Ear and hearing care programs for First Nations children: a scoping review

BACKGROUND

Ear and hearing care programs are critical to early detection and management of otitis media (or middle ear disease). Otitis media and associated hearing loss disproportionately impacts First Nations children. This affects speech and language development, social and cognitive development and, in turn, education and life outcomes. This scoping review aimed to better understand how ear and hearing care programs for First Nations children in high-income colonial-settler countries aimed to reduce the burden of otitis media and increase equitable access to care. Specifically, the review aimed to chart program strategies, map the focus of each program against 4 parts of a care pathway (prevention, detection, diagnosis/management, rehabilitation), and to identify the factors that indicated the longer-term sustainability and success of programs.

METHOD

A database search was conducted in March 2021 using Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Programs were eligible or inclusion if they had either been developed or run at any time between January 2010 to March 2021. Search terms encompassed terms such as First Nations children, ear and hearing care, and health programs, initiatives, campaigns, and services.

RESULTS

Twenty-seven articles met the criteria to be included in the review and described a total of twenty-one ear and hearing care programs. Programs employed strategies to: (i) connect patients to specialist services, (ii) improve cultural safety of services, and (iii) increase access to ear and hearing care services. However, program evaluation measures were limited to outputs or the evaluation of service-level outcome, rather than patient-based outcomes. Factors which contributed to program sustainability included funding and community involvement although these were limited in many cases.

CONCLUSION

The result of this study highlighted that programs primarily operate at two points along the care pathway-detection and diagnosis/management, presumably where the greatest need lies. Targeted strategies were used to address these, some which were limited in their approach. The success of many programs are evaluated as outputs, and many programs rely on funding sources which can potentially limit longer-term sustainability. Finally, the involvement of First Nations people and communities typically only occurred during implementation rather than across the development of the program. Future programs should be embedded within a connected system of care and tied to existing policies and funding streams to ensure long term viability. Programs should be governed and evaluated by First Nations communities to further ensure programs are sustainable and are designed to meet community needs.

Burden of respiratory infections and otitis media in the Inuit population of Nunavik, Quebec, Canada

BACKGROUND

Respiratory infections are a major health problem in the Inuit population of Nunavik, province of Quebec, Canada.

OBJECTIVES

A study was undertaken to assess the burden of lower (LRTI) and upper respiratory tract infections (URTI) and otitis media (OM) and to explore some of their determinants including the pneumococcal conjugate vaccine (PCV) status.

METHODS

The reference population includes children less than 5 years of age born in 1994-2010 and a sample of 825 children was selected for this study. Outpatient medical records were reviewed. Visits with a diagnosis of LRTI, URTI and OM were extracted. Univariate and multivariate statistical analyses were performed to identify predictors of disease risk.

RESULTS

The average number of LRTI, URTI and OM episodes were, respectively, 2.6, 6.2 and 5.9 from birth up to the 5th birthday. Seasonal patterns were similar for URTI and OM, but was different for LRTI. Children who received the recommended 4 PCV doses had a lower LRTI and OM risk than unvaccinated children. There was a trend towards a lower OM risk associated with a mixed PCV10+ PCV13 schedule compared with PCV7.

CONCLUSION

Results suggest a lower LRTI and OM risk associated with PCV use in this high-risk population but respiratory disease risk remains high compared with the general population in Quebec.

Otitis media: health and social consequences for aboriginal youth in Canada’s north

OBJECTIVES

Otitis media is endemic among Inuit, First Nations and Métis children in northern Canada, with prevalence rates in some communities as high as 40 times that found in the urban south. Hearing impairment, much of it attributable to chronic otitis media, is the most common health problem in parts of the arctic, and conductive hearing loss among children may affect as many as two-thirds.

STUDY DESIGN AND METHODS

There is a need for systematic data based on consistent disease definitions and measures, and taking account of cross-cultural methodological issues and sampling.

RESULTS

Otitis media is most likely to develop in infancy. Susceptibility has been linked to immune defects and to a variety of environmental factors. Among the most significant are diet, the decline in initiation and maintenance of breastfeeding, and exposure to cigarette smoke. Hearing loss has been related to difficulties in language acquisition, and to subsequent issues with literacy and school achievement, including learning disabilities and attention deficits. The economic and social costs of otitis media are substantial.

CONCLUSION

Approaches to treatment and prevention have enjoyed limited success. Public health and medical practice need to be informed by the traditional knowledge and practices of indigenous peoples.

Ethnic differences in acute hospitalisations for otitis media and elective hospitalisations for ventilation tubes in New Zealand children aged 0-14 years

AIMS

This paper describes ethnic differences in acute hospitalisations for otitis media (OM) and elective hospitalisations for ventilation tube insertion in New Zealand children aged 0-14 years. Ethnic differences in first attendances at Ear Nose and Throat (ENT) outpatient clinics are also described.

METHOD

The analysis included all hospital admissions of children aged 0-14 years during 2002-2008 which met the following criteria: Acute admissions with an ICD-10-AM primary diagnosis code of otitis media; and elective admissions with a primary procedure code of ventilation tube insertion. First attendances at ENT outpatient clinics during 2007-2008 were also reviewed. Explanatory variables included ethnicity, gender, age, and NZ Deprivation Index decile.

RESULTS

Among 0-4 year olds, Māori and Pacific children were more likely to be admitted acutely for otitis media than European children. In contrast, both Māori and Pacific children had lower rates of elective admissions for ventilation tube insertion, with ethnic differences being most marked for children from the most deprived areas. Māori and Pacific children aged 5-14 years also had higher acute otitis media admission rates than European children. In contrast to their younger counterparts however, they also had higher rates of ventilation tube insertion. Exploration of ENT outpatient data for children 0-4 years revealed similar first appointment rates for European and Māori children, but lower rates for Pacific and Asian children. For the 5-14 age group, first appointment rates were higher for Māori and Pacific children than for European children. However, Māori and Pacific children in both age groups had higher rates of non-attendance at their first ENT appointments than European children.

