Pediatricians’ opinions about otitis media and speech-language-hearing development

Pediatricians’ opinions about otitis media and speech-language-hearing development

Journal of Communication Disorders 37 (2004) 313–323 Pediatricians’ opinions about otitis media and speech-language-hearing development Esther Sonnen...

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Journal of Communication Disorders 37 (2004) 313–323

Pediatricians’ opinions about otitis media and speech-language-hearing development Esther Sonnenschein, Paul W. Cascella* Department of Communication Disorders, Southern Connecticut State University, 501 Crescent Street, New Haven, CT 06515, USA Received 21 July 2003; received in revised form 27 October 2003; accepted 21 December 2003

Abstract Twenty-five pediatricians responded to a confidential survey about their opinions on the relationship between otitis media and children’s speech-language-hearing status. Results found that pediatricians did not necessarily agree that otitis media has an impact on speech-language-hearing development. Pediatricians reported that an early otitis media onset (birth to age 2) affects speechlanguage development, but they also reported that parents and daycare environments could mitigate any otitis media effect. Pediatricians reported a possible otitis media impact on hearing status, but they did not necessarily agree that an otitis media history required referral for audiological testing. Clinical implications are discussed for collaboration among pediatricians, speech-language pathologists, and audiologists. Learning outcomes: (1) The reader will become familiar with pediatricians’ opinions about the impact of otitis media on speech-language development. (2) The reader will become familiar with strategies to support interdisciplinary collaboration between pediatricians, speech-language pathologists, and audiologists. # 2004 Elsevier Inc. All rights reserved. Keywords: Otitis media; Pediatricians; Medical practices; Speech-language development

Otitis media is a common childhood illness during the first 3 years of life and 50–75% of infants have at least one episode of otitis media in their first year (Eimas & Kavanagh, 1986; Friel-Patti & Finitzo, 1990; Wright et al., 1988). Over the past two decades, there has been a substantial amount of research regarding the possible impact of early otitis media on children’s speech-language development (Paradise et al., 2000; Roberts et al., 2000). * Corresponding author. Tel.: þ1-203-392-5956; fax: þ1-203-392-5968. E-mail address: [email protected] (P.W. Cascella).

0021-9924/$ – see front matter # 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.jcomdis.2003.12.002

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During the preschool years, children with recurrent otitis media are at-risk for reduced consonant inventories, reduced/delayed canonical babbling, smaller expressive vocabulary size, and receptive language delays (Abraham, Wallace, & Gravel, 1996; Friel-Patti & Finitzo, 1990; Harsten, Nettlebladt, Schalen, Kalm, & Prellner, 1992; Shriberg, Flipsen, et al., 2000; Shriberg, Friel-Patti, Flipsen, & Brown, 2000; Rvachew, Slawinski, Williams, & Green, 1999; Wallace, Gravel, McCarton, & Ruben, 1998;). Some studies identify longterm effects in that older children with strong otitis media histories have difficulty in sound discrimination, phonological knowledge, and auditory-based learning skills (Gravel & Wallace, 1995; Grievink, Peters, Van Bon, & Schilder, 1993; Mody, Schwartz, Gravel, & Ruben, 1999; Roberts, Burchinal, Davis, Colllier, & Henderson, 1991). In contrast, other studies report that any otitis media effect seems to be compensated for or disappears during the preschool years or later (Harsten et al., 1992; Roberts et al., 1989; Schilder et al., 1993; Wright et al., 1988). Despite two decades of otitis media research and its possible affect on speech-language development, the results appear to be less than conclusive. In a retrospective review, Shriberg and colleagues (2000) found that there was no direct evidence that otitis media with effusion caused speech-language disorders and there was limited evidence for a strong correlative association between the two. In light of the inconclusiveness of the research, the question arises about pediatricians’ opinions regarding the impact of early otitis media on speech-language-hearing. While pediatricians can refer to the Clinical Practice Guideline for the Management of Otitis Media with Effusion in Young Children (Stool et al., 1994), research finds that pediatricians prefer to use a combination of their own clinical judgment along with published protocols (Flores, Lee, Bauchner, & Kastner, 2000). Pediatricians’ opinions about otitis media and speech-language-hearing sequelae are important to consider since pediatricians act as gatekeepers to other rehabilitative services and often are the first professionals to address parent concerns regarding a possible speech-language delay. Pediatricians are in the advantageous position of being able to affect the health and well being of children from the earliest stages of their development. The diagnosis of otitis media is in their hands and its treatment is shared between pediatricians and parents. Therefore, this study addressed pediatricians’ self-reported opinions about speech-language and hearing outcomes secondary to otitis media.

