LSHSS
Research Article
Will Parents Participate in and Comply
With Programs and Regimens Using
Xylitol for Preventing Acute Otitis
Media in Their Children?
Jeffrey L. Danhauer,a Carole E. Johnson,b Jason A. Baker,a
Jung A. Ryu,a Rachel A. Smith,a and Claire J. Umedaa
Purpose: Antiadhesive properties in xylitol, a natural sugar
alcohol, can help prevent acute otitis media (AOM) in children
by inhibiting harmful bacteria from colonizing and adhering to
oral and nasopharyngeal areas and traveling to the Eustachian
tube and middle ear. This study investigated parents’ willingness
to use and comply with a regimen of xylitol for preventing
AOM in their preschool- and kindergarten-aged children.
Method: An Internet questionnaire was designed and
administered to parents of young children in preschool and
kindergarten settings.
Results: Most parents were unaware of xylitol’s use
for AOM and would not likely comply with regimens for
C
hildren from age 0 to 6 years are most susceptible
to acute otitis media (AOM), which can have a
negative impact on them; their families; and their
early education, hearing, speech, and language development
(Daly & Giebink, 2000; Rosenfeld, Goldsmith, Tetlus, &
Balzano, 1997). The American Academy of Pediatrics (AAP)
and the American Academy of Family Physicians (AAFP)
have provided practice guidelines for the early diagnosis
and management of AOM (AAP/AAFP, Subcommittee
on Management of Acute Otitis Media, 2004; Lieberthal
et al., 2013). The guidelines focused mainly on treatment
of AOM and indicated that predisposing factors—such as
craniofacial anomalies, hypotonia, immune deficiencies,
low socioeconomic status, and family history—cannot be
a
University of California, Santa Barbara
b
University of Oklahoma Health Sciences Center, Oklahoma City
Correspondence to Jeffrey L. Danhauer: danhauer@speech.ucsb.edu
Editor: Marilyn Nippold
Associate Editor: Sheila Pratt
Received April 23, 2014
Revision received July 22, 2014
Accepted December 8, 2014
DOI: 10.1044/2015_LSHSS-14-0048
Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015 • Copyright © 2015 American Speech-Language-Hearing Association
preventing AOM in their children; however, parents having
previous knowledge of xylitol and whose children had a
history of AOM would be more likely to do so.
Conclusions: Generally, most of these parents did not
know about xylitol and probably would not use it to prevent
ear infections. Unfortunately, these results parallel earlier
findings for teachers and schools, which present obstacles
for establishing ear infection prevention programs using
similar protocols for young children. The results showed that
considerable education and age-appropriate vehicles for
administering xylitol are needed before establishing AOM
prevention programs in schools and/or at home.
controlled by families. However, the guidelines suggested
that families could use behaviors—such as avoiding exposure
to passive cigarette smoke (Etzel, Pattishall, Haley, Fletcher,
& Henderson, 1992; Ilicali, Keleş, Değer, & Savaş, 1999),
extended pacifier use (Niemelä, Pihakari, Pokka, & Uhari,
2000), and bottle propping (Brown & Magnuson, 2000)—
to prevent ear infections. Further, the guidelines encouraged
breastfeeding for the first year of life, frequent hand wash-
ing, and limiting participation in day care centers to help
prevent AOM in children (AAP/AAFP, Subcommittee on
Management of Acute Otitis Media, 2004; Lieberthal et al,
2013). Although vaccines are being developed for preventing
ear infections, they were not available for general use until
the past few years (Marom et al., 2014; Schuerman, Borys,
Hoet, Forsgren, & Prymula, 2009). According to Marom
et al. (2014), pneumococcal conjugate vaccines PCV-7 and
PCV-13 were introduced in 2000 and 2010, respectively,
and are currently being received by about 90% of children
aged younger than 2 years. However, although these vaccines
show promise for reducing ear infections and their com-
plications in young children, there is still a place for alter-
native forms of prevention (AAP/AAFP, Subcommittee on
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
127
Management of Acute Otitis Media, 2004; Lieberthal et al,
2013).
In 2007, the National Ambulatory Medical Care
Survey and the National Hospital Ambulatory Medical
Care Survey (Centers for Disease Control and Prevention,
National Center for Health Statistics, n.d.) estimated that
there were 244.1 visits per 1,000 persons aged younger than
18 years to ambulatory care facilities that resulted in a
diagnosis of otitis media (OM). Healthy People 2020 (n.d.)
would like to see that number reduced to 221.5. One way to
reduce the number of cases of OM is through prevention
programs involving children’s families at home and with
their teachers at school. Public schools are possible venues
for wellness programs with the aim of preventing disease,
considering that they have been effective in preventing diseases
such as obesity (Waters et al., 2014), HIV/AIDS (Ma, Fisher,
& Kuller, 2014), and pertussis (Haselow, 2013). In a similar
way, although not demonstrating that ear infection preven-
tion programs actually reduced the prevalence of ear in-
fections, a recent study revealed that a sample of teachers,
community health nurses, and other staff believed that ear
infection prevention programs were effective in improving
health outcomes of children in lower primary school classes
in Australia (Doyle & Ristevski, 2010).
The preventative behaviors cited in the AAP/AAFP,
Subcommittee on Management of Acute Otitis Media
(2004) guidelines may not be sufficient alone. Several publi-
cations (e.g., Isokangas, Söderling, Pienihäkkinen, & Alanen,
2000; L. Jones, 2010; Milgrom, Rothen, & Milgrom, 2006;
