Incidence and Determinants of Ventilation Tubes in Denmark

Masked speech recognition by 6-13-year-olds with early-childhood otitis media: effects of acoustic condition and otologic history

OBJECTIVE

To investigate speech recognition in school-age children with early-childhood otitis media (OM) in conditions with noise or speech maskers with or without interaural differences. To also investigate the effects of three otologic history factors.

DESIGN

Using headphone presentation, speech recognition thresholds (SRTs) were measured with simple sentences. As maskers, stationary speech-shaped noise (SSN) or two-talker running speech (TTS) were used. The stimuli were presented in a monaural and binaural condition (SSN) or a co-located and spatially separated condition (TTS). Based on the available medical records, overall OM duration, OM onset age, and time since the last OM episode were estimated.

STUDY SAMPLE

6-13-year-olds with a history of recurrent OM (N = 42) or without any ear diseases (N = 20) with normal tympanograms and audiograms at the time of testing.

RESULTS

Mixed-model regression analyses that controlled for age showed poorer SRTs for the OM group (Δ-value = 0.84 dB, p = 0.009). These appeared driven by the spatially separated, binaural, and monaural conditions. The OM group showed large inter-individual differences, which were unrelated to the otologic history factors.

CONCLUSIONS

Early-childhood OM can affect speech recognition in different acoustic conditions. The effects of the otologic history warrant further investigation.

Middle ear effusion, ventilation tubes and neurological development in childhood

BACKGROUND

Otitis media with middle ear effusion (MEE) can be treated with ventilation tubes (VT) insertion, and it has been speculated that prolonged MEE in childhood can affect neurological development, which in turn may be important for later academic achievements.

OBJECTIVE

To investigate the association between middle ear effusion (MEE), treatment with ventilation tubes (VT) and childhood neurological development.

STUDY DESIGN

We examined 663 children from the Copenhagen Prospective Studies on Asthma in Childhood 2010 (COPSAC2010) unselected mother-child cohort study. Children were followed by study pediatricians with regular visits from pregnancy until 3 years of age. MEE was diagnosed using tympanometry at age 1, 2 and 3 years. Information regarding VT from age 0-3 years was obtained from national registries. We assessed age at achievement of gross motor milestones from birth, language scores at 1 and 2 years, cognitive score at 2.5 years and general development score at age 3 years using standardized quantitative tests.

RESULTS

Children with MEE had a lower 1-year word production vs. children with no disease: (median 2, IQR [0-6] vs. 4, IQR [1-7]; p = 0.017), and a lower 1-year word comprehension (median 36; IQR [21-63] vs. 47, IQR [27-84]; p = 0.03). Children with VT had a lower 2-5-year cognitive score vs. children with no disease; estimate -2.34; 95% CI [-4.56;-0.12]; p = 0.039. No differences were found between children with vs. without middle ear disease regarding age at achievement of gross motor milestones, word production at 2 years or the general developmental score at 3 years.

CONCLUSION

Our study supports the previous findings of an association between MEE and concurrent early language development, but not later neurological endpoints up to the age of 3. As VT can be a treatment of those with symptoms of delayed development, we cannot conclude whether treatment with VT had positive or negative effects on neurodevelopment.

Association of Prenatal Antibiotics and Mode of Birth With Otolaryngology Surgery in Offspring: A National Data Linkage Study

BACKGROUND

Pediatric otolaryngology surgery is commonly performed after recurrent infections and allergy/atopy. Prenatal antibiotic exposure and cesarean section deliveries increase the risk of severe infection and allergy/atopy in the offspring, but the relationship with common, related surgical outcomes is unknown. This study measures the associations between prenatal antibiotic use and mode of birth with common pediatric otolaryngology surgery.

METHODS

Data linkage analysis of all live-born, singleton children, born between 2008 and 2018 was done using Norwegian national health registry data. Exposures of interest were prenatal antibiotics and mode of birth. The primary outcome was common otolaryngology surgery before 10 years of age. Exposure-outcome associations were estimated through multivariable Cox proportional hazards models adjusting for predefined covariates. Interaction between exposures was explored.

RESULTS

Of 539,390 children, 146,832 (27.2%) had mothers who were prescribed antibiotics during pregnancy, 83,473 (15.5%) were delivered via cesarean section, and 48,565 (9.0%) underwent an otolaryngology surgery during the study period. Prenatal antibiotic exposure [adjusted hazard ratio (aHR), 1.22; 95% CI: 1.20-1.24] and cesarean section (aHR, 1.14; 95% CI: 1.11-1.16) were each associated with otolaryngology surgery after mutual adjustment. There was some evidence of an interaction between the 2 exposures (P = 0.03).