CONCLUSION

This study highlights ethnic differences in access to ventilation tubes amongst New Zealand's 0-4 year olds, with the greatest inequalities being seen for Māori, Pacific and Asian children living in the most deprived areas. For Māori and Pacific children, such differences cannot be attributed to lower rates of AOM or OME compared to European children. The fact that similar patterns are not seen for children aged 5-14 years potentially suggests that routine Well Child hearing screening may be playing a role in identifying unmet need in this older age group. Such disparities also suggest that factors over and above OM prevalence may be influencing access to ventilation tubes. Further research is required to determine why Māori and Pacific children (0-4 years) have similar/lower ENT appointment rates than European children, despite a higher burden of middle ear disease, as well as higher non-attendance rates at outpatient clinics. Given the importance of early detection and treatment of OM for children's ongoing well-being and education, a greater understanding of the reasons for these inequalities is urgently required.

Breastfeeding as a means to prevent infant morbidity and mortality in Aboriginal Canadians: A population prevented fraction analysis

OBJECTIVES

Canadian Aboriginal infants experience poor health compared with other Canadian infants. Breastfeeding protects against many infant infections that Canadian Aboriginals disproportionately experience. The objective of our research was to estimate the proportion of select infant infection and mortality outcomes that could be prevented if all Canadian Aboriginal infants were breastfed.

METHODS

We used Levin's formula to estimate the proportion of three infectious outcomes and one mortality outcome that could be prevented in infancy by breastfeeding. Estimates were calculated for First Nations (both on- and off-reserve), Métis and Inuit as well as all Canadian infants for comparison. We extracted prevalence estimates of breastfeeding practices from national population-based surveys. We extracted relative risk estimates from published meta-analyses.

RESULTS

Between 5.1% and 10.6% of otitis media, 24.3% and 41.4% of gastrointestinal infection, 13.8% and 26.1% of hospitalizations from lower respiratory tract infections, and 12.9% and 24.6% of sudden infant death could be prevented in Aboriginal infants if they received any breastfeeding.

CONCLUSION

Interventions that promote, protect and support breastfeeding may prevent a substantial proportion of infection and mortality in Canadian Aboriginal infants.

Estimated prevalence of hearing loss and provision of hearing services in Pacific Island nations

INTRODUCTION

Hearing impairment (HI) affects an estimated 538 million people worldwide, with 80% of these living in developing countries. Untreated HI in childhood may lead to developmental delay and in adults results in social isolation, inability to find or maintain employment, and dependency. Early intervention and support programmes can significantly reduce the negative effects of HI.

AIM

To estimate HI prevalence and identify available hearing services in some Pacific countries - Cook Islands, Fiji, Niue, Samoa, Tokelau, Tonga.

METHODS

Data were collected through literature review and correspondence with service providers. Prevalence estimates were based on census data and previously published regional estimates.

RESULTS

Estimates indicate 20-23% of the population may have at least a mild HI, with up to 11% having a moderate impairment or worse. Estimated incidence of chronic otitis media in Pacific Island nations is 3-5 times greater than other Australasian countries in children under 10 years old. Permanent HI from otitis media is substantially more likely in children and adults in Pacific Island nations. Several organisations and individuals provide some limited hearing services in a few Pacific Island nations, but the majority of people with HI are largely underserved.

DISCUSSION

Although accurate information on HI prevalence is lacking, prevalence estimates of HI and ear disease suggest they are significant health conditions in Pacific Island nations. There is relatively little support for people with HI or ear disease in the Pacific region. An investment in initiatives to both identify and support people with hearing loss in the Pacific is necessary.

Literacy skills of Australian Indigenous school children with and without otitis media and hearing loss

This study examined the relationship between reading, spelling, and the presence of otitis media (OM) and co-occurring hearing loss (HL) in metropolitan Indigenous Australian children, and compared their reading and spelling outcomes with those of their non-Indigenous peers. OM and HL may hinder language development and phonological awareness skills, but there is little empirical evidence to link OM/HL and literacy in this population. Eighty-six Indigenous and non-Indigenous children attending pre-primary, year one and year two at primary schools in the Perth metropolitan area participated in the study. The ear health of the participants was screened by Telethon Speech and Hearing Centre EarBus in 2011/2012. Participants' reading and spelling skills were tested with culturally modified sub-tests of the Queensland University Inventory of Literacy. Of the 46 Indigenous children, 18 presented with at least one episode of OM and one episode of HL. Results indicated that Indigenous participants had significantly poorer non-word and real word reading and spelling skills than their non-Indigenous peers. There was no significant difference between the groups of Indigenous participants with OM and HL and those with normal ear health on either measure. This research provides evidence to suggest that Indigenous children have ongoing literacy development difficulties and discusses the possibility of OM as one of many impacting factors.

Acute mastoiditis in Greenland between 1994-2007

INTRODUCTION

The indigenous populations of the Arctic are prone to middle ear infections starting with an early age first episode, followed by frequent episodes of acute otitis media (AOM) during childhood. A high proportion develop chronic otitis media. Acute mastoiditis is a serious complication of AOM in childhood with postauricular swelling, erythema, and tenderness, protrusion of the auricle, high fever and general malaise. The disease may protrude intracranially. The incidence rates for acute mastoiditis in the Western world range from 1.2 to 4.2 cases/100 000 per year. There exists no epidemiological data on acute mastoiditis in the Arctic region.

METHODS

A retrospective search was made for the WHO ICD-10 code DH70.0 (denoting acute mastoiditis) using the National Greenland Inpatient Register for the period 1994-2007, inclusive. Fifteen patients were registered and their medical records were retrieved. Four patients were obviously misclassified, leaving 11 patients for evaluation. The medical records were available for 10 patients. The diagnostic inclusion criterion was written clinical signs of acute mastoiditis.

RESULTS

Based on the case series the incidence rate was calculated to be 1.4 for the total Greenlandic population and 7.4 for children 0 and 10 years of age. Median age was 14 months (5-105 months) and eight were female (72%). Seven of the 10 were exclusively treated with antibiotics and three underwent additional ear surgery. Bacteriological examination was performed in five of 10. One 8 month-old girl presented with a contemporary facial nerve paralysis and was treated with intravenous antibiotics; one 8 year-old girl was evacuated to Copenhagen for urgent surgery due to signs of meningitis. Acute CT scan showed a cerebellar abscess and a thrombosis in the lateral sigmoid sinus vein. An extensive cholesteatoma was found and eradicated during surgery. Six weeks later the patient returned home with a maximal conductive hearing loss as the only complication. All patients recovered from the disease.

