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

Primary Health Care Interventions for Potentially Preventable Ear, Nose, and Throat Conditions in Rural and Remote Areas: A Systematic Review

Background:Primary and secondary level preventive primary health care programs providing early detection and timely management of ear, nose, and throat (ENT) conditions in rural and remote regions are fundamental to preventing downstream impacts on health, social, and educational outcomes. However, the range and quality of evidence is yet to be reviewed. Objectives: The study objectives were to identify and synthesize the evidence of primary health care interventions for detection and management of ENT conditions in rural and remote areas, and evaluate the quality of the research and effectiveness of interventions. Methods: A systematic literature search of 6 databases (February 2023). The review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, and the quality appraisal of studies was evaluated using the Mixed Methods Appraisal Tool (initial screening questions: Are there clear research questions? Do the collected data allow to address the research questions?). Results: Ten studies met the inclusion criteria. The results describe interventions for detection and management of respiratory tract infections, otitis media, and ear disease in primary health care settings. No studies met the inclusion criteria for tonsillitis. The role of community-based programs and allied health workers in the detection and management of ENT conditions was found to be effective in rural and remote regions. Only 2 of the studies met the screening criteria for quality appraisal. Conclusions: The study findings may inform future programs and policy development to address detection and management of ENT conditions in rural and remote primary care settings, and supports the need for further research on innovative models of care targeting potentially preventable hospitalizations through primary and secondary level prevention.

Trends in Otitis Media Ambulatory Visits in American Indian and Alaska Native Children During the Pneumococcal Conjugate Vaccine Period and the COVID-19 Pandemic

Otitis media-associated outpatient visits among American Indians/Alaska Natives children <5 years old decreased by 52% (100 to 48 per 100 children per year) from 2003 to 2019. Otitis media visits decreased by another 50% from 2019 to 2020, but rebounded between 2020 and 2021 back to a rate similar to 2019.

Telemedicine Referral to Improve Access to Specialty Care for Preschool Children in Rural Alaska: A Cluster-Randomized Controlled Trial

OBJECTIVES

Preschool programs provide essential preventive services, such as hearing screening, but in rural regions, limited access to specialists and loss to follow-up compound rural health disparities. We conducted a parallel-arm cluster-randomized controlled trial to evaluate telemedicine specialty referral for preschool hearing screening. The goal of this trial was to improve timely identification and treatment of early childhood infection-related hearing loss, a preventable condition with lifelong implications. We hypothesized that telemedicine specialty referral would improve time to follow-up and the number of children receiving follow-up compared with the standard primary care referral.

DESIGN

We conducted a cluster-randomized controlled trial in K-12 schools in 15 communities over two academic years. Community randomization occurred within four strata using location and school size. In the second academic year (2018-2019), an ancillary trial was performed in the 14 communities that had preschools to compare telemedicine specialty referral (intervention) to standard primary care referral (comparison) for preschool hearing screening. Randomization of communities from the main trial was used for this ancillary trial. All children enrolled in preschool were eligible. Masking was not possible because of timing in the second year of the main trial, but referral assignment was not openly disclosed. Study team members and school staff were masked throughout data collection, and statisticians were blinded to allocation during analysis. Preschool screening occurred once, and children who were referred for possible hearing loss or ear disease were monitored for follow-up for 9 months from the screening date. The primary outcome was time to ear/hearing-related follow-up from the date of screening. The secondary outcome was any ear/hearing follow-up from screening to 9 months. Analyses were conducted using an intention-to-treat approach.

RESULTS

A total of 153 children were screened between September 2018 and March 2019. Of the 14 communities, 8 were assigned to the telemedicine specialty referral pathway (90 children), and 6 to the standard primary care referral pathway (63 children). Seventy-one children (46.4%) were referred for follow-up: 39 (43.3%) in the telemedicine specialty referral communities and 32 (50.8%) in the standard primary care referral communities. Of children referred, 30 (76.9%) children in telemedicine specialty referral communities and 16 (50.0%) children in standard primary care referral communities received follow-up within 9 months (Risk Ratio = 1.57; 95% confidence interval [CI], 1.22 to 2.01). Among children who received follow-up, median time to follow-up was 28 days (interquartile range [IQR]: 15 to 71) in telemedicine specialty referral communities compared with 85 days (IQR: 26 to 129) in standard primary care referral communities. Mean time to follow-up for all referred children was 4.5 (event time ratio = 4.5; 95% CI, 1.8 to 11.4; p = 0.045) times faster in telemedicine specialty referral communities compared with standard primary care referral communities in the 9-month follow-up time frame.

CONCLUSIONS

Telemedicine specialty referral significantly improved follow-up and reduced time to follow-up after preschool hearing screening in rural Alaska. Telemedicine referrals could extend to other preventive school-based services to improve access to specialty care for rural preschool children.

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.

Expanding Clinical Trials Designs to Extend Equitable Hearing Care

Clinical trials are critically important to translate scientific innovations into clinical practice. Hearing healthcare depends on this translational approach to improve outcomes and quality of life. Across the spectrum of healthcare, there is a lack of diverse participation in clinical trials, a failure to recruit and retain underrepresented and underserved populations, and an absence of rigorous dissemination and implementation of novel research to broader populations. The field of hearing healthcare research would benefit from expanding the types and designs of clinical trials that extend hearing healthcare and novel interventions to diverse populations, as well as emphasizing trials that evaluate factors influencing how that care can be delivered effectively. This article explores the following: (1) the role, value, and design types of clinical trials (randomized controlled, cluster randomized, stepped wedge, and mixed methods) to address health equity; (2) the importance of integrating community and stakeholder involvement; and (3) dissemination and implementation frameworks and designs for clinical trials (hybrid trial designs). By adopting a broader range of clinical trial designs, hearing healthcare researchers may be able to extend scientific discoveries to a more diverse population.

Mobile health school screening and telemedicine referral to improve access to specialty care in rural Alaska: a cluster- randomised controlled trial

BACKGROUND

School-based programmes, including hearing screening, provide essential preventive services for rural children. However, minimal evidence on screening methodologies, loss to follow-up, and scarcity of specialists for subsequent care compound rural health disparities. We hypothesised telemedicine specialty referral would improve time to follow-up for school hearing screening compared with standard primary care referral.

