Otitis Media and Children’s Language and Learning Matthew, a 3-year-old, speaks in two- and three-word utterances and is being evaluated for speech and language delay. He has had persistent ear infections for the last six months. His parents want to know whether he should have tubes placed in his ears. Erin, a 2-year-old, has had frequent ear ... Features
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Features  |   October 01, 2002
Otitis Media and Children’s Language and Learning
Author Notes
  • Joanne Roberts, is a senior scientist at the Frank Porte Graham Child Development Institute and a professor of pediatrics and speech and hearing sciences at the University of North Carolina at Chapel Hill. She has published numerous articles and chapters and one book on OM and its implications for children’s development. She currently directs an NIDCD-funded grant studying the linkages between OM, auditory processing, language, and academic skills in young children and is ASHA’s representative to several panels reviewing evidence and developing guidelines on managing OME.
    Joanne Roberts, is a senior scientist at the Frank Porte Graham Child Development Institute and a professor of pediatrics and speech and hearing sciences at the University of North Carolina at Chapel Hill. She has published numerous articles and chapters and one book on OM and its implications for children’s development. She currently directs an NIDCD-funded grant studying the linkages between OM, auditory processing, language, and academic skills in young children and is ASHA’s representative to several panels reviewing evidence and developing guidelines on managing OME.×
  • Lisa Hunter, is an associate professor of communication disorders at the University of Utah in Salt Lake City. She has published numerous articles and book chapters on OM and hearing loss in children, and directed an NIDCD-funded study on language, academic, attention, and auditory long-term sequelae in children with chronic OME. She was ASHA’s audiology representative to a panel reviewing evidence on managing OME.
    Lisa Hunter, is an associate professor of communication disorders at the University of Utah in Salt Lake City. She has published numerous articles and book chapters on OM and hearing loss in children, and directed an NIDCD-funded study on language, academic, attention, and auditory long-term sequelae in children with chronic OME. She was ASHA’s audiology representative to a panel reviewing evidence on managing OME.×
Article Information
Development / Hearing Disorders / Attention, Memory & Executive Functions / Features
Features   |   October 01, 2002
Otitis Media and Children’s Language and Learning
The ASHA Leader, October 2002, Vol. 7, 6-19. doi:10.1044/leader.FTR2.07182002.6
The ASHA Leader, October 2002, Vol. 7, 6-19. doi:10.1044/leader.FTR2.07182002.6
Matthew, a 3-year-old, speaks in two- and three-word utterances and is being evaluated for speech and language delay. He has had persistent ear infections for the last six months. His parents want to know whether he should have tubes placed in his ears.
Erin, a 2-year-old, has had frequent ear infections for the past eight months. She had tubes placed in her ears two weeks ago, and her mother reports that she now speaks in sentences and is much more responsive.
Justin, a 4-year-old with Down syndrome, has had frequent otitis media since infancy. He has had three sets of tubes and a persistent mild hearing loss. His language seems to have reached a plateau.
Speech-language pathologists and audiologists have often heard these scenarios as they are called upon to share their expertise. Otitis media (OM) is the most frequent illness of early childhood after the common cold. Annual health care costs related to the disorder were estimated at $5.8 billion dollars in 1998. It continues to be debated whether recurrent or persistent OM during the first few years of life increases a child’s risk for later language and subsequent learning difficulties.
Definitions
The generic term “otitis media” is an inflammation that occurs within the middle-ear cavity, which is normally air-filled. Current theories of the pathogenesis of OM are that viruses and bacteria in the nose and throat invade the middle ear through the Eustachian tube. Where in adults this muscular tube is normally closed at rest, in young children it is open more frequently and thus provides less protection for the middle ear.
There are several different types of OM. Acute OM (AOM) has fluid behind the eardrum that is infected (purulent) and usually a rapid onset of symptoms such as fever and ear pain. OM with effusion (OME) is the presence of the fluid behind the eardrum that is not infected. Once OME has lasted for longer than eight weeks, it is called chronic OME. Studies have shown that 70% of children will continue to have OME at two weeks, 40% at one month, 20% at two months, and 10% at three months after an initial episode.
OM is very common in early childhood. Nearly all children have at least one episode of AOM or OME, and at least 80% of children have three or more episodes before 3 years of age. Children who have Down syndrome, fragile X syndrome, Turner syndrome, Williams syndrome, cleft palate, and other craniofacial differences often experience frequent and persistent OME in early childhood. This increased risk may be due to craniofacial structural abnormalities, hypotonia, or immune deficiencies. OME is also more prevalent among children who attend childcare, are exposed to passive smoke, are from families of low socioeconomic status, and have a family history of OME.
