Risk factors affecting the occurrence of acute otitis media among 2-3-year-old urban children

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.

Long-term effect of middle ear disease on temporal processing and P300 in two different populations of children

BACKGROUND/OBJECTIVE

The effects of otitis media on the function of the central auditory nervous system in different populations is unknown. Understanding how the history of otitis media affects children from different nations will guide health professionals worldwide on the importance of adequate auditory stimulus in childhood. For this reason, the aim of the present study was to investigate the long-term auditory effects of middle ear disease on temporal processing and P300 in two different populations of children: Australian and Brazilian.

METHODS

Temporal processing tests (Frequency Pattern Tests-FPT and Gaps in noise-GIN) and P300 were measured in 68 Brazilian and Australian children, aged between 8 to 14 years. The Brazilian otitis media group (BrOM) and Australian otitis media group (AusOM) consisted of 20 children each who had a documented history of otitis media. Control groups of 14 children (BrControl and AusControl) were also recruited from each country, all with no documented history of otitis media.

RESULTS

The BrOM group showed significantly poorer performance (p<0.001) for FPT and the GIN compared to BrControl. The P300 response showed significantly longer mean latencies (p = 0.02) compared to BrControls. The AusOM group also showed significant delayed latency of P300 (p = 0.04) compared to the AusControl. The FPT showed significantly poorer performance (p = 0.04) compared to AusControls. The two otitis media groups showed no significant differences between each other on P300. Significant differences were seen however in temporal processing tests performance between the two cohorts for the otitis media groups. The BrOM group had significantly poorer responses (p<0.001) for FPT and GIN compared to the AusOM group.

CONCLUSIONS

These findings support that although differences exist between BrOM and AusOM groups, otitis media can be demonstrated to affect the underlying mechanisms of the P300 measures and behavioral auditory responses in two different populations of children.

The effect of passive smoking on the etiology of serous otitis media in children

Serous otitis media (SOM) is a disease mostly seen in the pediatric age group and characterized by serous effusion in the middle ear. The disease which is mostly silent can cause permanent hearing loss if it is not diagnosed and treated early. Passive smoking is one of the environmental factors in the etiopathology of the disease and risk factors for SOM formation in children. In our study, smoking habits of family members of 75 children with SOM and 50 healthy controls were investigated. At the end of the study, the correlation between SOM and passive smoke exposed was statistically significant in children (p < 0.01). In this study, the effect of passive smoking, which is a preventable and controllable risk factor in the etiology of the SOM in children is emphasized.

Phenotype Profiling and Allergy in Otitis-Prone Children

Background: Otitis-prone children can present some distinctive clinical patterns and although a number of known risk factors for recurrent acute otitis media (RAOM) are known, no dedicated epidemiological models have been developed to explain clinical heterogeneity. Methods: A preliminary retrospective pilot study was planned to evaluate the possible effect of allergic disease in the development of different disease phenotypes in otitis-prone children aged 3-10 years, particularly the absence (simple RAOM), or presence of episodes of otitis media with effusion between acute infections (RAOM with OME). Results: Analysis was based on the data contained in 153 charts (55.6% males, mean age of 59.4 ± 16.4 months). 75.8% of children had a simple RAOM and 24.2% a RAOM with OME. Atopy or allergy were documented in respectively 47.7 and 41.3% of children considered as a whole. The prevalence of atopy or allergy was significantly higher in the children with a RAOM with OME (atopy: 73.0 vs. 39.5%, p < 0.001; allergy: 60.0 vs. 36.1%, p = 0.049), who also more frequently showed adenoidal hypertrophy (p = 0.016), chronic adenoiditis (p = 0.007), conductive hearing loss (p = 0.004), and impaired tympanometry (p < 0.001). Conclusions: These data suggest that children with a RAOM with OME are clinically different from children with simple RAOM, as they have a more complex clinical presentation that includes not only adenoidal disease and audiological impairment, but also an underlying allergy or atopy. The possibility that the factors mentioned above may be differently involved in the heterogeneous clinical manifestations occurring in otitis-prone children needs to be further investigated in ad hoc epidemiological studies.

Breastfeeding and the risk of respiratory tract infections after infancy: The Generation R Study

Background

The protection of breastfeeding against respiratory tract infections in the first year of life has often been suggested. Few studies examined the effect of breastfeeding on respiratory tract infections after infancy.

Objective

To examine the association between breastfeeding with lower respiratory tract infections (LRTI) and upper respiratory tract infections (URTI) after infancy up to 4 years of age (n = 5322).

Methods

This study was embedded in The Generation R study, a Dutch population-based prospective cohort study from fetal life until young adulthood. Information on breastfeeding duration (never; <3 months; 3–6 months; ≥6 months) and dose (never; partially until 4 months; predominantly until 4 months) were collected by questionnaire at 2, 6, and 12 months of age. Information on doctor attendance for LRTI and URTI were obtained by questionnaire at 2, 3, and 4 years of age.

Results

Breastfeeding for 6 months or longer was significantly associated with a reduced risk of LRTI up to 4 years of age (aOR: 0.71; 95% CI: 0.51–0.98). Similar ORs for LRTI were found with breastfeeding for less than 3 months and 3–6 months. Although in the same direction, weaker ORs were found for URTI and breastfeeding duration. The same trend was found for partial and predominant breastfeeding until 4 months and LRTI and URTI.

Conclusion

Breastfeeding duration for 6 months or longer is associated with a reduced risk of LRTI in pre-school children. These findings are compatible with the hypothesis that the protective effect of breastfeeding for respiratory tract infections persist after infancy therefore supporting current recommendations for breastfeeding for at least 6 months.

