A longitudinal study of otitis media with effusion among 2- to 5-year-old African-American children in child care

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

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

The incidence, prevalence and burden of OM in unselected children aged 1-8 years followed by weekly otoscopy through the "common cold" season

BACKGROUND

There is a continuing interest in defining the incidence, prevalence and burden of otitis media (OM) in the individual and population for purposes of assigning "risk factors". Often overlooked in past studies are the contributions of cold-like illnesses (CLIs) and sampling interval to those estimates.

OBJECTIVE

Describe the incidence of symptomatic (AOM) and asymptomatic (OME) OM, the prevalence of OM, the contribution of CLI incidence, burden and other OM "risk factors" to the incidence and burden of OM, and the effect of sampling interval on those measures in children.

METHODS

148 children (74 male; 131 white, aged 1.0-8.6 years) were followed from November 1 to April 30 by weekly pneumatic otoscopy to diagnose OM presence/absence and by daily parental diary to assign CLI episodes. Data for previously identified OM "risk factors" were collected on 127. Results were summarized using standard measures of incidence, prevalence and burden, and multiple regression techniques were used to identify OM "risk factors".

RESULTS

The basal OM prevalence was 20% with peaks in December and March and the temporal pattern was correlated with CLI prevalence. The incidence of OME (per 27,232 child-days) was 317, AOM was 74 and CLI was 456. The seasonal pattern of AOM and OME incidences tracked and was correlated with that for CLIs. New OM episodes were usually of short duration (<or=7 days in 40%, <or=4 weeks in 75-90%) and the usual OM burden was low (median=12%). OM and breastfeeding histories and CLI incidence/prevalence were significant predictors of OME and AOM incidence and OM burden. Longer sampling intervals were less efficient in capturing AOM and OME durations and incidences, but not OM burden.

CONCLUSIONS

These results demonstrate a high incidence and prevalence of OM, most OM episodes were of short duration and longer sampling intervals introduced biases into some parameter estimates. There was a significant relationship between OM and CLI incidence, prevalence and burden suggesting that CLI experience should be controlled for in assessing independent "risk factors" for AOM and OME.

Pacific Islands Families Study: risk factors associated with otitis media with effusion among Pacific 2-year-old children

OBJECTIVE

This study examined the risk factors associated with middle ear disease in a cohort of Pacific 2-year-old children residing in New Zealand.

METHODS

The data were gathered as part of the Pacific Island Families: first 2 years of life (PIF) study in which 656 2-year-old were screened using tympanometry to identify children at risk for otitis media with effusion (OME) and other otological disorders.

RESULTS

Within this 2-year-old cohort of Pacific children, one set of factors significantly associated with OME was clustered around the respiratory and auditory health of the child over the past year. OME was more likely for children who were regularly suffering from fluid/pus discharge from ears (OR=2.10, 95% CI: 1.01-4.35), children with five or more coughs/colds in the last year (OR=1.90, 95% CI: 1.22-3.00), and children who frequently/constantly snored (OR=2.60, 95% CI: 1.09-6.23) to have OME. Those children who were treated at home for breathing problems were more that two times more likely to have OME (OR=2.61, 95% CI: 1.55-4.42). A second set of factors was clustered around environmental risks that exposed children to a large number of other children. Children who attended a day care centre for more than 20h were five times more likely (OR=5.21, 95% CI: 2.90-9.35) and those who regularly attended church (OR=2.78, 95% CI: 1.05-7.40) were almost three times more likely to have OME.

CONCLUSIONS

These findings portray a child compromised by persistent ear infections and general coughs and colds as being at increased risk of contracting OME. In line with international research these findings raise questions about the negative child health effects associated with the day care environment for young children.

The relationship of otitis media in early childhood to attention dimensions during the early elementary school years

