteria. Out of 352 patients examined, 109 (30.9%) patients had OME. Age of the participants ranged from 14 to 50 years; individuals between the ages of 14 and 22 years had the highest infection rates, while individuals between 40 and 50 years had the lowest rate of infection. Tympanic membrane perforation, fever, cough, sore throat, ear pain and hearing problem showed association with symptoms of OME. Microscopic analysis and biochemical characterization showed the presence of streptococci and staphylococci in all the studied samples. The most frequently isolated bacteria were Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus with percentage of 53.3%, 20% and 13.3% respectively. Enterococcus faecalis (6.6%) and Staphylococcus epidermidis (6.6%) were also identified in the studied samples. This study will help in the better medical administration of OME affected individuals.

Long-term follow-up after recurrent otitis media and ventilation tube insertion: Hearing outcomes and middle-ear health at six years of age

OBJECTIVES

To investigate the long-term impact of recurrent otitis media (rOM) and ventilation tube insertion (VTI) in early childhood on hearing outcomes and middle-ear health three to five years later, in a prospective pregnancy cohort study.

METHODS

Children were classified into rOM (n = 314), VTI (n = 94), and reference (n = 1735) groups, according to their otitis media (OM) history in their first three years of life. Audiometry at frequencies 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz, and tympanometry were performed when children were approximately six years of age.

RESULTS

A binary logistic regression incorporating a range of potential confounding variables showed that hearing outcomes and middle-ear health status in children who had early childhood rOM with or without undergoing VTI were not significantly different to those in the reference group. The only significant difference was found in the VTI group for both tympanometry (OR = 2.190; 95% CI = 1.123, 4.270) and audiometry outcomes at 4000 Hz (OR = 3.202; 95% CI 1.341, 6.717), in the left ear only. The median score of the better ear 4FA was 20 dB in children in all groups.

CONCLUSION

Children with rOM with or without undergoing VTI in the first three years of childhood had comparable hearing outcomes and middle-ear health status to those with no history of the disease, at around the age of six years. Although children who underwent VTI had an increased risk of abnormal middle-ear status and some elevation in hearing levels in their left ear only, their audiometry results were still within normal limits, indicating that the impact of VTI in early childhood is unlikely to have clinically significant adverse impact on later hearing outcomes.

Influence of Respiratory Tract Infections on Vocabulary Growth in Relation to Child's Sex: The STEPS Study

Common health issues have been less examined in studies of early language development, particularly in relation to the child's sex. Respiratory tract infections, often complicated by acute otitis media, are common in children during the first years of life, when early vocabulary development takes place. The present study, conducted in Finland, aimed to investigate whether possible associations between recurrent respiratory tract infections, background factors, and vocabulary growth differ in boys and girls aged 13 to 24 months. The participants (N = 462, 248 boys and 214 girls) were followed for respiratory tract infections and acute otitis media from 0 to 23 months of age. The parents completed daily symptom diaries of respiratory symptoms, physician visits, and diagnoses. The expressive vocabulary was measured with parental reports. We found that recurrent respiratory tract infections were not associated with slower vocabulary development in boys or girls. In fact, boys with recurrent respiratory tract infections had more vocabulary growth during the second year than boys who were less sick. We found that vocabulary growth was associated differently with respiratory tract infections and background factors as a function of the child's sex. The vocabulary growth of boys seems to be more influenced by environmental factors than that of girls.

Recurrent Acute Otitis Media Could Be Related to the Pro-Inflammatory State That Causes an Incorrect Diet

Introduction: Acute Otitis Media (AOM) is the most commonly-occurring bacterial complication in childhood. After making certain corrections to the patients’ dietary habits, which we found to be excessively high in animal-based and industrially-processed foods, we observed a significant reduction in recurrent colds and their bacterial complications. We promote an original way of treating these diseases, since until now the conventional treatment is based on pharmacological and surgical treatment. From our point of view, the mucosa that covers the entire ENT area is in a pro-inflammatory and hyper-reactive state, as a consequence of the alterations produced by an inadequate diet. For us there is no difference in the nutritional treatment of the different mucous membranes that cover the ENT area. The purpose of the study was to assess the effects of the Traditional Mediterranean Diet (TMD) on patients diagnosed with Recurring Acute Otitis Media (RAOM). Methods: prospective pre-postest comparison study with 48 girls and 42 boys aged 1–5 years, each of whom had been and included on the 1-year programme “Learning to eat the Mediterranean Way”, designed to encourage the adoption of the TMD. We studied clinical and therapeutic variables and various anthropometric parameters. Results: all the symptomatic indicators studied (number and intensity of episodes of otitis and emergency admissions) showed a positive and statistically significant evolution in RAOM. By the end of the study, none of the patients met the criteria for classification as RAOM, and 60% percent of patients did not present any further episodes of AOM. In line with the above, the use of anti-microbial drugs and symptomatic treatments reduced considerably; the use of antibiotics dropped from 4.30 occasions/patient/year, to 0.66 (p < 0.001), and the used of symptomatic treatments dropped from 7.63 to 2.75 (p < 0.001). The level of family satisfaction was very high. Conclusions: the adoption of the Traditional Mediterranean Diet has been demonstrated to significantly reduce occurrence of acute otitis media and may contribute to the treatment of patients diagnosed with recurrent acute otitis media.