Information on co-morbidities collected by history is useful for assigning Otitis Media risk to children

OBJECTIVES

Determine if a 2-Step multivariate analysis of historical symptom/sign data for comorbid diseases can abstract high-level constructs useful in assigning a child's "risk" for different Otitis Media expressions.

METHODS

Seventeen items related to the symptom/sign expression of hypothesized Otitis Media comorbidities were collected by history on 141 3-year-old children. Using established criteria, the children were assigned to 1 of 3 groups: Control (no significant past Otitis Media, n=45), Chronic Otitis Media with Effusion (n=45) and Recurrent Acute Otitis Media (n=51). Principal Component Analysis was used to identify factors representing the non-redundant shared information among related items and Discriminant Analysis operating on those factors was used to estimate the best predictor equation for pairwise group assignments.

RESULTS

Six multivariate factors representing the assignable comorbidities of frequent colds, nasal allergy, gastroesophageal disease (specific and general), nasal congestion and asthma were identified and explained 81% of the variance in the 17 items. Discriminant Analysis showed that, for the Control-Chronic Otitis Media with Effusion comparison, a combination of 3 factors and, for the Control-Recurrent Acute Otitis Media comparison, a combination of 2 factors had assignment accuracies of 74% and 68%, respectively. For the contrast between the two disease expressions, a 2-factor combination had an assignment accuracy of 61%.

CONCLUSION

These results show that this analytic methodology can abstract high-level constructs, comorbidities, from low-level data, symptom/sign scores, support a linkage between certain comorbidities and Otitis Media risk and suggest that specific comorbidity combinations contain information relevant to assigning the risk for different Otitis Media expressions.

Age-dependent changes in pattern recognition receptor and cytokine mRNA expression in children with otitis media with effusion

OBJECTIVE

To investigate age-dependent changes in expression of pattern recognition receptors (PRRs) and cytokines in pediatric OME.

MATERIALS AND METHODS

Ninety five pediatric patients with OME were divided into 4 age groups: 0-2, 2-4, 4-7, and over 7 years. The presence of bacteria, and the levels of expression of mRNAs encoding Toll-like receptor (TLRs), NOD like receptors (NLRs) and cytokines in middle ear fluid were assessed, as were their correlations with age, gender, presence of bacteria and accompanying disease.

RESULTS

Bacteria were detected in 32.6% of patients. The levels of expression of PRR and cytokine mRNAs tended to be lower in children aged 2-4 and 4-7 years. The levels of expression of TLR-2, TLR-9, NOD-1, NOD-2, IL-1, IL-6, and TNF-α mRNAs in effusion fluid were significantly lower in these two groups than in children aged 0-2 and over 7 years (p<0.05 each). The levels of expression of TLR-4, TLR-5, TLR-9, and NOD-1 mRNAs were significantly lower in culture positive than in culture negative patients (p<0.05 each). However, the expression levels of PRR and cytokine mRNAs were unrelated to gender and accompanying disease (p>0.05 each).

CONCLUSIONS

The levels of expression of PRR and cytokine mRNAs differed by age in children with OME.

What does tympanostomy tube placement in children teach us about the association between atopic conditions and otitis media?

Otitis media is the most common infection second only to viral upper respiratory infection in the outpatient setting. Tympanostomy tube insertion (TTI) is the most common ambulatory surgical procedure in the USA. While many risk factors for otitis media have been identified, atopic conditions have been underrecognized as risk factors for recurrent and persistent otitis media. Given that asthma and other atopic conditions are the most common chronic conditions during childhood, it is worth examining the association between atopic conditions and risk of otitis media, which can provide insight into how atopic conditions influence the risk of microbial infections. This paper focuses its discussion on otitis media; however, it is important that the association between atopic conditions and risk of otitis media be interpreted in the context of the association of atopic conditions with increased risks of various microbial infections.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Breast-feeding and childhood hospitalizations for infections

BACKGROUND

Infectious disease is a leading cause of morbidity and hospitalization for infants and children. During infancy, breast-feeding protects against infectious diseases, particularly respiratory infections, gastrointestinal infections, and otitis media. Little is known about the longer-term impact of breast-feeding on infectious disease in children.

METHODS

We investigated the relationship between infant feeding and childhood hospitalizations from respiratory and gastrointestinal infections in a population-based birth cohort of 8327 children born in 1997 and followed for 8 years. The main outcomes were public hospital admissions for respiratory infections, gastrointestinal infections, and all infectious diseases. Cox regression was used to assess time to first hospitalization.

RESULTS

Breast-feeding only (no formula-feeding) for 3 or more months was associated with a lower risk of hospital admission in the first 6 months of life for respiratory infections (hazard ratio = 0.64 [95% confidence interval = 0.42-0.97]), gastrointestinal infections (0.51 [0.25-1.05]), and any infection (0.61 [0.44-0.85]), adjusted for sex, type of hospital at birth, and household income. Partial breast-feeding (both breast-feeding and formula-feeding) in the first 3 months also reduced hospitalizations from infections but with smaller effect sizes. Beyond 6 months of age, there was no association between breast-feeding status at 3 months and hospitalization for infectious disease.

CONCLUSIONS

Giving breast milk and no formula for at least 3 months substantially reduced hospital admissions for many infectious diseases in the first 6 months of life, when children are most vulnerable.

Natural history, definitions, risk factors and burden of otitis media

Otitis media remains a major health problem in Australia, with an unacceptably great dichotomy of incidence and severity of otitis media and its complications between Indigenous and non‐Indigenous Australians.

Among most children with acute otitis media, infection resolves rapidly with or without antibiotics, with ongoing middle ear effusion the only sequela.

Overcrowding, poor living conditions, exposure to cigarette smoke, and lack of access to medical care are all major risk factors for otitis media.

Estimates of the number of cases of otitis media in 2008 vary between 992 000 and 2 430 000 Australians, with a total estimated cost of $100 – $400 million.

