Epidemiology of otitis media onset by six months of age

Exploring the OTITIS Research Landscape Through a Scientometric Approach

Otitis media is a common health problem affecting people of all ages and significantly impacting public health and healthcare costs. Otitis media, a type of middle ear disease, is one of the most common types. This scientometric study aimed to provide an overview of the knowledge domain in otitis media research. Documents were retrieved from the Web of Science database. A scientometric study was then performed on a sample of 27,213 documents. This study found that research on otitis media has increased significantly in recent years, with an annual growth rate of 4.58%. The average age of the documents analyzed was 18 years, with an average of 21.88 citations and an average of 4.58 authors. The United States, the United Kingdom, and Japan ranked first to third in terms of number of publications. Still, the United States, China, and Sweden were in a better position in terms of impact on the research network. Co-occurrence word analysis showed that significant attention was given to topics such as chronic inflammation in autism, acute inflammation in otitis media, and increased fluid in the middle ear. This study highlights the need to prioritize and focus attention on otitis, particularly otitis media, due to its prevalence and impact on public health. The use of scientometric software, such as Biblioshiny and CiteSpace, provides a valuable means of assessing research trends and identifying important areas for future study in the field of knowledge.

Xylitol nasal spray for prevention of recurrent acute otitis media in children: A prospective two-center cohort study

OBJECTIVES

The purpose of this study was to assess the effectiveness and safety of xylitol nasal spray as a prophylactic treatment for children with recurrent acute otitis media (AOM).

METHODS

This is a prospective pilot study of children aged 1-4 years, diagnosed with recurrent AOM (at least three episodes in the three months before recruitment) between December 1, 2019 and January 31, 2023. Children were treated with nasal xylitol spray 2-3 times daily for 3 months. The number of AOM episodes and treatments administered were compared within 3-month intervals: before recruitment, during xylitol use, and during the three subsequent months.

RESULTS

Of 68 children enrolled, 66 (97%) completed the follow-up, until July 2023. Thirty-eight (58%) were males. Sixty-three children (95%) were 12-24-months old. The mean number of AOM episodes during xylitol use, 1.06 (95% confidence interval [CI]: 0.73-1.39), was lower than in the 3-month previous interval, 4.12 (95% CI: 3.89-4.40), p < 0.001; and similar to that in the subsequent 3-month interval, 0.79 (95% CI: 0.49-1.08), p = 0.082. A similar pattern was observed in an analysis of the number of AOM episodes per patient month. The data were similar during spring and summer months as during autumn and winter months. Across the consecutive three-month intervals, decreases were observed in the mean number of AOM episodes treated with systemic antibiotics (3.35, 0.65, and 0.41), p < 0.001; and with topical antibiotics (1.38, 0.55, and 0.32), p < 0.001. No major side effects were recorded.

CONCLUSIONS

The findings support the effectiveness and safety of nasal xylitol spray, for preventing recurrent AOM in children aged 1-4 years.

Health effects associated with exposure to secondhand smoke: a Burden of Proof study

Despite a gradual decline in smoking rates over time, exposure to secondhand smoke (SHS) continues to cause harm to nonsmokers, who are disproportionately children and women living in low- and middle-income countries. We comprehensively reviewed the literature published by July 2022 concerning the adverse impacts of SHS exposure on nine health outcomes. Following, we quantified each exposure-response association accounting for various sources of uncertainty and evaluated the strength of the evidence supporting our analyses using the Burden of Proof Risk Function methodology. We found all nine health outcomes to be associated with SHS exposure. We conservatively estimated that SHS increases the risk of ischemic heart disease, stroke, type 2 diabetes and lung cancer by at least around 8%, 5%, 1% and 1%, respectively, with the evidence supporting these harmful associations rated as weak (two stars). The evidence supporting the harmful associations between SHS and otitis media, asthma, lower respiratory infections, breast cancer and chronic obstructive pulmonary disease was weaker (one star). Despite the weak underlying evidence for these associations, our results reinforce the harmful effects of SHS on health and the need to prioritize advancing efforts to reduce active and passive smoking through a combination of public health policies and education initiatives.

Effects of pre-natal and post-natal exposures to air pollution on onset and recurrence of childhood otitis media

BACKGROUND

Despite mounting evidence linking outdoor air pollution with otitis media (OM), the role of air pollutant(s) exposure during which critical window(s) on childhood OM remains unknown.

OBJECTIVES

We sought to identify the key air pollutant(s) and critical window(s) associated with the onset and recurrent attacks of OM in kindergarten children.

METHODS

A combined cross-sectional and retrospective cohort study involving 8689 preschoolers aged 3-6 years was performed in Changsha, China. From 2013-2020, data on air pollutants were collected from ambient air quality monitoring stations in Changsha, and the exposure concentration to each child at their home address was calculated using the inverse distance weighted (IDW) method. The relationship between air pollution and OM in kindergarten children was studied using multiple logistic regression models.

RESULTS

Childhood lifetime OM was associated with PM2.5, SO2 and NO2, with ORs (95% CI) of 1.43 (1.19-1.71), 1.18 (1.01-1.37) and 1.18 (1.00-1.39) by per IQR increase in utero exposure and with PM2.5, PM2.5-10 and PM10, with ORs = 1.15 (1.00-1.32), 1.25 (1.13-1.40) and 1.49 (1.28-1.74) for entire post-natal exposure, respectively. The 2nd trimester in utero and the post-natal period, especially the 1st year, were key exposure time windows to PM2.5 and PM10 associated with lifetime OM and the onset of OM. Similarly, the 4th gestational month was a critical window for all pollutants except CO exposure in relation to lifetime OM and OM onset, but not recurrent OM attacks. PM2.5 exposure during the nine gestational months and PM10 exposure during the first three years had cumulative effects on OM development. Our subgroup analysis revealed that certain children were more susceptible to the OM risk posed by air pollution.

CONCLUSIONS

Early-life exposure to air pollution, particularly PM2.5 during the middle of gestation and PM10 during the early post-natal period, was associated with childhood OM.

Social distancing cut down the prevalence of acute otitis media in children

Objectives

To evaluate the additional, unintended benefits of social distancing in cutting down the prevalence of acute otitis media (AOM) in children, especially during coronavirus disease 2019 (COVID-19) periods.

Methods

The daily outpatient attendance of AOM for childhood (from 6 months to 12 years) was compared in the tertiary hospital in Shanghai during pre-COVID-19 and COVID-19 year.

Results

A total of 24,543 AOM cases were included from 2015 to 2020. When age was taken into account, children in kindergarten (aged 4-6) constitute 66.2% (16,236/24,543) of all case, followed by primary school students (6,441/24,543, 26.2%) and preschoolers <3 years old (1,866/24,543, 7.6%). There was an estimated 63.6% (54.32-70.36%) reduction in the daily outpatient attendance of AOM associated with the introduction of social distancing in 2020 (COVID-19 year). The epidemic trend of AOM in 2015-2019 was characterized by seasonal fluctuations, with highest incidence in December (18.8 ± 0.5%) and lower in February (4.5 ± 0.2%), June (3.7 ± 0.7%) and August (3.5 ± 0.5%). And distribution characteristics of different ages in COVID-19 period broadly in line with that in non-pandemic period.