1. Methods 1.1. Survey development A single page 16-item survey (Table 1) was constructed based on contemporary information in the medical and speech-language literature about otitis media. This survey included seven topics borne from the professional literature, including pediatricians’ opinions about: the possible affect otitis media has on speech-language development (# 12) and hearing (#’s 6, 8); the age at which otitis media has an impact (# 16); referrals for audiological testing after otitis media (#’s 9, 14); the role of parents and daycare providers to mediate the possible impact of otitis media (#’s 2, 4, 7); otitis media medical diagnosis and treatment (#’s 3, 10, 11, 15), and continuing education of medical personnel to identify

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Table 1 Survey of pediatricians, otitis media, and speech-language development 1. Fluctuating hearing loss can cause an impairment in a child’s foundation for speech-language development. (SA) (A) (D) (SD) 2. Pediatricians should encourage parents to increase verbal stimulation for their children during and after episodes of otitis media. (SA) (A) (D) (SD) 3. Antibiotics should not be administered for asymptomatic middle ear effusion until the fluid has been in the middle ear for at least 3 months. (SA) (A) (D) (SD) 4. Home and daycare environments can minimize the association between recurrent otitis media and speechlanguage delays. (SA) (A) (D) (SD) 5. Pediatricians should undergo continuing medical education to learn to identify children with early speechlanguage delays. (SA) (A) (D) (SD) 6. Persistent otitis media with effusion can result in mild to moderate fluctuating hearing loss. (SA) (A) (D) (SD) 7. Early language stimulation programs, conducted by parents, should be considered for infants prone to recurrent middle ear disease during their first year of life. (SA) (A) (D) (SD) 8. It is worthwhile to inform parents about the possible hearing loss associated with persistent or recurrent middle ear effusion (for 3 months or more). (SA) (A) (D) (SD) 9. I will send a child for audiological testing after 3 months of middle ear effusion. (SA) (A) (D) (SD) 10. I consider the median duration of effusion after the first diagnosis of acute otitis media to be approximately 23 days. (SA) (A) (D) (SD) 11. Accurate diagnosis of acute otitis media and otitis media with effusion can only be made using pneumatic otoscopy. (SA) (A) (D) (SD) 12. The presence of asymptomatic middle ear effusion in otherwise normal young children is likely to cause harm to their speech-language development. (SA) (A) (D) (SD) 13. Nurse managers, physician assistants, and other pediatric personnel should be familiar with normal speech-language development in order to be able to identify delays. (SA) (A) (D) (SD) 14. All children who experience otitis media during the first 2 years of life should be followed with serial ear, nose, and throat examinations and audiometric screening. (SA) (A) (D) (SD) 15. I diagnose otitis media with effusion when there is fluid in the middle ear and the tympanic membrane is immobile. (SA) (A) (D) (SD) 16. Early onset otitis media (birth to 2 years) may have a more significant affect on speech-language outcomes than later onset otitis media (3 years and beyond). (SA) (A) (D) (SD)

speech-language delays (#’s 5, 13). These seven variables were selected because they occurred recurrently in the professional literature, and they seemed especially relevant to speech-language pathologists and audiologists serving children with otitis media. One survey item addressed general hearing loss and speech-language development (# 1). Item

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Table 2 References for survey development Question