Comparison of the health of Roma and non-Roma children living in the district of Teplice

OBJECTIVES

To compare the morbidity of 66 Roma and 466 non-Roma children born and living in a diffused type of habitation in the district of Teplice.

METHODS

For each child, a complete list of illnesses that pediatricians recorded using ICD-10 codes for all physician visits and/or hospitalizations was obtained.

RESULTS

At the age 0-2 years the Roma/non-Roma rate ratios (RR) of the incidence of influenza (RR 1.6), otitis media (RR 2.3), intestinal infectious diseases (RR 1.7) and viral illnesses (RR 6.3) were statistically associated with ethnicity. The higher incidence of bronchitis (RR 1.7) and pneumonia (RR 2.2) in the Roma children was associated with the low education of mothers and not with ethnicity.

CONCLUSIONS

At the age of 0-2 years the incidence of influenza, otitis media, intestinal infectious diseases and of viral diseases was significantly higher in Roma than in non-Roma children and was not associated with education of mothers. There was no increase in the morbidity of Roma children over the non-Roma children at the age of 2-6 years. The prevalence of allergies in Roma children was extremely low.

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.

Histologic changes in the eustachian tube mucosa of rats after short-term exposure to cigarette smoke

OBJECTIVE AND BACKGROUND

It is generally accepted that cigarette smoke is a major risk factor for middle ear disease. However, the literature is void of articles addressing the direct relationship between cigarette smoke exposure and middle ear disease. Furthermore, there are many conflicting opinions concerning the role of cigarette smoke in the pathogenesis of middle ear disease. The purpose of this study was to evaluate the effects of cigarette smoke on the Eustachian tube mucosa.

MATERIALS AND METHODS

Thirty healthy 150 to 230 g Sprague Dawley rats with normal middle ears were used. The animals were divided into six groups of five. Five experimental groups (N=5 each) were exposed to a domestic cigarette (This, tar 7.0 mg, nicotine 0.75 mg) every 30 minutes (total 2.5 hours, 5 cigarettes total) on a daily basis in a smoking chamber for 1, 2, 4, 6, or 8 weeks. A control group (N=5) was placed in the same chamber without exposure to cigarette smoke. After exposure, the animals were sacrificed and cross sections of the Eustachian tubes were prepared. Histologic changes of the Eustachian tube mucosa were observed through light and electron microscopes.

RESULTS

Loss of cilia, goblet cell depletion, and squamous metaplasia of the Eustachian tube mucosa were observed following exposure to smoke. The one- and two-week exposure groups demonstrated the greatest decrease in goblet cell counts. The eight-week exposure group showed recovery from this decrease. Squamous metaplasia was observed in all experimental groups and was most prominent in the eight-week exposure group.

CONCLUSION

These findings suggest that cigarette smoke directly affects Eustachian tube mucosa in the early stages of exposure. Some of the mucosal changes, however, were reversed during the latter stages of exposure. A mechanism different from that which occurs in the nasal cavity and trachea may be activated in the Eustachian tube after exposure to passive smoke. The protective function of the Eustachian tube may play some role in this mechanism.

Risk factors for otitis media with effusion in Chinese schoolchildren: a nested case-control study and review of the literature

OBJECTIVE

To identify the risk factors for otitis media with effusion (OME) in Chinese schoolchildren and analyse the results with reference to the review of the literature.

METHODS

The study subjects were 6-7-year-old children drawn from a school-screening program for OME in Hong Kong. Both positive and negative screens attended a hospital clinic for further assessment with repeated otoscopic examination and tympanometry as well as pure tone audiometry within 3 weeks after the initial school-screening. During the visit, parents were interviewed to provide information with regard to the children's birth history, neonatal history, socio-economic background, otological history, past health, and medical history. These data formed the basis in the estimation of potential risk factors for OME.

RESULTS

In the univariate analysis of 127 cases and 173 controls, significantly elevated odds ratios (OR) for OME were detected on the symptoms of atopy (OR = 2.21, p = 0.04), hearing loss (OR = 4.13, p = 0.001), nasal obstruction (OR = 1.94, p = 0.005), rhinorrhoea (OR = 1.61, p = 0.04), tonsillitis in the past 12 months (OR = 1.82, p = 0.02), and previous history of acute otitis media (OR = 6.89, p < 0.001). However, only three of them were found to be significant in the multivariate logistic regression model: nasal obstruction (OR = 1.67, 95% CI: 1.01-2.75); acute tonsillitis (OR = 1.68, 95% CI: 1.00-2.80), and previous acute otitis media episodes (OR = 5.75, 95% CI: 2.60-12.69).

CONCLUSIONS

Risk factors identified in the Chinese schoolchildren for OME were comparable with previous western reports. A previous attack of acute otitis media was a major determinant for middle ear effusion.

Long-term prognosis of acute otitis media in infancy: determinants of recurrent acute otitis media and persistent middle ear effusion

OBJECTIVES

Children under 2 years of age with acute otitis media are known to have a relatively poor prognosis. The objective of this study was to assess whether known determinants for recurrent acute otitis media and persistent middle ear effusion after an episode of acute otitis media during childhood also apply to children under 2 years.

STUDY DESIGN

prospective study of 210 children under 2, with identification of potential prognostic determinants. Univariate and multivariate logistic regression analyses were applied to evaluate which parameters independently contributed to the prediction of both outcome measures (recurrent acute otitis media and persistent middle ear effusion). A prognostic function was developed, and the area under the receiving operating characteristic (ROC) was used to estimate the predictive ability of the prognostic models.

POPULATION

children under 2 years of age with an episode of acute otitis media in family practice.

OUTCOMES MEASURED

recurrent acute otitis media and persistent middle ear effusion.