CONCLUSION

The incidence of acute mastoiditis in Greenland is comparable to the incidence elsewhere, although AOM occurs more frequently among small children in the Greenlandic population. The disease is serious and must be treated immediately with intravenous antibiotics, followed by urgent surgery if there is no improvement.

Absent otoacoustic emissions predict otitis media in young Aboriginal children: a birth cohort study in Aboriginal and non-Aboriginal children in an arid zone of Western Australia

BACKGROUND

Otitis media (OM) is the most common paediatric illness for which antibiotics are prescribed. In Australian Aboriginal children OM is frequently asymptomatic and starts at a younger age, is more common and more likely to result in hearing loss than in non-Aboriginal children. Absent transient evoked otoacoustic emissions (TEOAEs) may predict subsequent risk of OM.

METHODS

100 Aboriginal and 180 non-Aboriginal children in a semi-arid zone of Western Australia were followed regularly from birth to age 2 years. Tympanometry was conducted at routine field follow-up from age 3 months. Routine clinical examination by an ENT specialist was to be done 3 times and hearing assessment by an audiologist twice. TEOAEs were measured at ages <1 and 1-2 months. Cox proportional hazards model was used to investigate the association between absent TEOAEs and subsequent risk of OM.

RESULTS

At routine ENT specialist clinics, OM was detected in 55% of 184 examinations in Aboriginal children and 26% of 392 examinations in non-Aboriginal children; peak prevalence was 72% at age 5-9 months in Aboriginal children and 40% at 10-14 months in non-Aboriginal children. Moderate-severe hearing loss was present in 32% of 47 Aboriginal children and 7% of 120 non-Aboriginal children aged 12 months or more. TEOAE responses were present in 90% (46/51) of Aboriginal children and 99% (120/121) of non-Aboriginal children aged <1 month and in 62% (21/34) and 93% (108/116), respectively, in Aboriginal and non-Aboriginal children at age 1-2 months. Aboriginal children who failed TEOAE at age 1-2 months were 2.6 times more likely to develop OM subsequently than those who passed. Overall prevalence of type B tympanograms at field follow-up was 50% (n = 78) in Aboriginal children and 20% (n = 95) in non-Aboriginal children.

CONCLUSION

The burden of middle ear disease is high in all children, but particularly in Aboriginal children, one-third of whom suffer from moderate-severe hearing loss. In view of the frequently silent nature of OM, every opportunity must be taken to screen for OM. Measurement of TEOAEs at age 1-2 months to identify children at risk of developing OM should be evaluated in a routine health service setting.

An overview of acute otitis media in Australian Aboriginal children living in remote communities

Australian Aboriginal children experience early, persistent and severe middle ear infections. We conducted a review of the medical literature that addressed acute otitis media (AOM) in Australian Aboriginal children. Comparisons were made with the recent guidelines on the diagnosis and management of AOM prepared by the American Academies of Pediatrics and Family Physicians (AAP & AAFP 2004). Otitis media in Aboriginal children living in remote communities begins in the first 3 months of life following early bacterial colonisation. Young children with persistent signs of suppurative disease (bulging of the tympanic membrane or middle ear discharge) are probably most at risk of developing chronic suppurative otitis media.

Early otitis media among Minnesota American Indians: the Little Ears Study

OBJECTIVES

We examined relationships between otitis media risk factors, sociodemographic characteristics, and maternal knowledge and attitudes and early onset of otitis media.

METHODS

Pregnant women from Minnesota American Indian reservations and an urban clinic were enrolled in our study between 1998 and 2001. Follow-up was performed on enrollees' infants until the children were 2 years old. Research nurses collected data by ear examination, from interviews and questionnaires given to enrolled mothers, and otitis media episodes that were abstracted from medical records.

RESULTS

Sixty-three percent of infants had experienced an otitis media episode by 6 months of age. Logistic regression analyses showed that maternal otitis media history, infant history of upper respiratory infection, and compliance with study visits were significantly related to early otitis media onset. Although high percentages of infants were exposed to cigarette smoke and other children and were formula fed, these factors were not related to otitis media. Mothers' prenatal awareness of otitis media risks associated with environmental tobacco smoke exposure and formula feeding did not predict their postpartum behaviors.

CONCLUSIONS

We found that infant history of upper respiratory infection and maternal otitis media history are risk factors for early otitis media in American Indian infants. Mothers' prepartum knowledge and attitudes regarding otitis media did not predict their postpartum avoidance of risk behaviors.

Upper respiratory tract bacterial carriage in Aboriginal and non-Aboriginal children in a semi-arid area of Western Australia

BACKGROUND

Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are associated with otitis media (OM). Indigenous children experience particularly high rates of OM. Few studies worldwide have described upper respiratory tract (URT) carriage in Indigenous and non-Indigenous children living in the same area.

AIM

The aim of this study was to describe URT bacterial carriage in Aboriginal and non-Aboriginal children in the Kalgoorlie-Boulder area, Western Australia, as part of an investigation into causal pathways to OM.

METHODS

Five hundred four and 1045 nasopharyngeal aspirates were collected from 100 Aboriginal and 180 non-Aboriginal children, respectively, followed from birth to age 2 years. Standard procedures were used to identify bacteria.

RESULTS

Overall carriage rates of S. pneumoniae, M. catarrhalis and H. influenzae in Aboriginal children were 49%, 50% and 41%, respectively, and 25%, 25% and 11% in non-Aboriginal children. By age 2 months S. pneumoniae and M. catarrhalis had been isolated from 37% and 36% of Aboriginal children and from 11% and 12% of non-Aboriginal children, respectively. From age 3 months onward, carriage rates in Aboriginal children were 51% to 67% for S. pneumoniae and M. catarrhalis and 42% to 62% for H. influenzae; corresponding figures for non-Aboriginal children were 26% to 37% for S. pneumoniae and M. catarrhalis and 11% to 18% for H. influenzae. Non-Aboriginal children had higher carriage rates in winter than in summer, but season had little effect in Aboriginal children. Staphylococcus aureus carriage was highest under age 1 month (55% Aboriginal, 61% non-Aboriginal) and was always higher in non-Aboriginal than Aboriginal children.

