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The New England

Journal of

Medicine

Copyright 2001 by the Massachusetts Medical Society

VOLUME 344

A

PRIL

19, 2001

NUMBER 16

N Engl J Med, Vol. 344, No. 16

April 19, 2001

www.nejm.org

1179

EFFECT OF EARLY OR DELAYED INSERTION

OF TYMPANOSTOMY TUBES FOR PERSISTENT OTITIS MEDIA

ON DEVELOPMENTAL OUTCOMES AT THE AGE OF THREE YEARS

J

ACK

L. P

ARADISE

, M.D., H

EIDI

M. F

ELDMAN

, P

H

.D., M.D., T

HOMAS

F. C

AMPBELL

, P

H

.D., C

HRISTINE

A. D

OLLAGHAN

, P

H

.D.,

D. K

ATHLEEN

C

OLBORN

, B.S., B

EVERLY

S. B

ERNARD

, R.N., B.S., H

OWARD

E. R

OCKETTE

, P

H

.D., J

ANINE

E. J

ANOSKY

, P

H

.D.,

D

AYNA

L. P

ITCAIRN

, M.A., D

IANE

L. S

ABO

, P

H

.D., M

ARCIA

K

URS

-L

ASKY

, M.S., AND

C

LYDE

G. S

MITH

, M.S.

A

BSTRACT

Background

A main indication for the insertion oftympanostomy tubes in infants and young childrenis persistent otitis media with effusion, reflecting con-cern that this condition may cause lasting impairmentsof speech, language, cognitive, and psychosocial de-velopment. However, evidence of such relations is in-conclusive, and evidence is lacking that the insertionof tympanostomy tubes prevents developmental im-pairment.

Methods

We enrolled 6350 healthy infants from 2 to61 days of age and evaluated them regularly for mid-dle-ear effusion. Before the age of three years 429 chil-dren with persistent effusion were randomly assignedto have tympanostomy tubes inserted either as soon

as possible or up to nine months later if effusion per-sisted. In 402 of these children we assessed speech,language, cognition, and psychosocial development atthe age of three years.

Results

By the age of three years, 169 children inthe early-treatment group (82 percent) and 66 childrenin the late-treatment group (34 percent) had receivedtympanostomy tubes. There were no significant dif-ferences between the early-treatment group and thelate-treatment group at the age of three years in themean (SD) scores on the Number of Different Wordstest, a measure of word diversity (12432 and 12630,respectively); the Percentage of Consonants CorrectRevised test, a measure of speech-sound production(857 vs. 867); the General Cognitive Index of Mc-Carthy Scales of Childrens Abilities (9914 vs. 10113); or on measures of receptive language, sentencelength, grammatical complexity, parentchild stress,and behavior.

Conclusions

In children younger than three yearsof age who have persistent otitis media, prompt inser-tion of tympanostomy tubes does not measurablyimprove developmental outcomes at the age of threeyears. (N Engl J Med 2001;344:1179-87.)

Copyright 2001 Massachusetts Medical Society.

From the Departments of Pediatrics (J.L.P., H.M.F., B.S.B.), FamilyMedicine and Clinical Epidemiology (J.E.J.), and Otolaryngology (C.G.S.),University of Pittsburgh School of Medicine; the Departments of Pediat-rics (J.L.P., H.M.F., D.K.C., B.S.B.) and Audiology and CommunicationDisorders (T.F.C., D.L.P., D.L.S., C.G.S.), Childrens Hospital of Pitts-burgh; the Department of Communication Science and Disorders, Univer-sity of Pittsburgh (H.M.F., T.F.C., C.A.D., D.L.S.); and the Departmentof Biostatistics, University of Pittsburgh Graduate School of Public Health(H.E.R., M.K.-L.) all in Pittsburgh. Address reprint requests to Dr. Par-adise at Childrens Hospital of Pittsburgh, 3705 Fifth Ave., Pittsburgh, PA15213-2538, or at [email protected].

