Chronic Otitis Media in Children
Helping Families Cope
By Pat Newell, RN, MSN, CDE, and Ella Churchill, ARNP-C, MSN
The families of children with chronic illnesses experience significant emotional, economic and physical stresses.1 For them, assistance often is available in the form of specialty clinics, respite services and support groups. Although the caregivers of children with recurrent acute illness face nearly identical stressors, clinicians often fail to recognize them. Nurse practitioners are uniquely qualified to assist families who are coping with chronic acute illness.
Chronic Otitis Media
Parents of children with chronic health problems experience common needs: health education, stress management, problem-solving techniques and financial relief.2 Families with children who have chronic otitis media often face these same stressors.
Otitis media that lasts 3 months or more is generally considered chronic. Ear problems in children with chronic otitis media often persist for several months to years, due in part to anatomic influences that hinder proper eustachian tube function. Bacteria spreads from the nasopharynx through the eustachian tube, often resulting in inflammation and infection. Eustachian tube function often improves as the shape of the skull and facial cranium evolve.3 Eustachian tube dysfunction is a significant contributor to recurrent otitis media.4
Environmental factors that are linked to otitis media with effusion include, but are not limited to, bottle feeding, passive smoking, group day care and the use of pacifiers.5
Parental Burden of Care
The families of children with chronic otitis media experience many stresses. In addition to the costs associated with treatment, chronic otitis media causes lost work time for parents. The discomfort associated with the illness often disrupts the affected child's sleep, and thus the sleep of his parents.
Repeated cases of otitis media may induce feelings of parental failure. In one study, parents who managed chronically ill infants at home reported inconsistent resources for coping, time and respite.1 Similar conclusions were reached in a study of families with medically fragile children.6 The families in the studies consulted health care providers for treatment issues, but not for routine child care issues.
Other factors that may contribute to parental guilt about chronic otitis media include infant feeding choices (if the mother did not breastfeed), group day care placement and smoke exposure. Exposure to secondhand smoke poses a risk for any child. Even if the caregiver smokes outside, clothing absorbs the smoke and the child is further exposed as the caregiver cuddles and cares for him. A disturbing 43% of U.S. children between the ages of 2 months and 11 years live in homes with at least one smoker.7
The child with chronic otitis media with effusion requires evaluation for hearing loss. If hearing loss is present at 20 dB or greater, ventilating tubes are indicated. When a hearing loss of less than 20 dB is present, prophylactic antibiotics are appropriate. Ventilating tubes are recommended for children who continue to experience chronic otitis media while taking prophylactic antibiotics.8
Otitis media is the most common cause of hearing loss in the United States. Approximately 3.5% of children younger than 18 have hearing loss (all causes).9 Though hearing loss due to otitis media with effusion may be temporary, parents are often concerned that permanent damage will result.9 Hearing difficulties in young children can lead to language difficulties later. Their learned speech reflects the way they hear when effusion is present: like they are under water. The fear of hearing impairment can be upsetting to parents already stressed by financial and emotional pressures resulting from chronic otitis media.
Supporting Caregiver Behaviors
A major part of the NP role is to identify self-care needs in patients and their families. In the case of chronic otitis media, identify stressors that may affect appropriate parenting. If you advise parents to remove their children from group day care because of chronic otitis media, suggest alternatives.8 Alternate child care arrangements may include readjustment of work schedules to avoid the need for care outside the home; having one spouse stop working or perform home-based work; or finding a family day care setting with only a few children.
Another area that typically requires extra attention is medication compliance. A family's health belief system affects compliance. This system encompasses the family's belief in susceptibility to disease, perception of disease severity, and their understanding of treatment benefits.10 For a 1- to 2-week treatment of acute childhood illness, compliance is approximately 50% for acute otitis media and streptococcal pharyngitis. Children on chronic therapy typically have a slightly higher compliance rate of approximately 70%.11
The complexity of a medication regimen significantly influences compliance. It's often impossible to determine whether medication is being given as prescribed. Time constraints on the length of visits limits honest discussion, and caregivers often do not want to admit that doses have been missed. An appropriate question for a caregiver would be: "What difficulties have you had in giving the medicine?" This form of questioning acknowledges that it can be difficult to administer prescribed medications, and a parent may feel more comfortable admitting to sporadic administration. If medication requires dosing during school hours, administration may be difficult due to differing school policies.