METHODS

In this cluster-randomised controlled trial conducted in 15 rural Alaskan communities, USA, we randomised communities to telemedicine specialty referral (intervention) or standard primary care referral (control) for school hearing screening. All children (K-12; aged 4-21 years) enrolled in Bering Straight School District were eligible. Community randomisation occurred within four strata using location and school size. Participants were masked to group allocation until screening day, and assessors were masked throughout data collection. Screening occurred annually, and children who screened positive for possible hearing loss or ear disease were monitored for 9 months from the screening date for follow-up. Primary outcome was the time to follow-up after a positive hearing screen; analysis was by intention to treat. The trial was registered with ClinicalTrials.gov, NCT03309553.

FINDINGS

We recruited participants between Oct 10, 2017, and March 28, 2019. 15 communities were randomised: eight (750 children) to telemedicine referral and seven (731 children) to primary care referral. 790 (53·3%) of 1481 children screened positive in at least one study year: 391 (52∤1%) in the telemedicine referral communities and 399 (50∤4%) in the primary care referral communities. Of children referred, 268 (68·5%) in the telemedicine referral communities and 128 (32·1%) in primary care referral communities received follow-up within 9 months. Among children who received follow-up, mean time to follow-up was 41·5 days (SD 55·7) in the telemedicine referral communities and 92·0 days (75·8) in the primary care referral communities (adjusted event-time ratio 17·6 [95% CI 6·8-45·3] for all referred children). There were no adverse events.

INTERPRETATION

Telemedicine specialty referral significantly improved the time to follow-up after hearing screening in Alaska. Telemedicine might apply to other preventive school-based services to improve access to specialty care for rural children.

FUNDING

Patient-Centered Outcomes Research Institute.

Clinical perspectives on nasopharyngeal morphology in humans

The nasopharynx is an integral component of the upper aerodigestive tract, whose morphologic features share an intimate relationship with a vast array of clinical, functional, and quality of life conditions related to contemporary humans. Its composite architecture and central location amidst the nasal cavity, pharyngotympanic tube, palate, and skull base bears implications for basic physiologic functions including breathing, vocalization, and alimentation. Over the course of evolution, morphological modifications of nasopharyngeal anatomy have occurred in genus Homo which serve to distinguish the human upper aerodigestive tract from that of other mammals. Understanding of these adaptive changes from both a comparative anatomy and clinical perspective offers insight into the unique blueprint which underpins many clinical pathologies currently encountered by anthropologists, scientists, and otorhinolaryngologists alike. This discussion intends to familiarize readers with the fundamental role that nasopharyngeal morphology plays in upper aerodigestive tract conditions, with consideration of its newfound clinical relevance in the era of the COVID-19 pandemic.

Caring for American Indian and Alaska Native Children and Adolescents

American Indian and Alaska Native (AI/AN) populations have substantial health inequities, and most of their disease entities begin in childhood. In addition, AI/AN children and adolescents have excessive disease rates compared with the general pediatric population. Because of this, providers of pediatric care are in a unique position not only to attenuate disease incidence during childhood but also to improve the health status of this special population as a whole. This policy statement examines the inequitable disease burden observed in AI/AN youth, with a focus on toxic stress, mental health, and issues related to suicide and substance use disorder, risk of and exposure to injury and violence in childhood, obesity and obesity-related cardiovascular risk factors and disease, foster care, and the intersection of lesbian, gay, bisexual, transgender, queer, and Two-Spirit and AI/AN youth. Opportunities for advocacy in policy making also are presented.

Hearing loss and speech understanding in noise in Aboriginal and Torres Strait Islander children from locations varying in remoteness and socio-educational advantage

OBJECTIVE

Otitis media resulting in conductive hearing loss is a major health issue for Aboriginal and Torres Strait Islander children, which can also lead to the child developing spatial processing disorder (SPD). This study examined the prevalence of hearing loss and deficits in speech understanding in noise, including SPD, in Aboriginal and Torres Strait Islander children from schools varying in remoteness and socio-educational advantage.

METHOD

288 Aboriginal and Torres Strait Islander children aged 4-14 years from three schools varying in remoteness and socio-educational advantage completed audiological assessment and the Listening in Spatialized Noise - Sentences test to assess for hearing loss and SPD. Children also completed Sound Scouts, a self-administered tablet-based hearing test which screens for these deficits. The prevalence of hearing issues was compared to what is expected from a typical population.

RESULTS

The proportion of children with hearing problems was related to the school's socio-educational advantage, with higher proportions in schools with a lower socio-educational advantage. Proportions of children with speech-in-noise deficits (including SPD) was related to the remoteness of the school, with higher proportions in schools that were more remote.

CONCLUSIONS

The prevalence of hearing loss and SPD is much higher in Aboriginal and Torres Strait Islander children than described for non-Aboriginal populations, and is related to the socio-educational advantage or remoteness of the school. Resources are needed to reduce the incidence of hearing loss and health disparity in Aboriginal communities, especially those in remote areas with lower socio-educational advantages.

Transient Otoacoustic Emissions and Auditory Brainstem Responses in Low-Risk Cohort of Newborn and One-Month-Old Infants: Assessment of Infant Auditory System Physiology in the Prenatal Alcohol in SIDS and Stillbirth Network Safe Passage Study

BACKGROUND

The Prenatal Alcohol and Sudden Infant Death Syndrome and Stillbirth Network, known as the "Safe Passage Study," enrolled approximately 12,000 pregnant women from the United States and South Africa and followed the development of their babies through pregnancy and the infant's first year of life to investigate the role of prenatal alcohol exposure in the risk for sudden infant death syndrome (SIDS) and adverse pregnancy outcomes, such as stillbirth and fetal alcohol spectrum disorders.

PURPOSE

Auditory system tests were included in the physiologic test battery used to study the effects of prenatal alcohol exposure on neurophysiology and neurodevelopment, as well as potential causal relationships between neurodevelopmental disorders and SIDS and/or stillbirth. The purpose of this manuscript is to describe normative results when using the auditory test battery applied.

RESEARCH DESIGN

The test battery included the auditory brainstem response (ABR) and transient-evoked otoacoustic emissions (TEOAEs). Data were collected on individual ears of newborns and 1-month-old infants.