CONCLUSIONS

Interventions are needed to reduce high transmission and carriage rates, particularly in Aboriginal communities, to avoid the serious consequences of OM.

Association of surfactant protein A polymorphisms with otitis media in infants at risk for asthma

Background

Otitis media is one of the most common infections of early childhood. Surfactant protein A functions as part of the innate immune response, which plays an important role in preventing infections early in life. This prospective study utilized a candidate gene approach to evaluate the association between polymorphisms in loci encoding SP-A and risk of otitis media during the first year of life among a cohort of infants at risk for developing asthma.

Methods

Between September 1996 and December 1998, women were invited to participate if they had at least one other child with physician-diagnosed asthma. Each mother was given a standardized questionnaire within 4 months of her infant's birth. Infant respiratory symptoms were collected during quarterly telephone interviews at 6, 9 and 12 months of age. Genotyping was done on 355 infants for whom whole blood and complete otitis media data were available.

Results

Polymorphisms at codons 19, 62, and 133 in SP-A1, and 223 in SP-A2 were associated with race/ethnicity. In logistic regression models incorporating estimates of uncertainty in haplotype assignment, the 6A⁴/1A⁵haplotype was protective for otitis media among white infants in our study population (OR 0.23; 95% CI 0.07,0.73).

Conclusion

These results indicate that polymorphisms within SP-A loci may be associated with otitis media in white infants. Larger confirmatory studies in all ethnic groups are warranted.

The posterior attic: An observational study of aboriginal Australians with chronic otitis media (COM) and a theory relating to the low incidence of cholesteatomatous otitis media versus the high rate of mucosal otitis media

OBJECTIVE

The incidence of COM without cholesteatoma in Australian aboriginals is quoted as being between 25 and 47%. The incidence of cholesteatomatous OM is very low in comparison (between 1 and 3%). A comprehensive literature search found no studies offering an explanation for the large discrepancy between these two types of OM. We offer a theory to account for the disproportionate rates of the two types of OM together with an observational study on aboriginals with COM to substantiate our argument.

METHOD/RESULTS

The crux of our hypothesis centres on the anatomy of the posterior attic. We found that in a study of 40 aboriginal patients undergoing tympanoplasty with audiometric evidence of an intact ossicular chain that, after posterior tympanomeatal flap elevation, no part of the incudostapedial assembly was visible in 95% of cases denoting its location behind the posterior attic wall.

CONCLUSION

We hypothesise that in aboriginal ears the resulting 'crowding' of the posterior attic by the incudostapedial assembly results in narrowing of the epitympanic space which compromises atticoantral drainage, thus leading to mucosal COM, however supporting the posterior-superior segment of the tympanic membrane, impeding the formation of a retraction pocket, and cholesteatoma formation migrating into the mastoid antrum.

Otitis media in young Aboriginal children from remote communities in Northern and Central Australia: a cross-sectional survey

BACKGROUND

Middle ear disease (otitis media) is common and frequently severe in Australian Aboriginal children. There have not been any recent large-scale surveys using clear definitions and a standardised middle ear assessment. The aim of the study was to determine the prevalence of middle ear disease (otitis media) in a high-risk population of young Aboriginal children from remote communities in Northern and Central Australia.

METHODS

709 Aboriginal children aged 6-30 months living in 29 communities from 4 health regions participated in the study between May and November 2001. Otitis media (OM) and perforation of the tympanic membrane (TM) were diagnosed by tympanometry, pneumatic otoscopy, and video-otoscopy. We used otoscopic criteria (bulging TM or recent perforation) to diagnose acute otitis media.

RESULTS

914 children were eligible to participate in the study and 709 were assessed (78%). Otitis media affected nearly all children (91%, 95%CI 88, 94). Overall prevalence estimates adjusted for clustering by community were: 10% (95%CI 8, 12) for unilateral otitis media with effusion (OME); 31% (95%CI 27, 34) for bilateral OME; 26% (95%CI 23, 30) for acute otitis media without perforation (AOM/woP); 7% (95%CI 4, 9) for AOM with perforation (AOM/wiP); 2% (95%CI 1, 3) for dry perforation; and 15% (95%CI 11, 19) for chronic suppurative otitis media (CSOM). The perforation prevalence ranged from 0-60% between communities and from 19-33% between regions. Perforations of the tympanic membrane affected 40% of children in their first 18 months of life. These were not always persistent.

CONCLUSION

Overall, 1 in every 2 children examined had otoscopic signs consistent with suppurative ear disease and 1 in 4 children had a perforated tympanic membrane. Some of the children with intact tympanic membranes had experienced a perforation that healed before the survey. In this high-risk population, high rates of tympanic perforation were associated with high rates of bulging of the tympanic membrane.

The clinical course of acute otitis media in high-risk Australian Aboriginal children: a longitudinal study

BACKGROUND

It is unclear why some children with acute otitis media (AOM) have poor outcomes. Our aim was to describe the clinical course of AOM and the associated bacterial nasopharyngeal colonisation in a high-risk population of Australian Aboriginal children.

METHODS

We examined Aboriginal children younger than eight years who had a clinical diagnosis of AOM. Pneumatic otoscopy and video-otoscopy of the tympanic membrane (TM) and tympanometry was done every weekday if possible. We followed children for either two weeks (AOM without perforation), or three weeks (AOM with perforation), or for longer periods if the infection persisted. Nasopharyngeal swabs were taken at study entry and then weekly.

RESULTS

We enrolled 31 children and conducted a total of 219 assessments. Most children had bulging of the TM or recent middle ear discharge at diagnosis. Persistent signs of suppurative OM (without ear pain) were present in most children 7 days (23/30, 77%), and 14 days (20/26, 77%) later. Episodes of AOM did not usually have a sudden onset or short duration. Six of the 14 children with fresh discharge in their ear canal had an intact or functionally intact TM. Perforation size generally remained very small (<2% of the TM). Healing followed by re-perforation was common. Ninety-three nasophyngeal swabs were taken. Most swabs cultured Streptococcus pneumoniae (82%), Haemophilus influenzae (71%), and Moraxella catarrhalis (95%); 63% of swabs cultured all three pathogens.

