You are on page 1of 4

International Journal of Infectious Diseases 17 (2013) e317e320

Contents lists available at SciVerse ScienceDirect

International Journal of Infectious Diseases


journal homepage: www.elsevier.com/locate/ijid

Clinical features and outcome of acute otitis media in early infancy


Stavroula Ilia, Emmanouil Galanakis *
Department of Paediatrics, University of Crete, POB 2208, 71003 Heraklion, Greece

A R T I C L E I N F O

S U M M A R Y

Article history:
Received 10 February 2012
Received in revised form 5 November 2012
Accepted 9 November 2012

Objectives: Acute otitis media (AOM) is common in childhood, but little is known on its course very early
in infancy. In this study we investigated predisposing factors, clinical characteristics, and long-term
outcomes of AOM in very young infants.
Methods: One hundred sixty infants aged less than 12 months with AOM hospitalized in two general
hospitals during 20052006 were included in the study and followed-up for 3 years. Demographics,
history, clinical manifestations, and further AOM episodes were studied in two infant groups dened by
age at the rst AOM episode: the very young infants, aged less than 60 days, and the older infants aged
61365 days.
Results: Of the 147/160 infants successfully followed-up, 48 (32.7%) were aged less than 60 days and 99
(67.3%) were aged 61365 days. The very young infants with AOM had more siblings (1.25 vs. 0.87;
p = 0.047) and used paciers less often (45.8% vs. 75.8%; RR 0.61, 95% CI 0.440.84; p = 0.0007). Purulent
otorrhea and irritability were more common in the early AOM onset group (52.1% vs. 32.3%; risk ratio
(RR) 1.61, 95% condence interval (CI) 1.092.39; p = 0.03, and 60.4% vs. 38.4%; RR 1.57, 95% CI 1.12
2.21; p = 0.01, respectively). AOM was complicated with meningitis in two infants, both in the very
young group, and with mastoiditis in a further two infants, one in each group. No difference in further
AOM episodes, use of ventilation tubes, or hearing impairment was observed between the two infant
groups.
Conclusions: AOM in the rst 2 months of life may have different predisposing factors and clinical
presentations, but not different recurrence rates or long-term outcomes.
2012 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Corresponding Editor: Eskild Petersen,


Skejby, Denmark
Keywords:
Acute otitis media
Early onset otitis media
Infants
Outcome
Risk factors

1. Introduction
Acute otitis media (AOM) is one of the most common infections
in childhood, and represents a substantial burden with regard to
doctor visits, consumption of antibiotics, absence from day care or
school, surgical procedures, and long-term sequelae such as
hearing impairment and speech disorders. AOM can occur at all
ages, but is principally a disease of young children. Immature
immunity, declining maternal antibodies, and a dysfunctional
Eustachian tube contribute to an increased prevalence in infancy.1,2 The pathogenesis of otitis media is multifactorial, implicating
interactions between the pathogen, environment, local anatomy,
and host. Several risk factors have been identied, including day
care, siblings, bottle-feeding, environmental tobacco smoke
exposure, season of the year, and respiratory tract infections, as
well as individual susceptibility affecting the hosts immune
response to infections in the middle ear.35
AOM in childhood has been adequately investigated, however
not many studies have focused on infants aged less than 2 months,

* Corresponding author. Tel.: +30 2810 392 012; fax: +30 2810 392 827.
E-mail address: emmgalan@med.uoc.gr (E. Galanakis).

who are often excluded from studies. As a result, prevalence is yet


uncertain in this population group and clear guidelines for
diagnosis and treatment seem not to exist.68 The initial clinical
presentation of AOM in this age group is often vague and diagnosis
is difcult.911 Most studies have suggested that the causative
pathogens are similar to those reported in older children, but data
concerning outcomes are still scarce and often controversial.6,1014
Furthermore, little is known of the risk factors, prevalence, and
long-term outcomes of AOM in the very rst months of life. This
prospective, longitudinal study analyzed the risk factors, clinical
characteristics, complications, and long-term outcomes associated
with a rst episode of AOM in infants aged less than 12 months and
focused on potential differences between infants with AOM onset
before 2 months of age and infants with AOM onset at 212 months
of age.
2. Methods
2.1. Population
The study population consisted of infants up to 12 months of
age hospitalized for AOM in the two paediatric departments of the
University General Hospital and Venizelion General Hospital, both