STUDY SAMPLE

From a cohort of 6,070 with auditory system exams, a normative subsample of 325 infants were selected who were not exposed prenatally to alcohol, cigarette smoke, or drugs nor were they preterm or low birthweight. The subsample is small relative to the overall study because of strict criteria for no exposure to substances known to be associated with SIDS or stillbirth and the exclusion of preterm and low birthweight infants. Expectant mothers were recruited from general maternity at two comprehensive clinical sites, in the northern plains in the United States and in Cape Town, South Africa. These populations were selected for study because both were known to be at high-risk for SIDS and stillbirth.

DATA COLLECTION AND ANALYSIS

ABR and TEOAE recordings were stored electronically. Peak latency and amplitude analysis of ABRs were determined by study personnel, and results were evaluated for differences by age, sex, test site, race, and ear (left versus right).

RESULTS

TEOAE findings were consistent with existing literature including the increase in signal-to-noise (SNR) over the first month of life. The SNR increase is due to an increase in amplitude of the emission. TEOAE amplitude asymmetry favoring the right ear was found, whereas SNR asymmetry was not, perhaps because of the small sample size. A nonsignificant trend toward larger responses in female babies was found; a result that is generally statistically significant in studies with larger samples. Latencies were found to be shorter in ABRs elicited in the right ear with amplitudes that were slightly bigger on average. An expected decrease in wave V latency was observed from birth to 1-month of age, but the finding was of borderline significance (p = 0.058).

CONCLUSIONS

One month is a short time to judge development of the auditory system; however, the ABR and TEOAE findings were consistent with current literature. We conclude that the auditory system data acquired for the Safe Passage Study, as reflected in the data obtained from this cohort of "unexposed" infants, is consistent with published reports of these auditory system measures in the general population.

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

Introduction

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

Objective

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

Material and methods

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

Results

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

Conclusions

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

Hearing Norton Sound: mixed methods protocol of a community randomised trial to address childhood hearing loss in rural Alaska

INTRODUCTION

Childhood hearing loss has implications for school achievement, economic outcomes and quality of life. This study will engage rural Alaska communities in research to improve the school hearing screening and referral process, partnering with stakeholders to develop a locally derived, evidence-based solution to improve timely identification and treatment of childhood hearing loss.

METHODS AND ANALYSIS

Mixed methods community randomised trial in 15 communities in the Norton Sound region of northwest Alaska. Data collection will span from April 2017 until February 2020. Qualitative and mixed methods components are described in this protocol and the community randomised trial in the companion protocol. Focus groups and community events will be held leading up to the randomised trial to obtain community perspectives on childhood hearing loss in Alaska and elicit community input during trial protocol refinement (exploratory sequential stage). Stakeholder groups, including parents, children, teachers, school administrators and community health aides, will participate, along with community leaders, tribal leaders and community members. The randomised trial will be combined with qualitative, semi-structured interviews to elicit stakeholder perspectives on the intervention (explanatory sequential stage). The five stakeholder groups described above will participate in interviews. The study will conclude with additional focus groups and community events to discuss results and provide community insight for future implementation. Concluding focus groups will include policymakers, healthcare administrators, and tribal and community leaders in addition to the stakeholder groups. Informed consent and child assent will be required. Recordings will be transcribed and deidentified, with only stakeholder group recorded. Analyses will include categorical coding as well as narrative and thematic analysis.

ETHICS AND DISSEMINATION

The Hearing Norton Sound study has been approved by the Institutional Review Boards of Alaska Area, Norton Sound, and Duke University, with trial registration on clinicaltrials.gov. Study results will be distributed with equal emphasis on scientific and community dissemination.

TRIAL REGISTRATION NUMBER

NCT03309553; Results.

Hearing Norton Sound: a community randomised trial protocol to address childhood hearing loss in rural Alaska

INTRODUCTION

The population in rural Alaska experiences a disproprionately high burden of infection-mediated hearing loss. While the state mandates school hearing screening, many children with hearing loss are not identified or are lost to follow-up before ever receiving treatment. A robust, tribally owned healthcare system exists in Alaska, but children with hearing loss must first be identified and referred for existing infrastructure to be used. This trial will evaluate a new school hearing screening and referral process in rural Alaska, with the goal of improving timely identification and treatment of childhood hearing loss.

METHODS AND ANALYSIS

Comparative effectiveness community randomised trial testing digital innovations to improve school hearing screening and referral in 15 communities in the Norton Sound region of northwest Alaska, with data collection from October 2017 to February 2020. All children (K-12) attending school in Bering Strait School District with parental informed consent and child assent will be eligible (target recruitment n=1500). Participating children will undergo both the current school hearing screen and new mobile health (mHealth) screen, with screening test validity evaluated against an audiometric assessment. Communities will be cluster randomised to continue the current primary care referral process or receive telemedicine referral for follow-up diagnosis and treatment. The primary outcome will be time to International Statistical Classification of Diseases, 10th Revision, ear/hearing diagnosis from screening date, measured in days. Secondary outcomes will include: sensitivity and specificity of current school and mHealth screening protocols measured against a benchmark audiometric assessment (air and bone conduction audiometry, tympanometry and digital otoscopy); hearing loss prevalence; hearing-related quality of life; and school performance (AIMSweb). Intention-to-treat analysis will be used.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Boards of Alaska Area, Norton Sound and Duke University and is registered on clinicaltrials.gov. Results will be distributed with equal emphasis on scientific and community dissemination.

TRIAL REGISTRATION NUMBER

NCT03309553; Pre-results.

Trends in Otitis Media and Myringotomy With Tube Placement Among American Indian and Alaska Native Children and the US General Population of Children After Introduction of the 13-valent Pneumococcal Conjugate Vaccine

BACKGROUND

American Indian/Alaska Native (AI/AN) children have experienced higher otitis media (OM) outpatient visit rates than other US children. To understand recent trends, we evaluated AI/AN OM rates before and after 13-valent pneumococcal conjugate vaccine introduction.

METHODS

We analyzed outpatient visits listing OM as a diagnosis among AI/AN children <5 years of age from the Indian Health Service National Patient Information Reporting System for 2010-2013. OM outpatient visits for the general US child population <5 years of age were analyzed using the National Ambulatory Medical Care and National Hospital Ambulatory Care Surveys for 2010-2011.