CONCLUSION

In this high-risk population, AOM was generally painless and persistent. These infections were associated with persistent bacterial colonisation of the nasopharynx and any benefits of antibiotics were modest at best. Systematic follow up with careful examination and review of treatment are required and clinical resolution cannot be assumed.

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.

Middle ear problems in Aboriginal school children cause developmental and educational concerns

An epidemiological study was carried out in the year 2000 and sought to measure the occurrences of middle ear disease and hearing loss within school aged (4 years to 12 years) Aboriginal children. A number of the local schools and preschools in Coraki and Lismore with a high percentage of Aboriginal students were selected in an effort to identify service gaps regarding essential hearing screenings and assessments. A total of 185 (370 ears) Aboriginal children aged 4 years to 12 years were examined from four schools and three preschools. This examination included otoscopy, tympanometry and audiometry. Data were collected as each child was tested and this was then entered into a computer database on returning to the work place. Results indicated that 61.08% of these children had middle ear problems of some type. Unilateral hearing loss of 30 dB or greater was found in 10.80% of children, bilateral hearing loss of 30 dB and greater was found in 22.16%, and perforation of tympanic membranes in 3.24%. Suggestions are made in relation to the need for ongoing training of Aboriginal Community Audiometrists to provide community, school and preschool screening programs together with health related promotional activities to minimise the occurrences of ear infections.

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.

Beliefs about and responses to childhood ear infections: a study of parents in eastern North Carolina

Middle ear infection, also known as otitis media (OM), is a major public health problem among American children. Although clinical and epidemiological aspects of OM have been intensely studied, cultural factors that may be contributing to the problem of OM have received less attention. This article presents findings from an ethnographic study exploring beliefs about OM and responses to the illness among parents from eastern North Carolina. In-depth interviews were conducted with a convenience sample of nine mothers in order to learn more about parents' explanatory models of OM, the source of their beliefs, and how they respond to the illness. A survey instrument based on their statements was then constructed and administered to a convenience sample of 79 parents. The survey consisted of belief statements about OM, as well as questions pertaining to sources of beliefs, the home management of the disease, and the effects of the illness on families. A cultural consensus analysis of responses to belief statements indicates that parents shared a common model of OM. Beliefs about risks, symptoms, and causes of OM were similar to the current biomedical model of the illness, but their divergent beliefs about the diagnosis, prognosis and treatment of OM could lead to unnecessary use of health care services. Clinicians, family, and friends were reported to be important sources of information about OM. Parents also reported using similar home management strategies and care seeking behaviors to minimize the impact of the illness on their children and families. While these findings need to be replicated in studies with larger, more representative samples, this study suggest that ethnographic approaches may provide new insights into the cultural dimension of the problem of OM.

Outpatient and hospital visits associated with otitis media among American Indian and Alaska native children younger than 5 years

OBJECTIVE

To describe the burden of otitis media (OM) among American Indian and Alaska Native (AI/AN) children.

METHODS

OM morbidity among AI/AN younger than 5 years was evaluated using OM-associated outpatient visit and hospitalization rates. These rates were compared with outpatient and hospitalization rates for the general US population of children younger than 5 years. AI/AN children who were younger than 5 years and receiving care through the Indian Health Service or tribally operated facilities and US children younger than 5 years of age were studied.

RESULTS

From 1994--1996, the average annual rate of AI/AN OM-associated outpatient visits was 138 per 100 children younger than 5 years. Among AI/AN children younger than 1 year (infants), these rates were almost 3 times greater than those for US infants (318 vs 110 visits per 100 infants, respectively). AI/AN children 1 to 4 years of age had rates 1.5 times greater than US children of the same age (107 vs 65 visits per 100 children, respectively). AI/AN children also experienced higher rates of OM-associated hospitalization than did US children (5643 vs 2440 per 100 000 infants, 823 vs 665 per 100 000 1- to 4-year-olds).

CONCLUSION

We found that AI/AN children, especially AI/AN infants, have higher OM-associated outpatient and hospitalization rates than those for the general US population of children. The disparity in rates suggests that additional prevention programs and continued resources are needed to reduce OM morbidity among AI/AN children.

Longitudinal observations (1987-1997) on the prevalence of middle ear disease and associated risk factors among Inuit children of Inukjuak, Nunavik, Quebec, Canada

The prevalence of middle ear disease in 2-6 year old children in 1997 was compared with that observed in 1987 in the same Inuit community in northern Quebec. Risk and protective factors associated with middle ear disease were also assessed. A total of 122 children participated. The assessments included: otological examination, cerumen sampling for analysis of organochlorine compounds, medical file review, and parent questionnaire regarding environmental and lifestyle factors. Comparison of ear examination results in 1997 and 1987 showed that there had been no change in the prevalence of chronic otitis media [9.4% to 10.8%] and proportion of ear drums with minimal scarring [45.6% to 45.4%], an increase in the proportion of normal ear drums [23.9% to 39.0%], a decrease the proportion with maximal scarring [17.8% to 2.0%] and little difference in the rate of serous otitis media [3.3% to 2.8%]. Factors found to be significantly associated with middle ear disease included: number of persons/bedroom, number of siblings with a history of ear disease, age at first, second and third visit to the nursing station for ear problems, and type of milk (formula vs. non-formula) in bottle fed children.

Direct expenditures related to otitis media diagnoses: extrapolations from a pediatric medicaid cohort

BACKGROUND

Treatment of otitis media in children is associated with substantial expenditures because of its high frequency during childhood. Vaccines against respiratory pathogens causing otitis media are now being developed. Information about otitis media-related medical expenditures will be needed to determine the cost-effectiveness of these preventive interventions.