Söderling & Hietala-Lenkkeri, 2010; Thorild, Lindau, &
Twetman, 2006; Uhari, Kontiokari, Koskela, & Niemelä,
1996; Uhari, Kontiokari, & Niemelä, 1998; Vernacchio
& Mitchell, 2007) and three recent systematic reviews
(Azarpazhooh, Limeback, Lawrence, & Shah, 2011; Danhauer,
Johnson, Corbin, & Bruccheri, 2010; Danhauer, Kelly, &
Johnson, 2011) have shown that xylitol, a natural sugar
alcohol that helps prevent harmful bacteria from colonizing
in the oral and nasopharyngeal areas, can also be used to
help prevent dental caries and ear infections in children.
When administered 5 times a day via chewing gum with a
cumulative dosage of 10.4 g (i.e., the standard regimen
for preventing dental caries), xylitol may reduce AOM by
about 40% compared with controls (Uhari et al., 1996, 1998),
and prevention rates may be even higher when xylitol is ad-
ministered via nasal spray (A. H. Jones, 2001). Laboratory
studies have suggested that xylitol has antiadhesive properties
that keep prominent bacterial pathogens (e.g., Streptococcus
pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis)
found in dental caries and upper respiratory infections
(Klein, 1994; Syrjänen, Auranen, Leino, Kilpi, & Mäkelä,
2005) from adhering to oral and aural structures. The anti-
adhesive properties in xylitol could also prevent these bacteria,
especially mutans streptococci, from traveling to the Eusta-
chian tube and middle ear, which should reduce the occur-
rence of AOM. Although xylitol products are commercially
available in chewing gums, mouthwashes, mints, syrups, and
nasal sprays, recent studies have shown that (a) pediatricians
in the United States are generally unaware of xylitol’s use
128 Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015
with AOM, and few recommend xylitol to their patients
(Danhauer, Johnson, Rotan, Snelson, & Stockwell, 2010;
Stockwell, Johnson, & Danhauer, 2010), and (b) schools
and teachers do not typically permit children to chew gum
on campus (Autio & Courts, 2001; Danhauer, Johnson, &
Caudle, 2011). Earlier, Autio and Courts (2001) found that
although chewing gum was helpful for preventing ear infec-
tions in children, the teachers in their study were generally
unwilling to participate in prevention programs, mainly due
to their potential for disrupting classrooms. Unfortunately,
missed dosages or discontinuation from participation often
result when programs and protocols necessary for prevent-
ing AOM in children require that parents and teachers must
adhere to a strict regimen of administering gum and/or
nasal sprays to children. Furthermore, children aged younger
than 5 years, who are most prone to AOM, are usually too
young to chew gum, which is a continuing problem for
implementing ear infection prevention programs that rely
on chewing gum as a vehicle for administering xylitol in
schools and at home.
The aim of the present study was not to determine
what age is safe for children to chew gum but rather whether
chewing gum is an appropriate vehicle for administering
xylitol in ear infection prevention programs directed at young
children. However, the former is a reasonable question con-
sidering that the AAP (n.d.) has warned that swallowing
gum could lead to diarrhea, abdominal discomfort, gas,
mouth ulcers, dental and jaw problems, and choking. Al-
though the AAP and others (e.g., International Chewing
Gum Association, n.d.) have stated that there is no set time
when children can begin chewing gum, they have indicated
that parents should generally know when their children can
grasp the concept of chewing without swallowing (usually
around 4–5 years) and, thus, be able to chew gum safely.
Further, our inspection of the literature revealed neither
specific guidelines for recommending when it is safe for
young children to begin chewing gum nor any empirical
evidence regarding studies that have been published on that
topic, only that those aged younger than 4 years or having
developmental issues may be at risk for choking, and paren-
tal monitoring and supervision should be involved (Nichols
et al., 2012).
Knowing whether parents are aware of xylitol’s use
as a prophylaxis for ear infections and whether parents
would comply with dosing schedules necessary for prevent-
ing AOM in their children using chewing gum or other
vehicles is an important first step before initiating xylitol
prevention programs with families either at home or within
school and day care settings. Thus, a feasibility study is
needed to determine parents’ willingness to comply with
protocols and regimens of xylitol that are necessary for es-
tablishing prevention programs in homes and preschool
and kindergarten settings. If parents are receptive to partici-
pating in prevention programs, then they might be encour-
aged to help persuade those in preschool and kindergarten
settings to partner with them in implementing programs
that would increase accessibility of health care delivery and
reduce ear infections in children.
 Therefore, the purpose of the present study was to de-
sign and administer a questionnaire directed at parents of
children aged younger than 6 years in preschool and kinder-
garten settings, with and without previous knowledge of xyli-
tol, to assess whether they were aware of xylitol products and
would use them with their children to prevent AOM. We hy-
pothesized that most parents would be unaware that xylitol
can reduce AOM in children; that few parents would be will-
ing to comply with the strict protocols and regimens of xylitol
that are necessary for preventing AOM in their children; and
that parental education would be necessary before establishing
ear infection prevention programs using xylitol with children
that could be implemented in home, preschool, and kinder-
