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Acute otitis media rates have dropped, but tied to upper respiratory infections

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Improving vaccines reduces rates of otitis media, as does breastfeeding

Otitis media, or middle ear infection, is one of the most common reasons for office visits to pediatricians, and for outpatient surgery. Indeed, operations to insert ear tubes are the most frequently performed surgical procedures in children in the United States, at more than 500,000 per year. Extensive use of broad-spectrum oral antibiotics in children selects for difficult-to-treat resistant strains of bacteria and alters the normal microbiome of children. Strategies to reduce otitis media in children hold substantial promise in improving child health and reducing the cost of medical care.

Against this backdrop, the data reported in the study by Chonmaitree et al. in the current issue of Pediatrics provide reassurance that we are, indeed, making progress in the fight against otitis media. This study shows that a number of simple interventions can decrease a child’s risk of otitis. Compared with studies of similar design in the late 1980s and early 1990s, the incidence of otitis media was appreciably lower in the current study – compatible with an impact of licensure and implementation of the conjugate pneumococcal vaccine in the 1990s. This study also confirms the risk conferred by cigarette smoke exposure on the incidence of otitis media in children. Finally, and perhaps most importantly, exclusivity of breastfeeding for the first 6 months of life, and total duration of breastfeeding, also had a substantial impact on otitis media. Thus, simple interventions such as ensuring compliance with routine immunization, avoiding cigarette smoke exposure, and encouraging breastfeeding can go a long way in reducing the risk of otitis media.

The study also points out important interactions between viruses that cause infections of the upper respiratory track and pathogenic bacteria that can lead to otitis media. Although we don’t think of otitis media as a viral infection, this study confirms that viruses in fact play a critical role in development of otitis, and antiviral vaccines, such as influenza vaccine, can decrease not only the risk of developing the flu, but also the risk of otitis media and its attendant complications. Future studies of antiviral vaccines will likely further contribute to the progress made in reducing otitis media that this interesting study nicely documents.

These comments were made by Mark R. Schleiss, M.D., professor and division director of pediatric infectious diseases and immunology and the American Legion Endowed Professor of Pediatrics at the University of Minnesota, Minneapolis. Dr. Schleiss had no disclosures.


 

FROM PEDIATRICS

References

Close to half of all infants have an episode of acute otitis media by age 1 year, but incidence appears to have dropped in the pneumococcal conjugate vaccine era, a recent study found.

“We clearly showed that frequent viral infections, bacterial colonization, and lack of breastfeeding are major acute otitis media (AOM) risk factors,” reported Dr. Tasnee Chonmaitree and her associates at the University of Texas Medical Branch in Galveston (Pediatrics 2016 March 28 doi: 10.1542/peds.2015-3555). “It is likely that medical interventions in the past few decades, such as the use of pneumococcal and influenza virus vaccines, higher breastfeeding rates and decreased smoking, helped reduce AOM incidence.”

“It is likely that medical interventions in the past few decades, such as the use of pneumococcal and influenza virus vaccines, higher breastfeeding rates and decreased smoking, helped reduce AOM incidence.” ©lokisurina/Thinkstock

“It is likely that medical interventions in the past few decades, such as the use of pneumococcal and influenza virus vaccines, higher breastfeeding rates and decreased smoking, helped reduce AOM incidence.”

Between October 2008 and March 2014, researchers began tracking 367 infants from birth until they experienced their first case of AOM (and then on to age 6 months) or until they reached age 12 months; 85% completed the study. Preterm infants and those with anatomic defects or major medical problems were not included. The researchers collected nasopharyngeal specimens once during each of the first 6 months, once in the child’s 9th month, and during any viral upper respiratory infections to conduct bacterial cultures and viral polymerase chain reactions for 13 respiratory viruses.

During the course of the study, 305 children experienced a total of 887 upper respiratory infections, and 143 children experienced a total of 180 AOM episodes. Upper respiratory infections occurred at a rate of 3.2 episodes per child per year, and lower respiratory infections occurred at a rate of 0.24 episodes per child per year. Clinical sinusitis complications followed 4.6% of the upper respiratory infections, and lower respiratory infections followed 7.6%.

The rate of AOM was 0.67 episodes per child per year. Although only 6% of the infants had experienced AOM by age 3 months, that rose to nearly a quarter (23%) of the children at age 6 months and nearly half (46%) at age 12 months. Still, it remained below the rates of 18% by 3 months and 30%-39% by 6 months that had been reported in the late 1980s and 1990s.

Children with AOM also had significantly greater pathogenic bacterial colonization overall and for Haemophilus influenzae (seen here) and Moraxella catarrhalis, in their monthly nasopharyngeal specimens. CDC/Dr. W.A. Clark

Children with AOM also had significantly greater pathogenic bacterial colonization overall and for Haemophilus influenzae (seen here) and Moraxella catarrhalis, in their monthly nasopharyngeal specimens.

Children who had AOM experienced 4.7 upper respiratory infections per year, compared with 2.3 episodes per year in children without AOM (P less than .002). They also had significantly greater pathogenic bacterial colonization overall and for Haemophilus influenzae and Moraxella catarrhalis, in their monthly nasopharyngeal specimens, although Streptococcus pneumoniae rates were not significantly greater.

“Interestingly, we found that not only viruses increased upper respiratory infection risk; M. catarrhalis and S. pneumoniae also increased upper respiratory infection risk,” the authors wrote “On the other hand, we found better protection for S. pneumoniae (infants born after 2010) associated with decreased upper respiratory infection risk.”

Upper respiratory infections were 74% more likely among children attending day care, and 7% more likely among children with at least one sibling at home. These infections were 37% less likely in children exclusively breastfed at least 6 months, 16% less likely in children born after February 2010, and 4% less likely for each month of any breastfeeding.

Similarly, AOM episodes were 60% less likely in children exclusively breastfed at least 3 months, and 15% less likely for each month children were breastfed.

The research was funded by the National Institutes of Health. The authors reported no disclosures.

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