CONCLUSIONS

Antibiotic exposure in pregnancy and cesarean section may adversely affect early immune development and increase the risk of recurrent upper airway infections and allergy/atopy that may require otolaryngology surgery. Mechanistic studies are warranted to explore genetic and/or molecular pathways that explain these findings. This may identify potential therapeutic targets to reduce the burden of otolaryngology surgery.

Pediatric Outpatient Prescriptions in Countries With Advanced Economies in the 21st Century: A Systematic Review

Importance

An international comparison of pediatric outpatient prescriptions (POPs) is pivotal to investigate inadequate practices at the national scale and guide corrective actions.

Objective

To compare annual POP prevalence among Organisation for Economic Co-operation and Development (OECD) member countries.

Evidence Review

Two independent reviewers systematically searched PubMed, Embase, and institutes of public health or drug agency websites for studies published since 2000 and reporting POP prevalence (expressed as number of patients aged <20 years with ≥1 POP per 1000 pediatric patients per year) in OECD member countries or large geographic areas within them. Risk of bias was assessed for exhaustiveness and representativeness. Prevalence ratios (PRs) were used to compare the highest and lowest POP prevalence among countries overall, by levels of Anatomical Therapeutic Chemical (ATC) classification for the overall pediatric population, and by age group (ie, ages <5-6 vs ≥5-6 years), stratifying on prescription-only drug (POD) status.

Findings

Among 11 studies performed on 3 regional and 8 national medicoadministrative databases in 11 countries, 35 552 550 pediatric patients were included. The overall risk of bias was low (10 studies were representative [90.9%], and the prevalence denominator included nonusers of health care for 9 studies [81.8%]). Prevalence of 1 or more POP per year ranged from 480 to 857 pediatric patients per 1000 in Sweden and France, respectively (PR, 1.8 [95% CI, 1.8-1.8]). Overall, among 8 studies reporting ATC level 1 drugs, Denmark had the lowest POP prevalence (eg, systemic hormonal preparations: 9 pediatric patients per 1000 per year) and France the highest (eg, systemic hormonal preparation: 216 pediatric patients per 1000 per year). Among 8 studies reporting ATC level 2 drugs for PODs, the PR between France and Denmark was 108.2 (95% CI, 108.2-108.2) for systemic corticosteroids and 2.1 (95% CI, 2.1-2.1) for drugs for obstructive airway disease. The PR for antibiotics was 3.4 (95% CI, 3.4-3.4) between New Zealand and Sweden. For pediatric patients aged 5 to 6 years or older, the PR for sex hormones was 2.1 (95% CI, 2.1-2.1) between Denmark and France. Among 7 studies reporting ATC level 5 drugs, the prevalence of the 10 most prevalent PODs was less than 100 pediatric patients per 1000 per year in Scandinavian countries and the Netherlands and less than 300 pediatric patients per 1000 per year in France and New Zealand.

Conclusions and Relevance

This study found large between-country variations in POPs, which may suggest substantial inappropriate prescriptions. The findings may suggest guidance for educational campaigns and regulatory decisions in some OECD member countries.

Postoperative controls of ventilation tubes in children by general practitioner or otolaryngologist? Study protocol for a multicenter randomized non-inferiority study (The ConVenTu study)

BACKGROUND

Otitis media with effusion is the major cause of acquired hearing problems in children. Some of the affected children need surgery with ventilation tubes in the tympanic membrane to reduce ear complaints and to improve hearing, middle ear function, and health-related quality of life. This is one of the most common ambulatory surgeries performed on children. Postoperative controls are needed to assess that the tubes are functional, to evaluate whether hearing loss has been improved, and to handle potential complications. The follow-up may continue for years and are usually done by otolaryngologists. Nevertheless, there exist no evidence-based guidelines concerning the level of expertise needed for postoperative controls of the ventilation tubes. The aim of this protocol is to describe the ConVenTu study that evaluates whether postoperative controls performed by general practitioners (GPs) represent a safe and sufficient alternative to controls performed by otolaryngologists.

METHODS/DESIGN

Multicenter randomized non-inferiority study conducted in clinical settings in seven hospitals located in Norway. Discharged children with ventilation tubes, aged 3-10 years, are allocated randomly to receive postoperative controls by either an otolaryngologist at the hospital where they had ventilation tube surgery or their regular GP. Study participants are enrolled consecutively until 200 patients are included in each group. Two years after surgery, we will compare the pure tone average of hearing thresholds (primary endpoint) and middle ear function, complication rate, health-related quality of life and the parents' evaluations of the postoperative care (secondary endpoints).