Conclusion

Seasonal fluctuation in the prevalence of AOM was observed in pre-COVID-19 period (2015-2019), with a peak in winter and a nadir in summer. The >50% drop of outpatient attendance of AOM in 2020 (COVID-19 year) suggest that social distancing, mask effects and good hand hygiene can significantly reduce the incidence of AOM, which provides a preventive and therapeutic point of view for AOM.

gom1 Mutant Mice as a Model of Otitis Media

Otitis media (OM) disease is a common cause of hearing loss that is primarily the result of middle ear infection. At present, our understanding of the mechanisms leading to OM is limited due to the lack of animal models of OM with effusion (OME). Here, we report that the mice with genetic otitis media one (gom1) mutants are prone to OM. gom1 Mice were produced by the N-ethyl-N-nitrosourea (ENU) mutagenesis program as an animal model to study OM. These mice demonstrate many common features of OM, such as middle ear effusion and hearing impairment. We revealed that gom1 mice display various signs of middle ear and inner ear dysfunctions, including elevated thresholds of auditory-evoked brainstem response (ABR) and lack of cochlear microphonic responses. Decreased compliance in tympanometry measurements indicates tympanic membrane and ossicular chain malfunction. We confirmed through histological examinations of middle ear structures that 34/34 (100 %) of the mutant mice suffered from severe OME. While individual ears had different levels of effusion and inflammatory cells in the middle ear cavity, all had thickened middle ear mucosa and submucosa compared to control mice (B6). Moreover, the mutant mice displayed cochlear hair cell loss. These observations also suggested the craniofacial abnormalities in the gom1 mouse model. Together, these results indicate that gom1 mice could be valuable for investigating the genetic contribution to the development of middle ear disease.

The broader impacts of otitis media and sequelae for informing economic evaluations of pneumococcal conjugate vaccines

INTRODUCTION

Otitis media (OM) is a common childhood infection. Pneumococcal conjugate vaccines (PCVs) prevent OM episodes, thereby reducing short- and long-term clinical, economic, humanistic, and societal consequences. Most economic evaluations of PCVs focus on direct health gains and cost savings from prevented acute episodes but do not fully account for the broader societal impacts of OM prevention.

AREAS COVERED

This review explores the broader burden of OM on children, caregivers, and society to better inform future economic evaluations of PCVs.

EXPERT OPINION

OM causes a substantial burden to society through long-term sequelae, productivity losses, reduced quality of life for children and caregivers, and contribution to antimicrobial resistance from inappropriate antibiotic use. The effect of PCVs on acute OM has been recognized globally, yet the broader impact has not been consistently quantified, studied, or communicated. Economic evaluations of PCVs must evolve to include broader effects for patients, caregivers, and society from OM prevention. Future PCVs with broader coverage may further reduce OM incidence and antimicrobial resistance, but optimal uptake will depend on increasing the recognition and use of novel frameworks that include broader benefits. Communicating the full value of PCVs to decision makers may result in wider access and positive societal returns.

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.

Respiratory Symptoms in Post-infancy Children. A Dutch Pediatric Cohort Study

Aim: To study the pattern of respiratory symptoms in children in the general population. Method: We followed a cohort of children for up to 2 years through parents completing weekly online questionnaires in the Child-Is-Ill study ("Kind-en-Ziekmeting" in Dutch); the study was running 2012-2015. Inclusion criteria were "an ordinary child" (according to the parents) and <18 years old at inclusion. We especially encouraged participation of post-infancy children. Age at inclusion, sex, smoking exposure, allergy in the family, and frequent infections in the family were noted. Pearson's correlation, principal component analysis, latent class analysis, latent profile analysis, linear regression, and linear mixed effects regression were used in the statistical analyses. Results: Data were collected on 55,524 childweeks in 755 children (50% girls; median age, 7 years; interquartile range, 4-11 years, 97% ≥2 years at inclusion), with reported symptom(s) in 8,425 childweeks (15%), leading to school absenteeism in 25%, doctor's visits in 12%, and parental sick leave in 8%; symptoms lasting ≥3 weeks were rare (2% of episodes). Linear mixed effects regression showed significant, but only limited, effects of season on the proportion of "symptom(s) reported" per individual child. Only runny nose showed a significant, but very small, age effect. However, the variability between the children was considerable. There were no obvious subgroups of children with specific symptom combinations. Conclusion: In any randomly chosen week, the vast majority of children (85%) in our-mainly-post-infancy cohort derived from the general population did not have any symptom, even in the younger age group, even in winter. The children showed considerable variability; no clear subgroups of symptom patterns could be identified, underlining the difficult position of healthcare providers. These results support our opinion that post-infancy children in the general population should not be evaluated as if they are infants when they have recurrent respiratory symptoms. If they clearly deviate from the above-described most common pattern, it is wise to keep an eye on potential, maybe even rare, serious underlying causes.

Reprioritization of biofilm metabolism is associated with nutrient adaptation and long-term survival of Haemophilus influenzae

Nontypeable Haemophilus influenzae (NTHI) is a human-restricted pathogen with an essential requirement for heme-iron acquisition. We previously demonstrated that microevolution of NTHI promotes stationary phase survival in response to transient heme-iron restriction. In this study, we examine the metabolic contributions to biofilm formation using this evolved NTHI strain, RM33. Quantitative analyses identified 29 proteins, 55 transcripts, and 31 metabolites that significantly changed within in vitro biofilms formed by RM33. The synthesis of all enzymes within the tryptophan and glycogen pathways was significantly increased in biofilms formed by RM33 compared with the parental strain. In addition, increases were observed in metabolite transport, adhesin production, and DNA metabolism. Furthermore, we observed pyruvate as a pivotal point in the metabolic pathways associated with changes in cAMP phosphodiesterase activity during biofilm formation. Taken together, changes in central metabolism combined with increased stores of nutrients may serve to counterbalance nutrient sequestration.

Prevalence of middle ear disease in Chilean natives and the impact of development over 14 years

Introduction

The prevalence of middle ear disease and its risk factors have been the subject of multiple studies. High prevalence of middle ear disease has been described among North American natives, especially chronic otitis media. Such studies have not been carried out in South America.

Objective

To describe the prevalence of middle ear pathology and risk factors in native schoolchildren from southern Chile who belong to the Mapuche ethnic group, as well as the impact of socio-economic and demographic changes after 14 years of development.

Material and methods

Two otologic evaluations with an interval of 14 years were performed in schoolchildren with a percentage of indigenous population above 85%. Socioeconomic and demographic data were collected from national official statistical data.

Results

A total of 1067 schoolchildren were examined. Many described risk factors for ear pathology were found. An overall prevalence of 0.19% for tympanic membrane perforation, 5.6% for pars tensa retraction pockets, 1.5% for pars flaccida retraction pockets and 11.1% of otitis media with effusion was found. There were several socioeconomic improvements after 14 years. The difference between the prevalence of symptoms and the presence of otitis media with effusion was statistically significant (p < 0.001).

Conclusions

Despite the presence of several risk factors for middle ear disease, this study population showed a low prevalence of middle ear disease. The ethnic-racial factor seems to be a protective factor.

