An 8-month-old boy is brought to the office due to recurrent episodes of otitis media, including 2 episodes of acute otitis media in the past 3 months. One episode was in his left ear; the second was in his right ear 2 weeks ago and resolved after a course of amoxicillin. He was born by spontaneous vaginal delivery at 38 weeks gestation and has had no other medical problems. He lives with his mother and 3-year-old brother, both of whom are in good health. There are no pets or carpets in the house. His mother smokes a pack of cigarettes a day but only outdoors. The patient does not attend day care. He eats solid foods twice a day and breastfeeds every 3 hours, including overnight when he falls asleep while feeding. His growth and developmental milestones are age-appropriate. On physical examination, he is awake, alert, and playful. His head is normocephalic. Pupils are equal and reactive to light and accommodation. The nares are clear; there is no erythema of the pharynx; the tympanic membranes are clear without erythema or effusion. Cardiopulmonary examination is normal. The mother is concerned that the recurrent infections will affect his hearing and asks for advice on avoiding future episodes. Which of the following is the most appropriate intervention in management of this patient?

Question

An 8-month-old boy is brought to the office due to recurrent episodes of otitis media, including 2 episodes of acute otitis media in the past 3 months.  One episode was in his left ear; the second was in his right ear 2 weeks ago and resolved after a course of amoxicillin.  He was born by spontaneous vaginal delivery at 38 weeks gestation and has had no other medical problems.  He lives with his mother and 3-year-old brother, both of whom are in good health.  There are no pets or carpets in the house.  His mother smokes a pack of cigarettes a day but only outdoors.  The patient does not attend day care.  He eats solid foods twice a day and breastfeeds every 3 hours, including overnight when he falls asleep while feeding.  His growth and developmental milestones are age-appropriate.  On physical examination, he is awake, alert, and playful.  His head is normocephalic.  Pupils are equal and reactive to light and accommodation.  The nares are clear; there is no erythema of the pharynx; the tympanic membranes are clear without erythema or effusion.  Cardiopulmonary examination is normal.  The mother is concerned that the recurrent infections will affect his hearing and asks for advice on avoiding future episodes.  Which of the following is the most appropriate intervention in management of this patient?

Quizplus · Accepted Answer

Explanation: Acute otitis media (AOM) is a common infection in children, as the horizontal position of their eustachian tubes leads to fluid accumulation in the middle ear. This patient, with 2 episodes of AOM in the last 3 months, requires evaluation to determine whether other risk factors for recurrences are present. Several well-known environmental risk factors include absence of breastfeeding, day care attendance, pacifier use, and exposure to secondhand smoke. Cigarette smoke affects the otic and nasopharyngeal mucosa and cilia and impairs clearance of fluids and microbes from the eustachian tubes, thereby increasing the risk of AOM and upper respiratory tract infections. Even if smoking is restricted to the outdoors, particulate matter will be brought indoors after accumulating in the hair and clothing. It is therefore imperative that the patient's mother be advised to quit smoking altogether, both for her own health and her child's. (Choice A) Breastfeeding, especially during the first 6-12 months of life, has been shown to decrease the incidence of AOM for multiple reasons (eg, transfer of immunoglobulins from the parent, inhibition of colonization of the nasopharynx by pathogens). It should therefore be encouraged, not stopped. (Choice B) Pneumococcal polysaccharide vaccine (PPSV) 23 is recommended for children at high risk for invasive pneumococcal disease (eg, those with sickle cell anemia, cardiac disease, cochlear implants, asplenia) but is not recommended for immunocompetent children. In addition, in patients age <2, PPSV 23 does not elicit an effective immune response (due to inability to mount a T-cell independent immune response), so the 13-valent pneumococcal conjugate vaccine would be recommended. (Choices C and D) Prophylactic antibiotic treatment and tympanostomy tube placement can reduce the number of AOM recurrences, but they are recommended only for patients at highest risk of recurrence (>3 episodes in 6 months or >4 episodes in 12 months, high risk for speech and hearing impairment such as children with craniofacial abnormalities or neurodevelopmental disorders). In addition, both because tympanostomy tube placement requires surgery and chronic antibiotic treatment contributes to antibiotic-resistant bacteria, smoking cessation should be discussed first. Educational objective: Exposure to cigarette smoke is an important risk factor for acute otitis media. Cessation of smoking, continuation of breastfeeding, avoidance of day care, and discontinuation of pacifier use should be encouraged before more aggressive action is taken. References: Risk factors for chronic and recurrent otitis media: a meta-analysis (http://www.ncbi.nlm.nih.gov/pubmed/24466073)

An 8-Month-Old Boy Is Brought to the Office Due to Recurrent