DISCUSSION

This protocol describes the first randomized non-inferiority study of GPs performing postoperative controls after surgery with ventilation tubes. Results from this study may be utilized for deriving evidence-based clinical practice guidelines of the level of postoperative controls after ventilation tube surgery which is safe and sufficient.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02831985 . Registered on 13 July 2016.

Early life bacterial airway colonization, local immune mediator response and risk of otitis media

Introduction. Acute otitis media (AOM) is the most common bacterial infection in early childhood, but the underlying mechanisms making some children more susceptible are poorly understood.Aim. To examine the associations between bacterial airway colonization in early life and the risk of AOM and tympanostomy tube insertion (TTI), and whether such associations are modulated by an insufficient local immune mediator response to bacterial colonization.Methodology. Bacterial cultures from hypopharyngeal samples were obtained at 1 week, 1 month and 3 months of age in the Copenhagen Prospective Studies on Asthma in Childhood 2010 (COPSAC₂₀₁₀) cohort comprising 700 children. Twenty immune mediators were quantified from airway mucosal lining fluid sampled at 1 month. AOM symptoms were registered in a daily diary until 3 years. Information on TTI in the first 3 years was obtained from national registers.Results. Children colonized with Streptococcus pneumoniae at 1 month of age had increased incidence of AOM [aIRR 2.43 (1.14-5.21)] and children colonized with Moraxella catarrhalis at 1 month or Haemophilus influenzae at 3 months had an increased risk of TTI [aHR 1.45 (1.00-2.10) and 1.73 (1.10-2.71)]. There were no associations between the local immune mediator response to colonization and risk of AOM or TTI.Conclusion. Pathogenic bacterial airway colonization in early life was found to be associated with an increased risk of otitis media, albeit not consistently. These associations were independent of the local immune response to colonization.

Increase in tympanostomy tube placements despite pneumococcal vaccination, a population-based study

AIM

The aim was to estimate the impact of the 10-valent pneumococcal vaccine (PHiD-CV) on tympanostomy tube placements (TTP) in children under five years of age in Iceland.

METHODS

This population-based observational cohort study followed 11 consecutive birth-cohorts 2005-2015 from birth until their fifth birthday. Population registries were merged using national identification numbers. The risk of TTP was compared between birth-cohorts adjusted for the number of previous otitis media diagnoses and antimicrobial prescriptions. A Cox regression model was applied and the hazard ratio (HR) of TTP was estimated between each birth-cohort and the last vaccine non-eligible birth-cohort. The vaccine impact of PHiD-CV10 on TTP was estimated as 1-HR ×100%.

RESULTS

In total, 51 247 children were followed for 210 724 person-years, of which 14 351 underwent 20 373 procedures. The estimated vaccine impact on TTP was -6% (95% CI -16% to 2.7%). Children in the vaccine-eligible cohorts had fewer previous otitis media diagnoses and had been prescribed fewer antimicrobials prior to the procedure than children in the vaccine non-eligible cohorts.

CONCLUSION

Despite high uptake of PHiD-CV10, tympanostomy procedures increased in Iceland during the study period. Vaccine-eligible children had milder disease prior to the procedure. The reason underlying these findings are speculative.

Antibiotics in Pregnancy Increase Children's Risk of Otitis Media and Ventilation Tubes

OBJECTIVES

To study the association between antibiotic intake in pregnancy and the development of otitis media and placement of ventilation tubes (VTs) in the offspring under the hypothesis that antibiotics in pregnancy may alter the offspring's propensity for disease.

STUDY DESIGN

Data from the 700 children in the Copenhagen Prospective Studies on Asthma in Childhood 2010 unselected birth cohort study were used. Information on maternal antibiotic use and other exposures during pregnancy was collected prospectively from interviews and validated in national registries. Otitis media episodes were registered in a prospective diary for 3 years. Information regarding children's VTs was obtained from national registries.

RESULTS

There were 514 children who had diary information and were included in the analysis regarding otitis media episodes. For VTs analysis, 699 children were included. Thirty-seven percent of the mothers received antibiotics during pregnancy, and this was associated with increased risk of otitis media (adjusted hazard ratio 1.30; 95% CI 1.04-1.63; P = .02). The risk of receiving VTs was especially associated with third trimester antibiotics (adjusted hazard ratio 1.60; 95% CI 1.08-2.36, P = .02). The risk of otitis media increased with increasing number of treatments (per-level adjusted hazard ratio 1.20; 95% CI 1.04-1.40; P = .02), but for VTs this association was not significant after adjustment.

CONCLUSION

Maternal use of antibiotics during pregnancy is associated with an increased risk of otitis media and VT insertions in the offspring. Antibiotics late in pregnancy mainly contributed to these effects, pointing toward potential transmission of an unfavorable microbiome from mother to child.