METHODS

This study used utilization data from claims to impute otitis media-related expenditures for medical visits, pharmaceuticals, and surgical procedures for 87 057 children 13 years of age and younger who were continuously enrolled in Colorado's fee-for-service Medicaid program during 1992. International Classification of Disease, Ninth Revision diagnostic codes were used to identify visits for otitis media. An antibiotic was considered to have been prescribed to treat otitis media if it was dispensed up to 24 hours before or within 48 hours after a physician encounter showing a diagnosis of otitis media. All tympanostomies, mastoidectomies, and adenoidectomies were assumed to be related to otitis media. Expenditures were imputed from utilization using a Medicaid fee schedule. National expenditures for 1992 to treat otitis media were extrapolated from Colorado's Medicaid data. We adjusted for differences between Colorado and the United States as a whole in terms of price, number, and intensity of services; for differences in reimbursement rates by service between Medicaid and private insurance; and for differences in utilization between Medicaid enrollees and the uninsured. To provide a more current expression of medical expenditures for otitis media, we inflated the 1992 expenditure estimates to 1998 dollars using the Consumer Price Index published by the US Bureau of Labor Statistics.

RESULTS

Twenty-eight percent of children experienced at least 1 episode of diagnosed otitis media. The proportion of children with a diagnosis of otitis media was highest (42%-60%) in the 7-month to 36-month age range. The proportion was also higher among white (34.5%) and Hispanic (25.3%) children than among black children (18.5%), as well as among rural (34.5%) compared with urban children (27.2%). Children 19 to 24 months of age incurred the highest total annual expenditures per child with otitis media ($239.68). Expenditures for drugs, visits, and procedures were all highest for this group. The per-patient cost to Medicaid was greater for visits than for drugs or procedures across all age groups. Total per-patient expenditures were higher for males ($174.67) than for females ($154.47) and higher for white children ($176.59) than for Hispanic ($154.12) or black children ($134.44). The differences among the ethnic groups can be attributed almost entirely to differences in expenditures for procedures and drugs. Although mean expenditures per patient varied substantially by some patient characteristics (eg, race), these differences accounted for only a small fraction of the enormous variation in costs per patient. Including children with and without otitis media, age-specific estimated expenditures per child peaked among children 1 ($132.94) and 2 years of age ($88.72). Children 3 to 6 years of age incurred expenditures only one third as great as those incurred by children 1 year of age. Total national expenditures were estimated to have been approximately $4.1 billion in 1992 dollars and $5.3 billion in 1998 dollars. Over 40% of national expenditures to treat otitis media in children younger than 14 years of age were incurred for children between 1 and 3 years of age ($453 per capita in 1992 dollars over these 2 years vs $1027 for all years of age from 2 to 13). Nationally, expenditures for visits remained the largest component of expenditures.

LIMITATIONS

This study assessed expenditures from the point of view of the health care system; that is, no social costs, such as lost work time, or expenditures not normally covered by insurance, such as those for transportation, we

Susceptibility to infections and immune status in Inuit infants exposed to organochlorines

We investigated whether organochlorine exposure is associated with the incidence of infectious diseases in Inuit infants from Nunavik (Arctic Quebec, Canada). We compiled the number of infectious disease episodes during the first year of life for 98 breast-fed and 73 bottle-fed infants. Concentrations of organochlorines were measured in early breast milk samples and used as surrogates to prenatal exposure levels. Immune system parameters were determined in venous blood samples collected from infants at 3, 7, and 12 months of age. Otitis media was the most frequent disease, with 80. 0% of breast-fed and 81.3% of bottle-fed infants experiencing at least one episode during the first year of life. During the second follow-up period, the risk of otitis media increased with prenatal exposure to p,p'-DDE, hexachlorobenzene, and dieldrin. The relative risk (RR) for 4- to 7-month-old infants in the highest tertile of p, p'-DDE exposure as compared to infants in the lowest tertile was 1. 87 [95% confidence interval (CI), 1.07-3.26]. The RR of otitis media over the entire first year of life also increased with prenatal exposure to p,p'-DDE (RR, 1.52; CI, 1.05-2.22) and hexachlorobenzene (RR, 1.49; CI, 1.10-2.03). Furthermore, the RR of recurrent otitis media ( [Greater/equal to] 3 episodes) increased with prenatal exposure to these compounds. No clinically relevant differences were noted between breast-fed and bottle-fed infants with regard to immunologic parameters, and prenatal organochlorine exposure was not associated with immunologic parameters. We conclude that prenatal organochlorine exposure could be a risk factor for acute otitis media in Inuit infants.

Susceptibility to infections and immune status in Inuit infants exposed to organochlorines

We investigated whether organochlorine exposure is associated with the incidence of infectious diseases in Inuit infants from Nunavik (Arctic Quebec, Canada). We compiled the number of infectious disease episodes during the first year of life for 98 breast-fed and 73 bottle-fed infants. Concentrations of organochlorines were measured in early breast milk samples and used as surrogates to prenatal exposure levels. Immune system parameters were determined in venous blood samples collected from infants at 3, 7, and 12 months of age. Otitis media was the most frequent disease, with 80. 0% of breast-fed and 81.3% of bottle-fed infants experiencing at least one episode during the first year of life. During the second follow-up period, the risk of otitis media increased with prenatal exposure to p,p'-DDE, hexachlorobenzene, and dieldrin. The relative risk (RR) for 4- to 7-month-old infants in the highest tertile of p, p'-DDE exposure as compared to infants in the lowest tertile was 1. 87 [95% confidence interval (CI), 1.07-3.26]. The RR of otitis media over the entire first year of life also increased with prenatal exposure to p,p'-DDE (RR, 1.52; CI, 1.05-2.22) and hexachlorobenzene (RR, 1.49; CI, 1.10-2.03). Furthermore, the RR of recurrent otitis media ( [Greater/equal to] 3 episodes) increased with prenatal exposure to these compounds. No clinically relevant differences were noted between breast-fed and bottle-fed infants with regard to immunologic parameters, and prenatal organochlorine exposure was not associated with immunologic parameters. We conclude that prenatal organochlorine exposure could be a risk factor for acute otitis media in Inuit infants.

Otitis media in Inuit children in the Eastern Canadian Arctic--an overview--1968 to date

Clinical observations made on the Inuit in the Eastern Canadian Arctic during the past three decades support that the current high prevalence of chronic otitis media among their children is a relatively new phenomenon. It is a social/economic disease related to their urbanization that occurred following World War II when the vast majority of the Inuit abandoned their isolated nomadic way of life and moved into permanent settlements. The disease, in a great many, runs a natural course with spontaneous healing. There is evidence that as the new millennium approaches the prevalence of the disease among the children is decreasing.