RESULTS

The 2010-2011 OM-associated outpatient visit rate for AI/AN children (63.5 per 100/year) was similar to 2010-2011 rate for same-age children in the general US population (62.8) and decreased from the 2003 to 2005 AI/AN rate (91.4). Further decline in AI/AN OM visit rates was seen for 2010-2011 to 2012-2013 (P < 0.0001). The AI/AN infant OM visit rate (130.5) was 1.6-fold higher than the US infant population. For 2010-2011, the highest AI/AN OM visit rate for <5 year olds was from Alaska (135.0).

CONCLUSIONS

AI/AN <5-year-old OM visits declined by one third from 2003-2005 to 2010-2011 to a rate similar to the US general population <5 years. However, the AI/AN infant OM rate remained higher than the US infant population. The highest AI/AN <5-year-old OM rate occurred in Alaska.

Vaccines for Nontypeable Haemophilus influenzae: the Future Is Now

Infections due to nontypeable Haemophilus influenzae result in enormous global morbidity in two clinical settings: otitis media in children and respiratory tract infections in adults with chronic obstructive pulmonary disease (COPD). Recurrent otitis media affects up to 20% of children and results in hearing loss, delays in speech and language development and, in developing countries, chronic suppurative otitis media. Infections in people with COPD result in clinic and emergency room visits, hospital admissions, and respiratory failure. An effective vaccine would prevent morbidity, help control health care costs, and reduce antibiotic use, a major contributor to the global crisis in bacterial antibiotic resistance. The widespread use of the pneumococcal conjugate vaccines is causing a relative increase in H. influenzae otitis media. The partial protection against H. influenzae otitis media induced by the pneumococcal H. influenzae protein D conjugate vaccine represents a proof of principle of the feasibility of a vaccine for nontypeable H. influenzae. An ideal vaccine antigen should be conserved among strains, have abundant epitopes on the bacterial surface, be immunogenic, and induce protective immune responses. Several surface proteins of H. influenzae have been identified as potential vaccine candidates and are in various stages of development. With continued research, progress toward a broadly effective vaccine to prevent infections caused by nontypeable H. influenzae is expected over the next several years.

Who needs admission among infants with acute otitis media?

AIM

Management of acute otitis media (AOM) in infants younger than 2 months old is controversial. It varies between treatment on an outside basis, and hospitalization for intravenous antibiotics and sepsis work-up based on variability of the reported AOM pathogens in this particular group. Our aim is to identify clinical indicators that may suggest a need for an invasive medical work-up and/or hospitalization of these young patients, and compare their management to that of older infants.

METHODS

Retrospective chart review. Admitted infants with AOM and a random sample of infants presenting to the emergency room with AOM over a 20-year period. Infants younger than 2 months were designated as 'young infants', and those older as 'older infants'. Demographic data, relevant history, physical examination, laboratory studies and treatment were reviewed.

RESULTS

Twenty-nine admitted infants were included (13 young infants). A sample of 58 outpatients was studied, including two young infants. Compared to older inpatient infants, admitted young infants were less febrile (P < 0.05), had more benign white cell count (P < 0.05) but had more otorrhea (P < 0.05). These grew gram-negative organisms. Sepsis work-up was negative. Young infants were more likely to be admitted (P < 0.05). Admitted older infants had more otorrhea than outpatients (P < 0.05) or a complication (P < 0.05).

CONCLUSIONS

Young infants often need admission for intravenous antibiotics, until middle ear culture is out. Sepsis work-up may be necessary only in toxic patients. Older infants need admission when severely ill or have a complication.

Impact of pneumococcal conjugate vaccination on otitis media: a systematic review

Reduced rates of consultations for otitis media after introduction of pneumococcal conjugate vaccines (PCVs) have been overinterpreted. This systematic review suggests that PCV is only somewhat modestly effective against all-cause otitis media.

Acute otitis media (AOM) is a leading cause of visits to physicians and of antibiotic prescriptions for young children. We systematically reviewed studies on all-cause AOM episodes and physician visits in which impact was attributed to pneumococcal conjugate vaccines, either as efficacy or effectiveness. Of 18 relevant publications found, most used the 7-valent pneumococcal conjugate vaccine (7vCRM). The efficacy of 7vCRM against all-cause AOM episodes or visits was 0%–9% in randomized trials and 17%–23% in nonrandomized trials. In observational database studies, physician visits for AOM were already declining in the 3–5 years before 7vCRM introduction (mean change, −15%; range, +14% to −24%) and continued to decline afterward (mean, −19%; range, +7% to −48%). This vaccine provides some protection against OM, but other factors have also contributed to the recent decline in OM incidence. Future effectiveness studies should thus use better-controlled methods to estimate the true impact of vaccination on AOM.

Pneumococcal disease manifestation in children before and after vaccination: what's new?

Pneumococcal infections remain a relevant cause of morbidity and mortality in children, especially in countries where vaccination has not been introduced. In contrast to the common belief by many pediatricians, the most important pneumococcal infections are of the respiratory tract and not invasive diseases. The recent pandemic of the H1N1 virus prompted studies to better understand the interaction between the influenza virus, Streptococcus pneumoniae, and pneumonia outcomes. Radiological findings of bacteremic pneumonia have been well investigated and besides the typical alveolar consolidation, a broad spectrum of atypical patterns has been reported. Molecular techniques, such as real-time polymerase chain reaction (PCR), can improve the detection of S. pneumoniae in sterile fluids, mainly in regions where previous antibiotic therapy is a common practice. In the post vaccination era, new manifestations of pneumococcal invasive disease, such as hemolytic uremic syndrome, have increased in association with parapneumonic empyema. Moreover, serotypes not included in PCV7, particularly serotypes 1, 3, 5, 7F, and 19A, have been among the most common isolates in pneumococcal disease. In Latin America, pneumococcal primary peritonitis has been described as an important clinical syndrome in a growing proportion of patients, mainly in girls. The development of newer and more specific diagnostic markers to distinguish bacterial and viral pneumonia are urgently sought, and will be especially pertinent after the introduction of pneumococcal conjugate vaccines with expanded serotypes. Such markers would minimize inappropriate diagnosis of false positive cases and treatment with antibacterial agents, while increasing positive predictive values for diagnosis of bacterial pneumonia. The extension of serotype coverage with the new conjugate vaccines is promising for pneumococcal infections and coverage against antibiotic-resistant strains.