Barriers to Equity in Pediatric Hearing Health Care: A Review of the Evidence

Purpose

We review the evidence regarding barriers to hearing health care for children who are deaf or hard of hearing.

Background

There are considerable data to suggest that hearing health care disparities constitute a major factor in loss to follow-up or documentation for children going through the Early Hearing Detection and Intervention process. Families are affected by a combination of factors underlying these disparities, resulting in delayed care and suboptimal developmental outcomes for children who are deaf or hard of hearing.

Conclusions

To address the socioeconomic, cultural, and linguistic inequities seen in the diagnosis and management of childhood hearing loss, pediatric audiologists and speech-language pathologists have a responsibility to provide culturally responsive practice to their individual clients and their families, as well as advocate for substantive changes at the policy level that impact their clients' daily lives.

Microbiota Associated With Cholesteatoma Tissue in Chronic Suppurative Otitis Media

Otitis media (OM), defined as infection or inflammation of the middle ear (ME), remains a major public health problem worldwide. Cholesteatoma is a non-cancerous, cyst-like lesion in the ME that may be acquired due to chronic OM and cause disabling complications. Surgery is required for treatment, with high rates of recurrence. Current antibiotic treatments have been largely targeted to previous culturable bacteria, which may lead to antibiotic resistance or treatment failures. For this study, our goal was to determine the microbiota of cholesteatoma tissue in comparison with other ME tissues in patients with long-standing chronic OM. ME samples including cholesteatoma, granulation tissue, ME mucosa and discharge were collected from patients undergoing tympanomastoidectomy surgery for chronic OM. Bacteria were profiled by 16S rRNA gene sequencing in 103 ME samples from 53 patients. Respiratory viruses were also screened in 115 specimens from 45 patients. Differences in bacterial profiles (beta-diversity) and the relative abundances of individual taxa were observed between cholesteatoma and ME sample-types. Additionally, patient age was associated with differences in overall microbiota composition while numerous individual taxa were differentially abundant across age quartiles. No viruses were identified in screened ME samples. Biodiversity was moderately lower in cholesteatoma and ME discharge compared to ME mucosal tissues. We also present overall bacterial profiles of ME tissues by sample-type, age, cholesteatoma diagnosis and quinolone use, including prevalent bacterial taxa. Our findings will be useful for fine-tuning treatment protocols for cholesteatoma and chronic OM in settings with limited health care resources.

The Indoor Environment and Otitis Media among Australian Children: A National Cross-Sectional Study

The association between the indoor environment and lifetime prevalence of otitis media (OM) in Australian children was assessed. We analysed data from a cross-sectional study of children, aged 7–11 years, performed in twelve Australian cities during 2007–2008. The main outcome was a parental report of their child’s diagnosis with OM by a doctor. Information on the indoor environment (energy sources used for heating, cooling, and cooking, pets, and second-hand smoke exposure), in the first year of life and at present, was collected from parents by a questionnaire. Multi-level logistic regression models were used to adjust for individual- and area-level confounders. Our analysis comprised 2872 children (51% female, mean age: 10.0 (SD 1.2)). Of those, 1097 (39%) were reported to have OM. Exposure to gas heating in the first year of life was significantly associated with higher odds of OM in adjusted models (OR:1.22; 95% CI: 1.00,1.47), as was current exposure to reverse-cycle air conditioning (OR: 1.52, 95% CI: 1.27,1.82). Ownership of a cat or dog at any time was also associated with high odds of OM (OR: 1.50; 95% CI: 1.17,1.92). No other significant associations were observed. In this national study of Australian children, indoor environmental exposures associated with the lifetime prevalence of OM were gas heating, reverse-cycle air conditioning and pet ownership. Exposures in both early life and later childhood may both play a role in OM.

Association between maternal insecticide use and otitis media in one-year-old children in the Japan Environment and Children's Study

Otitis media (OM) is common among young children and is related to hearing loss. We investigated the association between maternal insecticide use, from conception to the first and second/third trimesters, and OM events in children in the first year of age. Data from Japan Environment and Children's Study were used in this prospective cohort study. Characteristics of patients with and without history of OM during the first year of age were compared. The association between history of OM in the first year and insecticide use was evaluated using logistic regression analysis. The study enrolled 98,255 infants. There was no significant difference in the frequency of insecticide use between groups. Insecticide use of more than once a week from conception to the first trimester significantly increased the occurrence of OM in children in the first year (odds ratio [OR] = 1.30, 95% confidence interval [CI] 1.01–1.67). The association between OM in the first year and insecticide use from conception to the first trimester was only significant in the group without daycare attendance (OR 1.76, 95% CI 1.30–2.38). Maternal insecticide use more than once a week from conception to the first trimester significantly increased OM risk in offspring without daycare attendance.