RESULTS

For the outcome recurrent acute otitis media data from 210 children were used and winter season, male sex, passive smoking and persistent symptoms for more than 10 days at presentation were independent prognostic determinants. For the outcome persistent middle ear effusion data from 190 children were used and winter season, bilateral disease at entry, a sibling history of recurrent acute otitis media, and a previous episode of acute otitis media independently predicted the outcome. No sufficiently discriminatory prognostic model could be constructed for either outcome measure.

CONCLUSION

Prediction of recurrent acute otitis media or persistent middle ear effusion in individual young children remains poor.

Antibody levels after regular childhood vaccinations in the immunological screening of children with recurrent otitis media

Recurrent otitis media may be related to defects in specific antibody production, as suggested previously. This might be reflected in lower antibody responses to vaccinations administered in the context of the national childhood vaccination program in children suffering from recurrent otitis media. In a cross-sectional study we determined the levels of antidiphtheria, antitetanus, anti- Haemophilus influenzae type b (anti-Hib) and antimeasles antibodies in sera of 163 children with two or more episodes of acute otitis media per year and in 143 children with repeated periods of persistent otitis media with effusion each lasting at least 3 months. The control group consisted of 521 age-matched healthy children, who were free of recurrent respiratory tract infections. Children with recurrent acute otitis media, including highly otitis-prone children, showed higher antidiphtheria and antitetanus antibody titers compared to controls. No differences were observed in anti-Hib and antimeasles antibody levels between children with recurrent acute otitis media and controls, nor did any of the antibody levels in children with persistent otitis media with effusion differ from those in controls. Therefore, the results of our study do not point toward a generalized immunological hyporesponsiveness in children with recurrent acute otitis media and persistent otitis media with effusion. Determination of antibody responses to regular vaccines is not indicative for otitis-proneness.

Racial/ethnic disparities in the diagnosis of otitis media in infancy

OBJECTIVE

Otitis media (OM) is an extremely common pediatric diagnosis. Several risk factors have been associated with OM, but the relationship between OM and race/ethnicity remains controversial. We sought to define the relationship between OM diagnosis and race/ethnicity in infants.

METHODS

By multivariable logistic regression, we evaluated the association between OM diagnosis and race/ethnicity in 11,349 non-low-birthweight infants who were participants in a prospective cohort study of infant care practices.

RESULTS

As in previous studies, breastfeeding was associated with a decreased risk of OM diagnosis while other factors were independently associated with a substantially increased risk of OM diagnosis: out-of-home daycare, multiple children living in the home, and mother's multiparity. Daycare was associated with a "dose effect" in that the risk of OM diagnosis increased with an increasing number of children in the daycare. While the crude analysis suggested little relation of OM diagnosis and race/ethnicity, the association was confounded by several covariates including maternal marital status, number of children living in the home, breastfeeding status, and maternal age. After adjustment for relevant confounders, Black (OR 0.74; 95% CI 0.61-0.89) and Asian infants (OR 0.77; 95% CI 0.57-1.0]) were less likely to be diagnosed with OM than White infants.

CONCLUSIONS

This large prospective study confirms previous risk factors for OM and demonstrates a strong "dose effect" of the size of daycare centers on OM. The study also demonstrates that the association between race/ethnicity and OM diagnosis is confounded by social factors. After adjusting for such factors, Black and Asian infants are less likely to be diagnosed with OM than White infants. The reason for this racial disparity remains unknown.

[Incidence, air pollution and risk factors of acute otitis media in the first year of life: a prospective study]

BACKGROUND

Epidemiological studies of acute otitis media (AOM) are scarce and no prospective studies have been performed in Spain.

OBJECTIVES

To describe the incidence of AOM in the first year of life and its associated risk factors, with special focus on air pollution.

METHODS

We performed a prospective cohort study of 229 newborn infants during the first year of life stratified by pollution zones, and followed-up by their pediatricians in their health center. AOM was defined on clinical grounds. A questionnaire on risk/protective factors included items on the following: sex, older siblings, smoking, breastfeeding, socioeconomic status, parental education and the mother's occupational status.

RESULTS

The incidence of AOM episodes during the first year of life was 45 % and the proportion of children who experienced at least one episode was 32 %. Independent risk factors were male gender (aOR: 2.03; 95 % CI: 1.09-3.7) and living in a polluted area (aOR: 2.01; 95 % CI: 1.05-3.84). Independent protective factors were being born in spring (aOR: 0.41; 95 % CI: 0.19-0.88) and having a mother with at least primary school education (aOR: 0,53; 95 % CI: 0.24-1.15). Socioeconomic markers indicated a lower mean level among families whose children had at least one AOM episode.

CONCLUSIONS

Air pollution and low socioeconomic status are greater risk factors for AOM than having siblings or parents who smoke. A minimum educational level reduces the risk of AOM. The incidence of AOM could be reduced by modifying certain environmental factors.

Lack of association of race/ethnicity and otitis media in the first 2 years of life

Race has been identified as a risk factor for otitis media (OM) in several studies. To further explore this, a database of visits with age at visit < 24 months was constructed from data captured electronically at a public health clinic in North Carolina between July 1994 and December 1996. Among 3,108 children with at least 1 visit, 45% were African-American, 26% were Latino, and 29% were White. There were no differences among the groups in episodes of OM per child or ratio of OM episodes to total visits per child. A cohort of 166 children with follow-up throughout their first 2 years of life was identified. In this group, being uninsured or having exposure to out-of-home child care was associated with an increased risk of OM. Race/ethnicity had no association with frequency of OM as measured by episodes per child, proportion with > or = 1 episode, or proportion with > or = 3 episodes.

The laws of acute otitis media

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

Hospital system costs of artificial infant feeding: estimates for the Australian Capital Territory

OBJECTIVE

To estimate the attributable ACT hospital system costs of treating selected infant and childhood illnesses having known associations with early weaning from human milk.