YRINGOTOMY with the insertion oftympanostomy tubes is the most com-mon operation among children beyondthe newborn period in the United

States; an estimated 280,000 children younger thanthree years of age underwent the operation in 1996(Kozak LJ: personal communication). A main indica-tion for the procedure in young children is persistentotitis media with effusion,

1,2

which because of its com-monly associated conductive hearing loss,

3

has beenthought to result in lasting impairments of speech,language, cognitive, and psychosocial development.

4

Current guidelines of the American Academy of Oto-laryngologyHead and Neck Surgery list otitis media

with effusion of more than three months duration asan appropriate indication for the insertion of tympa-nostomy tubes,

2

and guidelines issued by the Agen-cy for Health Care Policy and Research for childrenone through three years of age list this procedure asoptional when otitis media with effusion has beenpresent for three months and as recommended whenthe condition has been present for four to six months,provided in each circumstance that the effusion is ac-companied by bilateral hearing loss characterized bya hearing-level threshold of 20 dB or more (higher val-ues reflect poorer hearing).

1

Studies addressing possible relations between otitismedia in young children and subsequent developmen-

M

The New England Journal of MedicineDownloaded from nejm.org on September 28, 2012. For personal use only. No other uses without permission.

Copyright 2001 Massachusetts Medical Society. All rights reserved.

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The New England Journal of Medicine

tal outcomes have had important limitations, and theresults have been inconsistent.

5

Moreover, all the stud-ies have been associational in nature and accordinglyunable to address the issue of causality. The presenttrial was part of a larger study

5

designed to addresstwo interrelated questions: whether, in young children,

the presence of middle-ear effusion for a period suf-ficient to be considered developmentally threateningby many investigators actually results in developmen-tal impairments, and whether prompt insertion of tym-panostomy tubes protects against or minimizes sub-sequent impairment.

METHODS

General Procedures

Between May 1991 and December 1995, we enrolled a total of6350 healthy infants who were 2 to 61 days of age at eight sitesin the greater Pittsburgh area: Childrens Hospital of Pittsburgh,Mercy Hospital of Pittsburgh, and two small-town and rural andfour suburban private pediatric group practices. The study was

approved by the institutional review boards of the two hospitals.Written informed consent was obtained from one or both parentsof each enrolled infant. The study procedures have been describedpreviously.

6-8

In brief, we excluded infants who met any of the fol-lowing criteria: a birth weight of less than 2270 g (5 lb), a smallsize for gestational age, a history of neonatal asphyxia or other se-rious illness, a major congenital malformation or chronic illness, orthe product of a multiple birth. Infants were also excluded if theyhad a sibling enrolled in the study; they were in foster care or adopt-ed; their mother was dead, seriously ill, a known drug or alcoholabuser, or (in the judgment of study personnel) too limited social-ly or intellectually to give informed consent or adhere to the studyprotocol; their mother was younger than 18 years of age; or Eng-lish was not the only language spoken in the household.

We used pneumatic otoscopy, supplemented by tympanometry,to evaluate the middle-ear status of the children at least monthlyuntil they were three years old. We continually monitored the va-

lidity of the study clinicians otoscopic observations and found sat-isfactory levels of interobserver agreement. Antimicrobial drugswere routinely prescribed for episodes of acute otit is media; theywere also routinely prescribed for episodes of otitis media witheffusion until 1995 but were prescribed selectively thereafter.

Audiometric Testing

Audiometric testing was carried out whenever possible in allchildren who had unilateral or bilateral middle-ear effusion contin-uously for eight weeks, every four weeks thereafter as long as effu-sion remained present, and once effusion had resolved. Audiomet-ric testing was also conducted in a sample of children to serve as apresumably normative comparison group. These children either hadnever had middle-ear effusion or had not had middle-ear effusionfor at least 60 days and were selected so as to represent a range ofage groups. Audiometric testing was also conducted in all children

about to undergo developmental testing and in any child in whomhearing loss was suspected by a parent or a clinician.Hearing levels were defined with the use of data on auditory

brain-stem responses in infants younger than six months of ageand pure-tone data in children six months of age or older. For be-havioral testing, stimuli were presented in the sound field to chil-dren up to 2