garten settings. Thus, a goal of the present study was to
determine obstacles to and solutions for using xylitol in ear
infection prevention programs with families. The questions
posed in the present study included the following:
1. Do parents know about xylitol and its use in
preventing ear infections in children?
2. Would parents be willing to do their part at home
and use xylitol on their children and comply with
dosages/regimens necessary for preventing AOM?
3. Would parents participate in ear infection prevention
programs using xylitol with their children and con-
sent to having teachers administer necessary dosages
while at school?
4. Are there differences in responses from parents of
children across private audiology practice (PP),
nursery school (NS), preschool (PS), or kindergarten
class (KC) settings?
5. Would parents with children aged ≤3 years be more
likely to use xylitol nasal spray on their children and
comply with ear infection prevention programs than
those with older children?
6. Do parents with prior knowledge of xylitol respond
differently than those having no prior knowledge?
This study was approved by the University of California,
Santa Barbara, Institutional Review Board.
Method
Questionnaire, Participants, and Procedure
Because no questionnaires were found in the literature
that met the needs of this study, we created a new question-
naire, as shown in the Appendix, according to procedures
recommended by Cummings and Hulley (2007). The 34-item
Internet survey was designed to be completed in less than
10 min and included sections on demographics (gender,
age, marital status, number of children and their ages, and
relationships to the child), factors related to AOM (bottle
propping, day care attendance, smokers in household, num-
ber of bouts of AOM, and previous treatments), commu-
nication disorders (speech/language delays and/or hearing
loss and effects on quality of life), preventative measures
for AOM (willingness to have children use chewing gum,
pacifier, or nasal spray 3–5 times/day for 3 months), and
willingness to participate in ear infection prevention programs
administered in school and preschool settings with or with-
out student mentors.
The potential participants in the present study were
from a convenience sample in southern California consisting
of parents having children in PP, NS, PS, and KC settings
who were invited to participate in the survey. All of the par-
ents in these groups were known to have children aged be-
tween 0 and 5 years, when AOM is most prevalent. The
survey was conducted with these particular families at a lo-
cal level with the intent of establishing ear prevention pro-
grams designed specifically for them. The teachers from the
NS, PS, and KC settings in the Santa Barbara area were
associates of the first author, and all of the families in the
PP group had children who were seen by the first author
for audiologic evaluations in the previous 6 months and
had documented cases of AOM. Thus, we knew that the
parents in the PP group had some basic previous knowledge
about hearing loss and about ear infections and how to
prevent them, especially through the use of xylitol products,
because the first author had personally counseled them
about these issues. We assumed that the parents from the
NS, PS, and KC groups had little or no prior knowledge
about ear infections and xylitol.
E-mails were sent to all of the parents in each group
with a link to the questionnaire on SurveyMonkey.com.
For confidentiality reasons, the teachers in the NS, PS, and
KC groups were given the link to the survey, which they in
turn e-mailed to 174 parents. Similarly, 23 e-mails were sent
to the parents of the children in the PP group with docu-
mented cases of AOM and who had been counseled on the
possible benefits of xylitol in preventing middle ear infec-
tions. Thus, a total of 198 e-mails were sent, and data were
collected over a 3-week period during February 2013; po-
tential participants were contacted only once. The families
were generally representative of the local area and were spe-
cifically being considered for future xylitol prevention pro-
grams in their community and schools. All of the potential
participants were known to have e-mail addresses and In-
ternet access. Thus, no parents should have been excluded
due to a lack of access to the Internet. Participants self-
selected their involvement by completing the questionnaire
and received a $20 gift card or donation to the schools (ex-
cept for the PS, which could not accept them) as incen-
tives for their participation. We hypothesized that parents
who had prior knowledge of or used xylitol and/or had chil-
dren with a history of AOM would be more willing to com-
ply with ear infection prevention programs administered
at home and through the schools than the others, but that
most parents would be unwilling to comply with the proto-
cols necessary to prevent ear infections in children.
Results
Demographics
A total of 136 parents answered the survey (PP = 23,
KC = 20, NS = 34, and PS = 59), which produced response
Danhauer et al.: Xylitol for Preventing AOM in Children 129
rates that ranged from 57% to 100% across the groups
(NS = 57%, PS = 66%, KC = 77%, PP = 100%). In nearly
all cases, the mothers completed the surveys (86%). Due to
space limitations, the participants’ responses are not repro-
duced here, but they are available from the authors. The
numbers of parents having a child in each of the following
age groups were as follows: 75 (4–6 years), 44 (2–3 years),
and 17 (≤1 year). Of all of the parents, only two (<1%) said
there was a smoker in the home, and only 17.3% admitted
to having used bottle propping with their child. As expected,
there were some differences between the PP parents and