Increased influenza-related healthcare utilization by residents of an urban aboriginal community

Most studies describing high rates of acute respiratory illness in aboriginals have focused on rural or remote communities. Hypothesized causes include socioeconomic deprivation, limited access to healthcare, and a high prevalence of chronic disease. To assess influenza rates in an aboriginal community while accounting for healthcare access, deprivation and chronic disease prevalence, we compared rates of influenza-related outpatient and emergency-department visits in an urban Mohawk reserve (Kahnawá:ke) to rates in neighbouring regions with comparable living conditions and then restricted the analysis to a sub-population with a low chronic disease prevalence, i.e. those aged <20 years. Using medical billing claims from 1996 to 2006 we estimated age-sex standardized rate ratios. The rate in Kahnawá:ke was 58% greater than neighbouring regions and 98% greater in the analysis of those aged <20 years. Despite relatively favourable socioeconomic conditions and healthcare access, rates of influenza-related visits in Kahnawá:ke were elevated, particularly in the younger age groups.

Racial/ethnic and socioeconomic disparities in the prevalence and treatment of otitis media in children in the United States

OBJECTIVES

Although racial/ethnic and socioeconomic disparities in child health are prevalent, little is known about them within common pediatric otolaryngic problems. Otitis media (OM) is a frequent diagnosis in children, and tympanostomy tube placement is the most common surgical treatment for OM. We sought to identify current knowledge regarding racial/ethnic and socioeconomic disparities in children with OM or tympanostomy tube placement.

METHODS

Qualitative systematic review of MEDLINE database for U.S.-based articles reporting on racial/ethnic or socioeconomic disparities in diagnosis or surgical treatment of OM over the last 30 years.

RESULTS

Of 428 abstracts identified, 15 met inclusion criteria. Articles addressed OM prevalence (12 of 15), risk factors (9 of 15), and tympanostomy tube insertion (4 of 15). Minority racial/ethnic groups studied were Black (11 of 15), Hispanic (6 of 15), American Indian/Alaska Native (2 of 15), and Asian (1 of 15). Predominant findings showed: 1) the most common identified risk factor for OM is socioeconomic status; 2) considerable variability exists concerning racial/ethnic disparities in disease prevalence; and 3) White children are more likely to undergo tympanostomy tube insertion compared to Black or Hispanic children.

CONCLUSIONS

Racial/ethnic and socioeconomic disparities exist for the prevalence and treatment of children with OM. Socioeconomic deprivation increases the risk of OM in children. Despite the frequency of tympanostomy tube insertion in children in the United States, few studies have addressed inequalities in access or utilization of surgical therapy. Given the changing healthcare climate and the social and economic impact of OM in children, further investigation of racial/ethnic and socioeconomic disparities targeting access to surgical treatment of OM should take precedence in health services research.

Theories of otitis media pathogenesis, with a focus on Indigenous children

Otitis media is a common childhood illness associated with hearing loss, social disadvantage and medical costs. Prevalence and severity are high among Indigenous children. Respiratory bacterial and viral pathogens ascend the eustachian tube from the nasopharynx to the middle ear, causing inflammation, fluid accumulation, and bulging of the tympanic membrane, with or without pain. Among Australian Indigenous children, ear disease commences earlier in life, and involves multiple strains of bacterial pathogens at high density that persist longer. Persistent nasal discharge, overcrowded living conditions (particularly exposure to many children) and poor facilities for washing children perpetuate a vicious cycle of transmission and infection. Risk factors include environmental tobacco smoke, season, lack of breastfeeding, younger age and immature immune system, and possibly genetic factors. The innate immune system is a critical first response to infection, particularly as passive maternal antibodies decline and during the maturation of the infant adaptive immune response. The relative contributions of innate factors to protection from otitis media are currently not well understood. A diversity of antibodies that target strain-specific and conserved antigens are generated in response to natural exposure to otitis media pathogens (or to vaccines). Deficiencies in these antibodies may explain susceptibility to recurrent infections. Incremental contributions from all these elements are likely to be important in otitis media susceptibility versus protection. Effective medical and social strategies to prevent early age of onset are urgently needed.

Pneumococcal conjugate vaccination and otitis media: differences among high-risk and low-risk populations

The impact of the heptavalent pneumococcal conjugate vaccine (PCV7) on the natural history of otitis media (OM) has been studied recently. In a high-risk population, PCV7 significantly reduced the risk of recurrent, bilateral or multiple tympanic membrane perforation, as well as the risk of chronic suppurative OM at 9 months of age. PCV7 did not reduce the time to the development of OM nor the burden of OM. Major challenges are the polymicrobial etiology of OM (Streptococcus pneumoniae and Haemophilus influenzae) in high-risk populations and the serotype replacement among pneumococcal strains. A vaccine including nontypable H. influenzae and 11 pneumococcal serotypes has been identified as a more efficacious option for preventing OM. In the near future, the development and evaluation of a vaccine containing pneumococcal protein, such as pneumococcal surface protein A, which is a structurally variable and serologically cross-reactive surface protein important to the pneumococcal virulence, will be a potential tool against OM.

Trends in otitis media and myringtomy with tube placement among American Indian/Alaska native children and the US general population of children

BACKGROUND

Otitis media (OM) morbidity in American Indian and Alaska Native (AI/AN) children is historically higher than that in other US children.

METHODS

Outpatient visits and hospitalizations listing OM as a diagnosis and outpatient visits listing myringotomy with insertion of tubes as a procedure among AI/AN children <5 years of age from the Indian Health Service National Patient Information Reporting system for 2003-2005 were analyzed. Outpatient visits and hospitalizations with OM for the general US child population were analyzed using the National Hospital Ambulatory Medical Care and National Ambulatory Medical Care Surveys for 2003-2005, and the 2003 Kids' Inpatient Database, respectively.

RESULTS

The OM-associated outpatient visit rate for AI/AN children <5 years of age (89 per 100 children/yr) for 2003-2005 was less than that reported for 1994-1996 (138); however, the rate increased for Alaska region (158 to 181). The OM outpatient visit and myringotomy with insertion of tubes rates (181 and 2.6 per 100 children/yr, respectively) for AI/AN children in Alaska were higher than rates for children in each of the other IHS regions and rates for US children (63 and 1.8 per 100 children/yr, respectively). The OM outpatient visit rates for AI/AN infants (184), especially in the Alaska region (334), were higher than the rate for US infants (84).