1201-9712/$36.00 see front matter 2012 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijid.2012.11.012

e318

S. Ilia, E. Galanakis / International Journal of Infectious Diseases 17 (2013) e317e320

in Heraklion, Crete, Greece during the 2-year period 20052006.


Only hospitalized infants were included in the study, the reason for
admission being severe clinical presentation, issues with regard to
compliance to oral antibiotics, and parental concern. The
diagnostic criteria for AOM were in line with those of the
guidelines of the American Academy of Pediatrics,15 and were
based on history of acute onset of signs and symptoms of middle
ear inammation and the presence of middle ear uid. In both
hospital settings, infants were routinely examined by a paediatrician and subsequently by an otolaryngologist using a microscope
and performing tympanocentesis in selected cases. Middle ear
uid cultures were not routinely obtained. Infants at a gestational
age of less than 35 weeks or who had undergone mechanical
ventilation in their neonatal life, and those with a known
immunological disorder or craniofacial or other major congenital
abnormality were excluded. Informed consent was obtained from
the parents and the study was approved by the Institutional
Committee of the Faculty of Medicine, University of Crete.

groups, respectively). Three infants were aged less than 1 month.


Ninety-nine (67.3%) infants had siblings, 50 (34.0%) had atopic
manifestations, 55 (37.4%) were never breastfed, and 86 (58.5%)
had at least one smoking parent. At enrolment, no infant in the
early AOM group was vaccinated, and 87% and 74% of infants in the
late AOM group were properly vaccinated for age against
Haemophilus inuenzae and Streptococcus pneumoniae, respectively. In the early AOM group, two infants developed meningitis and
one developed mastoiditis; in the late AOM group, one 3-monthold infant presented with mastoiditis. A total of 37 (25.2%) middle
ear uid cultures yielded a pathogen, 19 (39.6%) of them in the
early AOM group and 18 (18.2%) in the late AOM group. Isolated
pathogens included S. pneumoniae (9; 24.3%), Staphylococcus
aureus (3, 8.1%), Haemophilus spp (2; 5.4%), and enteric Gramnegative Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis (28; 75.7%).

2.2. Study variables

Study variables in the early and late AOM groups are depicted
in Table 1. As compared to their older peers, the very young infants
had more siblings (mean 1.25 vs. 0.87; p = 0.047) and used
paciers less often (45.8% vs. 75.8%; RR 0.61, 95% CI 0.440.84;
p = 0.0007). No signicant differences were found in terms of
ethnicity, gender, delivery mode, birth weight, season of birth,
feeding mode, environmental tobacco exposure, and family
history of atopy or AOM. Fever of 38 8C was the presenting
symptom in 82 (55.8%) infants, with no signicant difference
between the two age groups. Purulent otorrhea and irritability
were signicantly more common in the early AOM onset group
(52% vs. 32%; RR 1.61, 95% CI 1.092.39; p = 0.03, and 60% vs. 38%;
RR 1.57, 95% CI 1.122.21; p = 0.01, respectively). No differences
were observed regarding white blood cells, erythrocyte sedimentation rate, or C-reactive protein values. Concomitant reported
diagnoses, i.e., upper respiratory tract infection (26%), bronchiolitis (20%), conjunctivitis (5%), and vomiting and diarrhea (13%),
were comparable in the two groups.

