Develop. Med. Child Neurol. 1976,18, 239-248
Annotations INTERMITTENT HEARING LOSS IN YOUNG CHILDREN THEprevalence of middle-ear disease and intermittent hearing loss in infants and young children is unknown. This is largely because the diagnosis of otitis media is difficult to make in infants, and temporary hearing loss is easily missed by parents and by doctors. Yet recent research suggests that otitis media is an important cause of intermittent or persistent hearing loss in early childhood, and may result in the retardation of later speech development, which in turn may be followed by later difficulties in learning to read and spell. In the pioneer study of 1000 families in Newcastle upon Tyne‘, it was found that 19.2 per cent of children had one or more attacks of otitis media before the age of five years. One-third of these had more than one attack. Otorrhea, indicating that the ear drum had perforated, occurred in nine out of every 10 affected children. These findings were reported as a result of examinations of children during the period 1947 to 1952 and it is probable that suppurative otitis media is less frequent and better treated now than it was then. Yet middle-ear disease, including infective otitis~media, remains an important cause of intermittent and sometimes permanent hearing loss. MILLERand colleagues’ were impressed by the inadequate treatment of otitis media in the young children whom they studied. Ineffective ear-drops were all too often prescribed and systemic antibiotics all too rarely. In the Perinatal Mortality Survey, audiograms were obtained from 11,276 (73 per cent of the original cohort) at the age of seven years in t9652. 636 (approximately 5 . 7 per cent) were found to have significant hearing loss. Of these, 162 (25.5 per cent) had moderate or severe bilateral hearing impairment and‘ many were thought to be in need of special educational provision. It is significant that hearing loss was suspected clinically in only 2 . 6 per cent of the 4220 children who were not formally tested by audiometry. Unfortunately, the proportion of children whose hearing loss was due to middle-ear disease is not stated: nevertheless, the fact that significant hearing loss was unilateral in as many as 2 4 - 5 of the children with hearing loss suggests that middle-ear disease, rather than congenital or acquired nerve deafness, was responsible in many cases. Yet as late as 1967 PROFESSOR EWINGquoted: “No authoritative figures can yet be given for the evidence of hearing defects in ~hildren”~. In Edinburgh in 1970, PATTERSON and MCLEAN4 reported on the incidence of otitis media in 1947 children from the time of birth to the age of 15 years. They found that 212 (10.9 per cent) of the children suffered from otitis media in the course of one year. 938 of the children were aged five years or less, and 153 of these (approximately 17 per cent) suffered from otitis media. 21 per cent of the children were found to have a perforated ear-drum at the time they were first seen. Audiometric testing was carried out in 102 children over the age of four years, and hearing loss of 15dB or more was demonstrated in one or both ears in 45 per cent of the children tested. 239
.
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1976, 18
The National Child Development Survey5 indicated that 13-5 per cent of 14,064 sevenyear-old children assessed by school doctors had speech “other than fully intelligible”. In 1.4 per cent of cases, “many” or “almost all” words were unintelligible6. It would be of great interest to know how many of these speech-defective children had a history of upper respiratory tract infection in earlier childhood, with or without overt clinical signs and symptoms of otitis media and hearing loss. In Edinburgh in the last 20 years, a number of studies have been made of children suffering from defective speech7-10. Particular attention has been paid to children who are slow to talk, but who appear to be healthy and intelligent. In a proportion of these a family history is obtained of a relative having slow speech development and difficulties in learning to read and spell. A genetic influence is presumed to be the major causal factor in many of these cases. A number of families in Scotland are known by name, in which slow speech development and difficulties in learning to read and write are particularly common (Kerrs, MacLeans, MacDonalds and Campbells are examples). In many other case studies of children suffering from retarded speech development, it is found that they are mentally retarded, have obvious hearing loss at the time of examination, or have suffered from the effects of environmental deprivation. A significant proportion, however, have no clinical evidence of hearing loss or disease at the time of examination, but they do have a history of frequent upper respiratory tract infections and/or middle-ear disease. Sometimes parents have noticed that their offspring seemed to have been ‘deaf‘ at the time they suffered the infections. In a study of a group of 64 children with cleft palate”, it was found that 12.5 per cent had significant bilateral hearing loss (+ 30dB) as a result of upper respiratory tract infection, complicated by middle-ear disease. In a recent pilot study of 150 children referred sequentially to the Speech Clinic at the Royal Hospital for Sick Children, Edinburgh, one-third had a history of otitis media and/or required referral to the Ear, Nose and Throat Department. 18 per cent had been subjected to tonsillectomy and adenoidectomy before the age of five years and 7 per cent had been diagnosed as having ‘glue ear’ and had had paracentesis of the ear-drums carried out, or were under observation. 19 per cent had significant hearing loss on examination on one or more occasions. On direct questioning, an even higher proportion of children with retarded speech development were described by their parents as having had periods of apparent hearing loss during infancy, particularly between the ages of three and nine months. It is clear that hearing loss due to otitis media is an important cause of later retardation of speech development, and that middle-ear infections in young children, and especially in infants, are not being adequately diagnosed or treated by family doctors or by ear, nose and throat surgeons. T. T. S . INGRAM Department of Child Life and Health, University of Edinburgh, 25 Hatton Place, Edinburgh EH9 IUB. REFERENCES 1. Miller, F. J. W., Court, S. D. M., Walton, W. S., Knox, E. G. (1960) Growing Up in Newcusrle upon Tyne. London: Oxford University Press. 2. Sheridan, M. D. (1972) ‘Reported incidence of hearing loss in children of 7 years.’ Developmental Medicine and Child Neurology, 14, 296. 3. Ewing, A. W. G. (1967) Assessment of Children with Hearing Defects. London: H.M.S.O.