The FUT2 Variant c.461G>A (p.Trp154*) Is Associated With Differentially Expressed Genes and Nasopharyngeal Microbiota Shifts in Patients With Otitis Media

Otitis media (OM) is a leading cause of childhood hearing loss. Variants in FUT2, which encodes alpha-(1,2)-fucosyltransferase, were identified to increase susceptibility to OM, potentially through shifts in the middle ear (ME) or nasopharyngeal (NP) microbiotas as mediated by transcriptional changes. Greater knowledge of differences in relative abundance of otopathogens in carriers of pathogenic variants can help determine risk for OM in patients. In order to determine the downstream effects of FUT2 variation, we examined gene expression in relation to carriage of a common pathogenic FUT2 c.461G>A (p.Trp154*) variant using RNA-sequence data from saliva samples from 28 patients with OM. Differential gene expression was also examined in bulk mRNA and single-cell RNA-sequence data from wildtype mouse ME mucosa after inoculation with non-typeable Haemophilus influenzae (NTHi). In addition, microbiotas were profiled from ME and NP samples of 65 OM patients using 16S rRNA gene sequencing. In human carriers of the FUT2 variant, FN1, KMT2D, MUC16 and NBPF20 were downregulated while MTAP was upregulated. Post-infectious expression in the mouse ME recapitulated these transcriptional differences, with the exception of Fn1 upregulation after NTHi-inoculation. In the NP, Candidate Division TM7 was associated with wildtype genotype (FDR-adj-p=0.009). Overall, the FUT2 c.461G>A variant was associated with transcriptional changes in processes related to response to infection and with increased load of potential otopathogens in the ME and decreased commensals in the NP. These findings provide increased understanding of how FUT2 variants influence gene transcription and the mucosal microbiota, and thus contribute to the pathology of OM.

The role of CDHR3 in susceptibility to otitis media

Otitis media (OM) is common in young children and can cause hearing loss and speech, language, and developmental delays. OM has high heritability; however, little is known about OM-related molecular and genetic processes. CDHR3 was previously identified as a locus for OM susceptibility, but to date, studies have focused on how the CDHR3 p.Cys529Tyr variant increases epithelial binding of rhinovirus-C and risk for lung or sinus pathology. In order to further delineate a role for CDHR3 in OM, we performed the following: exome sequencing using DNA samples from OM-affected individuals from 257 multi-ethnic families; Sanger sequencing, logistic regression and transmission disequilibrium tests for 407 US trios or probands with OM; 16S rRNA sequencing and analysis for middle ear and nasopharyngeal samples; and single-cell RNA sequencing and differential expression analyses for mouse middle ear. From exome sequence data, we identified a novel pathogenic CDHR3 splice variant that co-segregates with OM in US and Finnish families. Additionally, a frameshift and six missense rare or low-frequency variants were identified in Finnish probands. In US probands, the CDHR3 p.Cys529Tyr variant was associated with the absence of middle ear fluid at surgery and also with increased relative abundance of Lysobacter in the nasopharynx and Streptomyces in the middle ear. Consistent with published data on airway epithelial cells and our RNA-sequence data from human middle ear tissues, Cdhr3 expression is restricted to ciliated epithelial cells of the middle ear and is downregulated after acute OM. Overall, these findings suggest a critical role for CDHR3 in OM susceptibility. KEY MESSAGES: • Novel rare or low-frequency CDHR3 variants putatively confer risk for otitis media. • Pathogenic variant CDHR3 c.1653 + 3G > A was found in nine families with otitis media. • CDHR3 p.Cys529Tyr was associated with lack of effusion and bacterial otopathogens. • Cdhr3 expression was limited to ciliated epithelial cells in mouse middle ear. • Cdhr3 was downregulated 3 h after infection of mouse middle ear.

Topical antibiotics with steroids for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM) is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antibiotics act to kill or inhibit the growth of micro-organisms that may be responsible for the infection. Antibiotics can be used alone or in addition to other treatments for CSOM, such as steroids, antiseptics or ear cleaning (aural toileting). Antibiotics are commonly prescribed in combined preparations with steroids.

OBJECTIVES

To assess the effects of adding a topical steroid to topical antibiotics in the treatment of people with chronic suppurative otitis media (CSOM).

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 16 March 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least a one-week follow-up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any combination of a topical antibiotic agent(s) of any class and a topical corticosteroid (steroid) of any class, applied directly into the ear canal as ear drops, powders or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic and steroid compared to a) placebo or no intervention and b) another topical antibiotic.

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks and after four weeks; health-related quality of life; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity.