Association of Nutritional Factors with Hearing Loss

Hearing loss (HL) is a major public health problem. Nutritional factors can affect a variety of diseases, such as HL, in humans. Thus far, several studies have evaluated the association between nutrition and hearing. These studies found that the incidence of HL was increased with the lack of single micro-nutrients such as vitamins A, B, C, D and E, and zinc, magnesium, selenium, iron and iodine. Higher carbohydrate, fat, and cholesterol intake, or lower protein intake, by individuals corresponded to poorer hearing status. However, higher consumption of polyunsaturated fatty acids corresponded to better hearing status of studied subjects. In addition to malnutrition, obesity was reported as a risk factor for HL. In studies of the relationship between middle ear infection and nutrition in children, it was reported that lack of vitamins A, C and E, and zinc and iron, resulted in poorer healing status due to vulnerability to infection. These studies indicate that various nutritional factors can affect hearing. Therefore, considering that multifactorial nutritional causes are responsible, in part, for HL, provision of proper guidelines for maintaining a proper nutritional status is expected to prevent some of the causes and burden of HL.

Microevolution in response to transient heme-iron restriction enhances intracellular bacterial community development and persistence

Bacterial pathogens must sense, respond and adapt to a myriad of dynamic microenvironmental stressors to survive. Adaptation is key for colonization and long-term ability to endure fluctuations in nutrient availability and inflammatory processes. We hypothesize that strains adapted to survive nutrient deprivation are more adept for colonization and establishment of chronic infection. In this study, we detected microevolution in response to transient nutrient limitation through mutation of icc. The mutation results in decreased 3',5'-cyclic adenosine monophosphate phosphodiesterase activity in nontypeable Haemophilus influenzae (NTHI). In a preclinical model of NTHI-induced otitis media (OM), we observed a significant decrease in the recovery of effusion from ears infected with the icc mutant strain. Clinically, resolution of OM coincides with the clearance of middle ear fluid. In contrast to this clinical paradigm, we observed that the icc mutant strain formed significantly more intracellular bacterial communities (IBCs) than the parental strain early during experimental OM. Although the number of IBCs formed by the parental strain was low at early stages of OM, we observed a significant increase at later stages that coincided with absence of recoverable effusion, suggesting the presence of a mucosal reservoir following resolution of clinical disease. These data provide the first insight into NTHI microevolution during nutritional limitation and provide the first demonstration of IBCs in a preclinical model of chronic OM.

Nontypeable Haemophilus influenzae (NTHI) inhabits diverse niches in the host. The ability to adapt to new microenvironments is consistent with the predominance of NTHI as a causative agent of otitis media (OM) in children. We evaluated the microevolution of NTHI associated with adaptation and persistence in response to nutrient limitation. We identified a naturally occurring mutation that enhances NTHI persistence and formation of intracellular bacterial communities (IBCs) in a pre-clinical model of OM. The presence of IBCs during OM provides the first opportunity to evaluate the role of intracellular populations in chronicity and quiescence as a new paradigm for recurrent OM. This model provides a new platform to identify novel therapeutics for this highly prevalent and costly infectious disease.

Air pollution influences the incidence of otitis media in children: A national population-based study

Background

Otitis media (OM) is a major reason for children’s visits to physicians and a major cause of their being treated with antibiotics. It not only causes economic burdens but also influences hearing, speech, and education. To our knowledge, no nationwide population-based study has assessed the association between air pollution and OM. Therefore, this study evaluated the association between air pollution levels and the incidence of OM.

Methods

We identified cases of OM that occurred in South Korea between January 2011 and December 2012 from the Korea National Health Insurance Service-National Sample Cohort database, and evaluated its relationship with five air pollutants: particulate matter (PM₁₀, particulates ≤10 μm in diameter), nitrogen dioxide (NO₂), ozone (O₃), sulfur dioxide, and carbon monoxide. Associations between the weekly incidence of OM and the five air pollutants were analyzed using generalized estimating equations. Conditional logistic regression analysis was used to obtain odds ratios (ORs) and their 99.9% Bonferroni-corrected confidence intervals after adjusting for gender, age, season, and region.

Results

We based our analysis on 160,875 hospital visits for OM by children aged <15 years. Correlations with higher concentrations of the five pollutants showed higher ORs than did the reference values at most time lags. PM₁₀ had the largest influence on the OM incidence at a time lag of 0 weeks, whereas NO₂ and O₃ had the largest impacts on OM incidence at time lags of 1 and 4 weeks, respectively.

Conclusion

These findings support the notion that the incidence of OM is associated with ambient air pollution.

Risk of childhood otitis media with focus on potentially modifiable factors: A Danish follow-up cohort study

INTRODUCTION

Otitis media is the primary cause of antibiotic prescription in children. Two-thirds of all children experience at least one episode of otitis media before the age of 7 years. The aim of this study was to characterise the attributable effect of several modifiable risk exposures on the risk of >3 episodes of otitis media at age 18 months and 7 years within a large prospective national birth cohort.

METHODS

The study used the Danish National Birth Cohort comprising information about otitis media and risk exposures from more than 50,000 mother-child pairs from the period 1996-2002. Logistic regression models were used to estimate odds ratios for the risk factors and to calculate the population attributable fraction.

RESULTS

Short time with breastfeeding, early introduction to daycare, cesarean section, and low compliance to the national vaccination program were all associated with an increased risk of >3 episodes of otitis media at 18 months of age and at 7 years of age. The fraction of children with otitis media attributed from breastfeeding lasting for less than 6 months was 10%. Introduction to daycare before the age of 12 months attributed with 20% of the cases of >3 episodes of otitis media.

CONCLUSIONS

Short duration of breastfeeding, early introduction into daycare, cesarean section, and low compliance with the national vaccination program increased the risk of experiencing >3 episodes of otitis media at 18 months, and at 7 years of age. These are factors that all can be modulated.

Does Acute Otitis Media in the First Month of Life Increase the Risk for Recurrent Otitis?

Acute otitis media (AOM) is a common childhood illness. The aim of this study was to assess whether AOM in the first month of life predicts recurrent AOM (rAOM) in early childhood. The medical records of all neonates with AOM and isolation of bacterial pathogen from middle-ear fluid during 2005-2010 were reviewed. Neonates without AOM admitted during the same period for neonatal fever workup were included as controls. Information regarding rAOM and possible risk factors were collected through a phone interview with the parents. A total of 84 neonates with AOM were enrolled; 25 (30%) had rAOM compared with 8/79 (10%) in the control group. Neonatal AOM increases 4-fold the odds of rAOM later in childhood (odds ratio = 4; 95% CI = 1.44-11.42; P = .008), independent of smoke exposure, numbers of siblings, AOM in siblings, breastfeeding, day care attendance, or use of pacifier. Neonatal AOM is a significant risk factor for rAOM during infancy.

Recurrent Acute Otitis Media: What Are the Options for Treatment and Prevention?

Purpose of Review

To survey current strategies for treatment and prevention of recurrent acute otitis media (rAOM).

Recent Findings

Treatment with systemic antibiotics is required in recurrent episodes of acute otitis media. A cautious attitude is recommended due to antibiotic resistance. Antibiotics also provide effective prophylaxis for rAOM. Topical treatment with ear drops is recommended in rAOM with otorrhea from tympanostomy tubes. Pneumococcal conjugated vaccines seem to have a moderate reductive effect on overall otitis media. The effect on rAOM is still unclear. Different administrations of immunoglobulins have not been effective against rAOM. Breastfeeding had a protective effect against rAOM. A recommendation against cigarette smoke exposure as a measure to prevent otitis seems warranted. An effect for adenoidectomy in children <2 years old with rAOM has been suggested. There is a strong genetic connection with rAOM. Probiotics and nasal spray with Streptococci might offer future opportunities as prophylaxis. Too little is known about complimentary treatments to give any recommendations.