1

2

to 3 years of age and by means of earphones to olderchildren. For each behavioral test the reliability of the results wasrated by the audiologist per forming the test as good, fair, or poor.On the basis of the data obtained in children who had no effusion,abnormal results were defined as an auditory brain-stemresponsethreshold more-than-20-dB above the normal hearing level or apure-tone average more-than-25-dB hearing level up to the age of

10 months, more-than-20-dB hearing level from 10 to 23 months,and more-than-15-dB hearing level from the age of 2 years onward.

Estimation of Cumulative Proportions of Dayswith Middle-Ear Effusion

We used the term middle-ear effusion to encompass all types ofotitis media in which effusion is present: acute otitis media with or

without otorrhea, otitis media with effusion, and otorrhea througha tympanostomy tube. To determine eligibility for the randomizedtrial, we estimated the cumulative proportions of days each child hadunilateral effusion and bilateral effusion on the basis of diagnosesmade at individual visits and interpolations for intervals between

visits. The rules we used to determine eligibility were more restric-tive

9

than the ones we used to assess the outcomes after random-ization.

6-8

The Randomized Clinical Trial

Children became eligible for the randomized clinical trial if, be-ginning at the age of 2 months and within the first 3 years of life,they had middle-ear effusion that appeared substantial in degreeand that persisted, despite treatment with antimicrobial drugs, for90 days in the case of bilateral effusion or 135 days in the case ofunilateral effusion. Children with intermittent bilateral or unilateralmiddle-ear effusion for specified proportions of longer periods were

also eligible (the criteria are listed in Appendix 2, available withthe full text of the article at http://www.nejm.org). For example,a child would be eligible if he or she had had bilateral effusionfor 67 percent of the preceding 180-day period or unilateral ef-fusion for 67 percent of the preceding 270-day period. Children

who met one of these criteria and whose parents or guardians gavewritten informed consent were stratified according to practice site,age (in six-month categories), and whether the eligibility criteria

were met on the basis of bilateral or unilateral effusion. They werethen assigned randomly, within these strata and in balanced blocksof four, to undergo either early or late insertion of tympanostomytubes. Assignments were made by designated nonclinical staff mem-bers using separate, computer-generated lists of random numbers.Children assigned to the early-treatment group were scheduled tohave tympanostomy tubes inserted as soon as practicable. Thoseassigned to the late-treatment group were to undergo the opera-tion six months later if bilateral effusion persisted or nine months

later if unilateral effusion persisted, but children in this group couldreceive tubes earlier if their parents requested the operation. Chil-dren for whom consent for randomization was withheld were of-fered tube insertion electively. In all children the tubes were insert-ed according to conventional methods

10

and allowed to remain inplace until they were extruded spontaneously.

Developmental Tests and Procedures

We attempted to conduct developmental testing of children assoon as possible after their third birthday, and in any case withintwo months afterward. Whenever possible, developmental testing

was conducted only if on the same day the childs hearing level metspecified criteria. For children whose hearing was tested by means ofearphones, the criteria consisted of a hearing-level threshold of 15dB or less in each ear at 1000, 2000, and 4000 Hz. For childrentested in the sound field, the criteria consisted of a hearing-level

threshold of 20 dB or less at 500, 1000, 2000, and 4000 Hz. Chil-dren who failed the hearing test were scheduled to be retested whenfeasible. When retesting was not feasible or when children failed thehearing test at or near the end of the two-month period of devel-opmental testing, developmental testing was undertaken withoutfurther delay. We used three methods of developmental assessment:formal, norm-referenced tests; samples of conversation; and parent-reported inventories (Table 1). Details concerning test conditions,examiners, and procedures and the recording, transcription, andanalysis of conversational samples have been described previous-ly.