METHOD

We identified relative risks of infant and childhood morbidity associated with exposure to artificial feeding in the early months of life vs. breastfeeding from cohort studies cited by the American Academy of Pediatrics in 1997 as establishing the protective effect of breastfeeding. Data for ACT breastfeeding prevalence is assessed from a 1997 prospective population-based cohort study of 1,295 women. ACT Hospital Morbidity Data and DRG treatment costs were used to estimate the attributable fraction of costs of hospitalisation for gastrointestinal illness, respiratory illness and otitis media, eczema, and necrotising enterocolitis.

RESULTS

Although initiation rates were high (92%), less than one in 10 ACT infants are exclusively breastfed for the recommended six months, mainly due to supplementation or weaning on to formula within the first three months and the early introduction of solids by breastfeeding mothers. This study suggests the attributable hospitalisation costs of early weaning in the ACT are about $1-2 million a year for the five illnesses.

CONCLUSIONS AND IMPLICATIONS

Early weaning from breastmilk is associated with significant hospital costs for treatment of gastrointestinal illness, respiratory illness and otitis media, eczema, and necrotising enterocolitis. These costs are minimum estimates of the cost of early weaning as they exclude numerous other chronic or common illnesses and out-of-hospital health care costs. Higher rates of exclusive breastfeeding would reduce these costs. Interventions to protect and support breastfeeding are likely to be cost-effective for the public health system.

Factors associated with the development of recurrent acute otitis media--the significance of choosing the right and accurate dependent and independent variables in the multivariate analysis

The results of univariate and multivariate statistical analysis were compared in identifying predictive factors of the development of recurrent acuta otitis media (RAOM) after an initial episode of acute otitis media (AOM) in 121 children. Univariate correlations between the development of RAOM and potential risk factors were analysed, and variables at p < 0.10 were incorporated into the stepwise multiple logistic regression analysis. The comparisons between the univariate and multivariate analysis in identifying the predictive factors were made and the importance of changing the dependent variables in the multivariate analysis was analysed. It seems that univariate analysis is over-sensitive, but multivariate analysis is over-conservative in finding possible predictors of RAOM. Choosing the right and accurate dependent and independent variables in the multivariate analysis is extremely important, when this method is used.

Clinical sinusitis in children attending primary care centers

OBJECTIVES

To determine the proportion of children who meet the clinical criteria for the diagnosis of sinusitis among all children attending primary care pediatric practices, to explore the relationship between passive smoking and the occurrence of sinusitis and to study the role of antibiotics in the management of sinusitis.

DESIGN

A prospective observational cohort study.

SETTING

Outpatient Pediatric Clinics of Jordan University of Science and Technology and Princess Rahma Teaching Hospital. Patients. All children ages 1 to 10 years presenting for any reason to participating practices.

METHODS

Physicians participating in this study completed a questionnaire on all children attending the primary care centers, detailing the presence of nasal congestion or discharge, the duration of symptoms, daytime cough and whether symptoms were improving. The presence or absence of smokers in the family was also recorded. Children meeting our clinical criteria for sinusitis were further evaluated for other signs and symptoms including the type of medication prescribed. The severity of symptoms was reassessed at 10-day follow-up after the first visit.

RESULTS

The study population was composed of 3001 children, of whom 249 met our clinical criteria for diagnosis of sinusitis (8.3%; 95% confidence interval, 7.3 to 9.3%). The prevalence rate of clinical sinusitis was greater among children age 5 years and older than among those younger (9.3% vs. 7.2%, P = 0.04). Children exposed to passive smoking in the household had clinical sinusitis significantly more than those not exposed (68.8% vs. 1.2%, P = 0.00). Antibiotics were prescribed for 80% of children who fulfilled the clinical criteria for diagnosis of sinusitis. Marked improvement of symptoms at the 10-day follow-up visit was reported among those who received antibiotics compared with those who did not (91% vs. 21.4%, P = 0.00).

CONCLUSIONS

Sinusitis is not an uncommon problem in children, passive smoking might be a contributing factor and a course of antibiotic therapy is beneficial.

Pulsed-field gel electrophoresis analysis of nasopharyngeal flora in children attending a day care center

To investigate how bacterial pathogens spread from child to child in a day care center, we monitored six children, two boys and four girls, born between August 1995 and November 1997, attending a day care center and analyzed nasopharyngeal samples from them using pulsed-field gel electrophoresis (PFGE). We obtained nasopharyngeal cultures from all of the affected children and almost all of the unaffected children between September 1998 and March 1999 after some children presented simultaneously with purulent rhinorrhea. Moreover, when a child was found to have acute otitis media, nasopharyngeal secretions from the child were independently cultured during treatment. During this period, 28 isolates of Moraxella catarrhalis, 13 of Streptococcus pneumoniae, and 4 of Haemophilus influenzae were recovered. PFGE gave 8 patterns for M. catarrhalis, 10 for S. pneumoniae, and 1 for H. influenzae. PFGE patterns demonstrated spread of M. catarrhalis between children. However, each occurrence of clusters of infection with M. catarrhalis lasted 2 to 6 weeks, with a change in PFGE pattern between occurrences of clusters. The M. catarrhalis strain infecting each child also changed. Similarly, the S. pneumoniae strain in each child also changed. In contrast, infection with H. influenzae persisted for about 3 months in an affected child.

Frequent ear infections in association with child-care characteristics, based on the 1988 Child Health Supplement to the National Health Interview Survey

Using the 1988 Child Health Supplement to the National Health Interview Survey, we analysed the association between child-care characteristics and frequent ear infections among children under 6 years attending child care. We observed strong associations for 1- to 2-year-old children for variables involving exposure to many different children, including number of children in the main setting and one or more changes in child-care arrangement in the past year. No significant effects were observed for the children under 1 year, but sample sizes were small. Likewise, no strong associations were observed for the 3- to 5-year-old children, but they may have outgrown the detrimental effects of repeated respiratory tract infections.