Summary

Systemic antibiotics are still needed as treatment against episodes of AOM in rAOM children. There are several preventive measures that can be taken to reduce the burden of AOM but they all have a small-moderate effect. Systemic antibiotics provide effective prophylaxis in rAOM, but must be used with extreme caution due to the emerging antibiotic resistance.

Early disease progression of Hurler syndrome

Background

Newborn screening for mucopolysaccharidosis type I (MPS I) shows promise to improve outcomes by facilitating early diagnosis and treatment. However, diagnostic tests for MPS I are of limited value in predicting whether a child will develop severe central nervous system disease associated with Hurler syndrome, or minimal or no central nervous system involvement associated with the attenuated phenotypes (Hurler–Scheie and Scheie syndromes). Given that the optimal treatment differs between Hurler syndrome and the attenuated MPS I phenotypes, the absence of a reliable prognostic biomarker complicates clinical decision making for infants diagnosed through newborn screening. Information about the natural history of Hurler syndrome may aid in the management of affected infants, contribute to treatment decisions, and facilitate evaluation of treatment effectiveness and prognosis. Thus, the aim of this study was to characterize the progression and timing of symptom onset in infants with Hurler syndrome.

Results

Clinical data from 55 patients evaluated at a single center were retrospectively reviewed. Information about each child’s medical history was obtained following a standardized protocol including a thorough parent interview and the review of previous medical records. All patients underwent systematic physical and neurodevelopmental evaluations by a multidisciplinary team. Nearly all patients (98%) showed signs of disease during the first 6 months of life. Common early disease manifestations included failed newborn hearing screen, respiratory symptoms, difficulty latching, and otitis media. Other symptoms such as kyphosis, corneal clouding, cardiac disease, joint restrictions, and enlarged head circumference typically appeared slightly later (median age, 8–10 months). During the first 12 months, gross motor development was the most severely affected area of functioning, and a significant number of patients also experienced language delays. Cognition was typically preserved during this period.

Conclusions

In this large cohort of patients with Hurler syndrome, the vast majority showed signs and symptoms of disease during the first months of life. More research is needed to determine the extent to which early clinical manifestations of MPS I can predict phenotype and treatment outcomes.

Controversies in the Medical Management of Persistent and Recurrent Acute Otitis Media Recommendations of a Clinical Advisory Committee

Streptococcus pneumoniae is the predominant bacterial pathogen associated with acute otitis media (AOM), causing an estimated 7 million cases annually in the United States. Bacterial resistance should be considered when selecting an antimicrobial agent for otitis media. Significant increases in drug-resistant S pneumoniae are documented worldwide, and less than 50% of S pneumoniae strains are fully susceptible to penicillin in some regions of the United States. Although amoxicillin is recommended for uncomplicated AOM, treatment guidelines should be flexible and adaptable, taking into consideration local and regional susceptibility patterns, the age of the patient, the frequency of prior infections, and the response to prior therapy. Resistant organisms are more prevalent in children younger than 2 years of age and in those who have recurrent or persistent AOM. Overdiagnosing AOM, selecting inappropriate empiric therapy, or both, leads to overuse and misuse of antibiotics and causes increased drug resistance. This article reviews persistent and recurrent AOM and discusses the pitfalls of diagnosis and the practical limitations of current treatment recommendations.

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.

Impact of Early-Onset Acute Otitis Media on Multiple Recurrences and Associated Health Care Use

OBJECTIVE

To quantify the critical age period of first episode of acute otitis media (AOM) and its consequences for AOM recurrences and AOM health care use.

STUDY DESIGN

Children enrolled in the Wheezing-Illnesses-STudy-LEidsche-Rijn cohort with at least 1 episode of AOM documented in their primary care health record before 2 years of age were followed until 6 years of age. Data on episodes of AOM and associated primary care consultations, antibiotic prescriptions, and specialist referrals were retrieved. Regression models assessed the presence and shape of the associations between age of first AOM and subsequent episodes of AOM and health care use.

RESULTS

A total of 796 of 2026 children (39%) experienced a first AOM before 2 years of age. Each month decrease in age at first AOM in the first 2 years of life increased the risk of developing recurrent AOM (≥3 AOM episodes in 6 months or ≥ 4 in 1 year) linearly by 6% (adjusted risk ratio: 1.06; 95% CI: 1.02-1.10). For first AOM occurring before 9 months, the cumulative 6-year primary care consultation rate increased by 8% (adjusted incidence rate ratio: 1.08; 95% CI: 1.03-1.15) and the associated specialist referral increased by 16% (adjusted risk ratio: 1.16; 95% CI: 1.07-1.27) for each month decrease in age. No associations were found between age at first AOM and total AOM episodes or antibiotic prescriptions.

CONCLUSIONS

The association between earlier age of first AOM and recurrent AOM as well as total health care use during childhood is particularly strong before 9 months of age.

Prevention of early episodes of otitis media by pneumococcal vaccines might reduce progression to complex disease

Otitis media is a common childhood infection of the middle ear and a major cause of morbidity. This multifactorial disease manifests as a spectrum of clinical syndromes from uncomplicated acute otitis media to more complex recurrent and chronic cases (frequently polymicrobial), with the major pathogens involved being Streptococcus pneumoniae and non-typeable Haemophilus influenzae. Pneumococcal conjugate vaccines (PCVs) target only a few serotypes that cause otitis media; however, results from studies suggest that existing PCVs can prevent early episodes of disease associated with vaccine serotypes, resulting in a reduction of subsequent complex cases caused by non-vaccine serotypes and other otopathogens, which contribute considerably to the disease burden. In this Review, we discuss the role of pneumococcus in the disease continuum and assess clinical evidence showing the effect of prevention of early episodes on the complex interplay between bacterial species implicated in otitis media.

Acute Otitis Media and Other Complications of Viral Respiratory Infection

BACKGROUND

Viral upper and lower respiratory tract infections (URI, LRI) are common in infants. We determined the prevalence of viral URI and its complications, including acute otitis media (AOM) and LRI, and assessed the effect of bacterial-viral interactions, and genetic and environmental risks on AOM development.

METHODS

Healthy infants were enrolled from near birth and followed to the first episode of AOM up to 12 months of age. Nasopharyngeal specimens were collected at monthly intervals (months 1-6, 9) and during viral URI episodes for bacterial culture and viral polymerase chain reaction studies. Subjects were followed closely for AOM development.

RESULTS

A total of 367 infants were followed for 286 child-years; 887 URI (305 infants) and 180 AOM episodes (143 infants) were documented. Prevalence of URI, LRI, and AOM in the first year was 3.2, 0.25, and 0.67 per child-year, respectively. Cumulative AOM incidence by ages 3, 6, and 12 months was 6%, 23%, and 46%. Infants with and without AOM had 4.7 and 2.3 URI episodes per child-year, respectively (P < .002). Pathogenic bacterial colonization rates by month were significantly higher in infants with AOM (P < .005). Breastfeeding reduced both URI and AOM risks (P < .05). Significant bacterial-viral interactions occurred with Moraxella catarrhalis and a variety of respiratory viruses and altered URI and AOM risks.

