Ina Wallace

Otitis media, hearing loss, and language learning: Controversies and current research

ABSTRACT. This article reviews research on the possible linkage of otitis media with effusion (OME) to childrens hearing and development, identifies gaps, and directions for research, and discusses implications for healthcare practices. About half of children with an episode of OME experience a mild hearing loss while about 5-10% of children have moderate hearing loss. Recent prospective and randomized clinical trials suggest none to very small negative associations of OME to childrens later language development. Based on both retrospective and prospective longitudinal studies, associations between OME and perceiving speech in noise and tasks that require equal binaural hearing have been reported but have not been adequately studied with regard to functional outcomes. Thus, on average, for typically developing children, OME may not be a substantial risk factor for later speech and language development or academic achievement. However, these conclusions should be interpreted cautiously, since most of these studies used OME rather than hearing loss as the independent variable (although hearing loss rather than OME is hypothesized to affect language development) and many studies did not control for important confounding variables such as socioeconomic status (SES).

Early Otitis Media with Effusion, Hearing Loss, and Auditory Processes at School Age

Objectives: To examine the effect of conductive hearing loss (HL) secondary to otitis media with effusion (OME) in the first 3 years of life on physiologic, peripheral, and higher-order behavioral auditory measures examined at school age. Methods: Peripheral hearing sensitivity for conventional and extended high-frequency audiometric ranges, physiologic (distortion product otoacoustic emissions, contralateral and ipsilateral acoustic middle ear muscle reflexes), auditory brain stem response (ABR), and higher-order auditory processing measures (masking level difference; Virtual Auditory Localization, Speech Intelligibility Gain; adaptive Pediatric Speech Intelligibility task) were examined at the end of the second grade of elementary school in two cohorts (North Carolina, N = 73, and New York, N = 59). All participants (mean age, 8 years) were followed prospectively in infancy and early childhood (7 to 39 months) for middle ear status and hearing loss (using pneumatic otoscopy/tympanometry and repeated conditioned behavioral audiometric response procedures). Multivariate analyses were conducted to address whether early OME and early conductive HL were related to physiologic, peripheral, and higher-order auditory processes. Results: Early hearing loss and OME were significantly associated with peripheral hearing at school age; extended high-frequency thresholds accounted for the result. Similarly, hearing loss in early life and OME were significantly associated with the acoustic middle ear muscle reflex: The contralateral stimulation condition accounted for the association. Significant associations with both early OME and early HL were also found for the auditory brain stem response measure and were explained by the correlations between early hearing loss and the ABR Wave V latency but not other ABR indices. There were no reliable associations between either early OME or early HL on any other auditory processes evaluated at the end of second grade. Conclusions: Extended high-frequency hearing and brain stem auditory pathway measures in childhood were significantly associated with children’s experiences with OME and hearing loss from 7 to 39 months of age. However, no significant associations were found for psychoacoustic measures of binaural processing or a behavioral adaptive speech-in-noise test at school age.

Relations between infant neurobehavioral performance and cognitive outcome in very low birth weight preterm infants

The predictive utility of three aspects of neonatal neurobehavioral performance was examined in 144 very low birth weight (<1500 g) preterms who were followed until 6 years of age. Visual-following and auditory-orienting composites derived from the Einstein Neonatal Neurobehavioral Assessment Scale were modestly related to the Mental Developmental Index (MDI) and IQ scores at several ages, whereas the active motility composite was only related to MDI scores at 1 year of age (corrected). Infants who showed deviant performance on both visual following and auditory orienting composites had significantly lower cognitive test scores at 1 and 6 years of age and were more likely to be classified as subaverage at 6 years of age (IQ < 85). Group differences were independent of both neonatal health status and motor scores and were not due to the performance of children with severe sensory impairments. These findings suggest that visual following and auditory orienting measured in the neonatal period can offer a useful way of indexing initial capacities.

Preventive interventions with low birth weight premature infants: An evaluation of their success

The outcome literature on low birthweight (LBW) premature children indicates that they are at risk for a variety of neurodevelopmental impairments throughout childhood. To prevent such disabilities, numerous interventions have been initiated with LBW children. Nineteen intervention programs designed for LBW preterms that have published study results dating from 1971 are reviewed. Included are interventions in the neonatal nursery, at home, and at centers as well as interventions that are both child-focused and parent-focused. One randomized clinical trial evaluating comprehensive intervention services, the Infant Health and Development Program, is described in detail. Conclusions from the studies reviewed indicate that intervention programs have had only modest success in altering neurodevelopmental outcomes, although parent-child interaction has often been facilitated. Future research on the effects of preventive intervention needs to examine long-term developmental competencies and to replicate positive findings in multiple settings.