MAIN RESULTS

We included 17 studies addressing 11 treatment comparisons. A total of 1901 participants were included, with one study (40 ears) not reporting the number of participants recruited, which we therefore could not account for. No studies reported health-related quality of life. The main comparisons were: 1. Topical antibiotics with steroids versus placebo or no treatment Three studies (210 participants) compared a topical antibiotic-steroid to saline or no treatment. Resolution of discharge was not reported at between one to two weeks. One study (50 'high-risk' children) reported results at more than four weeks by ear and we could not adjust the results to by person. The study reported that 58% (of 41 ears) resolved with topical antibiotics compared with 50% (of 26 ears) with no treatment, but the evidence is very uncertain. One study (123 participants) noted minor side effects in 16% of participants in both the intervention and placebo groups (very low-certainty evidence). One study (123 participants) reported no change in bone-conduction hearing thresholds and reported no difference in tinnitus or balance problems between groups (very low-certainty evidence). One study (50 participants) reported serious complications, but it was not clear which group these patients were from, or whether the complications occurred pre- or post-treatment. One study (123 participants) reported that no side effects occurred in any participants (very low-certainty evidence). 2. Topical antibiotics with steroids versus topical antibiotics (same antibiotics) only Four studies (475 participants) were included in this comparison. Three studies (340 participants) compared topical antibiotic-steroid combinations to topical antibiotics alone. The evidence suggests little or no difference in resolution of discharge at one to two weeks: 82.7% versus 76.6% (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.96 to 1.21; 335 participants; 3 studies (4 study arms); low-certainty evidence). No results for resolution of discharge after four weeks were reported. One study (110 participants) reported local itchiness but as there was only one episode in each group it is uncertain whether there is a difference (very low-certainty evidence). Three studies (395 participants) investigated suspected ototoxicity but it was not possible to determine whether there were differences between the groups for this outcome (very low-certainty evidence). No study reported serious complications. 3. Topical antibiotics with steroids compared to topical antibiotics alone (different antibiotics) Nine studies (981 participants plus 40 ears) evaluated a range of comparisons of topical non-quinolone antibiotic-steroid combinations versus topical quinolone antibiotics alone. Resolution of discharge may be greater with quinolone topical antibiotics alone at between one to two weeks compared with non-quinolone topical antibiotics with steroids: 82.1% versus 63.2% (RR 0.77, 95% CI 0.71 to 0.84; 7 studies; 903 participants, low-certainty evidence). Results for resolution of ear discharge after four weeks were not reported. One study (52 participants) reported usable data on ear pain, two studies (419 participants) reported hearing outcomes and one study (52 participants) reported balance problems. It was not possible to determine whether there were significant differences between the groups for these outcomes (very low-certainty evidence). Two studies (149 participants) reported no serious complications (very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain about the effectiveness of topical antibiotics with steroids in improving the resolution of ear discharge in patients with CSOM because of the limited amount of low-certainty evidence available. Amongst this uncertainty, we found no evidence that the addition of steroids to topical antibiotics affects the resolution of ear discharge. There is also low-certainty evidence that some types of topical antibiotics (without steroids) may be better than topical antibiotic/steroid combinations in improving resolution of discharge. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine with any certainty whether or not quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, adverse effects were poorly reported.

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.

ABO Genotype and Blood Type Are Associated with Otitis Media

Aim: To determine if there is an association between ABO variants or blood types and otitis media. Methods: DNA samples from 214 probands from Finnish families with recurrent acute (RAOM) and/or chronic otitis media with effusion (COME) were submitted for exome sequencing. Fisher exact tests were performed when (a) comparing frequencies of ABO genotypes in the Finnish probands with otitis media vs. counts in gnomAD Finnish, and (b) within the Finnish family cohort, comparing occurrence of RAOM vs. COME according to ABO genotype/haplotype and predicted blood type. Results: Female sex is protective against having both RAOM and COME. The wildtype genotype for the ABO c.260insG (p.Val87_Thr88fs*) variant resulting in blood type O was protective against RAOM. On the other hand, type A was associated with increased risk for COME. These findings remained significant after adjustment for age and sex. Conclusions: Within the Finnish family cohort, the wildtype genotype for the ABO c.260insG (p.Val87_Thr88fs*) variant and type O are protective against RAOM while type A increases risk for COME. This suggests that the association between the ABO locus and otitis media is specific to blood type, otitis media type and cohort.

High concentrations of middle ear antimicrobial peptides and proteins and proinflammatory cytokines are associated with detection of middle ear pathogens in children with recurrent acute otitis media

Recurrent and chronic otitis media (OM) are often refractory to antibiotics due to bacterial persistence in biofilm within the middle ear. In vitro and in vivo studies have demonstrated that antimicrobial proteins and peptides (AMPs) are bactericidal against otopathogens, indicating potential therapeutic value for recalcitrant OM. We measured concentrations of 6 AMPs and 14 cytokines in middle ear effusion (MEE) from 67 children undergoing ventilation tube insertion for recurrent acute OM. Sixty one percent of children had bacterial otopathogens detected in their MEE, 39% by PCR and 22% by PCR and culture. Groups were defined as: PCR-negative/culture-negative (absence of bacterial otopathogen), n = 26; PCR-positive/culture-negative (presence of nonculturable bacterial otopathogen), n = 26; PCR-positive/culture-positive (presence of culturable bacterial otopathogen), n = 15. Age, antibiotic usage, day-care attendance, presence of respiratory viruses in MEE and number of AOM episodes were similar between groups. AMP and cytokine concentrations were higher in children with bacterial otopathogens in their MEE compared to those with no bacterial otopathogens. Median concentrations of AMPs (except HBD2) were 3 to 56-fold higher in MEE from children with bacterial otopathogens detected in their MEE (P ≤ 0.01). Similarly, median cytokine concentrations (except TGFβ) were >16-fold higher in MEE with bacterial otopathogens detected (P ≤ 0.001). This is the first study to measure AMPs in MEE and together with the cytokine data, results suggest that elevated AMPs and cytokines in MEE are a marker of inflammation and bacterial persistence. AMPs may play an important role in OM pathogenesis.