CONCLUSIONS

Almost half of infants experienced AOM by age 1. Important AOM risk factors included frequent viral URI, pathogenic bacterial colonization, and lack of breastfeeding. Bacterial-viral interactions may play a significant role in AOM pathogenesis and deserve further investigation.

Use of symptoms and risk factors to predict acute otitis media in infants

OBJECTIVES

Infants and children with upper respiratory tract infection (URI) often have concurrent acute otitis media (AOM). Young infants have fewer specific symptoms than older children. The purpose of this study was to evaluate the usefulness of symptoms and other risk factors in predicting the presence of AOM in infants.

METHODS

Healthy infants, age less than four weeks, were enrolled and followed prospectively for up to age one year. Infants were scheduled for a research visit when their parents noted the onset of symptoms. At each URI visit, parents first reported the severity of symptoms. An investigator then diagnosed the presence or absence of concurrent AOM. Risk factors and symptom scores for infants with and without AOM were studied.

RESULTS

Infants (N=193, mean age at first URI 3.9±2.5 months) experienced 360 URI episodes and 63 AOM events. Symptoms consisting of fever, earache, poor feeding, restless sleep, and irritability together (ETG-5) were statistically associated with the prediction of AOM (P=0.006). A multiple variable statistical model (J-Score) that included day care attendance, age, severity of cough and earache best predicted AOM (P<0.001), with 95% specificity. Both ETG-5 and J-score yielded relatively low sensitivity for AOM prediction.

CONCLUSIONS

In infants with URI in the first year of life, severity of symptoms was significantly associated with concurrent AOM. Daycare attendance, presence and severity of earache and cough added to better correlation. These observations may have clinical application in identification of infants at risk for AOM.

Effect of osteopathic manipulative treatment on middle ear effusion following acute otitis media in young children: a pilot study

CONTEXT

Childhood acute otitis media (AOM) is highly prevalent. Its usual sequela of middle ear effusion (MEE) can lead to conductive hearing loss, for which surgery is commonly used.

OBJECTIVE

To evaluate the efficacy of an osteopathic manipulative treatment (OMT) protocol on MEE resolution following an episode of AOM. The authors hypothesized that OMT provided adjunctively to standard care for young children with AOM would reduce the duration of MEE following the onset of AOM.

METHODS

We compared standard care only (SCO) and standard care plus OMT (SC+OMT) for the duration of MEE following AOM. Patients were aged 6 months to 2 years. The SC+OMT group received OMT during 3 weekly visits. Weekly tympanometric and acoustic reflectometer (AR) readings were obtained from all patients.

RESULTS

There were 52 patients enrolled, with 43 completing the study and 9 dropping out. No demographic differences were noted. Only ears from each patient with abnormal tympanograms at entry were included. There were 76 ears in the tympanogram analysis (38 from SCO; 38 from SC+OMT) and 61 ears in the AR data analysis (31 from SCO; 30 from SC+OMT). Dependence of bilateral ear disease noted in AR readings was accounted for in statistical analysis. Tympanogram data demonstrated a statistically significant improvement in MEE at visit 3 in patients in the SC+OMT group (odds ratio, 2.98; 95% confidence interval, 1.16, 7.62; χ(2) test for independence, P=.02). The AR data analysis showed statistically significant improvement at visit 3 for the SC+OMT group (z=2.05; P=.02). There was no statistically significant change in MEE before or immediately after the OMT protocol.

CONCLUSION

A standardized OMT protocol administered adjunctively with standard care for patients with AOM may result in faster resolution of MEE following AOM than standard treatment alone. (ClinicalTrials.gov number NCT00520039.).

Association of Gestational Age at Birth with Reasons for Subsequent Hospitalisation: 18 Years of Follow-Up in a Western Australian Population Study

Background

Preterm infants are at a higher risk of hospitalisation following discharge from the hospital after birth. The reasons for rehospitalisation and the association with gestational age are not well understood.

Methods

This was a retrospective birth cohort study of all live, singleton infants born in Western Australia between 1^st January 1980 and 31^st December 2010, followed to 18 years of age. Risks of rehospitalisation following birth discharge by principal diagnoses were compared for gestational age categories (<32, 32–33, 34–36, 37–38 weeks) and term births (39–41weeks). Causes of hospitalisations at various gestational age categories were identified using ICD-based discharge diagnostic codes.

Results

Risk of rehospitalisation was inversely correlated with gestational age. Growth-related concerns were the main causes for rehospitalisation in the neonatal period (<1 month of age) for all gestational ages. Infection was the most common reason for hospitalisation from 29 days to 1 year of age, and up to 5 years of age. Injury-related hospitalisations increased in prevalence from 5 years to 18 years of age. Risk of rehospitalisation was higher for all preterm infants for most causes.

Conclusions

The highest risks of rehospitalisation were for infection related causes for most GA categories. Compared with full term born infants, those born at shorter GA remain vulnerable to subsequent hospitalisation for a variety of causes up until 18 years of age.

Diseases of the middle ear in childhood

Middle ear diseases in childhood play an important role in daily ENT practice due to their high incidence. Some of these like acute otitis media or otitis media with effusion have been studied extensively within the last decades. In this article, we present a selection of important childhood middle ear diseases and discuss the actual literature concerning their treatment, management of complications and outcome. Another main topic of this paper deals with the possibilities of surgical hearing rehabilitation in childhood. The bone-anchored hearing aid BAHA(®) and the active partially implantable device Vibrant Soundbridge(®) could successfully be applied for children. In this manuscript, we discuss the actual literature concerning clinical outcomes of these implantable hearing aids.

Maternal immunization with pneumococcal 9-valent conjugate vaccine and early infant otitis media

A randomized trial of an investigational 9-valent pneumococcal conjugate vaccine (PCV-9) or placebo given to pregnant women during the last trimester to prevent early infant otitis media (OM) was conducted. All infants received Prevnar(®) at 2, 4, 6, and 12 months. Clinic and adverse event records were reviewed to identify OM. Variables significantly related to acute OM by age 6 months (p<0.05) were: vaccine group (9 valent or placebo), sibling history of tympanostomy tubes, upper respiratory infection, and number of clinic visits by 6 months. Infant OM rates were similar between 6 and 12 months (58% and 56%). Results suggested that immunizing pregnant women with PCV-9 increased infants' risk of acute OM in the first 6 months of life, and this correlated with decreased infant antibody responses to their infant Streptococcus pneumoniae vaccine serotypes, but did not influence antibody responses to 3 other serotypes two of which were in maternal vaccine (types 1 and 5) and one was a control (type 7F). Explanations for these results include dampening of infant antibody production by high levels of passively acquired maternal pneumococcal antibodies and/or altered B lymphocyte immune responses in infants exposed to these specific polysaccharide antigens in utero.

New paradigms in the pathogenesis of otitis media in children

Acute otitis media (AOM) is a multifactorial disease with a significant socioeconomic impact. The pathogenesis of AOM is attributed to a variety of well-established internal and extrinsic factors. Recent evidence strongly points to bacterial biofilm formation as an important contributor to this disease entity. The nasopharynx is a likely reservoir for infection with subsequent seeding of pathogens to the middle ear via planktonic shedding. Various modalities have been used to directly detect biofilm formation in the middle ear mucosa of children with AOM. Further insights into this disease may lead to new strategies for prevention and treatment.

