LSHSS

Research Article

Will Parents Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis Media in Their Children? Jeffrey L. Danhauer,a Carole E. Johnson,b Jason A. Baker,a Jung A. Ryu,a Rachel A. Smith,a and Claire J. Umedaa

Purpose: Antiadhesive properties in xylitol, a natural sugar alcohol, can help prevent acute otitis media (AOM) in children by inhibiting harmful bacteria from colonizing and adhering to oral and nasopharyngeal areas and traveling to the Eustachian tube and middle ear. This study investigated parents’ willingness to use and comply with a regimen of xylitol for preventing AOM in their preschool- and kindergarten-aged children. Method: An Internet questionnaire was designed and administered to parents of young children in preschool and kindergarten settings. Results: Most parents were unaware of xylitol’s use for AOM and would not likely comply with regimens for

preventing AOM in their children; however, parents having previous knowledge of xylitol and whose children had a history of AOM would be more likely to do so. Conclusions: Generally, most of these parents did not know about xylitol and probably would not use it to prevent ear infections. Unfortunately, these results parallel earlier findings for teachers and schools, which present obstacles for establishing ear infection prevention programs using similar protocols for young children. The results showed that considerable education and age-appropriate vehicles for administering xylitol are needed before establishing AOM prevention programs in schools and/or at home.

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controlled by families. However, the guidelines suggested that families could use behaviors—such as avoiding exposure to passive cigarette smoke (Etzel, Pattishall, Haley, Fletcher, & Henderson, 1992; Ilicali, Keleş, Değer, & Savaş, 1999), extended pacifier use (Niemelä, Pihakari, Pokka, & Uhari, 2000), and bottle propping (Brown & Magnuson, 2000)— to prevent ear infections. Further, the guidelines encouraged breastfeeding for the first year of life, frequent hand washing, and limiting participation in day care centers to help prevent AOM in children (AAP/AAFP, Subcommittee on Management of Acute Otitis Media, 2004; Lieberthal et al, 2013). Although vaccines are being developed for preventing ear infections, they were not available for general use until the past few years (Marom et al., 2014; Schuerman, Borys, Hoet, Forsgren, & Prymula, 2009). According to Marom et al. (2014), pneumococcal conjugate vaccines PCV-7 and PCV-13 were introduced in 2000 and 2010, respectively, and are currently being received by about 90% of children aged younger than 2 years. However, although these vaccines show promise for reducing ear infections and their complications in young children, there is still a place for alternative forms of prevention (AAP/AAFP, Subcommittee on

hildren from age 0 to 6 years are most susceptible to acute otitis media (AOM), which can have a negative impact on them; their families; and their early education, hearing, speech, and language development (Daly & Giebink, 2000; Rosenfeld, Goldsmith, Tetlus, & Balzano, 1997). The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) have provided practice guidelines for the early diagnosis and management of AOM (AAP/AAFP, Subcommittee on Management of Acute Otitis Media, 2004; Lieberthal et al., 2013). The guidelines focused mainly on treatment of AOM and indicated that predisposing factors—such as craniofacial anomalies, hypotonia, immune deficiencies, low socioeconomic status, and family history—cannot be

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University of California, Santa Barbara University of Oklahoma Health Sciences Center, Oklahoma City Correspondence to Jeffrey L. Danhauer: [email protected]

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Editor: Marilyn Nippold Associate Editor: Sheila Pratt Received April 23, 2014 Revision received July 22, 2014 Accepted December 8, 2014 DOI: 10.1044/2015_LSHSS-14-0048

Disclosure: The authors have declared that no competing interests existed at the time of publication.

Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015 • Copyright © 2015 American Speech-Language-Hearing Association