CONCLUSIONS

The OM-associated outpatient visit rate in AI/AN children <5 years of age has decreased but remains higher than that of the US general child population; however, the rate increased in the Alaska region, where a limited decline in invasive pneumococcal disease has been demonstrated. The ongoing disparity in OM outpatient visit rates among AI/AN children, especially Alaska Native children, indicates a need for new prevention measures, including expanded-valency pneumococcal conjugate vaccines, to reduce OM morbidity.

Randomized, controlled trial efficacy of pneumococcal conjugate vaccine against otitis media among Navajo and White Mountain Apache infants

We report the phase III trial efficacy of 7-valent pneumococcal conjugate vaccine against clinical and culture proven otitis media (OM) among Navajo and White Mountain Apache infants. Efficacy was -0.4% (95% CI: -19.4 to 15.6) for clinically-diagnosed OM, 5.1% (95% CI: -51.5 to 40.6) for severe OM, and 64% (95% CI: -34% to 90%) for vaccine serotype pneumococcal OM suggesting that this vaccine is efficacious for pneumococcal OM in this high risk population.

The burden and outcome of respiratory tract infection in Australian and aboriginal children

The burden of otitis media in developing and disadvantaged populations is substantial. This article looks at that burden in developed affluent and indigenous populations (in Australia). A model is presented to explain the high prevalence of chronic suppurative otitis media in indigenous populations, and an assessment of efforts to improve these outcomes if not prevent these infections is provided. Lastly, various international guidelines for managing acute otitis media are compared.

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.

Asthma hospitalizations among American Indian and Alaska Native people and for the general US population

STUDY OBJECTIVES

Asthma is one of the most common chronic diseases in the United States. High rates of asthma hospitalization have been reported for some ethnic minorities; however, asthma hospitalization rates for American Indian/Alaska Native (AI/AN) populations of all ages have not been studied. In this study, we examined and compared hospitalization rates for AI/AN populations and the general population in the United States.

DESIGN

Hospital discharge records with a first-listed diagnosis of asthma were evaluated for AI/AN populations and the US general population of all ages from 1988 to 2002.

RESULTS

The asthma hospitalization rate for AI/AN populations decreased from 17.8/10,000 per year in 1988 to 1990 to 12.9/10,000 per year in 2000 to 2002. The overall age-adjusted rate for 2000 to 2002 was slightly lower than that for the general US population (12.9/10,000 and 16.4/10,000, respectively). However, AI/AN populations living in the Southwest region (17.6/10,000) had the highest asthma hospitalization rate among the Indian Health Service regions and the rate from 2000 to 2002 was similar to that for the general US population. The 2000 to 2002 asthma hospitalization rate for AI/AN populations < 1 year of age (infants) was higher than that in US infants, and the rates for AI/AN age groups > or = 1 year were similar to or lower than those for the general US population.

CONCLUSIONS

While asthma was rarely reported among AI/AN populations before 1975, the average annual age-adjusted asthma hospitalization rate was only slightly lower for AI/AN populations than that for the US general population from 2000 to 2002. Furthermore, the asthma hospitalization rates for AI/AN populations living in the Southwest and East regions were similar to the rate for the general US population. Efforts to further increase asthma awareness and symptom recognition among AI/AN populations should be implemented to help to reduce asthma hospitalizations.

Portrait of outpatient visits and hospitalizations for acute infections in Nunavik preschool children

OBJECTIVE

Inuit children from around the world are burdened by a high rate of infectious diseases. The objective of this study was to evaluate the incidence rate of infections in Inuit preschool children from Nunavik (Northern Québec).

METHODS

The medical chart of 354 children from a previously recruited cohort was reviewed for the first five years of life. All outpatient visits that led to a diagnosis of acute infection and all admissions for acute infections were recorded.

RESULTS

Rates of outpatient visits for acute otitis media (AOM) were 2314, 2300, and 732 events/1000 child-years for children 0-11 months, 12-23 months, and 2-4 years, respectively. Rates of outpatient visits for lower respiratory tract infections (LRTI) were 1385, 930, and 328 events/1000 child-years, respectively. Rates of hospitalization for pneumonia were 198, 119, and 31 events/1000 child-years, respectively.

CONCLUSION

Inuit children from Nunavik have high rates of AOM and LRTI. Such rates were higher than that of other non-native North-American populations previously published. Admission for LRTI is up to 10 times more frequent in Nunavik compared to other Canadian populations.

Tympanometry of a diverse group of preschool aged children

OBJECTIVE

Ethnicity has been previously described as a risk factor for middle ear disease. Little data exist on the presence of middle ear disease based on tympanometry screening comparing Asian children and children of other races.

METHODS

Two hundred and seventy children aged 3-5 were screened with tympanometry at six Head Start sites in St. Paul, Minnesota during the months of September and October of 2004. Gender, age, and race/ethnicity was recorded and entered into a database, along with values for canal volume, static admittance, peak pressure, and tympanometric width.

RESULTS

Criteria for abnormal tympanometry were based on American Speech-Language Hearing Association (ASHA) recommendations for a failed tympanogram for 1-5 year olds (admittance <0.3 mmho or width >200 daPa). There were no statistically significant differences in failure rates between males and females. There were, however, more failures for Asian (predominantly Hmong) children compared to children of other races/ethnicities after adjusting for age and gender differences (OR=6.39, CI 3.65-11.2, p<0.001) and for children <4-years-old compared to children 4-5-years-old after adjusting for race and gender differences (OR=1.99, CI 1.03-3.84, p<0.05).

CONCLUSIONS

Asian children were more than six times as likely to fail tympanometry as children of other races/ethnicities. The explanation for this difference is likely to be multifactorial, and further research is needed to characterize this difference.

Effect of prenatal exposure to polychlorinated biphenyls on incidence of acute respiratory infections in preschool Inuit children

OBJECTIVE

We set out to assess whether environmental prenatal exposure to polychlorinated biphenyls (PCBs) is associated with incidence of acute respiratory infections in preschool Inuit children.

STUDY DESIGN

We reviewed the medical charts of 343 children from 0 to 5 years of age and evaluated the associations between PCB-153 concentration in umbilical cord plasma and the incidence rates of acute otitis media (AOM) and of upper and lower respiratory tract infections (URTIs and LRTIs, respectively).