Once or twice daily versus three times daily amoxicillin with or without clavulanate for the treatment of acute otitis media

BACKGROUND

Acute otitis media (AOM) is a common problem in children, for which amoxicillin, with or without clavulanate, is frequently prescribed as a treatment of choice. The conventional recommendation is either three or four daily doses. However, nowadays it is frequently prescribed as once or twice daily doses. If once or twice daily amoxicillin, with or without clavulanate, is as effective for acute otitis media as three or four times a day, it may be more convenient to give the medication once or twice a day to children and hence improve compliance.

OBJECTIVES

To compare the effectiveness of one or two daily doses with three or four daily doses of amoxicillin, with or without clavulanate, for the treatment of AOM in children; and to compare complication rates and adverse reactions.

SEARCH METHODS

We searched CENTRAL 2013, Issue 2, MEDLINE (January 1950 to March week 1, 2013), EMBASE (1974 to March 2013) and the Science Citation Index (2001 to March 2013).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of children aged 12 years or younger with AOM, diagnosed by acute ear pain (otalgia) and inflamed ear drum (confirmed by positive tympanocentesis or tympanogram of type B or C).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on treatment outcomes from individual trials and assessed trial quality based on selection bias, performance bias and detection bias, attrition bias, reporting bias and other biases. We defined the quality grading as low risk of bias, high risk of bias or unclear risk of bias. We summarised the results as risk ratio (RR) with 95% confidence intervals (CI).

MAIN RESULTS

We included five studies with 1601 children in the review. Pooled analysis demonstrated that the following outcomes were comparable between the two groups: clinical cure at the end of therapy (RR 1.03, 95% CI 0.99 to 1.07); during therapy (RR 1.06, 95% CI 0.85 to 1.33) and at follow-up (RR 1.02, 95% CI 0.95 to 1.09); recurrent AOM (RR 1.21, 95% CI 0.52 to 2.81); compliance rate (RR 1.04, 95% CI 0.98 to 1.10) and overall adverse events (RR 0.92, 95% CI 0.52 to 1.63). When we performed subgroup analysis separately for trials with amoxicillin only and amoxicillin/clavulanate only, it showed that all important outcomes were comparable between once or twice daily groups and the three times daily group. The risk of bias amongst the five included studies was as follows: for random sequence generation we graded two studies as low and three unclear risk of bias; for allocation concealment all studies were at unclear risk of bias; for blinding (performance and detection bias) we graded four as high and one as unclear risk of bias; for incomplete outcome data (attrition bias) we graded two low, two high and one as unclear risk of bias; for reporting bias four were at low and one at high risk; and for 'other' bias four were at low and one at unclear risk of bias.

AUTHORS' CONCLUSIONS

This review showed that the results of using once or twice daily doses of amoxicillin, with or without clavulanate, were comparable with three doses for the treatment of AOM.

Recurrent acute otitis media in infants: analysis of risk factors

OBJECTIVE

Recurrence acute otitis media (RAOM) may cause a considerable morbidity and a great parental concern. The aim of this study was to analyze the risk factors that are likely to be responsible for RAOM in infants, and their impact on treatment failure.

METHODS

A retrospective study on 340 infants with RAOM was conducted. Data were collected from hospital charts. A 10 days course of amoxicillin/clavulanate was used for treatment of recurrence, while surgical management in the form of adenoidectomy and/or myringotomy was reserved for patients with persistent disease. We analyzed various risk factors that may affect the prognosis of RAOM, including: age, prematurity, upper respiratory tract infections (URTI), duration of breastfeeding, use of pacifiers, parental smoking, seasonality, the presence of siblings (family size), gender, adenoid hypertrophy, allergy, and craniofacial abnormalities.

RESULTS

Use of pacifiers, short duration of breastfeeding, older infantile age, winter season, URTI and presence of adenoid hypertrophy were identified as risk factors for RAOM. Treatment failure may be due to adenoid hypertrophy, short duration of breastfeeding and it is more common in older age infants. We did not find a significant association between RAOM and gender, prematurity, exposure to passive smoking, the presence of siblings, allergy, craniofacial abnormalities.

CONCLUSIONS

Factors that may cause recurrence of the disease in infant population are use of pacifiers, short duration of breastfeeding, older infantile age, winter season, upper respiratory tract infections and adenoid hypertrophy. Also, treatment failure may be caused by adenoid hypertrophy and short duration of breastfeeding. Good understanding of these factors may help to decrease the recurrence rate and to improve the treatment of the disease.

Otitis media and ear tubes

The placement of myringotomy tubes remains an effective treatment of recurrent acute otitis media and chronic otitis media with effusion. Infants and young children are prone to these entities because of their immature anatomy and immunology. Several host, pathogenic, and environmental factors contribute to the development of these conditions. The identification and modification of some these factors can preclude the need for intervention. The procedure continues to be one of the most common outpatient pediatric procedures. Close vigilance and identification of potential complications is of utmost importance in the ongoing management of the child with middle ear disease.

Screening for hearing loss versus parental concern regarding hearing problems: Subsequent referral and treatment for otitis media in the Netherlands

OBJECTIVE

The present study investigates whether general practitioner (GP) consultation initiated by failing the population hearing screening at age nine months or GP consultation because of parental concern over ear/hearing problems was more important in deciding on referral and/or surgical treatment of otitis media (OM).

DESIGN

A questionnaire covering the history between birth and 21 months of age was used to obtain information on referral after failing the hearing screening, GP consultations for ear/hearing problems, and subsequent referral to a specialist and possible surgical treatment at an ENT department.

SETTING

The province of Limburg, the Netherlands.

SUBJECTS

Healthy infants invited for the hearing screening at age nine months, who responded in an earlier study called PEPPER (Persistent Ear Problems, Providing Evidence for Referral, response rate 58%).

MAIN OUTCOME MEASURES

The odds of a child being surgically treated for OM.

RESULTS

The response rate for the present questionnaire was 72%. Of all children tested, 3.9% failed the hearing screening and were referred to their GP. Of all 2619 children in this study, 18.6% visited their GP with ear/hearing problems. Children failing the hearing screening without GP consultation for ear/hearing problems were significantly more often treated surgically for OM than children passing the hearing screening but with GP consultation for ear/hearing problems.

CONCLUSION

Objectified hearing loss, i.e. failing the hearing screening, was important in the decision for surgical treatment in infants in the Netherlands.

Otitis media

Otitis media represents a broad spectrum of disease, which include acute otitis media and otitis media with effusion. As immunization with the pneumococcal conjugate vaccine has become more widespread, the microbiological landscape of otitis media has changed, which affects the treatment options facing clinicians worldwide. This review discusses the diagnosis and medical management of acute and chronic suppurative otitis media, the changes noted over the past decade, and briefly expounds on the surgical management of their severe complications.

The economic burden of infant formula on families with young children in the Philippines

BACKGROUND

Infant formula usage places children at risk for illness and death. Studies in the United States demonstrated high economic burden, health care costs, and absenteeism of caregivers associated with formula usage. Despite high formula usage in developing countries, no economic studies were found. This study examines the financial burden of purchasing infant formula and increased health care expenditure in the Philippines, a developing country with a per capita income of $3930. The average exchange rate of the peso to the US dollar for 2003 was $1 to P52, according to Bangko Sentral ng Pilipinas (BSP).