those in other groups. For example, 48% of the PP parents
reported that their children had been diagnosed with
three or more bouts of AOM compared with an average of
25% reported by parents in the other groups. In addition,
43% of the PP parents reported that their children had speech
and language problems compared with only 11% of the
parents in the other groups. In addition, 38% of the PP par-
ents noted that their children had been diagnosed with a
hearing loss by an otolaryngologist or audiologist compared
with only 5% of the parents in the other groups. These repre-
sent the most interesting and relevant comparisons across
the groups, as fewer differences were noted for number of
siblings in the home, day care attendance, and other items
on the survey, but additional data are available from the
authors.
Prior Knowledge of and Willingness to Use Xylitol
For statistical analysis, prior knowledge of xylitol
was determined from parents’ responses to Item 18 on the
questionnaire: “Have you ever heard of xylitol?” Of all of
the parents, only 67 (49%) had heard of xylitol, and most
parents did not know that it could be used to prevent ear in-
fections; slightly more knew of its use in preventing dental
cavities. As expected, and confirming our hypothesis, signif-
icantly more of the PP parents knew about xylitol than
those from the other groups combined (PP: 17/21; c2 = 9.43
[1, n = number of the 23 participants who responded to
Item 18], p = .0021; all other groups combined: 48/115).
Similarly, significantly more of the PP parents than those in
the other groups combined knew that xylitol could prevent
middle ear infections (16/21; c2 = 67.19 [1, n = number of
the 23 participants who responded to Item 20, “Are you
aware that xylitol can be used to help prevent ear infections
in children?”], p < .0001).
As can be seen in Figure 1, on the basis of their response
to Item 20, parents across all four groups were significantly
more willing to comply with xylitol dosages and at least
two of the regimens to prevent AOM in their children when
they had prior knowledge about xylitol, which confirmed
our hypothesis. For example, all parents who were knowl-
edgeable regarding the effectiveness of xylitol in preventing
AOM had a significantly higher proportion of willingness
to comply with the chewing gum (c2 = 19.25 [1, p = percent
of all parents], p < .0001) and nasal spray (c2 = 19.25
[1, p = percent of all parents], p < .0001) regimens than those
who did not. No significant difference in proportions was
130 Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015
found between those same groups on their willingness to
comply with the pacifier regimen (c2 = 2.04 [1, p = percent
of all parents], p = .1534), which was low.
Similarly, Figure 2 shows that of all parents’ responses
to Item 10 (“How many times has a physician ever diag-
nosed your child with ear infections?”), parents were sig-
nificantly more willing to comply with xylitol dosages and
at least two of the regimens to prevent AOM in their children
as the number of previous episodes of AOM increased,
again confirming our hypothesis. For example, across all
four groups, a significantly higher proportion of parents
whose children had more than three diagnoses of AOM were
more willing to comply with the chewing gum (c2 = 28.3
[1, p = percent of all parents who responded to Item 10 and
Item 21; see the Appendix], p < .0001) and nasal spray
(c2 = 10.19 [1, p = percent of all parents who responded to
Item 10 and Item 22; see the Appendix], p = .0014) regimens
than those whose children had no diagnosis of this pathology.
No significant difference in proportions was found between
those same groups on their willingness to comply with the
pacifier regimen (c2 = 2.926 [1, p = percent of all parents who
responded to Items 10 and 23; see the Appendix], p = .087),
which was low.
On the basis of responses to Items 24, 25, and 26, gen-
erally, most of these parents said they would prefer to use
chewing gum over nasal sprays or pacifiers, but they did not
think that their children would comply with the necessary
dosages of xylitol needed to prevent ear infections, and they
indicated that nasal spray would be difficult to administer to
their children. Many parents said pacifiers might work, but
only if their child was young enough to use them, whereas
chewing gum could be given only to older children. Almost
half (63) of all of these parents said they would prefer a
one-time vaccine over the use of xylitol products.
Limitations to Study
Limitations to this study include the following:
1. Respondents self-selected their participation, making
it unknown as to how nonrespondents would have
answered the questions, which possibly biased the re-
sults by having data from only those who did respond.
2. Age, gender, ethnicity, and socioeconomic status
were not queried.
3. Because the parents were solicited as potential partici-
pants in a specific community and schools for devel-
oping ear infection prevention programs designed for
them at a local level, the findings from the survey
may not generalize to families in other parts of the
country.
However, these issues are true for any survey of this
nature, and responses were received from a wide range of
parents having different levels of previous knowledge about
xylitol before participating in the study and from families
across four settings with children from ages 0 to 5 years when
AOM is most prevalent. These parents’ candid, honest,
 Figure 1. Parents’ willingness to comply with xylitol dosages and regimens to prevent acute otitis media (AOM) in their children
on the basis of whether they had prior knowledge about xylitol (*chewing gum: p < .0001; **nasal spray: p < .0001).