7,8,14

The examiners and transcriptionists were unaware of the chil-drens histories and health insurance status and their mothers levelof education.



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1181

Statistical Analysis

All analyses excluded findings concerning middle-ear status with-in the first two months of life. We assumed a priori that a differ-ence of 0.33 SD or more between groups on any outcome measurecould be clinically important. On the basis of an assumption thatonly poorer outcomes in the late-treatment group would be clini-cally important, we calculated that 182 children would be needed

in each group for the study to have the ability to detect a differenceof 0.33 SD at a power of 0.80. Results of the clinical trial werebased on the intention-to-treat principle. We used two-tailed testsfor all analyses. We used chi-square tests to evaluate differences inproportions among children in different groups. We used analysis of

variance to test for differences between mean values, and a modifi-cation

20

to test for differences involving trends. We used linear re-gression analysis to adjust for potentially confounding variables.

RESULTS

Study Sample and Treatment Groups

Of 6350 children enrolled in the larger study, 588eventually met the eligibility criteria for the clinical tri-al. A total of 429 of these children (73 percent) un-derwent randomization after their parents or guard-

ians gave consent, and 402 of the 429 children (94percent) received developmental testing at the age ofthree years (Fig. 1). Selected demographic and clin-ical characteristics of the 402 children who were test-ed are shown in Table 2. Their mean age when theymet the randomization criteria was 15 months, and

their median age was 14 months; 57 percent wereboys, and 60 percent were white. In 73 percent of thechildren who met the criteria on the basis of havingunilateral middle-ear effusion, bilateral effusion hadbeen present for more than 25 percent of the pre-ceding six-month period. In 380 of the children (95percent), developmental testing was completed with-in two months after their third birthday. In compar-ison with the 429 children who underwent random-ization, a higher proportion of the 159 children whoseparents declined to consent to randomization wereseen at urban study sites (62 percent vs. 50 percent,P=0.02) and a lower proportion were seen at facilitiesin small towns or rural areas (23 percent vs. 35 per-

*Plusminus values are means SD.

Higher test scores reflect more favorable results.

Higher test scores reflect less favorable results.

T

ABLE

1.

D

EVELOPMENTAL

T

ESTS

P

ERFORMED

IN

THE

C

HILDREN

AT

THE

A

GE

OF

T

HREE

Y

EARS

.

T

YPE

OF

T

EST

F

OCUS

OF

T

EST

T

EST

S

CORING

M

ETHOD

*

Formal, norm-referenced

Cognition McCarthy Scales of Childrens Abilities,including General Cognitive Indexand Verbal, Perceptual Performance,and Quantitative Subscales

11

The number of correct responses is calculated. The norm-ative mean score is 10015 on the General CognitiveIndex and 5010 on each subscale.

Receptive language Peabody Picture Vocabulary TestRevised

12

The number of correct responses is calculated. The norma-tive mean score is 10015.

Assesses a sample of

approximately 15minutes of sponta-neous conversation

Expressive language

Word diversity Number of Different Words

13

With use of a computer-assisted analysis of the transcribedsample, all first-occurrence word roots, ignoring in-flectional morphemes, are counted in all utterances.

14

Sentence length andgrammatical complexity

Mean Length of Utterancein Morphemes

15,16

With use of a computer-assisted analysis of the transcribedsample, the mean length of all utterances that were bothcomplete and intelligible is calculated.

14

Speech-sound productionPercentage of intended

consonants that arearticulated correctly

Percentage of Consonants CorrectRevised

17

With use of a computer-assisted analysis of the phonetical-ly transcribed sample, the first 100 first-occurrence

words in the transcript are analyzed.

14

Parental report,norm-referenced

Parental distress Parenting Stress Index, Short Form

18

Parent rates the parentchild dyad on 36 items in 3 sub-scales in terms of the degree of agreement with eachstatement (strongly agree, agree, not sure, dis-agree, or strongly disagree). The total of the subscalescores is the Total Stress score. The normative meanscores are 267 for the Parental Stress subscale, 195for the ParentChild Dysfunctional Interaction sub-scale, 267 for the Difficult Child subscale, and 7115for the Total Stress score.