Examining parents' experiences and information needs regarding early identification of developmental delays: Qualitative research to inform a public health campaign

Objective: The purpose of this study was to assess the approach and materials of Centers for Disease Control and Preventions “Learn the Signs. Act Early.” (LTSAE) health education campaign, which aims to improve awareness of developmental milestones and early warning signs of developmental delay among parents of young children. Methods: We conducted 2 phases of qualitative research. Focus groups assessed the campaigns objectives by exploring the experiences of parents with children who have developmental delays or disabilities to determine facilitators of and barriers to identification. In-depth interviews were conducted with parents of typically developing children, who reviewed campaign materials and provided feedback on appropriateness, appeal, and clarity with regard to the campaigns objectives. Results: Phase 1: Parents were typically the first to express concern about their childs development, and most talked with their childs health care provider. Two categories of health care providers emerged: those who proactively asked about a childs development, used tools to facilitate conversations, and made referrals, and those who did not ask about development, told parents to “wait and see,” and did not provide information about services and supports. Few parents knew about special education services before identification. Phase 2: Participants found the campaign materials appealing, but were unclear about how to act early and why acting early was important. Conclusions: Results affirmed LTSAEs evidence-based approach to educating parents about child development. Additional campaign considerations include providing more information about how to act early and why acting early is important and enhancing outreach to providers to help them communicate with concerned parents.

A clinical research form for use in the documentation of middle ear effusion.

A form for use in both the clinical and research setting for documenting the presence and course of otitis media with effusion by pneumatic otoscopy has been developed. The form is based on the data obtained in a large Finnish study on pneumatic otoscopy signs and findings at myringotomy (Karma P, Penttilä M, Sipilä M, & Kataja M, Int J Pediatr Otorhinlaryngol 1989). The rationale for development and the clinical and research applications of the form are discussed.

9. Complications and Sequelae

s of the Eighth International Symposium on Recent Advances in Otitis Media, Ft Lauderdale, Fla, 2003:79. 30. Penido N, Cruz OLM, Iha LCN, Abreu CEC. Outcome in labyrinthine fistula caused by pronounced cholesteatomatous COM. In: Lim DJ, Bluestone CD, Casselbrant ML, eds. Abstracts of the Eighth International Symposium on Recent Advances in Otitis Media, Ft Lauderdale, Fla, 2003:183. 31. Jung TTK, John EO, Park SK, Row M. Effect of inflammatory mediators of otitis media on cochlear function. In: Lim DJ, Bluestone CD, Casselbrant ML, eds. Abstracts of the Eighth International Symposium on Recent Advances in Otitis Media, Ft Lauderdale, Fla, 2003:186. 32. Casselbrant ML, Furman JM, Mandel EM, et al. The long term effect of otitis media on the vestibular system. In: Lim DJ, Bluestone CD, Casselbrant ML, eds. Abstracts of the Eighth International Symposium on Recent Advances in Otitis Media, Ft Lauderdale, Fla, 2003:202. 157 Lim, Recent Advances in Otitis Media 157

52 WHO IS REALLY DEVELOPMENTALLY AT RISK AMONG VERY LOW BIRTHWEIGHT INFANTS

We studied the neurobehavioral development of 78 very low birthweight (VLBW) infants (< 1500 gms), beginning with the 1st week of life and continuing to 3 years of age. From birth through 40 weeks post-conceptional age (PCA) we used the Einstein Neonatal Neurobehavioral Exam (ENNBAS); from 40 weeks PCA to 2 years of age we used the Bayley Scales; in the third year we used the Stanford-Binet. The VLBW infants were divided into three age and weight-matched groups: 1) 12 infants with perinatal asphyxia (PNA) determined by an Apgar score of ≤ 4 at 5 minutes; 2) 14 infants with severe respiratory distress (RDS), requiring assisted ventilation for > 3 days (x=10 days), and 3) 52 healthy preterm infants without PNA, RDS, biochemical abnormalities, CNS infections or seizures. We found that: 1) during the preterm period, healthy VLBW infants and those with PNA develop equally well, and both do significantly better than RDS babies on all measures of visual, auditory and motor development; 2) from 40 weeks PCA to 3 years of age, healthy VLBW infants and those who had PNA consistently perform within normal standards on all tests of neurobehavioral development. VLBW infants who had RDS do significantly worse. We conclude that; 1) a short term respiratory insult (PNA) has very different developmental effects than a longer duration insult (RDS); 2) disturbances in neurobehavioral development which persist for up to 3 years may be detectable as early as the preterm period in certain groups of VLBW infants; 3) the “healthy” VLBW infant in our cohort develop normally through the third year of age.