This study examined the impact of otitis media with effusion (OME) and associated hearing loss between 6 and 48 months of age on attention dimensions (i.e., selective/focus, sustained) during the elementary school years. A prospective cohort design in which 74 African American infants were recruited between ages 6 and 12 months. Ear examinations were done repeatedly using both otoscopy and tympanometry, and hearing was assessed using standard audiometric procedures between 6 and 48 months. Multiple measures of attention (i.e., direct assessment, behavioral observations, parent/teacher ratings) were administered from kindergarten through second grade to assess two theoretical dimensions of attention: selective/focused and sustained. The home environment was assessed annually. Results indicated that neither early childhood OME nor hearing loss showed significant correlations with any of the longitudinal or cross-sectional measures of selective/focused attention and sustained attention. In contrast, children with mothers who had fewer years of education and who lived in less responsive and supportive home environments scored higher on both parent and teacher ratings of sustained attention (i.e., hyperactivity) through the second grade of elementary school. For NEPSY Auditory Attention in second grade, a significant interaction between the Home Observation for Measurement of the Environment and hearing loss was uncovered. This interaction showed that children with hearing loss from poor home environments experienced greater difficulties on the NEPSY Auditory Attention task than those with hearing loss from good home environments. These findings do not support a direct linkage of a history of OME and associated hearing loss to difficulties in selective/focused attention or sustained attention in early elementary school children. Relationships between sociodemographic variables and attention-related functions appear stronger and should be considered as mediators in any examination of the linkages between early OME and subsequent attention functions.

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

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

Otitis media in early childhood in relation to children's school-age language and academic skills

OBJECTIVE

To examine whether otitis media with effusion (OME) and associated hearing loss during the first 4 years of life are related to the language development and academic achievement of children between 4 years of age and second grade.

METHODS

In a prospective cohort study, 83 black children, primarily from low-income families and recruited from community-based child care programs, were examined repeatedly between the ages of 6 months and 4 years for the presence of OME and hearing loss, both when well and when ill with OME. Children's child-rearing environments at home were assessed annually from infancy through second grade, whereas children's language and academic skills were assessed repeatedly between 4 years of age and second grade.

RESULTS

We did not find in our longitudinal analyses a relationship between OME and hearing loss during the first 4 years of life and later academic skills in early reading and recognition of words heard. We did find that children with greater incidence of OME and hearing loss during the first 4 years of life scored lower in verbal math problems between kindergarten and second grade, even after partialing out important background factors. Children with more OME tended to score lower in math at the younger ages but caught up once they entered school. Follow-up analyses indicated also that children with more OME during the first 2 years of life scored lower in expressive language during the preschool and early elementary school years but caught up by second grade. In contrast, children from homes that were rated as more stimulating and responsive scored higher on every measure of language and academic skills than did children from less responsive homes. The home environment was related more strongly to all of the outcomes examined than was OME or hearing loss.

CONCLUSIONS

There was no evidence of a significant relationship between a history of OME or hearing loss and children's later academic skills in reading or word recognition during the early elementary school years. Children with greater incidence of OME and hearing loss scored lower in math and expressive language at the younger ages but caught up in math with their peers on entering school and in expressive language by second grade. Furthermore, a child's home environment was more related to early math and expressive language skills than was OME or hearing loss, and the home environment continued to be predictive of all of the language and academic outcomes through second grade. These study results should be interpreted cautiously when generalizing to other populations.

A longitudinal study of risk factors for otitis media in African American children

OBJECTIVE

Otitis media with effusion (OME) is a common health care problem for children. The purpose of this study was to examine factors that place children at risk for OME such as age, type of child care, number of people in the household, and smoking in the household.

METHODS

Eighty-six African American children, enrolled in center-based child care in infancy, entered the study at a mean age of 8.2 months and were followed prospectively until 48 months of age. Ear status was documented biweekly using pneumatic otoscopy and tympanometry. Data on risk factors were collected every 6 months.

RESULTS

Results indicated that children had a marked decrease in the proportion of time with OME between 6 and 48 months. The rate of OME decline was faster in the first 2.5 years than in subsequent years. Children in center-based child care showed a slightly slower rate of decline than did children in non-center-based care. Longitudinal analysis indicated that the age of the child and the number of other children in the household were significant predictors of OME. For each additional child under 12 years of age in the home, there was a 2% increase in the proportion of time with OME.

CONCLUSION

While attendance in group child care predicted a risk for OME, children's age and the number of other children in the household were still contributing risk factors for OME.