Otitis media in Australian Aboriginal children: an overview

Remote and rural Australian Aboriginal children achieve lower standards of numeracy and literacy than their non-Aboriginal peers. The reasons are complex, but extraordinarily high rates of conductive hearing loss (> 50%) are, in part, responsible for poor classroom success. In addition to the burden of acute bacterial respiratory illness (highest rates of invasive pneumococcal disease in the literature), chronic disease affects virtually every young child. In the Aboriginal community studied, otitis media commenced within 3 months of birth for all infants, progressed to chronic suppurative otitis media in 60% and did not resolve throughout early childhood. Our findings, supported by mathematical modelling, show that the vicious cycle of endemic chronic otitis media is perpetuated by high carriage rates of multiple species and multiple types of respiratory bacterial pathogens, by high cross-infection rates and thus, by early age of pathogen acquisition and prolonged carriage. Long-term damage to respiratory mucosa, possibly linked to later chronic bronchitis and bronchiectasis, follows a constant series of infections by each of the concurrently held pathogens, without periods of recovery. Overcrowding and poor hygiene promote this vicious cycle. Medical and social options for intervention are limited by poor resources, low expectations for health and a complex biology that includes antibiotic resistant pneumococci.

Nonencapsulated Haemophilus influenzae in Aboriginal infants with otitis media: prolonged carriage of P2 porin variants and evidence for horizontal P2 gene transfer

Aboriginal infants in the Northern Territory of Australia experience recurrent otitis media from an early age. Nonencapsulated Haemophilus influenzae (NCHi) colonization of the nasopharynx initially occurs within weeks of birth, persists throughout infancy and most of childhood, and contributes to otitis media. We established previously that the high carriage rates of NCHi in these infants result from concurrent and successive colonization with multiple strains, with sequential elimination of dominant strains. We have now sequenced loops 4, 5, and 6 of the NCHi P2 porin gene and characterized several strains with prolonged carriage times. Furthermore, despite a wide diversity of P2 gene sequences, we have four examples of P2 gene identity for strains with different genetic backgrounds as characterized by PCR ribotyping and randomly amplified polymorphic DNA typing, which leads us to suggest that the P2 gene has been transferred between strains. We also discuss the possibility that the paradoxical observation of cocolonization and prolonged carriage of P2-identical strains is related to immune suppression or tolerance in the host.

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.

Presentation of early otitis media in 'Top End' Aboriginal infants

Otitis media is highly prevalent in Aboriginal Australians. This study found that otitis media was universal in 41 Aboriginal infants from the north of the Northern Territory, who were examined monthly from birth; more than one-third had experienced eardrum perforation. The earliest age at perforation was 44 days and the mean duration was 44.3 days. All subjects had acute otitis media or otitis media with effusion before perforation and after drum healing. This study, therefore, recommends that individual medical treatment should not be postponed until drum perforation occurs because otitis media develops first behind an intact drum and then may progress to perforation.

Patterns of persistent otitis media in the first year of life in aboriginal and non-aboriginal infants

Australian Aboriginal infants experience very early otitis media (OM). A previous study reported that OM with effusion (OME) or acute OM (AOM) was observed in the first 8 weeks of life in 95% of 22 Aboriginal infants, but that OME was seen in only 30% of 10 non-Aboriginal infants. Tympanic membrane perforation was reported for 1 Aboriginal subject at 8 weeks of age. This requires further investigation, because early OM onset has been demonstrated in non-Aboriginal groups to increase the risk of chronic and persistent ear disease in later childhood. This prospective study used otoscopy and tympanometry to describe the course of OM in infants examined repeatedly from soon after birth. Disease course was described in two ways, based upon earlier findings from other studies of Aboriginal schoolchildren. First, patterns of disease in the first year were identified; non-Aboriginal infants had occasional episodes of OME or AOM from which they recovered spontaneously, usually within 1 month; Aboriginal infants had persistent AOM, OME, or tympanic membrane perforation with discharge that rarely, if ever, resolved to normal. Second, conditional probabilities were calculated for ear state transitions at consecutive ear examinations, and a model of the course of OM was proposed for the Aboriginal infants. Results also suggested that binaural patterns of chronic OM described previously in Aboriginal schoolchildren may already be established in the first year of life. These findings will help service providers determine when to intervene to avoid the chronic consequences of early OM.

Otitis media in a population of black American and white American infants, 0-2 years of age

To determine the incidence of otitis media (OM) and the bacteriology of acute otitis media (AOM) in a clinic population of young children in Pittsburgh, 138 black infants and 60 white infants were followed from birth to 2 years of age, examined at monthly intervals and whenever an upper respiratory tract infection (URI) or OM intervened. By 24 months of age the cumulative incidence of episodes of AOM was 43% and 42%, and of episodes of middle-ear effusion (MEE) was 86% and 85% in black and white infants, respectively. The average rate of episodes of AOM was 0.41 and 0.39 and of episodes of MEE was 1.68 and 1.70 in black and white infants, respectively. Tympanocentesis was performed for episodes of AOM and the following organisms were isolated from black and white infants, respectively: Streptococcus pneumoniae 43% and 43% of episodes; Moraxella catarrhalis 24% and 24%; non-typable Haemophilus influenzae 18% and 24%; and Haemophilus influenzae type b 5% and 0%. In both black and white infants first born children had less ear disease. We found no difference in the incidence of otitis media during the first 2 years of life between black and white infants.

Onset of otitis media in the first eight weeks of life in aboriginal and non-aboriginal Australian infants

Otitis media (OM) is highly prevalent among Aboriginal Australians, in whom eardrum perforations with discharge have been reported in the first 3 months of life. Only one published study, however, has described middle ear status at birth or prior to eardrum perforation in young Aboriginal infants. This prospective study used otoscopy, tympanometry, and hearing tests to compare middle ear status and hearing sensitivity in Aboriginal and non-Aboriginal neonates. Immobile eardrums were observed immediately after birth, but mobility generally appeared within the first week. At examinations at 6 to 8 weeks of age, OM with effusion or acute OM was observed in 95% of 22 Aboriginal infants, but OM with effusion was seen in only 30% of 10 non-Aboriginal infants. There was a clinic record of unilateral perforation in 1 Aboriginal infant only. Hearing impairment was demonstrated by auditory brain stem response in 5 ears, all with evidence of middle ear abnormalities. Improved knowledge and diagnosis of the signs and symptoms of OM will contribute to improvements in the provision of early medical intervention to populations at high risk for early OM.