Evidence-Based Medicine and OM
During the past decade, evidence-based medicine—which entails integrating clinical expertise with the available clinical evidence from systematic research in making decisions about individual clients and patients—has become increasingly influential in clinical practice. Consistent with this approach, in 1994 a multidisciplinary panel of experts developed the document, Clinical Practice Guideline: Otitis Media with Effusion in Young Children (Stool et al., 1994). This past year, a review of evidence on the effects of OME on hearing and language, Evidence Report: Diagnosis, History and Effects of OME (AHPR, 2002), was published. A revision of the 1994 guidelines is in process.
In addition, “Otitis Media and Language Learning Sequelae”—a conference sponsored by the National Institute on Deafness and Other Communication Disorders (NIDCD), the National Institute of Child Health and Human Development (NICHD), the Agency for Healthcare Research and Quality, the Maternal and Child Health Bureau, and the Deafness Research Foundation—was held earlier this year. The goal of the conference was to use an evidence-based medicine model to review current research on the effects of OM on children’s hearing and development, identify gaps and future directions for research, and discuss implications for health care practices. The information presented in this article is based in part on the findings of this recent conference.
Diagnosis and Treatment
The Agency for Health Care Policy and Research recommended guidelines for treatment of OME (1994; www.aap.org/policy/otitis.htm) in otherwise healthy children from birth to 3 years of age. A pneumatic otoscope should be used to examine the movement of the eardrum. Tympanometry is also useful, especially when the diagnosis is in question. Antibiotics, although helpful in reducing infections in AOM, are less effective at clearing fluid from the middle ear in OME. There is only a small increase (14%) in OME resolution when antibiotics are given. When bilateral OME persists more than three months, a hearing evaluation is recommended. For the child who has bilateral middle-ear effusion with hearing impairment for 4–6 months, myringotomy with ventilation tube insertion is recommended. Tube placement in chronic OME allows the middle ear to ventilate and mucosal linings to normalize, resulting in improved hearing and a reduced frequency of symptomatic acute otitis media episodes while the tubes remain in place.
Developmental Concerns
OM occurs most often during the first three years of life, a time that is most important for early language development. One of the major reasons for medical and surgical management, including antibiotics and tympanostomy tubes (which is the most common minor surgical procedure done on young children), is to prevent any developmental consequences related to OM.
OME typically causes a mild-to-moderate hearing loss that lasts as long as the fluid persists and has been hypothesized to disrupt children’s ability to process language at a rapid rate, affecting both comprehension and production in phonology, vocabulary, syntax, and discourse. For example, the disruption and variability in auditory input due to OME may possibly cause children to encode information incompletely and inaccurately into their phonological working memory, building up inaccurate representations of words. Children with OME may not hear or may inaccurately hear certain low-substance grammatical morphemes such as inflections of short duration and low intensity (e.g., third person /s/, past tense /“ed”/).
Finally, children with prolonged or frequent OME are hypothesized to become inattentive, especially in noisy situations, resulting in attention difficulties for auditory-based information. Academic achievement, particularly in reading and other language-based subjects, may subsequently be affected. Recent models of the potential linkage of a history of OME to children’s language development hypothesize that not only factors within the child, but also the child’s environment and the interaction between the child and the environment can affect this linkage. These include a number of risk factors (e.g., child has poor phonemic awareness skills, mother with less than a high school education, noisy childcare environment) and protective factors (e.g., child has excellent vocabulary, literacy-rich home environment, and responsive child care environment).
Linking OM to Hearing
OME results in hearing loss about half the time. The hearing loss is generally conductive, meaning that sound is not conducted through the middle ear to the inner ear, or cochlea. The average hearing loss is 20–25 dB, but can range from none to 50 decibels, and the audiometric configuration (shape of hearing loss) may be highly variable as well. When OME resolves, hearing will generally return to normal. However, research has shown that repeated bouts of OM can cause a sensory hearing loss in the high frequencies (4000 Hz and above). Although the functional effect of such high-frequency hearing loss is debatable, it has been shown to be important for perception of high-frequency speech sounds such as “s.” OM also can be a problem for children who have pre-existing sensory hearing loss, such that hearing aids may be temporarily ineffective. Studies of the impact of OME on central auditory processing have shown effects on functions believed to originate in the lower brainstem and require equal (binaural) hearing by the two ears. These effects resolve slowly over a period of years and are gone by adolescence for the typical child who had OME.