A pre-constructed questionnaire was used to record demographic data and symptoms such as fever, pain, irritability, rhinitis,
and cough. Inquiries were made about potential risk factors,
including history of breast- or bottle-feeding, use of paciers,
environmental tobacco smoke exposure, respiratory tract infections, history of atopy, number of siblings, and day care attendance.
An infant was characterized as breastfed when breastfeeding was
the principal feeding mode. Atopic manifestations included
recurrent wheezing, asthma, allergic rhinitis, and atopic dermatitis. A family history of atopy and episodes of otitis media in rstdegree relatives were recorded. Two infant groups were formed as
dened by the age at the rst AOM episode: the early AOM group,
aged less than 60 days, and the late AOM group, aged 61365 days.
2.3. Follow-up
Follow-up was conducted at 6-monthly intervals for the next 3
consecutive years and included telephone contact between the
same investigator and parents regarding further AOM episodes,
chronic otitis media with effusion, insertion of ventilation tubes,
hearing impairment, and speech disorders. Every reported episode
of AOM that was conrmed by a physician was considered a
further AOM episode.
2.4. Statistics
Data were analyzed by descriptive statistics, including frequencies, percentages, means, and medians. Unadjusted associations
between early vs. late onset otitis media and recurrence rates with
study variables were evaluated by two-tailed Fishers exact test
and t-test, and risk ratios (RR) and 95% condence intervals (CI)
were calculated. Multiple linear regression analysis was further
performed in order to conrm signicant relationships that were
observed in the univariate analysis. In all cases, p values <0.05
were considered to be signicant.
3. Results
3.1. Population
A total of 160 infants were enrolled, of whom 13 (8.1%) were
lost to follow-up. Of the 147 who successfully completed the 3year follow-up period, 48 (32.7%) belonged to the early AOM group
and 99 (67.3%) to the late AOM group. The mean age at inclusion
was 0.36 years (0.13 and 0.48 years for the early and late AOM

3.2. Characteristics of infants by age at onset of AOM

3.3. Further AOM episodes


One hundred twenty-two of 147 children had more than one
episode of AOM (a total of 451 episodes, mean 3.7 episodes per
child) during the follow-up period. No differences were observed
regarding further AOM episodes and the insertion of ventilation
tubes in the early and late AOM groups (Table 1). Hearing
impairment was reported in six children, all of them in the late
AOM group, but this difference was not signicant (RR 1.06, 95% CI
1.011.12; p = 0.178).
In the whole study population, infants using a pacier (70.5% vs.
44%; RR 1.60, 95% CI 1.012.53; p = 0.019), attending day care
(36.9% vs. 12%; RR 3.07, 95% CI 1.049.11; p = 0.018), having a
positive family history of atopy and AOM (26% vs. 4%; RR 6.56, 95%
CI 0.9445.8; p = 0.016, and 55.7% vs. 24.0%; RR 2.32, 95% CI 1.13
4.75; p = 0.004, respectively), and belonging to a Greek rather than
an immigrant family (74.6% vs. 40%; RR 1.86, 95% CI 1.143.05;
p = 0.0015) were more prone to multiple AOM episodes. Multiple
AOM episodes were further more common in children with a
hearing impairment (9.5 vs. 4.44 episodes; p = 0.0001) and
insertion of ventilation tubes (7.36 vs. 3.57 episodes;
p = 0.0001). No signicant differences were found regarding
gender, birth weight, parental smoking habits, and number of
siblings. Multiple linear regression analysis conrmed the signicant relationship between multiple AOM episodes and family
history of AOM (p = 0.045), family history of atopy (p = 0.027),
hearing impairment (p = 0.001), and need for ventilation tubes
(p < 0.0001).

S. Ilia, E. Galanakis / International Journal of Infectious Diseases 17 (2013) e317e320

e319

Table 1
Acute otitis media in infants with rst episode in the rst 2 months of life as compared to infants with rst episode in months 212 of life
Total, N = 147, n (%)
Gender
Boys
Girls
Birth weight
Mean (g)
Season of birth
Springsummer
Fallwinter
Breastfeeding
Mean (months)
Delivery
Vaginal
Caesarean section
Use of pacier
Yes
No
Smoking mother
Yes
No
Smoking father
Yes
No
Family history of atopy
Yes
No
Family history of AOM
Yes
No
Number of siblings
Mean (range)
Ethnicity
Greek
Immigrant
Complications
Yes
No
Further AOM episodes
Yes
No
Further AOM episodes
Number (mean)
Ventilation tubes
Yes
No
Hearing impairment
Yes
No