and not necessarily positive responses lend credence to the
results.
Discussion
First, it was encouraging to find that less than 1% of
the families in this study reported having a smoker in the
home, which suggested that the importance of antismoking
messages is being received by these parents. However, less
encouraging were the valuable insights that were obtained
from these parents who might use xylitol products on their
children, which helped answer the questions posed for this
study. Generally, except for those in the PP group, these
parents had not been educated about xylitol’s use and effec-
tiveness for preventing ear infections. Many of these par-
ents were aware of the benefits of xylitol for oral and nasal
health issues, probably due to educational efforts by the
dental industry and product manufacturers. However, an
apparent lack of public awareness is an obstacle to wide-
spread use of xylitol products for preventing ear infections.
The information provided from this study is critical for de-
signing and establishing AOM prevention programs using
xylitol that would be administered in home, school, and
preschool settings. Such programs will require parental edu-
cation prior to participation and as little time, effort, and
disruption from daily activities as possible from parents,
teachers, and schools. This information is also valuable to
clinicians interested in establishing ear infection prevention
programs using xylitol products for their patients. Parental
education is an essential component of establishing ear in-
fection prevention programs using xylitol in children. Infor-
mation from this study should also be helpful to researchers
interested in conducting clinical trials of parents’ use of
xylitol products for preventing ear infections in children that
involve valuable financial resources, time, and personnel.
The survey results generally confirmed our hypothe-
ses, and we concluded that most of these parents did not
know about xylitol products and their potential use in pre-
venting ear infections in children and would be unwilling
to use xylitol products or comply with dosages/regimens
necessary to prevent ear infections in their children. Further-
more, most of these parents indicated that they would not
be more likely to comply with xylitol regimens if univer-
sity student mentors helped them follow the protocols. It is