Some studies involving central auditory function (higher order tasks) have reported an association between early OME history and complex auditory tasks, such as understanding speech in fluctuating background noises. Prospective studies of children with chronic OME at the University of Minnesota by Lisa Hunter and colleagues showed that histories of hearing loss due to OME after age 3 years were associated with poorer high-frequency hearing. Studies examining the effects of OME on auditory processing should thus far be interpreted cautiously, because the translation of laboratory measures into academic performance has not been established.
Linking OM to Speech, Language, and Learning
Despite a considerable number of studies conducted during the past three decades on whether children with frequent OME in early childhood score lower on measures of speech, language, and academic achievement than children without such a history, the literature is still controversial. There are, however, some areas of consensus within the literature. Several prospective studies (where a group of children are followed over time with a pre-determined protocol) have found a relationship between a history of OM in early childhood and later of receptive and expressive language, syntax, vocabulary, and narratives during the preschool and early elementary school years. But other studies failed to find associations between an early history of OME and later measures of receptive or expressive language, vocabulary, syntax, or narratives.
Several ongoing prospective studies are providing new and important information. Studies at the University of North Carolina by Joanne Roberts and colleagues, funded by NIDCD, are examining the linkages between OME and hearing loss in early childhood and later auditory processing, language, and academic skills in a group of children who have had their OME, hearing loss, and caregiving environments followed prospectively since infancy. The researchers found that the responsiveness of the child’s home and childcare environments played an important role in the relationship of OME and associated hearing loss and children’s language development during infancy. They also reported a mild association between a history of OME and later development of expressive language, but that children caught up by second grade and that a child’s home environment was a much stronger predictor of language than was a history of OME.
Jack Paradise and colleagues at the University of Pittsburgh are conducting innovative experimental studies, funded by NICHD. These studies are examining whether prompt insertion of tympanostomy tubes, which drain fluid and equalize middle-ear pressure, improved children’s language development as compared to delayed insertion of tubes. Paradise and colleagues have reported that prompt insertion did not improve children’s language development.
In summary, there is increasing support that on average for typically developing children, OME may not be in general a substantial risk factor for later speech and language development. Although a few studies report a very mild association between OME and later speech, language, or academic achievement, the effect size is generally very small, accounting for zero to about 4% of the variance in children’s development. However, the findings should be interpreted cautiously, given that almost all of these studies used OME rather than hearing loss as the independent variable (it is the degree of hearing loss that is hypothesized to affect development), and many did not control for important confounding variables such as socioeconomic factors.
Implications for Practice
Considering these findings, these authors suggest a clinical approach that gives special consideration to children at high risk for developmental difficulties when hearing loss is present with persistent OME. These include children who are already at risk for language and learning difficulties, such as children from special populations and children who have experienced persistent hearing loss greater than 20 DB HL caused by OME. There are several clinical implications of a history of OME in these children for SLPs and audiologists to consider.
A child’s hearing, speech, and language should be screened after three months of bilateral OME, 4–6 episodes of OM in a six-month period, and/or when families or caregivers express concerns regarding a child’s development. Special populations of children below the age of 3 years who are at increased risk for OME (e.g., children with Down syndrome, cleft palate) should be screened for OME and hearing loss at least twice a year, especially during the winter months. For children enrolled in speech-language treatment who have chronic OME, screening of hearing and middle-ear status should occur routinely as part of an ongoing intervention program. Families and other caregivers (e.g., childcare providers) of young children who have recurrent or persistent OME need current, clear, and accurate information in order to make decisions about their child’s medical and educational management. Children who experience recurrent or persistent OME will benefit from a highly responsive language- and literacy-enriched environment. Children with chronic OME will benefit from an optimal listening environment where the speech signal is easy to hear and background noise is kept to a minimum. Some children with a history of OME may exhibit language and other developmental difficulties, and benefit from early intervention. A child should receive speech and language intervention if a speech delay or disorder is present. The use of personal or sound-field FM systems has been shown to be beneficial for some children with fluctuating and persistent hearing loss associated with OME. The speaker, such as a teacher, wears a small microphone and FM transmitter and the sound is sent to either an earphone worn by the child or to a loudspeaker in the classroom. SLPs and audiologists can serve as referral sources to work with families to refer children to other health care professionals when appropriate. Clinicians also can provide families and health care professionals information about children’s speech, language, hearing, and behavior, which may be important in making such decisions as whether a child should have tubes placed in his/her ears. OME is highly prevalent in early childhood. There continues to be a lack of consensus on whether a history of OME in early childhood affects children’s language development.