A2ML1 and otitis media: novel variants, differential expression, and relevant pathways

A genetic basis for otitis media is established, however, the role of rare variants in disease etiology is largely unknown. Previously a duplication variant within A2ML1 was identified as a significant risk factor for otitis media in an indigenous Filipino population and in US children. In this report exome and Sanger sequencing was performed using DNA samples from the indigenous Filipino population, Filipino cochlear implantees, US probands, Finnish, and Pakistani families with otitis media. Sixteen novel, damaging A2ML1 variants identified in otitis media patients were rare or low-frequency in population-matched controls. In the indigenous population, both gingivitis and A2ML1 variants including the known duplication variant and the novel splice variant c.4061 + 1 G>C were independently associated with otitis media. Sequencing of salivary RNA samples from indigenous Filipinos demonstrated lower A2ML1 expression according to the carriage of A2ML1 variants. Sequencing of additional salivary RNA samples from US patients with otitis media revealed differentially expressed genes that are highly correlated with A2ML1 expression levels. In particular, RND3 is upregulated in both A2ML1 variant carriers and high-A2ML1 expressors. These findings support a role for A2ML1 in keratinocyte differentiation within the middle ear as part of otitis media pathology and the potential application of ROCK inhibition in otitis media.

Preventative and medical treatment of ear disease in remote or resource-constrained environments

BACKGROUND

Important ear problems can affect the outer ear, the middle ear and the inner ear. Globally, the greatest burden of disease is due to ear conditions that are associated with otorrhoea and hearing loss.

METHODS

This study reviewed the literature on the prevention and treatment of common ear conditions that are most relevant to settings with high rates of ear disease and limited resources. The grading of recommendations assessment, development and evaluation ('GRADE') approach was utilised to assess interventions.

RESULTS

Accurate diagnosis of ear disease is challenging. Much of the preventable burden of ear disease is associated with otitis media. Nine otitis media interventions for which there is moderate to high certainty of effect were identified. While most interventions only provide modest benefit, the impact of treatment is more substantial in children with acute otitis media with perforation and chronic suppurative otitis media.

CONCLUSION

Disease prevention through good hygiene practices, breastfeeding, reducing smoke exposure, immunisation and limiting noise exposure is recommended. Children with acute otitis media with perforation, chronic suppurative otitis media, complications of otitis media, and significant hearing loss should be prioritised for medical treatment.

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

OBJECTIVES

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

DESIGN

Longitudinal cohort study.

SETTING

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Prevalence of upper respiratory tract infections in habitually snoring and mouth breathing children

OBJECTIVES

The aim of the study was to investigate the prevalence of upper respiratory tract infections (URI) - as indicated by rhinosinusitis (RS), ear infections (EI), and antibiotic consumption - in a general pediatric population and evaluate the relationship between these conditions and habitual snoring and mouth breathing during sleep.

METHODS

A population-based cross-sectional study was performed in three medium-sized Polish cities from 2011 to 2015.

RESULTS

4837/6963 questionnaires (69.5%) were completed, returned and analyzed. Mean age of studied group was 7.07 ± 0.72 and 7.14 ± 0.73 in girls and boys, respectively. Habitual mouth breathing during sleep (MB) was reported in 907 (18.7%) children and habitual snoring (HS) in 290 (6.0%). 230/290 (79.3%) of children with HS were also MB. Both HS and MB were more prevalent in boys than in girls (p = 0.027 and p < 0.0001, respectively) and neither was associated with BMI (p = 0.11 and p = 0.07, respectively). Habitual snoring and habitual mouth breathing were highly associated with more frequent bouts of rhinosinusitis, ear infections, and antibiotic use (p < 0.0001 for each parameter).

CONCLUSIONS

Higher rates of rhinosinusitis, ear infections, and antibiotic consumption were similarly associated with HS and MB. MB is over three times more prevalent in the pediatric population relative to HS, therefore it might be considered as a risk factor for URI and may be included in history of URI.

A microbiome case-control study of recurrent acute otitis media identified potentially protective bacterial genera

Background

Recurrent acute otitis media (rAOM, recurrent ear infection) is a common childhood disease caused by bacteria termed otopathogens, for which current treatments have limited effectiveness. Generic probiotic therapies have shown promise, but seem to lack specificity. We hypothesised that healthy children with no history of AOM carry protective commensal bacteria that could be translated into a specific probiotic therapy to break the cycle of re-infection. We characterised the nasopharyngeal microbiome of these children (controls) in comparison to children with rAOM (cases) to identify potentially protective bacteria. As some children with rAOM do not appear to carry any of the known otopathogens, we also hypothesised that characterisation of the middle ear microbiome could identify novel otopathogens, which may also guide the development of more effective therapies.