Clinical perspectives on sinusitis and otitis media

As the leading cause of physician office visits and loss of time from school as well as the cause of significant morbidity among young children, respiratory infections impose a major burden on the health care system. The most common causative pathogens are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. In young children acute otitis media and sinusitis may present with relatively nonspecific symptoms such as irritability. Older children may complain of more specific problems; for example those with otitis media may complain of otalgia. Upper respiratory tract infections are typically diagnosed by signs and symptoms and treated empirically with an antimicrobial agent that offers coverage of the usual causative respiratory pathogens.

A nation-wide, population-based survey of otitis media and school achievement

The purpose of the study was to evaluate whether there is an association between early recurrent otitis media and later school achievement. A nation-wide, population-based random cluster sampling of 1708 children in 119 school classes was performed throughout Finland. Data were collected with questionnaires sent to the parents and teachers of the children. Teachers evaluated each child's performance at school, and the association between the number of episodes of early otitis media and school achievement was determined. Recurrent otitis media episodes before the age of 3 years associated significantly with lower performance in mathematical skills (risk ratios [RR] 1.2-1.4, 95% confidence intervals [95% CI] 1.0-1.7, P-values 0.04-0.02) and classroom concentration (RR 1.4, 95% CI 1.1-1.8, P-value 0.02) among the girls. The boys with recurrent otitis episodes performed more poorly in reading (RR 1.3, 95%, CI 1.0-1.6, P-value 0.05) and oral performance (RR 1.2, 95% CI 1.1-1.4, P-value 0.01). No association between otitis episodes after the age of 3 years and school achievement was found. Our findings suggest that recurrent otitis media episodes before the age of 3 years have adverse long-term consequences even when treated actively. Even though the risk ratios were low our finding is important because recurrent otitis media is a common problem during infancy and school achievement has many practical influences on a child's future.

Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children

BACKGROUND

A systematic quantitative review was conducted of evidence relating parental smoking to acute otitis media, recurrent otitis media, middle ear effusion, and adenoidectomy and/or tonsillectomy.

METHODS

Forty five relevant publications were identified after consideration of 692 articles selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified 13 studies of acute otitis media, nine of recurrent otitis media, five of middle ear effusion, nine of glue ear surgery, and four of adenotonsillectomy. A quantitative meta-analysis was possible for all outcomes except acute otitis media, using random effects modelling where appropriate to pool odds ratios from each study.

RESULTS

Evidence for middle ear disease is remarkably consistent, with pooled odds ratios if either parent smoked of 1.48 (95% CI 1.08 to 2.04) for recurrent otitis media, 1.38 (1.23 to 1.55) for middle ear effusion, and 1.21 (0.95 to 1.53) for outpatient or inpatient referral for glue ear. Odds ratios for acute otitis media are in the range 1.0 to 1.6. No single study simultaneously addresses selection bias, information bias and confounding, but where these have been investigated or excluded in the design or analysis, the associations with parental smoking persist virtually unchanged. Large French and British studies are inconsistent with regard to the association of parental smoking and tonsillectomy.

CONCLUSIONS

There is likely to be a causal relationship between parental smoking and both acute and chronic middle ear disease in children.

Sequelae of recurrent acute otitis media. Ten-year follow-up of a prospectively studied cohort of children

In a cohort of 113 children prospectively followed from birth to the age of 3, two subgroups were discerned: one with recurrent acute otitis media (rAOM), the other subgroup with no AOM at all ("healthy" children). At further follow-up at the age of 10, no child had AOM or secretory otitis media (SOM), but between 3 and 7 y of age the rAOM subgroup was characterized by a significantly higher incidence of AOM as well as protracted secretory otitis media (SOM) episodes than was the "healthy" subgroup. The two subgroups did not differ significantly in hearing-thresholds at pure tone audiometry. After the age of 7, the incidence of AOM was the same in both groups. It is concluded that children with frequent AOM episodes before the age of 3 need long-term follow-up to school age, but seem not be predisposed to chronic SOM.

Otitis-prone children and controls: a study of possible predisposing factors. 2. Physical findings, frequency of illness, allergy, day care and parental smoking

In a retrospective study of 179 otitis-prone children and 305 controls, various possible predisposing factors for acute otitis media (AOM) were compared. The children were matched with the controls for age and sex. There were 61% boys and 39% girls in the otitis-prone group and 58% boys and 42% girls among the controls. Information about the family and living conditions, the children's illnesses, ear, nose and throat (ENT) operations and possible allergies were obtained from a questionnaire, and the children were called for a physical examination. The otitis-prone children had more middle-ear problems with pathological tympanograms and conductive hearing loss than the controls. No differences were found in bacterial colonization of the nasopharynx. Besides AOM and secretory otitis media, the otitis-prone children had more other ENT diseases and had consequently undergone more ENT operations and hospitalizations than the controls. There were no differences between the two groups regarding allergy, day care or parental smoking alone, but on comparing children with combinations of these factors there were more otitis-prone children than controls exposed, indicating an additive effect. The combination of different factors, less important separately, may for some children mean the difference between becoming otitis-prone or not.