RESULTS

The incidence rates of AOM and LRTIs were positively associated with prenatal exposure to PCBs. Compared with children in the first quartile of exposure (least exposed), children in fourth quartile (most exposed) had rate ratios of 1.25 (p<0.001) and 1.40 (p<0.001) for AOM and LRTIs, respectively. There was no association between prenatal PCB exposure and incidence rate of URTIs or hospitalization.

CONCLUSION

Prenatal exposure to PCBs could be responsible for a significant portion of respiratory infections in children of this population.

Endemic iron deficiency associated with Helicobacter pylori infection among school-aged children in Alaska

OBJECTIVES

Rural Alaska Natives have a high prevalence of iron deficiency and Helicobacter pylori infection. The objective of this study was to estimate the prevalence of iron deficiency, iron-deficiency anemia, and active H pylori infection among school-aged children in rural Alaska.

METHODS

We enrolled 68% (688) of the 7- to 11-year-old children from 10 predominantly Alaska Native villages in southwestern Alaska. We collected venous blood samples to assess iron deficiency and anemia. Each child was tested for active H pylori infection by 13C-urea breath test (UBT). Evaluated risk factors included age, gender, village of residence, number of household members, number of household members who were younger than 5 years, recent antibiotic use, and household water source.

RESULTS

Of 688 enrolled children, iron deficiency was present in 38%, iron-deficiency anemia was present in 7.8%, and H pylori infection by UBT was present in 86%. Iron deficiency was independently associated with living in a household with >6 people and village of residence. H pylori infection by UBT was independently associated with child's age > or =10 years and village of residence. Ninety-one percent of children with iron deficiency had H pylori infection by UBT, and children with active H pylori infection were more likely to be iron deficient than uninfected children. Children with H pylori infection by UBT were also more likely to have iron-deficiency anemia than uninfected children.

CONCLUSIONS

In this study of nearly 700 children in 10 different villages in Alaska, we confirmed that the high prevalence of iron deficiency persists among school-aged children. We found that active H pylori infection was independently associated with iron deficiency and iron-deficiency anemia among children in this region. H pylori infection may account for a portion of the iron deficiency and iron-deficiency anemia in rural Alaska and other areas with high prevalences of both conditions. Innovative approaches are critically needed to address the iron deficiency in high prevalence areas such as rural Alaska and most of the developing world.

Otitis media: review of the 2004 treatment guidelines

OBJECTIVE

To review the 2004 treatment guidelines provided by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) regarding the treatment of otitis media in pediatric patients.

DATA SOURCES

A MEDLINE search, restricted to English-language articles about pediatric patients, was conducted (1966-May 2005) using the key words acute otitis media (AOM), guideline, observation therapy, and vaccination. Additional references were located through review of the bibliographies of cited articles.

STUDY SELECTION AND DATA EXTRACTION

Studies related to the fundamental basis of the updated guidelines and articles addressing current issues related to otitis media infection were included.

DATA SYNTHESIS

Otitis media affects many children in the US. Concerns have been raised about the proper treatment of AOM in the face of increasing drug resistance among primary pathogens responsible for infection. Some countries have chosen to observe patients for a designated period of time prior to initiation of antibiotic therapy. The AAP and AAFP have updated the treatment guidelines for otitis media to include the option of observation therapy, recommendations for dosing of various antibiotic regimens and their place in therapy, and the importance of initial pain management.

CONCLUSIONS

Updated treatment guidelines for otitis media have been developed in an effort to properly treat children while decreasing current resistance rates for common organisms that cause AOM. In the future, the therapeutic outcomes of observation therapy related to both the incidence of drug resistance and the possibility of increased complications related to otitis media will need to be evaluated in the US.

Lower respiratory tract infections among american Indian and Alaska Native children and the general population of U.S. Children

BACKGROUND AND OBJECTIVE

Lower respiratory tract infections (LRTIs) cause substantial childhood morbidity. This study characterizes and compares LRTI-associated morbidity among American Indian/Alaska Native (AI/AN) children and the general population of U.S. children.

METHODS

Hospitalization and outpatient records with a diagnosis indicating LRTIs were evaluated for children aged younger than 5 years during 1990-2001.

RESULTS

For 1999-2001, the LRTI-associated hospitalization rate was significantly higher for AI/AN children than for U.S. children (116.1 versus 63.2/1000, respectively), with the disparity being greater for infants than for 1- to 4-year-old children. Also the rate of LRTI-associated outpatient visits among AI/AN infants was higher than that for all U.S. infants (737.7 versus 207.2/1000, respectively). LRTI hospitalization and outpatient visit rates were highest in the Alaska and Southwest Indian Health Service regions. During 1990-2001, the LRTI hospitalization rate among AI/AN infants in the Alaska region and among the general U.S. infant population increased. Bronchiolitis-associated hospitalization rates increased for AI/AN and U.S. infants, whereas the pneumonia-associated hospitalization rate decreased among AI/AN infants and remained stable among U.S. infants.

CONCLUSIONS

LRTIs continue to be an important cause of morbidity in children, especially among AI/AN infants in the Alaska and Southwest regions. Strategies to reduce LRTI hospitalizations and outpatient visits are warranted for all infants, but the greatest potential impact would be among AI/AN infants.

Gestational exposure to cigarette smoke imperils the long-term physical and mental health of offspring

BACKGROUND

In this study, we sought to understand whether prenatal exposure to cigarette smoke would be associated with increased offspring hospitalization through age 22 years for various physical and mental health diagnoses.

METHODS

We used multivariate logistic regression to investigate the relationship between gestational exposure to cigarette smoke and offspring hospitalization for physical and mental health conditions based on International Classification of Diseases (ICD; World Health Organization) diagnoses.

RESULTS

When controlling for parental psychiatric status, maternal somatic health, socioeconomic status, parity, and maternal age, youth born to mothers who smoked six or more cigarettes per day were more likely to have experienced hospitalization for neuroses (OR, 1.97), diseases of the nervous system (i.e., neurological disorders) (OR, 1.47), respiratory infections (OR, 1.28), accidents (OR, 1.44), infections (OR, 1.54), undiagnosed symptoms (OR, 1.65), and total admissions (OR, 1.48). Female offspring prenatally exposed were more likely to have experienced hospitalization for obstetric complications (OR, 2.94). No association was found for the remaining categories analyzed: blood disorders, skin diseases, psychoses, metabolic/endocrine disease, circulatory disease, digestive disease, disease of the skeletal/muscular system, physical anomalies, neoplasms, and genital/urinary disease.