Figure 2. Parents’ willingness to comply with xylitol dosages and regimens to prevent acute otitis media (AOM) in their children
on the basis of the number of previous cases of AOM their children had (*chewing gum: p < .0001; **nasal spray: p = .0014).

Danhauer et al.: Xylitol for Preventing AOM in Children 131

interesting that although many of these parents indicated
that they would prefer a one-time vaccine as opposed to a
regimen involving the use of xylitol products to prevent ear
infections in their children, none of them indicated that
their children had received such vaccines. This is inconsis-
tent with the statement made earlier that about 90% of chil-
dren aged younger than 2 years are currently receiving
these vaccines (Marom et al., 2014) and suggests that vac-
cines may not yet be in widespread use, or that parents may
not be aware of or understand the purpose of the vaccines
for preventing ear infections.
Generally, most of the parents of children from the
PP who had heard of xylitol previously were more knowl-
edgeable about it, provided more favorable responses, and
were more willing to participate in ear infection prevention
programs and/or clinical trials than those from the other
groups, which had little or no prior knowledge about it. Of
those parents who would consider using xylitol with their
children, most would prefer chewing gum for older children
and pacifiers for younger children. Parents with children
aged ≤3 years (i.e., those most prone to AOM) and those
with children having a history of ear infections would be
more likely to use a xylitol nasal spray or pacifier and to
comply with prevention programs than those with older
children or those not having a history of ear infections.
Obstacles revealed from this study regarding use of
xylitol via chewing gums, pacifiers, and nasal sprays were
realistic and need to be overcome with more appropriate
ways to administer xylitol to young children both at home
and in school and preschool settings. Again, the results
from this study showed that considerable education will be
required from manufacturers of xylitol products and from
audiologists and hearing health care providers to enlighten
the public about the potential benefits of xylitol and the
importance of parental and school compliance for successful
AOM prevention regimens. Nevertheless, the information
obtained from this study is valuable to audiologists inter-
ested in counseling families about preventing AOM in their
children. Although xylitol has been shown to be effective
as a prophylaxis for AOM, it will serve that purpose only if
the public is aware of it, if it actually works for its intended
uses, and if parents and schools will participate in AOM
prevention programs and comply with the necessary dosage
regimens. From the results of this study, we question whether
it is practical at this time to recommend the current vehicles
(i.e., chewing gum, nasal sprays, or pacifiers) for adminis-
tering xylitol to infants and young children. Because chewing
gum may represent a possible choking hazard for children
aged younger than 4 years (Nichols et al., 2012), nasal sprays
or pacifiers might be more suitable vehicles for children in
this age group. The lack of any empirical studies or guide-
lines on when children can safely chew gum precludes any
recommendations for the type or frequency of gum chewing
supervision protocols (International Gum Chewing Asso-
ciation, n.d.), but all parents should know their children,
be aware of when they can chew without swallowing, and
supervise and monitor their children when using this vehicle
for administering xylitol or any chewing gums. The results
132 Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015
of this study support those of earlier investigations (e.g.,
Autio & Courts, 2001; Danhauer, Johnson, & Caudle, 2011;
Danhauer, Johnson, Rotan, et al., 2010; Danhauer, Kelly,
& Johnson, 2011; Stockwell et al., 2010), which suggest
that researchers need to continue the search for more age-
appropriate vehicles and consider the information provided
here before conducting expensive clinical trials. In the mean-
time, it may be wise to target mainly families with children
who are most at risk for AOM and inform them about
xylitol and let them select those vehicles that would best
meet the needs of their individual situations.
Acknowledgments
This research was supported in part by two John C. Snidecor
Fund Awards from the University of California, Santa Barbara,
Department of Speech and Hearing Sciences, awarded to Jason A.
Baker and Rachel A. Smith. Portions of this research were pre-
sented at AudiologyNOW!, Anaheim, California, April 2013. We
wish to thank Alonzo Jones for assisting with the development
of the questionnaire and for comments about the results. We thank
Daniella P. Galindo, Kayla T. Ichiba, Anna Marie Jilla, Nicole
Kashani, James C. Sullivan, and Raquel Valencia for their assis-
tance in preparing this article. We also thank Irene Buzzard, Leilani
Price, Keyo Russell, Aana Strickler, and all the parents from the
preschool and kindergarten schools and the private practice who
assisted with the data collection for this study. Finally, we express
our appreciation and dedicate this study to the late Samantha
Willows Baker-Olson, who also helped us with the pilot data for
the parent questionnaire.
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Danhauer et al.: Xylitol for Preventing AOM in Children 133
 Appendix ( p. 1 of 7)
Parents’ Willingness to Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis
Media in Their Children Questionnaire