Professional reference

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Petinou, Schwartz, Mody, and Gravel (1999) Berman (2001) Altemeier (1998) Hemmer and Ratner (1994) Self-designed Menyuk (1980), Roberts and Zeisel (2000), Gravel and Wallace (2000) Wallace et al. (1998) Self-designed Altemeier (1998), Joint Committee on Infant Hearing (2000) Teele, Klien, Rosner, and The Greater Boston Otitis Media Study Group (1984) Altemeier (1998), Eimas and Kavanagh (1986), Roberts et al. (1989) Berman (2001) Self-designed Brookhouser, Hixson, and Matkin (1979) Roberts, Burchinal, and Zeisel (1998) Roberts (1997)

validity was ensured by directly paraphrasing thirteen of the items from research articles and clinical practice guidelines (Table 2). Because ‘‘otitis media’’ (inflammation in the middle ear cavity) and ‘‘otitis media with effusion’’ (uninfected fluid behind the eardrum) are both cited in the professional literature, the survey included both terms. Four survey items used the term otitis media (#’s 2, 4, 14, 16), four used the term middle ear effusion or otitis media effusion (#’s 6, 8, 9, 12), and one item used the term middle ear disease (# 7). Each item was followed by a forced choice for level of agreement (strongly agree; agree; disagree; strongly disagree). To help establish content validity, the survey was reviewed by a pediatrician colleague with 25þ years experience and his suggestions for wording and content were included. 1.2. Survey distribution and participants Fifty-three surveys were mailed to pediatricians who practiced in three midsize New England cities and whose names were listed on an American Medical Association (AMA) website (http://www.ama-assn.org). These pediatricians practiced in single and group practices, and hospitals. Pediatricians listed as residents or pediatric specialists were not included. The three cities were chosen because they cumulatively represented a range of ethnicities, including White (77%), Black (9%), Hispanic (10%), Asian/Pacific (2%), and other (3%) (United States Census Bureau, 2001). Each survey included an introductory letter and self-addressed stamped return envelope. In a cover letter, pediatricians were asked to state their opinion about each of the survey items. The introductory letter identified the purpose and confidentiality of the study, a reminder that participation was voluntary, and the option of completing and returning the survey by mail or by telephone. The cover letter indicated that anyone who did not respond within two weeks of the mailing would be telephoned. Telephone contacts were completed

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two weeks after the initial mailing and a second mailing occurred one month after the initial mailing.

2. Results 2.1. Response rate A usable response rate of 52.0% was achieved (25/48). Thirty pediatricians responded to the mailed survey and none of the pediatricians chose to complete the survey via the telephone. Five surveys were disqualified because the pediatricians had retired, reported that they were practicing in another field, or they were no longer practicing in the location designated on the AMA website. 2.2. Pediatricians’ opinions about otitis media and speech-language development The survey data were analyzed descriptively. Descriptive analysis included the mean, standard score, and standard deviation for each participant and survey item. Homogeneity was found among both the pediatricians and the survey items, in that all of the standard scores for the participants (range þ0.54 to 0.70) and survey items (range þ0.85 to 0.62) were within one standard deviation from the total mean. Means and standard deviations are reported for each survey item in Table 3. Among the individual survey items, the pediatricians most often agreed that: pediatricians should undergo continuing medical education to learn to identify children with early Table 3 Pediatricians’ responses to survey items Question

Mean

S.D.

Z score

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

1.68 2.08 2.28 2.02 1.56 1.64 2.00 1.64 2.32 2.32 2.21 2.48 1.56 2.60 1.92 1.80

0.63 0.70 0.89 0.53 0.51 0.49 0.58 0.57 0.69 0.48 0.98 0.59 0.51 0.87 0.49 0.50

0.45 0.11 0.39 0.03 0.62 0.51 0.00 0.51 0.45 0.45 0.30 0.68 0.62 0.85 0.11 0.28

Total

2.00

0.71

1 ¼ strongly agree; 2 ¼ agree; 3 ¼ disagree; 4 ¼ strongly disagree.

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Table 4 Pediatricians’ opinions about otitis media

b

Medical personnel need education about S/L delays (#’s 5, 13) Otitis media affects hearing (#’s 6, 8) Otitis media affects S/L based on age of onset (# 16) Parents/daycare can help S/L delays (#’s 2, 4, 7) Otitis media medical diagnosis and treatment (#’s 3, 10, 11, 15) Otitis media requires referral for audiological testing (#’s 9, 14) Otitis media affects S/L development (# 12) a b

Meana

S.D.