Results

Middle ear fluids, middle ear rinses and ear canal swabs from the cases and nasopharyngeal swabs from both groups underwent 16S rRNA gene sequencing. The nasopharyngeal microbiomes of cases and controls were distinct. We observed a significantly higher abundance of Corynebacterium and Dolosigranulum in the nasopharynx of controls. Alloiococcus, Staphylococcus and Turicella were abundant in the middle ear and ear canal of cases, but were uncommon in the nasopharynx of both groups. Gemella and Neisseria were characteristic of the case nasopharynx, but were not prevalent in the middle ear.

Conclusions

Corynebacterium and Dolosigranulum are characteristic of a healthy nasopharyngeal microbiome. Alloiococcus, Staphylococcus and Turicella are possible novel otopathogens, though their rarity in the nasopharynx and prevalence in the ear canal means that their role as normal aural flora cannot be ruled out. Gemella and Neisseria are unlikely to be novel otopathogens as they do not appear to colonise the middle ear in children with rAOM.

Electronic supplementary material

The online version of this article (10.1186/s12866-018-1154-3) contains supplementary material, which is available to authorized users.

The Effect of Breastfeeding on Childhood Otitis Media

PURPOSE OF REVIEW

The purpose of this review is to summarize the literature regarding the association between breastfeeding and childhood otitis media (OM), with focus on the literature published within the past 5 years. The review comprises original articles and recent reviews.

RECENT FINDINGS

The effect of a protective effect of breastfeeding on the risk of OM is still being discussed. Within the past 5 years, 6 reviews and 15 original articles have been published. No randomized controlled trials have been published, and the diversity of exposure and outcome measures in the studies was significant. Also, we provide a summary of the recent literature on cost-benefit of breastfeeding and believed mechanism of protection against OM. Breastfeeding for more than 6 months seems to protect against OM during the first 6 years of life. Exclusive breastfeeding may have a more protective effect than non-exclusive breastfeeding. Introduction of formula feeding before the age of 6 months increased the risk of OM.

Panel 1: Epidemiology and Diagnosis

Objective

To create a literature review between 2011 and June 1, 2015, on advances in otitis media (OM) epidemiology and diagnosis (including relevant audiology studies).

Data Sources

Electronic search engines (PubMed, EMBASE, and Cochrane Library) with a predefined search strategy.

Review Methods

Articles with appropriate epidemiologic methodology for OM, including acute mastoiditis and eustachian tube dysfunction. Items included OM worldwide and in high-risk populations, OM-related hearing loss, news in OM diagnostics, prenatal risk factors and comorbidities, postnatal risk factors, genetics, microbiological epidemiology, guidelines, and quality of life.

Conclusions

Diagnostic evidence and genetic studies are increasing; guidelines are introduced worldwide; and there is evidence of benefit of pneumococcal conjugate vaccines. New risk factors and comordities are identified in the study period, and quality of life is affected in children and their families.

Implications for Practice

Chronic suppurative OM occurs worldwide and contributes to lifelong hearing loss. Uniform definitions are still lacking and should be provided. An association between HIV and chronic suppurative OM has been found. Tympanometry is recommended for diagnosis, with or without pneumatic otoscopy. Video otoscopy, algorithms, and validated questionnaires may assist clinicians. Childhood obesity is associated with OM. Heritability accounts for 20% to 50% of OM diagnoses. OM-prone children seem to produce weaker immunologic responses to pneumococcal conjugate vaccines. Clinicians tend to individualize treatment without adhering to guidelines.

Protective effects of breastfeeding against acute respiratory tract infections and diarrhoea: Findings of a cohort study

AIM

The objective of this paper is to identify associations between breastfeeding and acute respiratory tract infections (ARTIs) and diarrhoea.

METHODS

A cohort of 458 mothers was recruited at the antenatal clinics at Indira Gandhi Memorial and Abdul Rahman Dhon Kaleyfaanu Hospitals. Mothers were interviewed 'face-to-face' at 36 weeks of gestation and at 1, 3 and 6 months after delivery. The questionnaires included demographic information about parents, infant feeding methods and breastfeeding duration. The number of episodes of ARTIs and diarrhoea was also recorded. Ethics approval was obtained from the National Research Committee of the Maldives and Curtin University Human Research Ethics Committee. Descriptive, univariate, logistic and survival analyses were used to assess the effects of breastfeeding on infant ARTIs and diarrhoea.

RESULTS

The partial, predominant and exclusive breastfeeding rates at 1 month were 98.9, 67.6 and 26.9%, respectively. The risk of acquiring ARTIs is significantly reduced when the infants were predominantly breastfed for 3 months (adjusted odds ratio (OR): 0.56, 95% of adjusted OR: 0.34-0.94) and 6 months (adjusted OR: 0.45, 95% of adjusted OR: 0.24-0.84). The risk of getting diarrhoea is significantly reduced even when the babies were partially breastfed for 6 months (adjusted OR): 0.31, 95% of adjusted OR: 0.11-0.90). Kaplan Meier curves demonstrated that the risk lowers with longer duration of breastfeeding.

CONCLUSION

Breastfeeding need to be promoted because the risk of infant morbidity is negatively associated with the duration of breastfeeding.

Determinants of chronic otitis media with effusion in preschool children: a case-control study

Background

Chronic otitis media with effusion (COME) is a prevalent upper airway infection resulting in hearing loss. The aim of this research was to determine risk factors for COME in preschool children.