Lemon-flavored cod liver oil and a multivitamin-mineral supplement for the secondary prevention of otitis media in young children: pilot research

We measured blood levels of fatty acids, vitamin A, and trace metals in children undergoing ambulatory surgery for placement of tympanostomy tubes and a comparison group having other ambulatory surgical procedures. We then performed a small, outpatient, secondary prevention study using nutritional supplements chosen on the basis of those blood levels. The study subjects had lower levels of red blood cell eicosapentaenoic acid (EPA) than did adult controls. Consistent with previous reports, the levels of vitamin A were < or = 40 microg/dL for 69% of our subjects, and the plasma selenium levels for children were lower than published values for adults. We then studied one otitis media (OM) season; 8 children (0.8 to 4.4 years of age) received 1 teaspoon of lemon-flavored cod liver oil (containing both EPA and vitamin A) and 1 half-tablet of a selenium-containing children's chewable multivitamin-mineral tablet per day. During this OM season, study subjects received antibiotics for OM for 12.3% +/- 13.4% (SD; p < .05) fewer days during supplementation than before supplementation. Larger, controlled trials are warranted to assess the utility of cod liver oil (of acceptable purity and taste) and a children's multivitamin-mineral preparation containing selenium, both for the prevention of OM and for the acceptance of delayed prescription of antibiotics for this disorder.

Early childhood otitis media in relation to children's attention-related behavior in the first six years of life

OBJECTIVE

This study examined whether otitis media with effusion (OME) and associated hearing loss during the first 4 years of life were related to the ratings of parents, teachers, and clinicians of children's attention and behavior in the first 6 years of life.

METHODS

In a prospective study, 85 black children were recruited from community-based child care programs when they were between 6 and 12 months old. OME and hearing status were monitored repeatedly from 6 months to 4 years old. Measures of attention and behavior were collected from parents, teachers, and clinicians when the children were infants, preschoolers, and first graders.

RESULTS

On average, children experienced either bilateral or unilateral OME 30% of the time and hearing loss 19.9% of the time between 6 months and 4 years old. Descriptive and inferential analyses revealed no significant associations between OME or hearing loss and the measures of attention or behavior completed by parents, teachers, and clinicians.

CONCLUSIONS

In this sample of children, there was no relationship between amount of early childhood OME or hearing loss and measures of attention or behavior in the first 6 years of life as reported by parents, teachers, and clinicians.otitis media, hearing, attention, behavior.

Otitis media in childhood in relation to preschool language and school readiness skills among black children

OBJECTIVE

To examine whether otitis media with effusion (OME) and associated hearing loss (HL) during the first 5 years of life were related to children's language skills during the preschool years and to school readiness skills at entry to kindergarten.

METHODS

In a prospective study, the ears of 85 black children primarily from low-income families and recruited from community-based childcare programs were repeatedly examined from 6 months to 5 years of age for the presence of OME and from 6 months to 4 years of age for HL when well and ill with OME. Assessments were made annually of the children's child-rearing environments at home and in childcare, and children's language skills between 3 and 5 years of age and readiness skills in literacy and math were evaluated at entry into kindergarten.

RESULTS

Children had either bilateral or unilateral OME approximately 30.4% and HL 19.6% of the observation time. OME and associated HL were significantly positively correlated with some measures of expressive language at 3 and 4 years of age; however, these direct relationships were no longer significant when the child's gender, socioeconomic status, maternal educational level, and the responsiveness and support of the home and childcare environments were also considered. Further, both OME and HL were moderately correlated with school readiness skills at entry to school, with children having more OME scoring lower in verbal math problems and with children with more HL scoring lower in math and recognizing incomplete words. These associations continued to remain significant even after partialing out the child and family background factors.

CONCLUSIONS

There was not a significant relationship between children's early OME history or HL and language skills during the preschool years. However, children with more frequent OME had lower scores on school readiness measures. These associations were moderate in degree, however, and the home environment was more strongly related to academic outcomes than was OME or HL. These results should be interpreted cautiously when generalizing to other populations.

Effects of otitis media with effusion on hearing in the first 3 years of life

Hearing sensitivity was examined prospectively in young children as a function of otitis media with effusion (OME) status in Years 1, 2, and 3. Hearing and OME status were sampled bimonthly from 5 to 36 months of age. Behavioral thresholds were obtained at 4 test frequencies (500, 1000, 2000, and 4000 Hz) using visual reinforcement audiometry and conditioned play audiometry techniques. The majority of children's audiograms were obtained using a computer-controlled test procedure. Thresholds for the test frequencies were averaged for each visit and then averaged across all visits in each year. Reference values were developed for infants and children in Years 1, 2, and 3 who were OME free. Results reveal that children who were classified as bilaterally OME positive in Years 1, 2, and 3 had significantly poorer hearing than children classified as bilaterally OME free in each of these time periods. There was no difference in hearing as a function of gender, socioeconomic status, or birth-risk status.