1.56 1.64 1.80 2.03 2.18 2.46 2.48

0.50 0.53 0.50 0.60 0.75 0.79 0.59

1 ¼ strongly agree; 2 ¼ agree; 3 ¼ disagree; 4 ¼ strongly disagree. S/L ¼ speech/language.

speech-language delays (# 5); it is worthwhile to inform parents about the possible hearing loss associated with persistent or recurrent middle ear effusion (for 3 months or more) (# 8); and, nurse managers, physician assistants, and other pediatric personnel should be familiar with normal speech-language development in order to be able to identify delays (# 13). The pediatricians least often agreed that: all children who experience otitis media during the first 2 years of life should be followed with serial ear, nose and throat examinations and audiometric screening (# 14); the presence of asymptomatic middle ear effusion in otherwise normal young children is likely to cause harm to their speech-language development (# 12); I will send a child for audiological testing after 3 months of middle ear effusion (# 9); and, I consider the median duration of effusion after the first diagnosis of acute otitis media to be approximately 23 days (# 10) (Table 4). Analysis of the seven themes found that the participants had diverse opinions about otitis media and speech-language-hearing sequelae. For example, although pediatricians agreed that otitis media affects a child’s hearing status (mean ¼ 1:64, S:D: ¼ 0:53), they were less likely to agree that a history of otitis media required referral for audiological testing (mean ¼ 2:46, S:D: ¼ 0:79). Pediatricians also agreed that early otitis media onset (birth to age 2) could affect speech-language development (mean ¼ 1:80, S:D: ¼ 0:50), but they did not necessarily agree about an overall otitis media impact on speech-language development (mean ¼ 2:48, S:D: ¼ 0:59). Pediatricians most strongly agreed with the need for medical personnel to have continuing education about speech-language delays (mean ¼ 1:56, S:D: ¼ 0:50) and they agreed that parents and daycare environments could help mitigate speech-language delays secondary to otitis media. For items that focused on medical issues instead of speech-language-hearing issues, the pediatricians generally agreed (mean ¼ 2:18, S:D: ¼ 0:75) with contemporary approaches to medical management.

3. Discussion The purpose of this study was to examine pediatricians’ opinions otitis media and speech-language-hearing development. Results can be summarized as follows. While pediatricians agreed with contemporary medical management viewpoints about otitis

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media, they did not necessarily agree that otitis media affects children’s overall speechlanguage development. Pediatricians expressed that early otitis media onset (birth to age 2) affects speech-language development, but they also reported that parents and daycare environments could mitigate any otitis media impact on speech-language development. These results suggest that pediatricians are aware of the ambiguity within the professional literature on otitis media and a possible speech-language impact. In addition, pediatricians reported that they and other medical personnel need continuing education on the identification of speech-language delays. Although preliminary, these results are encouraging for several reasons. First, pediatricians appear to understand the contemporary literature about the inconclusiveness of an otitis media impact on speech-language development. Second, these results suggest that pediatricians are likely to discuss speech-language development with parents of children with otitis media, especially children with an early otitis media onset age. Third, the results suggest that pediatricians want to know more about identifying speech-language delays in young children. There are practical implications for speech-language pathologists who work with young children (i.e., birth-to-three programs, preschool settings, daycare environments). First, the results of this survey suggest a potential basis for speech-language pathologists to further network with their local pediatricians. Pediatricians are interested in obtaining more information about speech-language development for themselves and for other pediatric medical personnel (e.g., physician assistants, nurse practitioners). Because so many young children are diagnosed with otitis media, it may be helpful to pediatricians if they had written information readily available to share with parents about ways to encourage speech-language development and the local resources available in their own community. Speech-language pathologists can make themselves available to provide informal consultative services to their pediatric colleagues about what to look for in young children’s speech-language development. This opens the door for referral and interdisciplinary collaboration across work settings when more formal early intervention services are warranted. A nearby birth-to-three service provider could prepare an informational booklet, or, for older children, the local preschool speech-language pathologist affiliated with the public school district. In either case, this material should specifically reflect the unique characteristics (e.g., ethnicities, languages) of the community and the local resources for families to access. This booklet could contain information about speechlanguage milestones and adjustments in the listening environment when children have otitis media (Roberts & Hunter, 2002). Parents can also be introduced to proactive speechlanguage stimulation approaches, such as language models (e.g., parallel and self-talk) and language expansion strategies. A disappointing result of this research was the lack of referral for audiological testing by pediatricians for children with a history of otitis media. Even though pediatricians agreed with a possible otitis media affect on hearing status, they did not necessarily agree that an otitis media history required referral for audiological testing. For audiologists, this research suggests that pediatricians may need additional in-service training about the availability and benefits of early audiological testing for children with strong otitis media histories. Audiologists need to continue to network with pediatricians, especially those pediatricians who are concerned about the hearing status of young children but who are not apt to refer