CONCLUSIONS

This is the first study to investigate the impact of gestational exposure to cigarette smoke on global measures of somatic and physical health in offspring. This study adds to the literature by demonstrating that smoking during pregnancy increases offspring risk for additional health outcomes not previously recognized in the literature, and that the effect of smoking during pregnancy persists throughout the developmental period. The possibility that these findings are related to lifestyle markers or smoke exposure during childhood should also be considered.

Respiratory syncytial virus hospitalizations among American Indian and Alaska Native infants and the general United States infant population

OBJECTIVE

To determine the burden of respiratory syncytial virus (RSV) disease among American Indian (AI) and Alaska Native (AN) infants, by examining RSV-associated hospitalizations.

METHODS

Infant hospitalizations from 1997 through 2001 with RSV listed as a diagnosis were selected by using Indian Health Service/tribal hospital discharge data for AIs/ANs and National Hospital Discharge Survey data for the general US population.

RESULTS

In 2000-2001, RSV disease was listed as a diagnosis for 14.4% of all AI/AN infant hospitalizations, with bronchiolitis attributable to RSV infection (12.2%) being among the top 5 listed diagnoses. The rate of RSV-specific hospitalizations was 34.4 hospitalizations per 1000 infants for AI/AN infants and 27.4 hospitalizations per 1000 births for the general US infant population. The hospitalization rates for AI/AN infants living in the Alaska and Southwest regions (70.9 and 48.2 hospitalizations per 1000 infants, respectively) were much higher than the overall rate for US infants.

CONCLUSIONS

RSV infection is one of the leading causes of hospitalization among all infants in the United States, and AI/AN infants living in the Southwest and Alaska regions are at especially high risk for hospitalizations associated with RSV infection. Development of vaccines, antiviral agents, and other strategies to prevent RSV disease could yield substantial public health benefits.

Tympanometry measures in native and non-native Hawaiian children

BACKGROUND

Ethnicity has been readily accepted as a variable affecting the incidence of otitis media, with certain indigenous groups having an increased risk of middle ear dysfunction. Tympanometry provides objective information on middle ear status, and findings obtained from this procedure have often served as a criterion for medical referral.

OBJECTIVE

To extend previous research and to facilitate use of normative tympanometry measures obtained from children with native Hawaiian ancestry.

METHODS

Data were collected from 718 ears of 359 children in academic levels ranging from preschool to third grade. Subjects were matched across groups (182 native Hawaiian; 177 non-native Hawaiian) for academic level and gender. Variables included physical ear-canal volume (Vec), tympanometric peak compliance (peak Y, also known as static admittance), tympanometric width (TW), and tympanometric peak pressure (TPP).

RESULTS

Significantly higher TW (F1,714=8.82, P=0.008) and TPP (F1,714=9.98, P=0.002) values occurred in ears of native Hawaiian children. Statistical interaction between gender and age was not significant.

CONCLUSION

Differences in tympanometric findings between groups suggest differences in middle ear function, and these findings continue to underscore the importance of including tympanometry within a hearing screening protocol for early identification of possible hearing impairment.

Diagnosis and management of acute otitis media

This evidence-based clinical practice guideline provides recommendations to primary care clinicians for the management of children from 2 months through 12 years of age with uncomplicated acute otitis media (AOM). The American Academy of Pediatrics and American Academy of Family Physicians convened a committee composed of primary care physicians and experts in the fields of otolaryngology, epidemiology, and infectious disease. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to AOM. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific definition of AOM. It addresses pain management, initial observation versus antibacterial treatment, appropriate choices of antibacterials, and preventive measures. Decisions were made based on a systematic grading of the quality of evidence and strength of recommendations, as well as expert consensus when definitive data were not available. The practice guideline underwent comprehensive peer review before formal approval by the partnering organizations. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

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.

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

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

Modern management of acute otitis media

Although recent clinical trials suggest that conjugate vaccination will be less effective for the prevention of AOM than for IPD, these trials have demonstrated impressive reductions in the incidence of AOM due to invasive and antibiotic-resistant pneumococcal serotypes. These data suggest that if serotype replacement does occur in immunized children, the causative agents are likely to be less virulent than vaccine strains. Furthermore, a recent cost-effectiveness analysis projected that immunization of healthy infants with the heptavalent conjugate vaccine could prevent over one million episodes of AOM and 12,000 cases of invasive pneumococcal disease. Because significant reductions have been demonstrated in the incidence of frequently recurrent AOM, children with the worst disease stand to benefit most from vaccination. Based on data currently available, however, the conjugate vaccine is not going to eradicate AOM. Consequently, there will continue to be a need to scrutinize the threshold for prescribing antibiotics. In addition, there will be an ongoing need for surgery in some cases of recurrent AOM and persistent OME.

Infectious disease hospitalizations among American Indian and Alaska native infants

OBJECTIVE

To describe the burden and trends in hospitalizations associated with infectious diseases among American Indian and Alaska Native (AI/AN) infants.

METHODS

First-listed infectious disease hospitalizations and hospitalization rates among AI/AN infants and infants in the general US population from 1988-1999 were analyzed by using Indian Health Service/tribal hospital discharge data and the National Hospital Discharge Survey data, respectively.

RESULTS

Infectious disease hospitalizations accounted for 53% of all AI/AN infant hospitalizations and approximately 43% of all US infant hospitalizations during 1988-1999. The annual hospitalization rate for infectious diseases among AI/AN infants declined from 27,486 per 100,000 infants in 1988 to 14,178 per 100,000 infants in 1999. However, the rates for AI/AN infants within the Alaska, Southwest, and Northern Plains regions remained higher than that for the general US infant population at the end of the study period. Lower respiratory tract infection hospitalizations accounted for almost 75% of AI/AN infant infectious disease hospitalizations, and the lower respiratory tract infection hospitalization rate for AI/AN infants was twice that for US infants.

CONCLUSIONS

Although infectious disease hospitalization rates for AI/AN infants have declined, AI/AN infants continue to have a higher infectious disease burden than the general US infant population.