Methods

A case–control design was conducted in Auckland, New Zealand from May 2011 until November 2013. The cases were children aged 3 and 4 years referred for tympanostomy tube placement due to a diagnosis of COME (n = 178). The controls were a random sample of healthy children aged 3 and 4 years from primary care practices (n = 209). The children’s guardians completed an interviewer-administered questionnaire that covered topics including socio-demographic information, pregnancy and birth, infant feeding practices, home environment, and respiratory health. In addition, skin prick tests for atopy were performed. Odds ratios (OR) estimating the risk of COME independently associated with the exposures were calculated using a logistic regression model.

Results

Children with COME frequently had nasal obstruction (OR: 4.38 [95% CI: 2.37–8.28]), always snored (OR: 3.64 [95% CI: 1.51–9.15]) or often snored (OR: 2.45 [95% CI: 1.04–5.96]), spent more hours per week in daycare (OR per hour/week: 1.03 [95% CI: 1.00–1.05]), had frequent colds (OR: 2.67 [95% CI: 1.59–4.53]), had siblings who had undergone tympanostomy tube placement (OR: 2.68 [95% CI: 1.22–6.02]), underwent long labour (OR: 2.59 [95% CI: 1.03–6.79]), and had early introduction of cow’s milk (OR: 1.76 [95% CI: 1.05–2.97]). Asian ethnicity (OR: 0.20 [95% CI: 0.07–0.53]) and having older siblings (OR: 0.54 [95% CI: 0.31–0.93]) were inversely associated with COME.

Conclusion

COME in preschool children was associated with pathogen exposure, respiratory infection, and nasal obstruction. Strategies to prevent pathogen transmission warrant investigation. The novel findings of long labour and early cow’s milk introduction require replication in future studies.

Risk Factors of Early Otitis Media in the Danish National Birth Cohort

OBJECTIVE

To assess risk factors of otitis media (OM) in six-months-old children.

METHOD

The sample consisted of 69,105 mothers and their children from the Danish National Birth Cohort. The women were interviewed twice during pregnancy and again 6 months after birth. The outcome "one or more" maternal reported episodes of OM at age six months. In total 37 factors were assessed, covering prenatal, maternal, perinatal and postnatal factors.

RESULTS

At age six months 5.3% (95% CI 5.1-5.5) of the children had experienced one or more episodes of OM. From the regression analysis, 11 variables were associated with a risk of OM. When a Bonferroni correction was introduced, gender, prematurity, parity, maternal age, maternal self-estimated health, taking penicillin during pregnancy, and terminating breastfeeding before age six months, was associated with a risk of early OM. The adjusted ORs of OM for boys versus girls was 1.30 (95% CI 1.18-1.44). The OR having one sibling versus no siblings was 3.0 (95% CI 2.64-3.41). If the woman had been taking penicillin during pregnancy, the OR was 1.35 (95% CI 1.15-1.58). Children born before 38th gestational week had an increased OR for early OM of 1.49 (95% CI 1.21-1.82). Children of young women had an increased OR of early OM compared to children of older women. Additionally, children of women who rated their own health low compared to those rating their health as high, had an increased OR of 1.38 (95% CI 1.10-1.74). Finally, children being breastfeed less than 6 months, had an increased OR of 1.42 (95% CI 1.28-1.58) compared to children being breastfeed beyond 6 months.

CONCLUSION

These findings indicate that prenatal factors are of less importance regarding early OM before the age of six months. Postnatal risk factors seem to pose the main risk of early OM.

Otitis media

Otitis media (OM) or middle ear inflammation is a spectrum of diseases, including acute otitis media (AOM), otitis media with effusion (OME; 'glue ear') and chronic suppurative otitis media (CSOM). OM is among the most common diseases in young children worldwide. Although OM may resolve spontaneously without complications, it can be associated with hearing loss and life-long sequelae. In developing countries, CSOM is a leading cause of hearing loss. OM can be of bacterial or viral origin; during 'colds', viruses can ascend through the Eustachian tube to the middle ear and pave the way for bacterial otopathogens that reside in the nasopharynx. Diagnosis depends on typical signs and symptoms, such as acute ear pain and bulging of the tympanic membrane (eardrum) for AOM and hearing loss for OME; diagnostic modalities include (pneumatic) otoscopy, tympanometry and audiometry. Symptomatic management of ear pain and fever is the mainstay of AOM treatment, reserving antibiotics for children with severe, persistent or recurrent infections. Management of OME largely consists of watchful waiting, with ventilation (tympanostomy) tubes primarily for children with chronic effusions and hearing loss, developmental delays or learning difficulties. The role of hearing aids to alleviate symptoms of hearing loss in the management of OME needs further study. Insertion of ventilation tubes and adenoidectomy are common operations for recurrent AOM to prevent recurrences, but their effectiveness is still debated. Despite reports of a decline in the incidence of OM over the past decade, attributed to the implementation of clinical guidelines that promote accurate diagnosis and judicious use of antibiotics and to pneumococcal conjugate vaccination, OM continues to be a leading cause for medical consultation, antibiotic prescription and surgery in high-income countries.