Behavior Child Behavior Checklist

19

Parent rates the childs overall behavioral and emotionalhealth by responding to 99 items and scoring each state-ment as not true, somewhat or sometimes true, orvery or often true. The results are organized into6 specific scales and a miscellaneous scale. Scores of the6 specific scales and a Total Problem score are calculat-ed and converted to T scores.

19

The normative meanT score on each scale and for Total Problems is5010.



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cent, P=0.005); there were no other significant dif-ferences in demographic or clinical characteristics.

Also, there were no significant differences in charac-teristics between the 402 children who received de-

velopmental testing and the 27 randomized childrenwho were not tested, or between the 206 childrenwho were tested in the early-treatment group and the196 children who were tested in the late-treatmentgroup.

Among the 402 children who were tested, the num-ber who had tympanostomy tubes inserted and theintervals from randomization to insertion are summa-rized in Figure 1. In the children in the early-treat-ment group, delays resulted mainly from requirementsto obtain third-party authorization; in other children,surgery was initially withheld because the middle-eareffusion cleared or improved markedly soon after ran-domization, but surgery was subsequently performedbecause the effusion recurred. In the children in thelate-treatment group, tubes were sometimes inserted

before the scheduled time because of supervening ep-isodes of acute otitis media, parental request, or both.

Duration of Middle-Ear Effusion after Randomization

During the first 12 months after randomization,the percentage of children in the late-treatment group

who had effusion more than 50 percent of the timewas approximately three times the percentage in theearly-treatment group. During the first 24 months,the percentage in the late-treatment group was approx-imately twice that in the early-treatment group (Ta-ble 3).

Hearing in Relation to Middle-Ear Effusion

The 402 children underwent 765 audiometric ex-aminations before randomization and 952 examina-tions after randomization. Of the total, 50 were testsof auditory brain-stem responses and 1667 were be-havioral tests. A total of 1522 behavioral tests (91percent) were conducted in the sound field, and 145

Figure 1.

Enrollment and Randomization of the Children and the Time of Insertion of Tympanostomy Tubes.

Consent for randomizationwithheld in the case of 159

588Eligible children

429Underwent randomization

196Underwent developmental

testing at 3 yr of age

206Underwent developmental

testing at 3 yr of age

Time of insertion of tympanostomy tubes:Within 30 days after randomization in 3Within 60 days after randomization in 8Within 180 days after randomization in 21By the age of 3 yr in 66

130 Had not received tubes by the age of 3 yr

Time of insertion of tympanostomy tubes:Within 30 days after randomization in 63Within 60 days after randomization in 132Within 180 days after randomization in 162By the age of 3 yr in 169

37 Had not received tubes by the age of 3 yr

198Followed to3 yr of age

210Followed to3 yr of age

213Assigned to

late treatment

216Assigned to

early treatment



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(9 percent) were conducted with the use of earphones.Both before and after randomization among the chil-dren in the two groups, hearing was normal in approx-imately two thirds of instances in which children weretested when they did not have effusion and abnormalin approximately one half of instances in which theyhad unilateral effusion during testing and in approx-imately three quarters of instances in which they hadbilateral effusion during testing.

Scores on Developmental Measures

In the study group as a whole, mean scores on alloutcome measures were significantly most favorableamong the most socioeconomically advantaged chil-dren and least favorable among the least advantagedchildren. On measures of cognition, receptive lan-guage, expressive language, and speech-sound produc-tion, mean scores were also significantly more favorablein girls than in boys.

The mean scores on measures of cognition, recep-

tive language, expressive language, and speech-soundproduction are shown in Table 4 (higher scores reflectmore favorable results), and the mean scores on par-ent-rated measures of parentchild stress and chil-drens behavior are shown in Table 5 (higher scoresreflect less favorable results). There were no significantdifferences between the two treatment groups on anymeasure, either before or after adjustment for age (inmonths) at the time of testing. Similarly, there were nosuch differences within subgroups constituted respec-tively according to the age at which the randomizationcriteria were met and according to whether the criteria

were met on the basis of the presence of unilateral orbilateral effusion.

