The relationship between otitis media with effusion and contact with other children in a British cohort studied from 8 months to 3 1/2 years

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Abstract

Objective: It is generally acknowledged that otitis media with effusion is more prevalent among children attending grouped day care. This study aimed to refine this by determining the relationships with the numbers of children at the place of day care, the age of the child and the number of siblings he/she had. Methods: ALSPAC (the Avon Longitudinal Study of Pregnancy and Childhood) is a population based longitudinal study starting early in pregnancy and following the children throughout their lives. Nested within this study, a randomly selected group of 1590 children, the Children in Focus, were invited to attend a clinic for hands on examinations. Tympanometry was carried out at ages 8, 12, 18, 25, 31, 37 and 43 months of age. Bilateral otitis media with effusion (OME) was identified if both ears showed a flat trace. Multi-level modelling with logistic regression adjusted for a number of social and environmental influences. Results: Of the 1590 children invited to the 8-month clinic, 300 (19%) were excluded from the analysis because of failure to attend or because of missing data. The analyses were based on 1290 children. The prevalence of bilateral OME decreased with age, from 24.6% at 8 months to 11.9% at 43 months. Children with older siblings and those attending day care with four or more other children were at an increased risk of OME. The adjusted odds ratios (AOR) were 1.52 (95% confidence interval [CI]=1.23, 1.88) and 1.36 (95% CI=1.02, 1.82), respectively. The risk associated with older siblings declined with age and by 3 years these children were no longer more likely to have OME than children with no older siblings. No such interaction with age was found for children in group day care and these children continued to be at an increased risk over the entire age period of the study. There was no increased risk associated with day care when no other children attended (AOR=1.18, 95% CI=0.88, 1.58) or when one to three others were present (AOR=1.10, 95% CI=0.85, 1.42). Although there was no relationship with the number of hours spent in day care, children who had started attending group care with four or more other children before 9 months of age did have an increased risk compared with children starting later AOR=1.88, 95% CI=1.12, 3.14. Conclusions: These results provide evidence that early contact with other children increases the risk of OME and that children attending day care with four or more other children remain at an increased risk of OME at least until 3 1/2 years.

Introduction

The association between otitis media with effusion (OME), otherwise known as secretory, nonsuppurative, serous or mucoid otitis media and respiratory infections has long been established (see Daly [1] for a review of the literature). At a conference in Denmark over a decade ago, it was recorded as the consensus of opinion that children experiencing repeated upper respiratory tract infections (URTI) were at an increased risk of OME and therefore all causes of URTI were also causes of OME [2], such as the common cold and catarrh [3], [4], [5].

Many studies have investigated risk and protective factors preceding URTI on the causal pathway to OME including season, sex, breast feeding, exposure to tobacco smoke, allergies and contact with other children [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21]. In those studies where results of multivariate analyses were presented [7], [8], [9], [12], [16], [17], [18], [19], the most consistent and largest effect associated with URTI tended to be for day care with other children. Studies focusing on the relationship between day care attendance and respiratory illness generally show that the number of other children present is an important factor [22], [23], [24], [25], [26], [27], [28], [29], [30], [31]. Groups with as few as four others increased the risk of infections and associated outcomes including OME and hospitalization for its surgical treatment with tympanostomy tubes. The number of hours spent at day care [16], [23], [26], [32] and the age at which the care started have also been found to be associated with differing prevalence rates for OME [16].

When the same diagnostic criteria are used, estimates of the prevalence of OME from studies of children up to 5 years of age are remarkably consistent (10–20%) across contrasting countries such as Denmark [4], [33], [34], the United States [11], New Zealand [10], the United Kingdom [6] and Japan [14] and in different age groups. Prevalence rates decrease beyond this age [10], [14]. No studies have been published that examine whether prevalence varies over age in the pre-school years in subgroups of the population defined by other risk factors. The suggestion has been made that early entry into day care may, through the evolution of immunity, protect the child from infections during the later pre-school years [24], [26], [28], [35]. However, research into the onset and duration of OME has found that earlier age at onset predicts greater risk of chronic OME [5], [36] and increased duration of OME in the first year [16].

This study presents the prevalence of OME in a group of children observed at 8, 12, 18, 25 months and thereafter every 6 months up to 43 months of age. The different courses that the relationship between risk of OME and age takes for groups of children defined by their contact with other children including older siblings and at day care are investigated taking into consideration other cofactors.

Section snippets

Subjects and methods

All births to mothers resident in that part of the former county of Avon, UK, that was also in the Southwest Regional Health Authority with an expected date of delivery between 1 April 1991 and 31 December 1992 were eligible for the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC). Over 80% of the known births from the geographically defined catchment area were included, resulting in 14 185 surviving live births. From this population cohort, the children of a sample of 1560 mothers

Results

Of those invited to the 8-month clinic, 219 were excluded because they did not have tympanometry results from any occasion between 8 and 43 months of age and a further 81 were excluded because they had no data about older siblings or day care arrangements. Five hundred and eighty seven (45.5%) children had results on all seven occasions, 283 (21.9%) on six occasions, 151 (11.7%) on five occasions, 87 (6.7%) on four, 69 (5.3%) on three, 60 (4.7%) on two and 53 (4.1%) on only one occasion.

Discussion

As expected the presence of older siblings and day care attendance with four or more others proved to be the major factors contributing to an increased risk of OME in pre-school children. The effect of older siblings remained important in the multivariate analysis, but there was a significant interaction with age. The trend with age was steeper for those children with older siblings and by 3 years these children were no longer at an increased risk of bilateral OME. Children experiencing day

Acknowledgements

We are extremely grateful to all mothers who took part and to the midwives for their co-operation and help in recruitment. The whole ALSPAC study team comprises interviewers, computer scientists, laboratory technicians, clerical workers, research scientists, volunteers and managers who continue to make this study possible. The authors would especially like to thank Jean Golding for reading previous drafts and for her suggestions that have been incorporated in this paper. This study could not

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