Some children who are already at risk for language and learning difficulties, such as children from special populations, may be at increased risk for later language and learning difficulties due to a history of OME and associated hearing loss. Until further research can resolve whether a relationship between a history of OME and later developmental skills exists, each child’s hearing status, language skills, and development need to be considered in the management of young children with histories of OME.
Future research will help us understand whether history of hearing loss associated with OME plays a role in children’s language development and later literacy skills.
This article is dedicated to the memory of Sandy Friel-Patti who, along with her colleagues, conducted the first prospective study of the impact of OME and hearing on children’s language.
The following appear in Roberts, J. E., & Zeisel, S. A. (2000). Ear infections and language development. American Speech-Language-Hearing Association and the National Center for Early Development and Learning. Washington, DC: U.S. Department of Education.
What Are Signs of Otitis Media?
Child pulls on ear Child says ear hurts Drainage from ear Fever (acute otitis media) Irritability Poor sleep NOTE: A child may have all, some, or none of these symptoms.
How Can I Recognize If My Child Has a Hearing Loss?
Has difficulty paying attention Shows a delayed response or no response when spoken to Says “huh?” often Does not follow directions well Turns up sound on radios, television, CDs Withdraws from other children Is over-active or uncooperative.
How to Promote a Healthy Setting
These suggestions help all children stay healthy. They may be especially important for children who tend to get ear infections and ear fluid.
Wash child and adult hands after blowing noses or going to the bathroom. This will fight the spread of germs. Clean toys that have been in the child’s mouth before another child plays with them. Follow directions for giving medicine so that it is given on time and for the entire time that it is recommended. If possible, breastfeed for at least the first 4–6 months of life to reduce the chance of otitis media. Bottle-feed in an upright or slightly leaning position. Cuddle the child in your lap with his head raised. A child should not be put to bed with a bottle. A bottle should not be propped in bed. Those practices may cause fluid from the bottle to go up a small tube leading to the middle ear, causing ear fluid. Keep children away from smoke. Cigarette smoke increases a child’s chances of middle-ear disease. If possible, put children in small rather than large groups of children. Colds pass more easily in large groups, and colds in young children can lead to middle ear fluid.
Promote Listening
It can be difficult to hear and concentrate in a noisy area such as a classroom (with lots of children talking) or home (with television on), even with only a small amount of hearing loss. These suggestions will help all children listen better.
Help children hear and understand your speech
Get within three feet of the child before speaking. Get your child’s attention before speaking. Face the child and speak clearly with a normal tone and normal loudness. Use visual cues such as moving your hands and showing pictures in addition to using speech. Seat your child near adults and children who are speaking. Speak clearly and repeat important words, but use natural speaking tones and pattern. Check often to make sure the child understands what is being said. Stand still when talking to your child to decrease distractions. Decrease background noise, especially for children with hearing loss.
Turn off unnecessary music and television in the background. Fix noisy appliances such as heaters or air conditioners. Limit play with noisy toys. Encourage teachers to create quiet areas. For example, use dividers for small group play and reading. Close windows and doors when it is noisy outside.
Promote Language Learning
Take advantage of opportunities every day to help children develop their language. All children can benefit from responsive language interactions, especially children with hearing loss due to otitis media.
Get down to your child’s eye level when talking. Talk about familiar things—snacks, pets, rain—anything your child knows about and is interested in. Talk with your child during mealtimes, baths, and throughout the day. Play interactive games with your child to encourage talking, such as pat-a-cake. Ask simple questions and pause for your child to respond. When your child says something, respond to what the child is talking about immediately and with interest. Add to what the child is saying by using more words. Praise the child for talking even if the speech is unclear. Take your child to lots of places (library, supermarket, the park) and talk about what you see there. Say the names of things your child sees or plays with and describe things that happen. Talk with preschoolers about what they did, what they will do, why things happen, and their feelings. Encourage children to talk to one another. Repeat language activities so children learn what to expect.
Promoting Early Literacy Learning
Activities such as reading to your child help develop early literacy skills.
Read often to children, describing and explaining pictures and referring to the child’s own experiences (e.g., “Spot is like your dog”). Read slowly to children, pausing at times to ask questions (“What do you think will happen next?”). Give children books and magazines to look at. Read out loud traffic and store signs, labels on packages, and words on a menu. Let children draw and write using crayons, markers, and pencils. Sing simple songs with repeated words and phrases. Talk about sounds and names of letters. Play sound, alphabet, and word games that focus on beginning and ending sounds of words. Play word and listening games to encourage children to listen to familiar patterns and fill in words. For older preschoolers, play rhyming games such as hat, cat, bat.