METHODS

This is a secondary analysis of the 2003 Family Income and Expenditure Survey, a national cross-sectional multistage cluster survey of 42 094 households.

RESULTS

Almost half of Philippine families with a young child and one-third of families living on less than $2 per day purchase formula. Nationally, $260 million was spent on infant formula in 2003. Formula-buying families with young children had spent an aggregate of $143.9 million on medical care compared to $56.6 million by non-formula-buying families. After adjusting for income and nonmilk family expenditures, the average formula-purchasing Philippine family spent an additional $0.30 (95% CI: 0.24 - 0.36; r(2) = 0.08) on medical expenditure for every $1 spent on formula.

CONCLUSIONS

The economic burden from infant formula purchase and out-of-pocket medical expenditure exceeded $400 million in 2003. This cost was aside from other costs, such as absenteeism and the risk of childhood death and illness. These expenses caused an unnecessary burden on Filipino families and could instead have been invested in education and other social services.

Pneumococcal vaccination in children at risk of developing recurrent acute otitis media - a randomized study

AIM

Acute otitis media (AOM) is a common childhood disease, which often becomes recurrent (rAOM). A small reduction in AOM episodes has been noted in unselected child cohorts after vaccination with heptavalent conjugate pneumococcal vaccine (PCV7). The purpose of this study was to investigate how vaccination affects young children at risk of developing rAOM.

METHODS

Ninety-six children with an AOM onset before 6 months of age, implying a high risk for rAOM, were closely monitored until the age of 2 years. Forty-six were vaccinated with PCV7 and 50 were not. All episodes of AOM, emergency visits and ventilation tube insertions were registered.

RESULTS

A total of 363 AOM episodes were diagnosed. The incidence was reduced by 26% (p = 0.03), the number of emergency visits because of suspected AOM by 36% (p = 0.01) and the proportion of children who received ventilation tubes was halved in the vaccine group (p = 0.02).

CONCLUSIONS

During the first 2 years of life, PCV7 significantly reduced AOM episodes, emergency visits and ventilation tube insertions in children with rAOM. Pneumococcal vaccine may be a future route to reduce antibiotic use and health care consumption in otitis-prone children.

Differential diagnosis in allergy

The otolaryngic allergist must be able to distinguish between common nonallergic diagnoses that present very similarly to allergic conditions. This article describes a few of the vast myriad of conditions that must be ruled out before a diagnosis of allergy may be made. After reading this article clinicians will be able to identify various conditions, which will enhance their ability to appropriately make correct decisions for prompt and efficient management of their patients with allergic or nonallergic diseases of the head and neck.

Otitis media and associations with overweight status in toddlers

INTRODUCTION

Otitis media (OM) is a significant disease that affects nearly all children early in life. Recently, childhood overweight has become an epidemic. Past research has demonstrated that a history of OM is related to food preferences and overweight through proposed physiological mechanisms. The purpose of this study was to explore the relationship between recurrent OM (ROM)/tympanostomy tube treatment and overweight status.

METHODS

Data were analyzed from a prospective cohort of mothers and children recruited from 1991-1996 from a local health maintenance organization. ROM and tympanostomy tube status were obtained through a combination of physical exam and medical record abstraction. ROM and tympanostomy tube status were analyzed as categorical variables with weight-for-length (WFL) data from well child checks. Chi-square and logistic regression for univariate and multivariate analyses were performed.

RESULTS

11.4% of children had a WFL measure at two years of age ≥ 95 th percentile. Those children with a history of tympanostomy tube treatment had a significantly increased risk of having a WFL ≥ 95 th percentile after controlling for birth weight, maternal prenatal smoking, maternal education, and family income (OR 3.32, 95% CI 1.43-7.72). The alternative hypothesis that children with larger WFL at two month of age would have a greater number of OM episodes by two years of age was not significant.

CONCLUSION

The findings of this study are consistent with the hypothesis and prior research that OM treated with tympanostomy tubes is associated with overweight status.

Novel method for non-invasive induction of a middle-ear biofilm in the rat

Otitis media and other middle ear diseases are extremely common among all children worldwide. Chronic otitis media is strongly associated with the presence of a bacterial middle ear biofilm, which if left untreated, may result in hearing loss or delays in the development of speech and language. Many animal models and methods used to study the progression of various middle ear diseases exist. However, there are no reported approaches to biofilm induction in which this infectious process can be investigated. Here we report a unique, non-invasive method of biofilm induction in the rat through repeated bacterial inoculations and pressure changes within the ear.

Incidence and recurrence of acute otitis media in Taiwan's pediatric population

OBJECTIVE

To report the incidence and recurrence of acute otitis media (AOM) in Taiwan's pediatric population.

METHODS

Information from children (aged <= 12 years) with a diagnosis of AOM was retrieved from the 2006 National Healthcare Insurance claims database. We calculated the cumulative incidence rate and the incidence density rate of recurrent AOM within one year after the initial diagnosis in 2006. We used a multivariate logistic regression model to assess the predictors for recurrence of AOM.

RESULTS

The annual incidence rate of AOM was estimated to be 64.5 cases per 1,000 children. The overall one-year cumulative incidence rate of recurrence was 33.1%, and the incidence density rate was 33.5 cases per 100 person-years, with the highest figure (41.2 cases per 100 person-years) noted for children aged 0-2 years. Recurrence was significantly associated with age, gender, place of treatment, and physician specialty.

CONCLUSION

AOM remains a major threat to children's health in Taiwan. Male children and very young children require more aggressive preventive strategies to reduce the risk of recurrence.

Chronic suppurative otitis media in a birth cohort of children in Greenland: population-based study of incidence and risk factors

BACKGROUND

Inuits of the Arctic experience very high rates of chronic suppurative otitis media (CSOM), yet world-wide, very little is known about the epidemiology of CSOM. The study aims were to determine incidence, median age at debut, risk factors, and associated population attributable risks for CSOM in young children in Sisimiut, the second biggest town of Greenland (population 5400), where living conditions are relatively western and approximately 90% are Inuits.

METHODS

A population-based birth cohort of 465 children aged between 0 and 4 years was followed for a 2-year period (1996 to 1998), and cases of CSOM were registered based on medical history and clinical examinations. Kaplan-Meier curves were used for estimations of cumulative risk and Cox regression analyses for hazard rates associated with risk factors.

RESULTS

Cumulative risk of CSOM at 4 years of age was 14%, and median age at debut was 336 days. Risk factors were attending childcare centers (hazard ratio [HR]: 3.18, 95% confidence interval [CI]: 1.53- 6.61), having smokers in the household (HR: 4.56, 95% CI: 1.07-19.4), having a mother who reported a history of purulent ear discharge (3.27, 95% CI: 1.74-6.13), having a high burden of upper respiratory tract infections (HR: 1.19, 95% CI: 1.03-1.37), and being Inuit (HR: 5.56, 95% CI: 0.78-50).

CONCLUSIONS

Greenlandic children have high rates of CSOM with debut early in life, but the identified risk factors and the associated population attributable risks indicate that preventive measures regarding use of childcare centers and passive smoking may reduce the high frequency of CSOM in this high-risk population.

Frequent ear infections in infancy and the risk of asthma in Mexican American children

OBJECTIVES

This study examined the associations of history of ear infections in infancy with doctor-diagnosed asthma in a large sample of Mexican American children.