You can help improve compliance by providing the caregiver with a simple one-page medication diary to record doses. Ask the parent to return it at the time of follow-up. Written instructions for the patient and caregiver that include information about adverse effects can also encourage adherence. The literacy and visual acuity of the caregiver may require assessment, since written instructions are useless if reading skills or vision are impaired. Medication may be scheduled to correspond with morning cartoons and an afternoon activity to aid the caregiver in remembering to administer the medication.12 Medications that are dosed less frequently are associated with higher rates of administration. Once- or twice-daily regimens have compliance rates of 70% to 80%, while regimens with three or four daily doses have compliance rates of 40% to 50%.8
Families with comprehensive insurance plans that include prescription drug benefits don't experience the same compliance and financial stresses as families who don't. Many pharmaceutical companies offer assistance programs that provide free or reduced cost medications to patients who meet established criteria.10 For example, SmithKline Beecham supplies Amoxil and Augmentin to eligible patients through its Access to Care program. A well-stocked sample closet may assist in the initial days of therapy but cannot be relied on to provide long-term therapy for every patient.
Medicaid is another option for qualified families, and local agencies such as Catholic Social Services, Salvation Army and local churches may offer one-time payment for needed medication. State and federal programs often provide coverage for office visits and medication. Some parents resist government assistance for privacy and pride reasons, however.
As with any illness, prevention of otitis media is the ideal medicine. Breastfeeding should be part of an overall risk reduction plan, particularly if a sibling was prone to otitis media. Maternal antibodies in breast milk protect against early infection.8 In addition, breastfeeding promotes eustachian tube drainage because the mother holds the infant in a more upright position during feeding. Bottle-fed infants are at higher risk for otitis media if they are fed while supine or allowed to go to sleep with a bottle. Bacteria multiplies in the formula held in the mouth and can migrate up the eustachian tubes. Infants should be held while being bottle-fed, and the bottle removed before being placed in the crib. Breastfed infants should be treated in a similar manner so that breast milk doesn't remain in the mouth and become a medium for bacteria growth.
Avoidance of tobacco smoke decreases the incidence of otitis media and other respiratory infections. The cost of cigarettes rivals the cost of medication for the treatment of otitis media. The prevention of otitis media and smoking will save the family a great deal of money; use this as an incentive to encourage smoking cessation.
Another strategy for prevention is pharmacologic prophylaxis with antibiotics. This approach is generally recommended after three episodes of acute illness in 6 months or four episodes in 12 months. Amoxicillin or sulfisoxazole may be administered at half the therapeutic dose once or twice daily. Algorithms vary, but include chemoprophylaxis during the winter months; prophylactic therapy for 90 days after the third episode of acute otitis media in 6 months; and treatment with antibiotics during the course of each new infection.8
Education is Crucial
Parent and caregiver education about chronic otitis media is paramount to the completion of prescribed treatment, to reduce the incidence of further episodes, and to prevent complications. Do not ignore factors that can derail treatment of chronic otitis media, such as lack of understanding of causative factors and treatment regimens, financial needs that prevent treatment completion, and health practices that increase risk.
By looking at the patient as part of the family unit, examining the family health beliefs and practices, and facilitating behaviors that will provide a reduction in morbidity, chronic otitis media can be prevented.
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12. Weinstein AG. Clinical management strategies to maintain compliance in asthmatic children. Ann Allergy Asthma Immunol. 1995;74:304-310.
Pat Newell is a diabetes specialist and post-graduate student in the family nurse practitioner program at the University of South Alabama in Mobile. Ella Churchill is a pediatric and family nurse practitioner who works in association with Shoreline Medical Group in Port St. Joe, Fla.