Early AOM, n = 48, n (%)

Late AOM, n = 99, n (%)

p-Value
NS

92 (62.6)
55 (37.4)

30 (62.5)
18 (37.5)

62 (62.6)
37 (37.4)
NS

3159

3234

3123
NS

69 (46.9)
78 (53.1)

18 (37.5)
30 (62.5)

51 (51.5)
48 (48.5)
NS

4.86

5.5

4.53
NS

93 (63.3)
54 (36.7)

31 (64.6)
17 (35.4)

62 (62.6)
37 (37.4)

97 (66.0)
50 (34.0)

22 (45.8)
26 (54.2)

75 (75.8)
24 (24.2)

45 (30.6)
102 (69.4)

16 (33.3)
32 (66.7)

29 (29.3)
70 (70.7)

74 (50.3)
73 (49.7)

28 (58.3)
20 (41.7)

46 (46.5)
53 (53.5)

33 (22.4)
114 (77.6)

9 (18.7)
39 (81.3)

24 (24.2)
75 (75.8)

74 (50.3)
73 (49.7)

26 (54.2)
22 (45.8)

48 (48.5)
51 (51.5)

0.0007

NS

NS

NS

NS

0.047
0.99 (07)

1.25 (07)

0.87 (04)
NS

101 (68.7)
46 (31.3)

28 (58.3)
20 (41.7)

73 (73.7)
26 (26.3)

4 (2.7)
143 (97.3)

3 (6.3)
45 (93.7)

1 (1.0)
98 (99.0)

122 (83.0)
25 (17.0)

38 (79.2)
10 (20.8)

84 (84.8)
15 (15.2)

NS

NS

NS
451 (3.7)

177 (3.68)

274 (3.8)
NS

19 (12.9)
128 (87.0)

4 (8.3)
44 (91.7)

15 (15.2)
84 (84.8)

6 (4.1)
141 (95.9)

0 (0)
48 (100)

6 (6.1)
93 (93.9)

NS

AOM, acute otitis media; NS, not signicant.

4. Discussion
AOM is very common in childhood, affecting nearly all children
at some time, but little is known on the disease in the very rst
months of life. As factors predisposing to AOM are quite well
known,3,14,16 we focused on potential differences between infants
with early as opposed to late AOM onset and found that factors
known to contribute to AOM, such as the use of paciers and the
number of siblings, seem to have a different impact in infant
groups of different ages. We also found that infants with early AOM
more often presented with otorrhea and/or irritability. Burton et al.
reported that patients aged less than 6 weeks with AOM had a 30
50% incidence of recurrent otitis media during the rst 2 years of
life, and once in this category they had a 50% incidence of the need
for ventilating tubes, which was not conrmed by others.13,14
In our study, infants using a pacier were shown to be prone to
late AOM and to multiple AOM episodes. The relationship between
pacier use and AOM has been debated for almost two decades,
with most studies concluding that pacier use is a risk factor for
AOM.1722 This association has been attributed either to the
increase in the reux of nasopharyngeal secretions into the middle

ear or to changes induced by the pacier on the dental structures


and the function of the Eustachian tube. Our ndings pointing to
multiple AOM episodes in infants using paciers are thus in
accordance with the aforementioned studies; however, this
relationship did not remain signicant after applying multiple
regression statistics. Having older siblings was associated with
early age of AOM onset. Infants with a positive family history of
AOM and a positive family history of atopy had more AOM
episodes, in line with previous studies,23 but were not more
susceptible to otitis onset in early infancy. The relationship
between family history of otitis media and early otitis media has
been attributed to genetic predisposition or greater awareness of
otitis media leading to increased medical care-seeking.2,24
The vast majority of the participating subjects (83.0%) in this
study had multiple AOM episodes, probably because our cohort
comprised infants hospitalized for AOM, i.e., the more severely
affected children. These ndings should therefore not be generalized to all infants with AOM. Of note, in a study in the same area,
further AOM episodes during the rst year of life were observed in
41.8% of infants with an initial episode.16 Our study demonstrated
that early-onset AOM infants were not more susceptible to