METHODS

In this population-based cross-sectional study, parents of 2023 children completed a questionnaire that collected data on doctor-diagnosed asthma, doctor-diagnosed ear infections, as well as antibiotics use in infancy, and other potential confounding variables.

RESULTS

Children with a history of ear infections in infancy were more likely to have asthma compared with those who had no history of ear infections in infancy; the adjusted odds ratios (ORs) were 2.52 (95% confidence interval [CI]: 1.35-4.69) and 1.27 (95% CI: 0.79-2.04) in children who had >or=3 and 1-2 (versus none) ear infections in infancy, respectively, p for trend = .0074. These associations were independent of antibiotics use, acetaminophen consumption, and history of various infections (other than ear infections) in the first year of life. In stratified analyses, the increased risk of asthma in children with recurrent ear infections in infancy persisted among children whose parents reported no lifetime history of rhinitis but not in children who had a history of rhinitis.

CONCLUSIONS

This study demonstrated significant associations of asthma with history of ear infections in infancy, with a significant dose-response effect of repeated ear infections on the odds of asthma. These findings add to the growing body of literature linking early childhood infections with the risk of asthma and highlight the need for more research to identify the mechanisms through which ear infections may be associated with asthma.

Birth characteristics and acute otitis media in early life

OBJECTIVE

To assess whether preterm birth and low birth weight were associated with single and recurrent episodes of acute otitis media (AOM) the first 18 months of life.

METHODS

The study population consisted of 33,192 children in the Norwegian Mother and Child Cohort, conducted at the Norwegian Institute of Public Health. The majority of all pregnant women in Norway were invited to participate and the response rate was 44%. Participating women received questionnaires during pregnancy and when the child was 6 and 18 months. Main outcome measures were maternal reports of AOM at ages 6, 11 and 18 months. Information on birth weight and gestational age was obtained from the Medical Birth Registry of Norway. Regression analyses were performed controlling for a variety of potential confounders.

RESULTS

Preterm birth was slightly associated with both single and recurrent episodes of AOM the first 18 months of age. The adjusted relative risk (aRR) for having any episode of AOM was 1.37, 95%CI (1.12-1.68) if born before week 33, and the aRR for having recurrent AOM was 1.34, 95%CI (1.01-1.77) if born in weeks 33-36 (reference group: >or=37 weeks). A corresponding tendency was not found for low birth weight.

CONCLUSIONS

The finding indicates a modest increased risk of having AOM in children born preterm, and preterm birth seems to be more important than low birth weight in determining risk of having AOM in early life.

Prenatal and postnatal parental smoking and acute otitis media in early childhood

AIM

To explore the associations between acute otitis media in early childhood and prenatal and postnatal tobacco smoke exposure.

METHODS

Subjects were 32 077 children born between 2000 and 2005 in the Norwegian Mother and Child Study with questionnaire data on tobacco smoke exposure and acute otitis media up to 18 months of age. Multivariate regression models were used to obtain adjusted relative risks for acute otitis media.

RESULTS

Acute otitis media was slightly more common in children exposed to parental smoking. The incidence from 0 to 6 months was 4.7% in unexposed children and 6.0% in children exposed both prenatally and postnatally. After adjusting for postnatal exposure and covariates, the relative risk for acute otitis media 0-6 months when exposed to maternal smoking in pregnancy was 1.34, 95% confidence interval: 1.06-1.69. Maternal smoking in pregnancy was associated with acute otitis media up to 12 months of age. Compared with non-exposed children, there was a slightly increased risk of recurrent acute otitis media for children exposed both prenatally and postnatally with a relative risk of 1.24, 95% confidence interval: 1.01-1.52.

CONCLUSION

Even in a cohort with relatively low exposure levels of parental smoking, maternal smoking in pregnancy was associated with an increased risk of acute otitis media in early childhood.

Burden of otitis media and pneumonia in children up to 6 years of age: results of the LISA birth cohort

Infections play an important role in childhood. For Germany, few data are available on the epidemiology of infectious diseases such as otitis media and pneumonia in children. We therefore described the prevalence, first episode proportions and recurrence of these childhood infection diseases in selected regions of Germany in children up to 6 years of age. The analysis was based on data from the LISA Study, a prospective population-based birth cohort study including 3,097 full-term infants. Information was collected by parent questionnaire. The first episode proportions for the first 6 years of life were high for otitis media (66.7%; 95%CI 0.65-0.69) and pneumonia (13.5%; 95%CI 0.12-0.15). The annual first episode proportions for otitis media ranged from 7.3% to 25.6% and for pneumonia from 1.4% to 3.4%; both peaked during the second year. The average number of otitis media episodes was 2.2 (SD 2.0) episodes per child within the first 2 years. During the first 2 years of life, hospitalisations due to otitis and pneumonia occurred in up to 7.8 per thousand and 3.0 per thousand of the children, respectively. On average, 50.6% of the children with otitis media were treated with antibiotics during the first year of life. In conclusion, this analysis shows that infectious diseases, especially otitis media, are very frequent childhood diseases in Germany. Thus, parents and physicians should not per se worry about a high frequency of otitis media during early childhood.

Chinchilla as a robust, reproducible and polymicrobial model of otitis media and its prevention

There is compelling evidence that many infectious diseases of humans are caused by more than one microorganism. Multiple diverse in vitro systems have been used to study these complex diseases, and although the data generated have contributed greatly to our understanding of diseases of mixed microbial etiology, having rigorous, reproducible and relevant animal models of human diseases are essential for the development of novel methods to treat or prevent them. All animal models have inherent limitations; however, they also have important advantages over in vitro methods, including the presence of organized organ systems and an intact immune system, which promote our ability to characterize the pathogenesis of, and the immune response to, sequential or coinfecting microorganisms. For the highly prevalent pediatric disease otitis media, or middle-ear infection, the chinchilla (Chinchilla lanigera) has served as a gold-standard rodent host system in which to study this multifactorial and polymicrobial disease.

Nutritional factors in the pathogenesis of ear disease in children: a systematic review

BACKGROUND

Ear disease is a major health problem in poorly resourced countries. The role of nutritional deficiencies in its pathogenesis and in relation to chronic suppurative otitis media (CSOM) has not been reviewed previously.

METHODS

A systematic review was undertaken using Pubmed, SCOPUS, Cinahl on Ovid, the Cochrane Database and selected medical journals, with no language restriction. Nutritional mechanisms potentially related to ear disease and CSOM risks were reviewed. All studies (observational, case-control, cohort and clinical trials including randomised controlled trials) with nutrition-related information were included. The titles and/or abstracts of all retrieved studies were reviewed and full articles were obtained for relevant studies. Exclusion criteria were multiple publication or studies which did not report nutritional information.

RESULTS

Supplementation studies using single micronutrients and vitamins to determine efficacy in reducing acute or chronic otitis media provided some evidence for an association of middle-ear pathology with deficiencies of zinc or vitamin A. Multi-micronutrient supplementation studies provided further support for a beneficial effect, although the number of studies was small and they were heterogeneous and uncontrolled. No human study was identified which specifically examined the association between copper, selenium or vitamin D status and middle-ear disease or infection.

CONCLUSION

Particularly in developing countries, research on micronutrient status and vitamin deficiency and their influence on middle-ear disease is required to improve knowledge of the pathogenesis of middle-ear infection and to determine the relevance of nutritional interventions in prevention and treatment.