1. Indicate how you were contacted about this survey.

◯ My child was seen at…
◯ My child is enrolled in…
◯ My child is enrolled in…
◯ My child is enrolled in…
2. How old is the child (i.e., in Question 1) for which you are being contacted about this survey?
◯ 1 year or younger
◯ 2 to 3 years
◯ 4 to 6 years
◯ Older than 6 years
3. Indicate how many children in your household are in each of the following age groups.
0 1 2 3 4
Less than 1 year □ □ □ □ □
1 to 3 years □ □ □ □ □
4 to 6 years □ □ □ □ □
Older than 6 years □ □ □ □ □

4. What is your relationship to any children under 7 years of age in your household? (Check all that apply.)
□ Mother
□ Father
□ Stepmother
□ Stepfather
□ Grandmother
□ Grandfather
□ Aunt
□ Uncle
□ Legal guardian
Other (please specify)

134 Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015
Appendix ( p. 2 of 7)
Parents’ Willingness to Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis
Media in Their Children Questionnaire

5. Does anyone in the household smoke?

◯ Yes
◯ No
6. For how many months did your child ever use a pacifier?
◯ Never
◯ Less than 6 months
◯ 6 months or more
◯ I am not sure
7. For how many months was your child breastfed?
◯ Never
◯ Less than 6 months
◯ 6 months or more
◯ I am not sure
8. Was “bottle propping” (e.g., placing a pillow under the bottle to let the child feed him or herself ) ever used with
your child?
◯ Yes
◯ No
◯ I am not sure
9. For how many months has your child been in preschool, day care, or kindergarten?
◯ Never
◯ Less than 6 months
◯ 6 months or more
10. How many times has a physician ever diagnosed your child with ear infections?
◯ 0
◯ 1 to 3
◯ More than 3
11. Do you believe that ear infections run in your family (e.g., in parents or grandparents in addition to the child
surveyed here)?
◯ Yes
◯ No
◯ I am not sure

Danhauer et al.: Xylitol for Preventing AOM in Children 135

 Appendix ( p. 3 of 7)
Parents’ Willingness to Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis
Media in Their Children Questionnaire

12. Please rate how negatively you believe that ear infections have ever impacted your family.
◯ Very much ◯ Somewhat ◯ Neutral ◯ Little ◯ Very little
13. Do you believe that your child has ever had a speech and/or language problem?
◯ Yes
◯ No
◯ I am not sure
14. Has an Audiologist or Ear, Nose, and Throat (ENT) doctor ever diagnosed your child with a hearing loss?
◯ Yes
◯ No
◯ I am not sure
15. Do you believe that your child has ever had a hearing loss?
◯ Yes
◯ No
◯ I am not sure
16. What treatments has your child ever received for ear infections? (Check all that apply.)
□ Child never had ear infections
□ None
□ Antibiotics
□ Pressure equalization (PE) tubes
□ I am not sure
Other (please specify)