e320

S. Ilia, E. Galanakis / International Journal of Infectious Diseases 17 (2013) e317e320

recurrent episodes, conrming earlier results, while elsewhere


infants with early AOM onset have been shown to be prone to
recurrent AOM, chronic otitis media, and placement of ear
tubes.1,14,25 These conicting results may be related to differences
in study design and populations. In our study, placement of
ventilation tubes was only associated with multiple AOM episodes,
which is rather expected given that grommets are used for the
relief of children with AOM recurrences. In the literature, the most
consistent risk factor for AOM recurrence has been day care
attendance, which was not conrmed in our study by multivariate
analysis.
A limitation of our study is that the denition of AOM was based
on clinical ndings and not always conrmed by culture; hence,
differences in pathogens between the early and late AOM onset
groups could not be analyzed properly. As information on AOM
episodes during the 3-year follow-up was based on parental
reports, recall bias cannot be excluded. Previous studies have
shown parental over-reporting of AOM episodes, while elsewhere
parents have been shown to report fairly accurately.26 In order to
diminish recall bias, we consulted parents relatively often, and
thus their reports are expected to be credible. Information on the
long-term outcome, including hearing, speech, and developmental
impairment, could have been validated by objective methods.
Socioeconomic status might well interfere in the long-term
outcome, nevertheless access to hospitals was rather homogeneously feasible in the study area. Not many infants (8.1%) were
lost to follow-up, and comparison of baseline characteristics did
not reveal any differences, therefore lost cases did not indicate
selective losses.
In conclusion, our data show that factors predisposing to or
preventing AOM in infancy may act differently in early and late
infancy. The clinical presentation may be different, but recurrences
and long-term outcomes are similar in infants with early and late
AOM onset.

4.
5.
6.
7.

8.

9.

10.

11.

12.

13.
14.

15.

16.
17.
18.
19.

20.

Acknowledgements

21.

We thank the parents for their contribution to this longduration study.


Ethical approval: The study was approved by the Institutional
Committee of the Faculty of Medicine, University of Crete.
Conict of interest: No conict of interest to declare.

22.

References

24.

1. Marchant CD, Shurin PA, Turczyk VA, Wasikowski DE, Tutihasi MA, Kinney SE.
Course and outcome of otitis media in early infancy: a prospective study. J
Pediatr 1984;104:82631.
2. Daly KA, Brown JE, Lindgren BR, Meland MH, Le CT, Giebink GS. Epidemiology of
otitis media onset by six months of age. Pediatrics 1999;103:115866.
3. Daly KA, Hoffman HJ, Kvaerner KJ, Kvestad E, Casselbrant ML, Homoe P, et al.
Epidemiology, natural history, and risk factors: panel report from the Ninth

23.

25.

26.

International Research Conference on Otitis Media. Int J Pediatr Otorhinolaryngol


