December 1996
BOSTON — Physicians should develop a five-prong approach in treating the otitis-prone child, said Jerome O. Klein, MD, professor of pediatrics at Boston University School of Medicine.
"Parents need a plan to prevent new episodes and to give them a framework so they can respond and feel empowered," he said at the annual American Academy of Pediatrics meeting held here. He suggested a five-step plan that includes education, chemoprophylaxis, vaccination, surgery and an immunologic work up.
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"You have to spend some time — at least one-half hour — to go over these issues with the parent. You want them to know something about the disease and to know about the risk factors of the disease," said Klein, vice-chairman for academic affairs, department of pediatrics at the Boston Medical Center.
Tell the parents about the biology of the disease and emphasize that it is a disease of infancy, that the highest age-specific attack rate is 6 months to 18 months and that most episodes subside after 3 years. "There is a light at the end of the tunnel," he said. "Otitis does not continue throughout life."
Parents should be told that having one child with otitis in the household means that subsequent children are at risk of recurrent otitis. "The nature of the genetic predisposition is not usually identifiable," he said, but if you query parents, you will often find that one or both also had recurrent episodes when they were children.
Tell parents that the disease tends to be seasonal. Otitis media is more prevalent during the respiratory infection season from winter to early spring. "You would not want to start an aggressive management plan in late spring or early summer because the child would get better anyway, and there is a chance that the following winter will not be as bad," Klein said.
Then tell parents what actions they can take to limit episodes. These include breast feeding, smaller day care settings, reducing exposure to smoke and placing the infant in a supine position.
Breast feeding is important and reduces episodes during the first year of life. Although this information probably will not help the child sitting in your office, it may be useful for subsequent siblings. "If you can get parents through the first year, it may give some breathing room in a family with recurrent disease," he said.
Parents should be told to stop smoking. Exposure to second-hand smoke is a known risk factor for respiratory infections, he said calling the data "very solid." He suggested that children be placed in day care with only a few children, because larger day care settings are a risk factor for recurrent disease. The children pass infections back and forth.
Finally, parents can put infants in the supine position when they put them down to sleep. One large study in England showed that infants who slept in the supine position had fewer episodes of OM than those who slept in a prone position. "I bring it up because it is another empowering issue where you can introduce it to the parents and give them something they can do [to help the child]," he said.
After the parents have been told about the disease and given some ideas about how to improve the situation at home, Klein said he puts the child on chemoprophylaxis, even though some experts worry about the continued growth of resistant organisms.
The criteria for children who should be enrolled in chemoprophylaxis are: children who have had three AOM episodes in six months or four in 12 months; or if children have had two episodes in the first year in a family with a history of disease.
Klein uses amoxicillin as a first-line drug. The regimen is half of the therapeutic dose once a day (20 mg/kg/d). The child stays on the antibiotic until the spring, usually this is about six months, depending on when the regimen is started. The data supporting chemoprophylaxis is extensive. All the studies show that there is a benefit to patients, with infants younger than 2 years old being most likely to benefit, he said.
Klein is likely to give influenza and pneumococcal vaccines to children who suffer recurrent episodes of AOM. "I think pneumococcal vaccine has been underused by pediatricians," he said. This is because the immune response is limited in those younger than 2 years old, which is the age group that suffers most of the otitis, respiratory and invasive infections. However, by age 2, a child will respond to about five of the 23 antigens, and with each successive year, will respond to about three more.
"So, I start using pneumococcal vaccine at age 2," he said, "it is a small bang for your buck, but I think it is some insurance in a product that has limited downside risk. It is been available and used in children for 15 years, and there is almost nothing in the way of side effects and toxicity.
"I would begin using it at 2 years of age; the older they are the more types they will respond to. But I would suggest that every child who has had a bad winter the year before, should be considered for influenza vaccine," he added.
There have been studies that influenza vaccine reduces otitis episodes, but they were not well designed. "But intuitively it makes sense if you can prevent one respiratory episode, where the potential in a child is so great for having associated OM, that it probably is useful. The data are not substantial, but intuitively I would suggest this as part of your strategy."
If a child does not respond to chemoprophylaxis, it may be time to sit down with the otolaryngologist and surgeon and talk about surgical intervention. Ventilating tubes do prevent new episodes. "Children still get infectious disease," he said, "so they still may be ill, but if the tubes are adequately draining they won't get the acute bulging drum or the suppurative event."
These breakthrough episodes will still require antimicrobial agents, but children will not be as sick as they were before surgery. If the child fails chemoprophylaxis and ventilating tubes, consider an adenoidectomy. "I would hold that for the child who has gone through chemoprophylaxis and ventilating tubes and failed," he said.
Most children have a local problem, not a systemic immune system disorder, but there are those with immune problems. Those that signal the need for an immune work-up are those that have multiple system disease, such as respiratory and urinary tract infections with invasive disease.
The work-up should include phagocytosis, t-lymphocyte mucosal antibody, intrinsic cell defects, low or no IgG, IgG2, IgG3 and IgA deficiency. These tests should tell whether the child has phagocytosis, neutropenia, chronic granulomatous disease or HIV. "Children with HIV will continue to have otitis after age 3," he warned.
This work-up should be performed with the assistance of an immunologist and an immune laboratory, he concluded.
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