240
ANNOTATIONS
4. Patterson, J. E., McLean, D. W. (1970) ‘Acute otitis media in children. A medical social study from general practice.’ Scottish Medical Joumol, 15, 289. 5 . Davie, R., Butler, N. R., Goldstein, H. (1972) From Birth to S e w n with Appendix Tables. London: Longman, in association with National Children’s Bureau. 6. Peckham, C. S. (1973) ‘Speech defects in a national sample of children aged seven years.’ British Journal of Disorders of Communication, 8, 2. 7. Ingram, T. T. S. (1959) ‘A description and classification of the common disorders of speech in childhood.’ Archives of Disease in Childhood. 34, 444. 8 . Ingram, T. T. S. (1960) ‘The differential diagnosis of speech disorders in childhood.’ Practitioner, 185, 188. 9. Ingram, T. T. S. (1963) ‘Late and poor talkers.’ In Renfrew, C., Murphy, K . (Eds.) The Child Who Does Not Talk. Clinics in Developmental Medicine no. 13. London: S.I.M.P./Heinemann Medical, n 71.r. 10. Ingram, T. T. S., Mason, A. W., Blackburn, I. (1970) ‘A retrospective study of 82 children with reading disability.’ Developniental Medicine and Child Neurology, 12, 27 I . 11. Drillien, C. M., Ingram, T. T. S., Wilkinson, E. M. (1966) The Causes and Natural History of Cleft Lip and Palare. Edinburgh: Livingstone.
THE BRITISH BIRTHS SURVEY THE1958 Perinatal Mortality Survey had a profound influence on maternity services in the United Kingdom and therefore the publication of the first report from the British Births Survey*-the 1970 cohort-carried out 12 years later is an event of considerable importance. Like its predecessor, the cohort of this survey covers all births in one week and reports in considerable detail the circumstances and outcome. In contrast to the previous survey, the emphasis has shifted from mortality to morbidity and the report makes wide use of a ‘respiratory depression ratio’ (the number of babies taking more than three minutes to the start of respiration, expressed as a percentage of the total number of babies in that group) to compare different kinds of delivery and care in the first week of life. Obviously, an account as wide-ranging as this is provides many topics for discussion, but the following remarks are restricted to three topics-analgesics in labour, induction, and special care baby units. But first the point can be made that the data are presented in a generally dead-pan style. In some cases much space is occupied in explaining findings away, but often the most interesting points are hidden and can only be discovered by reading between the lines and re-calculating the data. Often there is no attempt to point to valuable evidence which shows the way to improvement in obstetric practice. One of the most valuable uses of the perinatal surveys is that they provide an accurate description of the use of various drugs and many other factors that are not covered by the statistics gathered by the Department of Health and Social Security. For instance, we learn that in the slrvey week in 1970, pethidine was used in 46 per cent of deliveries and pethidine with levallorphan (‘Pethilorfan’) in a further 23 per cent. This last figure is of some interest, as the criticisms of ‘Pethilorfan’ (that it is more likely to cause respiratory depression than pethidine and that it is an even less effective analgesic) have been countered by claims that it has passed out of use. Clearly this was not so in 1970. Unfortunately, the survey data for ‘Pethilorfan’ is not analysed by place of delivery, so there are no indications of where this ineffective and potentially dangerous drug continues to be used. The respiratory depression ratios are compared by deliveries with and without pethidine, but it is hard to know what to make of the finding that babies are more likely to be depressed after pethidine. It is, of course, well established that pethidine can cause respiratory depression, but the analysis given here can hardly count as further evidence. All singleton births where pethidine was used were compared with those where it was not. Implicitly, this latter group is treated as a control group. However, we are told nothing about use of other drugs in either group. 24 1
Annotations INTERMITTENT HEARING LOSS IN YOUNG CHILDREN THEprevalence of middle-ear disease and intermittent hearing loss in infants and young children is unknown. This is largely because the diagnosis of otitis media is difficult to make in infants, and temporary hearing loss is easily missed by parents and by doctors. Yet recent research suggests that otitis media is an important cause of intermittent or persistent hearing loss in early childhood, and may result in the retardation of later speech development, which in turn may be followed by later difficulties in learning to read and spell. In the pioneer study of 1000 families in Newcastle upon Tyne‘, it was found that 19.2 per cent of children had one or more attacks of otitis media before the age of five years. One-third of these had more than one attack. Otorrhea, indicating that the ear drum had perforated, occurred in nine out of every 10 affected children. These findings were reported as a result of examinations of children during the period 1947 to 1952 and it is probable that suppurative otitis media is less frequent and better treated now than it was then. Yet middle-ear disease, including infective otitis~media, remains an important cause of intermittent and sometimes permanent hearing loss. MILLERand colleagues’ were impressed by the inadequate treatment of otitis media in the young children whom they studied. Ineffective ear-drops were all too often prescribed and systemic antibiotics all too rarely. In the Perinatal Mortality Survey, audiograms were obtained from 11,276 (73 per cent of the original cohort) at the age of seven years in t9652. 