Diagnosis of hearing loss using automated audiometry in an asynchronous telehealth model: A pilot accuracy study

Introduction

Standard criteria exist for diagnosing different types of hearing loss, yet audiologists interpret audiograms manually. This pilot study examined the feasibility of standardised interpretations of audiometry in a telehealth model of care. The aim of this study was to examine diagnostic accuracy of automated audiometry in adults with hearing loss in an asynchronous telehealth model using pre-defined diagnostic protocols.

Materials and methods

We recruited 42 study participants from a public audiology and otolaryngology clinic in Perth, Western Australia. Manual audiometry was performed by an audiologist either before or after automated audiometry. Diagnostic protocols were applied asynchronously for normal hearing, disabling hearing loss, conductive hearing loss and unilateral hearing loss. Sensitivity and specificity analyses were conducted using a two-by-two matrix and Cohen’s kappa was used to measure agreement.

Results

The overall sensitivity for the diagnostic criteria was 0.88 (range: 0.86–1) and overall specificity was 0.93 (range: 0.86–0.97). Overall kappa ( k) agreement was ‘substantial’ k = 0.80 (95% confidence interval (CI) 0.70–0.89) and significant at p < 0.001.

Discussion

Pre-defined diagnostic protocols applied asynchronously to automated audiometry provide accurate identification of disabling, conductive and unilateral hearing loss. This method has the potential to improve synchronous and asynchronous tele-audiology service delivery.

Protective benefit of predominant breastfeeding against otitis media may be limited to early childhood: results from a prospective birth cohort study

OBJECTIVES

To examine the long-term effects of predominant breastfeeding on incidence of otitis media.

DESIGN

Prospective birth cohort study.

SETTING

The West Australian Pregnancy Cohort (Raine) Study recruited 2900 mothers through antenatal clinics at the major tertiary obstetric hospital in Perth, Western Australia, between 1989 and 1992.

PARTICIPANTS

In total, 2237 children participated in a 6-year cohort follow-up, and a subset of 1344 were given ear and hearing assessments.

MAIN OUTCOME MEASURES

OM diagnosis at 6 years of age (diagnosed by low-compliance tympanograms, 0-0.1 mmho). This was compared to OM diagnosed at the 3-year cohort follow-up using parent-report measures. Main exposure measures were duration of predominant breastfeeding (defined as the age other milk was introduced) and duration of partial (any) breastfeeding (defined as the age breastfeeding was stopped).

RESULTS

There was a significant, independent association between predominant breastfeeding (OR = 1.33 [1.04, 1.69]; P = 0.02) and OM, and breastfeeding duration (OR = 1.35 [1.08, 1.68]; P = 0.01) with OM at 3 years of age. However, at 6 years of age, this relationship was no longer statistically significant (predominant breastfeeding OR = 0.78 [0.48, 1.06]; P = 0.09; duration of breastfeeding, OR = 1.34 [0.81, 2.23]; P = 0.25).

CONCLUSIONS

Our findings are in line with a number of epidemiological studies which show a positive association between breastfeeding and OM in early childhood. However, the long-term follow-up of these children revealed that by 6 years of age, there was no significant influence of breastfeeding on presence of OM. These results suggest that the protective effect of predominant breastfeeding for at least 6 months does not extend to school-age children, where other social and environmental factors may be stronger predictors of OM.

Preschool-Adapted Liking Survey (PALS): A Brief and Valid Method To Assess Dietary Quality of Preschoolers

BACKGROUND

Feasible, valid, and reliable tools are needed to assess dietary quality among preschoolers. We aimed to test construct-/criterion-related validity and reliability of a dietary quality index generated from a liking survey and novel dietary patterns for characterizing food hedonism and parental feeding practices.

METHODS

Participants included 416 economically disadvantaged, diverse preschoolers (41% overweight/obese) from educational centers and their parents. Parents completed liking and frequency surveys; the liking survey took half as long to complete. Preschoolers' skin carotenoid status (measured by Resonance Raman spectroscopy) and BMI percentile (measured weight/height) were assessed. The Healthy Eating Preference Index (HEPI) was constructed from weighted averages of liking scores for food groups and healthy variety score and Healthy Eating Index 2010 (HEI) from nutrient analysis of the frequency survey.

RESULTS

The HEPI was normally distributed and showed construct validity and adequate internal reliability. In hierarchical regression analyses, the HEPI explained carotenoid status and adiposity as alternative or value-added predictors to HEI, supporting criterion-related validity of HEPI. Parental reporting of children's liking of high-fat/sweet/salty foods in excess of pleasurable activities (food hedonism) predicted heavier preschoolers, as did discord between HEI and HEPI (potential parental pressure toward healthy eating). HEPI alone or with HEI explained variability in carotenoid status and adiposity in path models with adequate to good fits.

CONCLUSIONS

With simple collection and processing, the liking survey can generate a valid/reliable dietary quality index in child care settings to identify preschoolers at risk for lower nutritional status. Using liking and frequency-based screeners could improve understanding of parental feeding behaviors and precision of predicting nutritional status.