Recurrent acute otitis media: the significance of age at onset

In order to assess the relationship between recurrent acute otitis media (rAOM) and age at first acute otitis media (AOM) episode, a prospective cohort of 3754 Norwegian children born in 1992-1993 was followed from birth to 2 years. Recurrent acute otitis media was defined by the criterion of four or more episodes of AOM during a 12-month period. Approximately 5.4% of the children experienced rAOM before the age of 2. Furthermore, children whose first AOM episode occurred before the age of 9 months were at a significantly higher risk for developing rAOM compared to children whose first AOM episode was 10-12 months. In children who had the first ear infection during the first 9 months of life, one-quarter developed rAOM before the age of 2. Multiple logistic regression analysis adjusted for confounding showed that gender and a familial history of atopy were significantly associated with rAOM. In conclusion, the present study found an association between age at first AOM episode and the later subsequent AOM proneness. Additionally, both gender and a family history of atopy seemed to predispose towards otitis-proneness.

Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life

OBJECTIVE

As part of a long-term study of possible effects of early-life otitis media on speech, language, cognitive, and psychosocial development, we set out to delineate the occurrence and course of otitis media during the first 2 years of life in a sociodemographically diverse population of infants, and to identify related risk factors.

METHODS

We enrolled healthy infants by age 2 months who presented for primary care at one of two urban hospitals or one of two small town/rural and four suburban private pediatric practices. We intensively monitored the infants' middle-ear status by pneumatic otoscopy, supplemented by tympanometry, throughout their first 2 years of life; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated infants for otitis media according to specified guidelines.

RESULTS

We followed 2253 infants until age 2 years. The proportions developing > or = 1 episode of middle-ear effusion (MEE) between age 61 days (the starting point for data analysis) and ages 6, 12, and 24 months, respectively, were 47.8%, 78.9%, and 91.1%. Overall, the mean cumulative proportion of days with MEE was 20.4% in the first year of life and 16.6% in the second year of life. Tympanostomy-tube placement was performed on 1.8% and 4.2% of the infants during the first and second years of life, respectively. By every measure, the occurrence of MEE was highest among urban infants and lowest among suburban infants; these differences were greatest in the earliest months of life. Overall, unadjusted mean cumulative proportions of days with MEE were higher among boys than girls, higher among black than white infants, and higher among Medicaid than private health insurance enrollees. Cumulative proportions of days with MEE varied directly with the number of smokers in the household and with the number of other children to whom infants were exposed, whether at home or in day care, and varied inversely with birth weight, maternal age, level of maternal education, a socioeconomic index, and duration of breastfeeding. After adjustment, using multivariate analysis, the only variables that each remained independently and significantly related to the cumulative proportion of days with MEE were: during the first year of life, study site grouping, sex, the socioeconomic index, breastfeeding for > or = 4 months, the number of smokers in the household, and an index rating the degree of exposure to other children at home or in day care; and during the second year of life, sex, the socioeconomic index, and the child exposure index. The duration of breastfeeding and the degree of exposure to tobacco smoke contributed little to the explained variance; most was attributable to differences in the socioeconomic index and the child exposure index.

CONCLUSIONS

Contrary to findings in many previous reports, the prevalence of otitis media during the first 2 years of life among lower-socioeconomic-status black infants appears to be as high as, if not higher than among lower-socioeconomic-status white infants, and certainly higher than among middle-class white infants. Among middle-class white infants the prevalence may also be higher than commonly assumed. The most important sociodemographic risk factors for otitis media appear to be low socioeconomic status and repeated exposure to large numbers of other children, whether at home or in day care.

Is there a relationship between proximity to industry and the occurrence of otitis media with effusion in school entrant children?

In a study of the relationship between the prevalence of persistent otitis media with effusion (OME) in school entrant children in Redcar and Cleveland and the distance of the homes of these children from known industrial emission points, 1156 school entrant children were screened for the presence of persistent OME. The social disadvantage scores and map references were determined from the postcode area of each of the study entrants and map references were also obtained of known industrial emission points in the locality. Analyses were conducted on the association between the presence of OME and distance from emission sources and between the presence of OME and disadvantage score. A significantly greater proportion of study entrants with OME lived within 1000 meters of an industrial emission point than further away. However, there was no trend established between the proportion of study entrants with OME and increasing distance from an emissions source, nor was there any significant relationship established between the social disadvantage score of the areas of residence of the study entrants and the presence of OME. Further research is required to establish the effect of confounding variables on this relationship.

Prognosis of acute otitis media. Factors associated with the development of recurrent acute otitis media

Clinical factors associated with the development of recurrent acute otitis media (RAOM) (> or = 3 recurrences during 6 months' follow-up period) after acute otitis media (AOM) were analysed in 121 children aged 3 months to 7 years (median 2 years 6 months). After AOM, 19 (16%) children had primary recurrence (pre-treatment signs and symptoms firstly improved or cured, but worsened or recurred within 30 days' post-treatment) and 33 (27%) developed RAOM during 6 months' follow-up period. It seemed that children < 2 years of age (p = 0.04), children with bilateral disease (p = 0.007), strong infection status (p = 0.05), primary clinical failure (p = 0.04) and development of primary recurrence after AOM (p = 0.001) were significantly related to the development of RAOM in univariate analysis, but only children < 2 years of age (OR 1.5, 95% CI 1.0-5.7, p = 0.04) and the development of primary recurrence (OR 5.1, 95% CI 1.8-14.1, p = 0.002) related to the development of RAOM in multivariate analysis. None of the bacteria cultured from middle ear effusion were related to the development of RAOM.

Occurrence of otitis media in an arctic region

The occurrence of otitis media (OM) was examined retrospectively in files at Longyearbyen Hospital, Svalbard, Norway during 1991-1994. Acute OM (AOM) with and without spontaneous drum perforation, secretory OM (SOM) and chronic OM (COM) with and without suppuration were registered, as were patient's sex, age, and climatic conditions. These findings were compared with weather observations obtained from the Norwegian Meteorological Institute, Tromsø in the same period. Sixty-four percent of the OM patients registered were classified as AOM, 17% having a spontaneous drum perforation. Thirty percent suffered from SOM, whereas 6% had COM. Forty percent of the patients were younger than 6 years. The distribution of OM cases during the year showed a peak during the spring, especially in May. Another minor peak was noted in September. Average daily temperature in the period was -5.6 degrees C, range -14 degrees C to +6 degrees C. Humidity and precipitation were fairly stable throughout the observation period 74% and 240 mm/year, respectively. OM is a common disease at Svalbard and is apparently related to seasonal shifts in temperature.