Among the 159 children whose parents declinedpermission for randomization, we obtained test resultsat the age of three years regarding cognition, language,and speech in 105 and regarding parentchild stressand behavior in 79. With the exception of a slightlylower mean score for the Percentage of Consonants

*Because of rounding, percentages may not equal 100.

For children tested by means of earphones, the criteria consisted of a hearing-level threshold of15 dB or less in each ear at 1000, 2000, and 4000 Hz. For children tested in the sound field, the

criteria consisted of a hearing-level threshold of 20 dB or less at 500, 1000, 2000, and 4000 Hz.

TABLE 2. CHARACTERISTICS OFTHE TESTED CHILDRENACCORDINGTO TREATMENT GROUP.*

CHARACTERISTIC

EARLY-TREATMENTGROUP

(N=206)

LATE-TREATMENTGROUP

(N=196)ALL CHILDREN

(N=402)

no. of children (%)

Location of study siteUrban 104 (50) 95 (48) 199 (50)Small town or rural area 70 (34) 73 (37) 143 (36)Suburban 32 (16) 28 (14) 60 (15)

Maternal level of educationLess than high school 25 (12) 27 (14) 52 (13)High-school graduate 80 (39) 67 (34) 147 (37)Technical or other training 83 (40) 87 (44) 170 (42)College graduate 18 (9) 15 (8) 33 (8)

Health insurance statusMedicaid 132 (64) 127 (65) 259 (64)Private 72 (35) 68 (35) 140 (35)None 2 (1) 1 (0.5) 3 (1)

Year of life during which randomizationcriteria were met

First 82 (40) 80 (41) 162 (40)

Second 96 (47) 94 (48) 190 (47)Third 28 (14) 22 (11) 50 (12)

Laterality and sequence of middle-ear ef-fusion serving as basis for meetingrandomization criteria

Bilateral, continuous 40 (19) 33 (17) 73 (18)Bilateral, discontinuous 40 (19) 35 (18) 75 (19)Unilateral, continuous 34 (17) 31 (16) 65 (16)Unilateral, discontinuous 92 (45) 97 (49) 189 (47)

Hearing thresholds at time of develop-mental testing

Protocol-specified criteria met 156 (76) 152 (78) 308 (77)Protocol-specified criteria not met 44 (21) 32 (16) 76 (19)

Audiometric results incomplete orchilds hearing not tested

6 (3) 12 (6) 18 (4)



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CorrectRevised test (84 vs. 86, P=0.04), meanscores for these children did not differ significantlyfrom the mean scores for the children in the random-ized study.

DISCUSSION

The rationale of our study hinged on an expecta-tion, based on earlier experience,21,22 that childrenassigned to receive tympanostomy tubes as soon as

possible after randomization would thereafter remainrelatively free of middle-ear effusion, whereas in mostchildren in the group assigned to receive tubes up tonine months after randomization, effusion would per-sist for varying periods. That expectation was borneout. Nonetheless, despite the difference in the durationof effusion, we found no significant differences be-tween the two groups in the range of developmentaloutcomes that we measured. The associated confi-

*The analysis was limited to children who had no gaps in information concerning middle-ear statusduring the specified period.

P

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dence intervals afforded assurance that differences assmall as 0.33 SD favoring the early-treatment group,if present, would have been detected.