636 (approximately 5 . 7 per cent) were found to have significant hearing loss. Of these, 162 (25.5 per cent) had moderate or severe bilateral hearing impairment and‘ many were thought to be in need of special educational provision. It is significant that hearing loss was suspected clinically in only 2 . 6 per cent of the 4220 children who were not formally tested by audiometry. Unfortunately, the proportion of children whose hearing loss was due to middle-ear disease is not stated: nevertheless, the fact that significant hearing loss was unilateral in as many as 2 4 - 5 of the children with hearing loss suggests that middle-ear disease, rather than congenital or acquired nerve deafness, was responsible in many cases. Yet as late as 1967 PROFESSOR EWINGquoted: “No authoritative figures can yet be given for the evidence of hearing defects in ~hildren”~. In Edinburgh in 1970, PATTERSON and MCLEAN4 reported on the incidence of otitis media in 1947 children from the time of birth to the age of 15 years. They found that 212 (10.9 per cent) of the children suffered from otitis media in the course of one year. 938 of the children were aged five years or less, and 153 of these (approximately 17 per cent) suffered from otitis media. 21 per cent of the children were found to have a perforated ear-drum at the time they were first seen. Audiometric testing was carried out in 102 children over the age of four years, and hearing loss of 15dB or more was demonstrated in one or both ears in 45 per cent of the children tested. 239
.
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1976, 18
The National Child Development Survey5 indicated that 13-5 per cent of 14,064 sevenyear-old children assessed by school doctors had speech “other than fully intelligible”. In 1.4 per cent of cases, “many” or “almost all” words were unintelligible6. It would be of great interest to know how many of these speech-defective children had a history of upper respiratory tract infection in earlier childhood, with or without overt clinical signs and symptoms of otitis media and hearing loss. In Edinburgh in the last 20 years, a number of studies have been made of children suffering from defective speech7-10. Particular attention has been paid to children who are slow to talk, but who appear to be healthy and intelligent. In a proportion of these a family history is obtained of a relative having slow speech development and difficulties in learning to read and spell. A genetic influence is presumed to be the major causal factor in many of these cases. A number of families in Scotland are known by name, in which slow speech development and difficulties in learning to read and write are particularly common (Kerrs, MacLeans, MacDonalds and Campbells are examples). In many other case studies of children suffering from retarded speech development, it is found that they are mentally retarded, have obvious hearing loss at the time of examination, or have suffered from the effects of environmental deprivation. A significant proportion, however, have no clinical evidence of hearing loss or disease at the time of examination, but they do have a history of frequent upper respiratory tract infections and/or middle-ear disease. Sometimes parents have noticed that their offspring seemed to have been ‘deaf‘ at the time they suffered the infections. In a study of a group of 64 children with cleft palate”, it was found that 12.5 per cent had significant bilateral hearing loss (+ 30dB) as a result of upper respiratory tract infection, complicated by middle-ear disease. In a recent pilot study of 150 children referred sequentially to the Speech Clinic at the Royal Hospital for Sick Children, Edinburgh, one-third had a history of otitis media and/or required referral to the Ear, Nose and Throat Department. 18 per cent had been subjected to tonsillectomy and adenoidectomy before the age of five years and 7 per cent had been diagnosed as having ‘glue ear’ and had had paracentesis of the ear-drums carried out, or were under observation. 19 per cent had significant hearing loss on examination on one or more occasions. On direct questioning, an even higher proportion of children with retarded speech development were described by their parents as having had periods of apparent hearing loss during infancy, particularly between the ages of three and nine months. It is clear that hearing loss due to otitis media is an important cause of later retardation of speech development, and that middle-ear infections in young children, and especially in infants, are not being adequately diagnosed or treated by family doctors or by ear, nose and throat surgeons. T. T. S . INGRAM Department of Child Life and Health, University of Edinburgh, 25 Hatton Place, Edinburgh EH9 IUB. REFERENCES 1. Miller, F. J. W., Court, S. D. M., Walton, W. S., Knox, E. G. (1960) Growing Up in Newcusrle upon Tyne. London: Oxford University Press. 2. Sheridan, M. D. (1972) ‘Reported incidence of hearing loss in children of 7 years.’ Developmental Medicine and Child Neurology, 14, 296. 3. Ewing, A. W. G. (1967) Assessment of Children with Hearing Defects. London: H.M.S.O.