Otitis-prone children and controls: a study of possible predisposing factors. 1. Heredity, family background and perinatal period

In a retrospective study of 179 otitis-prone children and 305 controls, various possible predisposing factors for acute otitis media (AOM) were compared. The children were matched for age and sex. There were 61% boys and 39% girls in the otitis-prone group and 58% boys and 42% girls among the controls. Eighty-eight (49%) of the otitis-prone children experienced > or = 11 episodes of AOM and 162 (53%) of the controls had none or at the most one episode of AOM. There were no differences between the groups concerning dwelling districts, the size of family, number of siblings or the education and occupation of the parents. In the otitis-prone group there were more fathers who had been otitis-prone as children. This was not seen for the mothers when comparing all the children, but was seen when comparing the most otitis-prone (> or = 11 AOM) with the controls (0-1 AOM). The otitis-prone children more often had siblings who were otitis-prone compared with the controls. There were no differences between the two groups regarding pregnancy, birthweight or duration of breast-feeding. Thus, male gender and heredity for middle-ear problems appeared to be of importance for otitis-proneness.

Early acute otitis media: determined by exposure to respiratory pathogens

The purpose of the present study is to assess the relationship between early acute otitis media (AOM) and exposure to respiratory pathogens mediated by siblings and day-care. A prospective cohort of 3,754 Norwegian children born in 1992-93 was followed from birth through 12 months. One or more episodes of AOM had been experienced by 25% of the children before age one. Logistic regression analysis showed that siblings attending day-care is the most important risk factor for early AOM (ORadj = 1.9 (1.4-2.3)). The total number of children in the day-care setting is another determinant for early AOM (ORadj = 2.0 (1.4-2.6) in groups of 4 or more other children and ORadj = 1.3 (1.0-1.7) in groups of 1-3 other children as compared with those who are cared for alone). Siblings who attend day-care and the number of children in the child's own day-care setting are the most important determinants for AOM the first year of life.

Early acute otitis media and siblings' attendance at nursery

To assess the relation between early acute otitis media and exposure to respiratory pathogens mediated by siblings and other children, a prospective cohort of 3754 Norwegian children born in 1992-3 was followed up from birth to 12 months. Of these, 25% had one or more episodes of acute otitis media during the first year. Results from multiple logistic regression analysis adjusted for confounding showed that siblings' attendance at daycare is the most important risk factor for early acute otitis media (adjusted odds ratio, ORadj = 1.9). The total number of children in the daycare setting is another determinant for early acute otitis media (ORadj = 2.0 in groups of four or more other children and ORadj = 1.3 in groups of one to three other children, as compared to those who are cared for alone). Having siblings in daycare outside the home and the number of children in the daycare setting are the most important determinants for early acute otitis media.

Otitis media: relationship to tonsillitis, sinusitis and atopic diseases

In order to estimate the co-morbidity between ear infections and related childhood diseases, data about the occurrence of recurrent ear infections, tonsillitis, sinusitis and atopic diseases from a population based sample of 7992 Norwegian twins were analysed. Correlational results revealed two general clusters, one consisting of upper respiratory tract infections (URI), the other defined by the atopic diseases. Overall, associations between the diseases were greater in males. The sizes of the correlations within each subgroup of infections were moderate, but significant, ranging from 0.191 to 0.363. Similar results were found for the relationship within the subgroup of atopies, with correlations ranging from 0.134 to 0.466. The correlations between the infectious and atopic diseases were weak. Both ear infections and tonsillitis seemed to be predisposing factors for sinusitis. The relative risk of sinusitis among individuals with a history of ear infections was 3.4 (1.9-6.2) and 1.9 (1.2-3.0) for males and females, respectively. Ear infections conferred an increase in tonsillitis, estimated at 2.3 (1.6-3.0) and 2.0 (1.2-3.6) for males and females, respectively. In conclusion, the present study finds evidence for a common predisposition of upper respiratory infections as well as for atopic diseases, but only moderate correlation between the subgroups. Specifically, between ear infections and hay fever there was no covariation.

Late effects on ear disease in otitis-prone children: a long-term follow-up study

A group of 88 otitis-prone children, 66% boys and 34% girls, born in 1978-81 with more than 11 episodes of acute otitis media, were examined in 1984-85. Seventy-four of the children (with the same distribution of sex) were reexamined in 1990-92. Their medical history of ear, nose and throat diseases was studied and an examination, including otomicroscopy, tympanometry and audiometry, was performed. Fifty-one (69%) continued to have episodes of acute otitis media during the follow-up period and 34 (46%) continued to have episodes of secretory otitis media. Surgery had been performed during this period in 25 (34%) and most common was the need for ventilation tubes. The condition of the tympanic membranes showed improvement for many children. In 1984-85, 31 (35%) of the children had normal tympanic membranes and in 1990-92, 44 (60%). Scar/tympanosclerosis was more common at the follow-up examination: 11 (13%) vs. 20 (27%). In 1984-85 one child was found to have a central perforation and in 1990-92, 5 children were found to have adhesive otitis, chronic secretory otitis or central perforation. No cases of cholesteatomas were found in 1984-85 or in 1990-92. Audiometry was found to be a poor indicator of ear-drum pathology The results support the opinion that otitis-prone children should be treated and continuously followed by an ear, nose and throat specialist until a stable normalization of the middle-car is observed.