Read More About Otitis Media
Bluestone, C. D., & Klein, J. O. (2001). Otitis media in infants and young children (3rd. ed.). Philadelphia: W.B. Saunders Co.
Bluestone, C. D., & Klein, J. O. (2001). Otitis media in infants and young children (3rd. ed.). Philadelphia: W.B. Saunders Co.×
Gravel, J., & Hunter, L. (1999). Otitis media and hearing loss. Seminars in Otitis Media, 2, 3–10.
Gravel, J., & Hunter, L. (1999). Otitis media and hearing loss. Seminars in Otitis Media, 2, 3–10.×
Hunter, L. L., Margolis, R. H., Rykken, J. R., Le, C. T., Daly, K. A., & Giebink, G. S. (1996). High frequency hearing loss associated with otitis media. Ear and Hearing, 17, 1–11. [Article] [PubMed]
Hunter, L. L., Margolis, R. H., Rykken, J. R., Le, C. T., Daly, K. A., & Giebink, G. S. (1996). High frequency hearing loss associated with otitis media. Ear and Hearing, 17, 1–11. [Article] [PubMed]×
Paradise, J. L., Feldman, H. M., Campbell, T. F., Dollaghan, C. A., Colborn, D. K., Bernard, B. S., Rockette, H. E., Janosky, J. E., Pitcairn, D. L., Sabo, D. L., Kurs-Lasky, M., & Smith, C. G. (2001). Effect of early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at the age of three years. New England Journal of Medicine, 344(16), 1179–1187. [Article] [PubMed]
Paradise, J. L., Feldman, H. M., Campbell, T. F., Dollaghan, C. A., Colborn, D. K., Bernard, B. S., Rockette, H. E., Janosky, J. E., Pitcairn, D. L., Sabo, D. L., Kurs-Lasky, M., & Smith, C. G. (2001). Effect of early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at the age of three years. New England Journal of Medicine, 344(16), 1179–1187. [Article] [PubMed]×
Roberts, J. E., Burchinal, M. R., & Zeisel, S. A. (2002). Otitis Media in early childhood in relation to children’s school-age language and academic skills. Pediatrics 110(4), 1–11. [PubMed]
Roberts, J. E., Burchinal, M. R., & Zeisel, S. A. (2002). Otitis Media in early childhood in relation to children’s school-age language and academic skills. Pediatrics 110(4), 1–11. [PubMed]×
Roberts, J. E., Wallace, I. F., & Henderson, F. W. (1997). Otitis media in young children. Medical, developmental, and educational considerations. Baltimore: Paul H. Brookes Publishing Co.
Roberts, J. E., Wallace, I. F., & Henderson, F. W. (1997). Otitis media in young children. Medical, developmental, and educational considerations. Baltimore: Paul H. Brookes Publishing Co.×
Roberts, J. E., & Zeisel, S. A. (2000). Ear infections and language development. American Speech-Language-Hearing Association and the National Center for Early Development and Learning. Washington, DC: U. S. Department of Education.
Roberts, J. E., & Zeisel, S. A. (2000). Ear infections and language development. American Speech-Language-Hearing Association and the National Center for Early Development and Learning. Washington, DC: U. S. Department of Education.×
Rosenfeld, R. M., & Bluestone, D. (1999). Evidence-based otitis media. St. Louis, MO: B.C. Decker.
Rosenfeld, R. M., & Bluestone, D. (1999). Evidence-based otitis media. St. Louis, MO: B.C. Decker.×
Stool, S. E., Berg, A. O., Berman, S., Carney, C. J., Cooley, J. R., Culpepper, , Eavy, R. D., Feagans, L. V., Finitzo, T., Friedman, E. M., Goertz, J. A., Goldstein, A. J., Grundfast, K. M., Long, D. G., Macconi, L. L. Melton, L. Roberts, J. E., Sherrod, J. L., and Sisk, J. E. (1994). Otitis media with effusion in young children. Clinical Practice Guideline, Number 12. AHCPR Publication No. 94-0622. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.
Stool, S. E., Berg, A. O., Berman, S., Carney, C. J., Cooley, J. R., Culpepper, , Eavy, R. D., Feagans, L. V., Finitzo, T., Friedman, E. M., Goertz, J. A., Goldstein, A. J., Grundfast, K. M., Long, D. G., Macconi, L. L. Melton, L. Roberts, J. E., Sherrod, J. L., and Sisk, J. E. (1994). Otitis media with effusion in young children. Clinical Practice Guideline, Number 12. AHCPR Publication No. 94-0622. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.×
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October 2002
Volume 7, Issue 18