2010;74:23140.
Uhari M, Mantysaari K, Niemela M. A meta-analytic review of the risk factors for
acute otitis media. Clin Infect Dis 1996;22:107983.
Ilia S, Goulielmos GN, Samonis G, Galanakis E. Hosts response in otitis media:
understanding genetic susceptibility. Pediatr Infect Dis J 2008;27:92933.
Pestalozza G. Otitis media in newborn infants. Int J Pediatr Otorhinolaryngol
1984;8:10924.
Teele DW, Klein JO, Rosner B, the Greater Boston Otitis Media Study Group.
Epidemiology of otitis media during the rst seven years of life in children in
greater Boston: a prospective cohort study. J Infect Dis 1989;160:8394.
Bentdal YE, Haberg SE, Karevold G, Stigum H, Kvaerner KJ, Nafstad P. Birth
characteristics and acute otitis media in early life. Int J Pediatr Otorhinolaryngol
2010;74:16872.
Turner D, Leibovitz E, Aran A, Piglansky L, Raiz S, Leiberman A, et al. Acute otitis
media in infants younger than two months of age: microbiology, clinical
presentation and therapeutic approach. Pediatr Infect Dis J 2002;21:66974.
Sakran W, Makary H, Colodner R, Ashkenazi D, Rakover Y, Halevy R, et al. Acute
otitis media in infants less than three months of age: clinical presentation,
etiology and concomitant diseases. Int J Pediatr Otorhinolaryngol
2006;70:6137.
Berkun Y, Nir-Paz R, Ben Ami A, Klar A, Deutsch E, Hurvitz H. Acute otitis media
in the rst two months of life: characteristics and diagnostic difculties. Arch
Dis Child 2008;93:6904.
Smith-Vaughan H, Byun R, Halpin S, Nadkarni MA, Jacques NA, Hunter N, et al.
Interventions for prevention of otitis media may be most effective if implemented in the rst weeks of life. Int J Pediatr Otorhinolaryngol 2008;72:5761.
Burton DM, Seid AB, Kearns DB, Pransky SM. Neonatal otitis media. Arch
Otolaryngol Head Neck Surg 1993;119:6725.
Bentdal YE, Karevold G, Nafstad P, Kvaerner KJ. Early acute otitis media:
predictor for AOM and respiratory infections in schoolchildren. Int J Pediatr
Otorhinolaryngol 2007;71:12519.
American Academy of Pediatrics and American Academy of Family Physicians.
Subcommittee on management of acute otitis media. Diagnosis and management of acute otitis media. Pediatrics 2004;113:145165.
Ladomenou F, Kafatos A, Tselentis Y, Galanakis E. Predisposing factors for acute
otitis media in infancy. J Infect 2010;61:4953.
Niemela M, Uhari M, Hannuksela A. Paciers and dental structure as risk factors
for otitis media. Int J Pediatr Otorhinolaryngol 1994;29:1217.
Niemela M, Uhari M, Mottonen M. A pacier increases the risk of recurrent
acute otitis media in children in day care centers. Pediatrics 1995;96:8848.
Niemela M, Pihakari O, Pokka T, Uhari M, Uhari M. Pacier as a risk factor for
acute otitis media: a randomized, controlled trial of parental counselling.
Pediatrics 2000;106:4838.
Jackson JM, Mourino AP. Pacier use and otitis media in infants twelve months
of age or younger. Pediatr Dent 1999;21:25560.
Victora CG, Behague DP, Barros FC, Olinto MT, Weiderpass E. Pacier use and
short breastfeeding duration: cause, consequence, or coincidence? Pediatrics
1997;99:44553.
Rovers MM, Numans ME, Langenbach E, Grobbee DE, Verheij TJM, Schilder AG.
Is pacier use a risk factor for acute otitis media? A dynamic cohort study.
Family Practice 2008;25:2336.
Albersen M, Bulatovic M, Lindner SH, van Stiphout F, van der Heijden GJ,
Schilder AG, et al. Is a positive family history predictive for recurrent acute
otitis media in children? An evidence-based case report. Otolaryngol Head Neck
Surg 2010;142:315.
Daly KA, Pirie PL, Rhodes KL, Hunter LL, Davey CS. Early otitis media among
Minnesota American Indians: the little ears study. Am J Public Health
2007;97:31722.
Damoiseaux RA, Rovers MM, Van Balen FA, Hoes AW, de Melker RA. Long-term
prognosis of acute otitis media in infancy: determinants of recurrent acute
otitis media and persistent middle ear effusion. Family Practice 2006;23:405.
Vernacchio L, Vezina RM, Ozonoff A, Mitchell AA. Validity of parental reporting
of recent episodes of acute otitis media: a Slone Center Ofce-based Research
(SCOR) network study. J Am Board Fam Med 2007;20:1603.