240
ANNOTATIONS
4. Patterson, J. E., McLean, D. W. (1970) ‘Acute otitis media in children. A medical social study from general practice.’ Scottish Medical Joumol, 15, 289. 5 . Davie, R., Butler, N. R., Goldstein, H. (1972) From Birth to S e w n with Appendix Tables. London: Longman, in association with National Children’s Bureau. 6. Peckham, C. S. (1973) ‘Speech defects in a national sample of children aged seven years.’ British Journal of Disorders of Communication, 8, 2. 7. Ingram, T. T. S. (1959) ‘A description and classification of the common disorders of speech in childhood.’ Archives of Disease in Childhood. 34, 444. 8 . Ingram, T. T. S. (1960) ‘The differential diagnosis of speech disorders in childhood.’ Practitioner, 185, 188. 9. Ingram, T. T. S. (1963) ‘Late and poor talkers.’ In Renfrew, C., Murphy, K . (Eds.) The Child Who Does Not Talk. Clinics in Developmental Medicine no. 13. London: S.I.M.P./Heinemann Medical, n 71.r. 10. Ingram, T. T. S., Mason, A. W., Blackburn, I. (1970) ‘A retrospective study of 82 children with reading disability.’ Developniental Medicine and Child Neurology, 12, 27 I . 11. Drillien, C. M., Ingram, T. T. S., Wilkinson, E. M. (1966) The Causes and Natural History of Cleft Lip and Palare. Edinburgh: Livingstone.
THE BRITISH BIRTHS SURVEY THE1958 Perinatal Mortality Survey had a profound influence on maternity services in the United Kingdom and therefore the publication of the first report from the British Births Survey*-the 1970 cohort-carried out 12 years later is an event of considerable importance. Like its predecessor, the cohort of this survey covers all births in one week and reports in considerable detail the circumstances and outcome. In contrast to the previous survey, the emphasis has shifted from mortality to morbidity and the report makes wide use of a ‘respiratory depression ratio’ (the number of babies taking more than three minutes to the start of respiration, expressed as a percentage of the total number of babies in that group) to compare different kinds of delivery and care in the first week of life. Obviously, an account as wide-ranging as this is provides many topics for discussion, but the following remarks are restricted to three topics-analgesics in labour, induction, and special care baby units. But first the point can be made that the data are presented in a generally dead-pan style. In some cases much space is occupied in explaining findings away, but often the most interesting points are hidden and can only be discovered by reading between the lines and re-calculating the data. Often there is no attempt to point to valuable evidence which shows the way to improvement in obstetric practice. One of the most valuable uses of the perinatal surveys is that they provide an accurate description of the use of various drugs and many other factors that are not covered by the statistics gathered by the Department of Health and Social Security. For instance, we learn that in the slrvey week in 1970, pethidine was used in 46 per cent of deliveries and pethidine with levallorphan (‘Pethilorfan’) in a further 23 per cent. This last figure is of some interest, as the criticisms of ‘Pethilorfan’ (that it is more likely to cause respiratory depression than pethidine and that it is an even less effective analgesic) have been countered by claims that it has passed out of use. Clearly this was not so in 1970. Unfortunately, the survey data for ‘Pethilorfan’ is not analysed by place of delivery, so there are no indications of where this ineffective and potentially dangerous drug continues to be used. The respiratory depression ratios are compared by deliveries with and without pethidine, but it is hard to know what to make of the finding that babies are more likely to be depressed after pethidine. It is, of course, well established that pethidine can cause respiratory depression, but the analysis given here can hardly count as further evidence. All singleton births where pethidine was used were compared with those where it was not. Implicitly, this latter group is treated as a control group. However, we are told nothing about use of other drugs in either group. 24 1