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for audiological services. It is important that audiologists and other early childhood personnel explore the reasons why pediatricians are unlikely to make this referral. Examples of effective pediatrician in-service training methods are also needed. Caution is advised in the generalization of these results. Although three midsize New England cities were used in the survey with the intent of representing ethnic diversity, it is reasonable to suggest there may be a geographic influence among these pediatricians. In addition, the number of pediatricians in this study was small and it is possible that only pediatricians interested in this topic responded to the survey. Although the survey questions were drawn from the professional literature and reviewed by an experienced pediatrician, they have not otherwise been empirically tested for validity or reliability. Further, the survey did not objectively verify pediatrician’s actions and it is reasonable to suggest that these results do not fully represent pediatricians’ opinions or actual practices. For example, it would be helpful to know how pediatricians screen for speech-language delays and whether they proactively address this issue or wait until parents raise concerns. Finally, the survey only included pediatricians and not other medical personnel who routinely evaluate young children, including nurse practitioners and physician assistants. Future research should explore the opinions and practices of related medical and early intervention personnel who routinely interact with families and evaluate young children’s communication development within the medical context.

Acknowledgements This research was completed in partial fulfillment of the Master of Arts degree requirements at Southern Connecticut State University by the first author. The authors gratefully acknowledge the insights and expertise of Rhea Paul, Robert LaCamera, Marianne Kennedy, and Yosef Sonnenschein. This research was partially funded by a Graduate School Research Fellowship and the authors gratefully acknowledge Sandra Holley.

Appendix A. Continuing education questions 1. Children with a history of chronic otitis media are at risk for the following during the preschool years: a. reduced consonant inventories b. reduced/delayed canonical babbling c. smaller expressive vocabulary size d. receptive language delays e. all of the above 2. It is important to consider pediatricians’ opinions about otitis media and speechlanguage development because: a. pediatricians diagnose children with speech-language delays as part of birth-tothree services b. pediatricians act as gatekeepers to other rehabilitative services

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c. pediatricians generally regard otitis media as having no affect on speech-language development d. pediatricians are often the first professionals to address parent concerns regarding a possible speech-language delay e. b and d above 3. To help ensure content validity in survey research, which of the following step is taken: a. survey questions are directly paraphrased from research articles b. survey questions are replicated from previously published reports c. survey questions are reviewed by an outside expert in the topic being studied d. survey questions do no include the response ‘‘no opinion’’ e. respondents are told to answer all of the survey items even if they are not sure of the best answer 4. Based on the results of this study, which of the following is not true about pediatricians who work with families of children with otitis media: a. pediatricians are likely to elicit parent concerns about speech-language development b. pediatricians counsel parents about developmental tests and speech-language screenings c. pediatricians think it is important for physician assistants to have training in the identification of speech-language delays d. pediatricians think it is important for nurse practitioners to have training in the identification of speech-language delays e. pediatricians think it is important that parents mitigate any impact of otitis media on speech-language development 5. Based on the results of this study, pediatricians least often agreed with which of the following survey questions: a. all children with otitis media during the first 2 years of life should be followed with serial ear, nose, and throat examinations b. it is worthwhile to inform parents about the possible hearing loss associated with persistent or recurrent middle ear effusion c. persistent otitis media with effusion can result in mild to moderate fluctuating hearing loss d. pediatricians should be familiar with normal speech-language development in order to be able to identify delays e. otitis media affects children’s speech-language development

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