Otitis media. How are First Nations children affected?

To determine whether otitis media affects First Nations children more severely than other children, I studied the data on otitis media occurrence among these children; on risk factors, particularly bottle feeding; and on prevention and treatment. First Nations children do seem to have more severe otitis media than other children. Health promotion might help ameliorate the situation. Supporting breastfeeding in the community is strongly recommended.

The epidemiology of invasive pneumococcal disease in Alaska, 1986-1990--ethnic differences and opportunities for prevention

To assess prevention strategies for pneumococcal disease in Alaska, prospective surveillance during 1986-1990 identified 672 invasive pneumococcal infections, including 315 among Alaska Natives. Age-adjusted annual incidence was 74 per 100,000 for Alaska Natives and 16 per 100,000 for nonnatives. The annual incidence in Alaska Native children < 2 years old was 624 per 100,000; rates of 84 per 100,000 for meningitis and 290 per 100,000 for bacteremic pneumonia were 8-10 times higher than for other US groups. By age 75, cumulative incidence (7%) and mortality (1%) in Alaska Natives were almost 4 times higher than for nonnatives. Only 17% of Alaska Native adults with predisposing conditions and invasive infections previously received pneumococcal vaccine. For Alaska Natives, a proposed heptavalent conjugate pneumococcal vaccine will include serotypes responsible for 85% of invasive isolates from children < 2 years but only 32% of those from adults. The 23-valent polysaccharide pneumococcal vaccine, which contains > 94% of serotypes identified in Alaska Native toddlers and adults, should be used more widely.

Reflectometric screening for otitis media: inconsistencies in a sample of Australian aboriginal children

This paper evaluates reflectometry, or acoustic otoscopy, as an objective test for the mobility of intact tympanic membranes in Australian Aboriginal children, who are a population at high risk for otitis media. Reflectometry, pneumotoscopy and tympanometry were compared in 395 ears in 198 Aboriginal children living in remote communities in Northern Australia. A strong interaction was found between pneumotoscopy and tympanometry (P < 0.001), there was some interaction between pneumotoscopy and reflectometry (breakpoint 5.0) (P < 0.05) and there was no significant interaction between reflectometry and tympanometry. Results showed that intra-observer and inter-observer agreement for measures of reflectivity were 0.87 and 0.83, respectively. Unexpected differences between reflectivity measures for right (mean 5.4 units) and left (mean 4.9 units) ears and for different test locations were attributed to procedural artifact or training effects. It was concluded that, despite its practical advantages, reflectometry cannot be recommended as a screening tool for tympanic membrane (TM) immobility in this population.

The light at the end of the tunnel associated with the high prevalence of chronic otitis media among Inuit elementary school children in the Eastern Canadian Arctic is now visible

Longitudinal observations made during the past two decades on the prevalence of chronic ear disease in Inuit Elementary School Children in the Eastern Canadian Arctic reveal that as the current segment of this population enters into the 1990's a significant decrease in the prevalence is occurring. While we can speculate ad infinitum why this is happening we really do not know the answer. The usual cliché is adaptation to contact, improved medical/social services, housing, diet, etc.

The prevalence of hearing impairment amongst Maori schoolchildren

A survey of hearing amongst a population of Maori schoolchildren in the eastern North Island of New Zealand has demonstrated a high prevalence of hearing impairment. Out of 194 children undergoing audiometry an impairment of 20 dB or greater at 0.5, 1.2 and 4 kHz was found in the worse hearing ear in 29% and in the better hearing ear in 12%. Comparison with a similar survey done in the same valley in 1977 revealed an apparent reduction in the prevalence of hearing loss and the prevalence of otitis media. This improvement appears to be due to a reduced prevalence of otitis media. An unexpected finding was that at least 2% of the children had a bilateral sensorineural hearing impairment.

Infant tympanometry: differential results by race

Black (N = 63) and White (N = 74) infants, ages 6-13 months, were screened by tympanometry for signs of middle ear dysfunction. More White infants (57%) than Black (33%) failed initial screening (p less than .01). Retest of initial failures after a minimum 6-week interval showed an overall reduction in failure rates, but the significant (p less than .05) racial effect was still obtained. Implications of these findings for the clinician are discussed.

Otologic findings in an Inuit population of cleft palate children

Otitis media with effusion is almost universal in infants with cleft palate. Inuit children have a very high incidence of otitis media. The otologic problems of Inuit infants and children with cleft palate have not previously been reported. The current study presents 14 Inuit children with cleft palate. All show significant otitis media with effusion or chronic otitis media with tympanic membrane perforation. The management of otitis media in this special population of cleft palate children is discussed.

Racial and familial factors in otitis media. A point prevalence study on Easter Island

Of the 249 children aged 5 to 9 years who live on Easter Island, 220 underwent complete otolaryngological evaluation. Twenty children were found to have otitis media (acute, chronic, or both). Three of these children were genetically impure natives, nine were of mixed parentage, and eight were "continentals" (with a birth origin other than the island). None of the genetically pure natives had otitis media. Our data show that, in a population with all factors in common except for familial and racial background, the point prevalence of otitis media is higher in children of mixed or continental origin than in genetically pure native children. The high prevalence of otitis media in children of mixed parentage and in one particular family of European ancestry suggests the presence of intrinsic or pronicity factors that are seemingly transmissible.

Lack of association of cleft uvula with otitis media in Apache Indian children

Cleft uvula occurs in approximately 20% of Athabaskan Indians. The association of cleft uvula with otitis media was examined in a cohort of 175 Apache Indian children followed up prospectively from birth. No association was found between the occurrence of cleft uvula and the rate, frequency, or timing of otitis media attacks.