17. If your child had medical treatment for an ear infection, do you believe that the treatment solved your child’s
ear infection problems?
◯ Child never had ear infections
◯ Yes
◯ No
◯ I am not sure

136 Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015
Appendix ( p. 4 of 7)
Parents’ Willingness to Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis
Media in Their Children Questionnaire

18. Have you ever heard of xylitol?

◯ Yes
◯ No
◯ I am not sure
19. Are you aware that xylitol can be used to help prevent dental cavities in children?
◯ Yes
◯ No
◯ I am not sure
20. Are you aware that xylitol can be used to help prevent ear infections in children?
◯ Yes
◯ No
◯ I am not sure
21. If a special chewing gum containing xylitol could help prevent ear infections in your child when chewed 5 times
per day for 3 months, would you be willing to make sure that he/she used it that often?
◯ Yes
◯ No
◯ Maybe
22. If a special nasal spray containing xylitol could help prevent ear infections in your child when used 3 to 4 times
a day for 3 months, would you be willing to make sure that he/she used it that often?
◯ Yes
◯ No
◯ Maybe
23. If a special pacifier containing xylitol could help prevent ear infections in your child when used every night for
3 months before falling asleep, would you be willing to ensure that he/she used it that often?
◯ Yes
◯ No
◯ Maybe

Danhauer et al.: Xylitol for Preventing AOM in Children 137

 Appendix ( p. 5 of 7)
Parents’ Willingness to Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis
Media in Their Children Questionnaire

24. Do you think your child would be willing to use chewing gum 5 times a day for 10 minutes each for a period of
3 months?
◯ Yes
◯ No
◯ Maybe
25. Do you think your child would be willing to use nasal spray 3 to 4 times a day for 3 months?
◯ Yes
◯ No
◯ Maybe
26. Do you think your child would be willing to use a pacifier each night before falling asleep for 3 months?
◯ Yes
◯ No
◯ Maybe
27. If any of the following could be used to help prevent ear infections in your child, indicate whether you would be
willing to use them on a daily basis for 3 months.
Yes No Maybe
None ◯ ◯ ◯
Chewing gum containing xylitol ◯ ◯ ◯
Nasal spray containing xylitol ◯ ◯ ◯
Pacifier containing xylitol ◯ ◯ ◯

28. Would you be more likely to comply with the dosages of chewing gum, nasal spray, or pacifier necessary to
help prevent ear infections in your child if a University of California, Santa Barbara (UCSB) student mentor
checked in with you weekly to monitor your progress than if you had to complete the process by yourself?
◯ Yes
◯ No
◯ I am not sure

138 Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015
Appendix ( p. 6 of 7)
Parents’ Willingness to Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis
Media in Their Children Questionnaire

29. Indicate whether you would be willing to participate in a study assessing the effectiveness of each of the
following preventions for ear infections in your child.
Yes No Maybe
None ◯ ◯ ◯
Chewing gum containing xylitol ◯ ◯ ◯
Nasal spray containing xylitol ◯ ◯ ◯
Pacifier containing xylitol ◯ ◯ ◯

30. If a once-a-year vaccine (e.g., similar to annual flu shots) was made available to help prevent ear infections in
your child, how much would you be willing to pay for it?
◯ I would not be willing to use it
◯ $0
◯ $5 to $15
◯ $16 to $25
◯ $26 to $50
◯ $51 or more
◯ I am not sure
31. Assuming that overall costs were similar, if a once-a-year vaccine (e.g., similar to annual flu shots) was made
available to help prevent ear infections in your child, would you be more likely to use it than to use other types of
prevention like chewing gums, nasal sprays, or pacifiers containing xylitol?
◯ Yes
◯ No
◯ I am not sure
32. The following information is optional, but if you wish to do so, please provide your mailing address in the space
below so that we can send the class reward for completing this survey.
Address:
City/Town:
State:
ZIP:
E-mail Address:
Phone Number:

Danhauer et al.: Xylitol for Preventing AOM in Children 139

 Appendix ( p. 7 of 7)
Parents’ Willingness to Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis
Media in Their Children Questionnaire

33. Thank you for completing this survey. Please add any comments you may have about this survey in the space
below.

140 Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015
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