One might question whether the absence of any dif-ferences reflects the possibility that, even in the chil-dren in the early-treatment group, middle-ear effusion

had been present long enough before the tubes wereinserted to impair development. In that regard, it isinstructive to compare developmental outcomes in thechildren in the late-treatment group with outcomesreported previously in the larger study among three-

year-old children in whom effusion was less preva-lent. One such subgroup comprised 241 children who

were randomly selected and selected within sociodem-ographic strata and who ranged from having no ef-fusion to having effusion just short of meeting thecriteria for the present trial.8 The other subgroup wasan unselected sample of 2278 children.7 Because thesociodemographic compositions of those subgroupsdiffered from that of the present sample and because

health insurance status was our most objective indi-cator of socioeconomic status, we compared devel-opmental outcomes within categories on the basis ofhealth insurance status (Medicaid vs. private insur-ance). Within these categories, the mean scores onmeasures of language, speech-sound production, andcognition in the children in the late-treatment groupdiffered little and in no consistent direction from themean scores in the 241 randomly selected children.8

Similarly, the mean scores on measures of parentchild stress and childrens behavior in the children inthe late-treatment group did not differ significantlyfrom the mean scores in the 2278 unselected chil-dren.7 These findings argue against the likelihood that

antecedent middle-ear effusion poses any developmen-tal risk at the age of three years within the durationof effusion that we studied. The findings also suggestthat the weak negative associations we had found inthe group of 241 randomly selected children betweenthe cumulative duration of antecedent middle-ear ef-fusion and scores at the age of three years on measuresof receptive vocabulary and verbal aspects of cogni-tion8 were not causal but rather were the result of con-founding.

Certain important caveats apply to our findings. Noconclusions are justified concerning children with pe-riods of effusion longer than those that we studied orconcerning children whose effusion is accompanied bymoderately severe (rather than the usual mild-to-mod-erate) hearing loss. Longer periods of effusion or moresevere degrees of hearing loss may well have adversedevelopmental effects. Also, relations that were notconsistently apparent at the age of three years mightbecome apparent at later ages, either because chil-drens responses when they are older may be morerepresentative of their actual abilities or because cer-tain impairments may emerge only at later ages.23-25

Recently, Maw and colleagues undertook a ran-*Thetestsandthemeaningofth

escoresareexplainedinTable1.Higherscoresreflectlessfavorableresults.ScoresfortheParentingStressIndex,ShortForm,wereavailablefor206

childrenintheearly-

treatmentgroupand193childrenin

thelate-treatmentgroup;TscoresfortheChildB

ehaviorChecklistwereavailablefor202childrenintheearly-treatmentgroupand193childreninthelate-treatmentgroup.

Ascoreoneveryscalewasnotavailableforeverychild.Threechildrenintheearly-treatmentgroupand2childreninthelate-treatmentgroupwerenotamongthe402childrenwhoha

dotherdevelopmental

assessmentsattheageofthreeyears.

P=0.05forthecomparisonwith

thelate-treatmentgroup.

TABLE5.SCORESON

MEASURESOFPARENTCHILD

STRESSANDCHILDRENSBEHAVIOR

ATTHEAGEOFTHREEYEARS.*

TREATMENTGROUP

PARENTING

STRESSINDEX,SHORTFORM

CHILD

BEHAVIORCHECKLIST

PARENTALDISTRESS

SUBSCALE

PARENTCHILD

DYSFUNCTIONAL

INTERACTION

SUBSCALE

DIFFICUL

TCHILD

SUBSCALE

TOTALSTRESS

ANXIOUS/

DEPRESSED

SCALE

WITHDRAWN

SCALE

SLEEP

PROBLEMS

SCALE

SOMATIC

PROBLEMS

SCALE

AGGRESSIVE

BEHAVIOR

SCALE

DESTRUCTIVE

BEHAV

IOR

SCALE

TOTALPROBLEMS

mean(SD)score

mean(SD)Tscore

Earlytreatment

238

186

258

6618

535

557

547

546

557

54

6

5010

Latetreatment

249

186

269

6821

534

546

545

535

547

53

5

4910

95%Confidenceintervalofthedif-

ferenceinmeanscores(early

treatmentminuslatetreatment)

2.6to0.6

1.5to0.9

1.7to1.5

5.3to2.3

0.3to1.5

0.4to2.0

0.8to1.6

0.0to2.2

1.0to1.8

0.2to2.0

0.6to3.4



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domized clinical trial of the effect of the insertion oftympanostomy tubes on language development.26 Inthat trial, children in the early-treatment group hadslightly better scores for receptive and expressive lan-guage than children in the watchful-waiting group9 months but not 18 months after randomization.

The design of the trial differed from ours in impor-tant ways. First, at enrollment, all children had dis-ruptions to speech, language, learning, or behavior.Second, the mean age of the children at randomiza-tion was 3 years, whereas in our trial all children wereassigned to a treatment group within the first 3 yearsof life, and most within the first 18 months, during

which periods many crucial aspects of language de-velopment are taking place. Third, in that trial, manyof the children may have had effusion before enroll-ment for periods much longer than those specifiedin our trial. Fourth, only language development wasassessed and only by means of a single formal test.

How may our results contribute to clinical decision

making with respect to young children who have per-sistent otitis media with effusion? Our results areparticularly applicable to the commonly encounteredchild of less than three years who is otherwise healthyand who has had effusion for the intervals that westudied, with its usual, attendant mild-to-moderatehearing loss, but who has no other, less debatable in-dications for the insertion of tympanostomy tubes,such as a severe retraction pocket of the tympanicmembrane or a recent history of frequent episodes ofacute otitis media. For such a child our results indi-cate that the insertion of tympanostomy tubes cannotbe expected to result in improved developmental out-come at the age of three years. This finding may help

clinicians and parents weigh the hypothetical risk ofdevelopmental impairment at older ages against theestablished cost and risks of the insertion of tympa-nostomy tubes.1,27-30

Supported by a grant (HD26026) from the National Institute for ChildHealth and Human Development and the Agency for Healthcare Researchand Quality and by gifts from SmithKline Beecham Laboratories and Pfizer.

Presented in part at the joint meeting of the Pediatric Academic Societiesand the American Academy of Pediatrics, Boston, May 1216, 2000.

We are indebted to Lawrence Shriberg, Ph.D., and Chad Allen ofthe Phonology Project at the University of WisconsinMadison forconducting the computer analyses of the speech samples; and to themany pediatric house officers of Childrens Hospital of Pittsburgh

and Mercy Hospital of Pittsburgh who served as primary care clini-cians for the study subjects and whose collaboration was essential forthe successful conduct of the study.

APPENDIX

In addition to the authors, the following persons participated in thestudy: Childrens Hospital of Pittsburgh I. Fabian, N.J. Guerra, L.M. Ha-kos-Zoffel, A. Hoberman, and P.H. Kaleida; Beaver D.J. Cahill, A.H.Chamovitz, S.N. Cowden, V.E. DiCenzo, V.S. Graf, S.N. Ghorbanian,G.R. Haddad, J.D. Liljestrand, J.J. Momen, J. Scibilia, and J.A. Vogel, Jr.;Brentwood N.L. Cohen, M. Diamond, K.L. Frederick, J. Schiebel, T.D.Skelly, and B.E. Watkins; Gibsonia A.V. Agustin and E.A. Vogeley; Kit-

tanning H.A. Altman, T. Balentine, S. Baum, L.J. Butler, J.K. Green-baum, K.R. Keppel, T.G. Lynch, J. Nickleach, and D.J. Vigliotti; Mt. Leb-anon B.J. Bahl, B. Braman, M.B. Devlin, H.A. Frost, T.L. Herlich, E.H.Michael, S.L. Tyson, and C.J. Welkon; Pleasant Hills K.G. Pai, H.M.Rubin, and T.H. Wolynn; and Mercy Hospital of Pittsburgh B.L. Ayars,B.J. Bradford, K. Brown, M.J. Daly, K. Falcon, P. Heald, C.M. Hoess, B.L.McNulty, Y. Moore-Forbes, C.A. Pohl, S.M. Roncevich, S.J. Rudy, E.J.Schmidt, S.H. Springer, and K.S. Vargo.

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