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Management of Acute Otitis Media, 2004; Lieberthal et al, 2013). In 2007, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (Centers for Disease Control and Prevention, National Center for Health Statistics, n.d.) estimated that there were 244.1 visits per 1,000 persons aged younger than 18 years to ambulatory care facilities that resulted in a diagnosis of otitis media (OM). Healthy People 2020 (n.d.) would like to see that number reduced to 221.5. One way to reduce the number of cases of OM is through prevention programs involving children’s families at home and with their teachers at school. Public schools are possible venues for wellness programs with the aim of preventing disease, considering that they have been effective in preventing diseases such as obesity (Waters et al., 2014), HIV/AIDS (Ma, Fisher, & Kuller, 2014), and pertussis (Haselow, 2013). In a similar way, although not demonstrating that ear infection prevention programs actually reduced the prevalence of ear infections, a recent study revealed that a sample of teachers, community health nurses, and other staff believed that ear infection prevention programs were effective in improving health outcomes of children in lower primary school classes in Australia (Doyle & Ristevski, 2010). The preventative behaviors cited in the AAP/AAFP, Subcommittee on Management of Acute Otitis Media (2004) guidelines may not be sufficient alone. Several publications (e.g., Isokangas, Söderling, Pienihäkkinen, & Alanen, 2000; L. Jones, 2010; Milgrom, Rothen, & Milgrom, 2006; Söderling & Hietala-Lenkkeri, 2010; Thorild, Lindau, & Twetman, 2006; Uhari, Kontiokari, Koskela, & Niemelä, 1996; Uhari, Kontiokari, & Niemelä, 1998; Vernacchio & Mitchell, 2007) and three recent systematic reviews (Azarpazhooh, Limeback, Lawrence, & Shah, 2011; Danhauer, Johnson, Corbin, & Bruccheri, 2010; Danhauer, Kelly, & Johnson, 2011) have shown that xylitol, a natural sugar alcohol that helps prevent harmful bacteria from colonizing in the oral and nasopharyngeal areas, can also be used to help prevent dental caries and ear infections in children. When administered 5 times a day via chewing gum with a cumulative dosage of 10.4 g (i.e., the standard regimen for preventing dental caries), xylitol may reduce AOM by about 40% compared with controls (Uhari et al., 1996, 1998), and prevention rates may be even higher when xylitol is administered via nasal spray (A. H. Jones, 2001). Laboratory studies have suggested that xylitol has antiadhesive properties that keep prominent bacterial pathogens (e.g., Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) found in dental caries and upper respiratory infections (Klein, 1994; Syrjänen, Auranen, Leino, Kilpi, & Mäkelä, 2005) from adhering to oral and aural structures. The antiadhesive properties in xylitol could also prevent these bacteria, especially mutans streptococci, from traveling to the Eustachian tube and middle ear, which should reduce the occurrence of AOM. Although xylitol products are commercially available in chewing gums, mouthwashes, mints, syrups, and nasal sprays, recent studies have shown that (a) pediatricians in the United States are generally unaware of xylitol’s use

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with AOM, and few recommend xylitol to their patients (Danhauer, Johnson, Rotan, Snelson, & Stockwell, 2010; Stockwell, Johnson, & Danhauer, 2010), and (b) schools and teachers do not typically permit children to chew gum on campus (Autio & Courts, 2001; Danhauer, Johnson, & Caudle, 2011). Earlier, Autio and Courts (2001) found that although chewing gum was helpful for preventing ear infections in children, the teachers in their study were generally unwilling to participate in prevention programs, mainly due to their potential for disrupting classrooms. Unfortunately, missed dosages or discontinuation from participation often result when programs and protocols necessary for preventing AOM in children require that parents and teachers must adhere to a strict regimen of administering gum and/or nasal sprays to children. Furthermore, children aged younger than 5 years, who are most prone to AOM, are usually too young to chew gum, which is a continuing problem for implementing ear infection prevention programs that rely on chewing gum as a vehicle for administering xylitol in schools and at home. The aim of the present study was not to determine what age is safe for children to chew gum but rather whether chewing gum is an appropriate vehicle for administering xylitol in ear infection prevention programs directed at young children. However, the former is a reasonable question considering that the AAP (n.d.) has warned that swallowing gum could lead to diarrhea, abdominal discomfort, gas, mouth ulcers, dental and jaw problems, and choking. Although the AAP and others (e.g., International Chewing Gum Association, n.d.) have stated that there is no set time when children can begin chewing gum, they have indicated that parents should generally know when their children can grasp the concept of chewing without swallowing (usually around 4–5 years) and, thus, be able to chew gum safely. Further, our inspection of the literature revealed neither specific guidelines for recommending when it is safe for young children to begin chewing gum nor any empirical evidence regarding studies that have been published on that topic, only that those aged younger than 4 years or having developmental issues may be at risk for choking, and parental monitoring and supervision should be involved (Nichols et al., 2012). Knowing whether parents are aware of xylitol’s use as a prophylaxis for ear infections and whether parents would comply with dosing schedules necessary for preventing AOM in their children using chewing gum or other vehicles is an important first step before initiating xylitol prevention programs with families either at home or within school and day care settings. Thus, a feasibility study is needed to determine parents’ willingness to comply with protocols and regimens of xylitol that are necessary for establishing prevention programs in homes and preschool and kindergarten settings. If parents are receptive to participating in prevention programs, then they might be encouraged to help persuade those in preschool and kindergarten settings to partner with them in implementing programs that would increase accessibility of health care delivery and reduce ear infections in children.

Language, Speech, and Hearing Services in Schools • Vol. 46 • 127–140 • April 2015

Therefore, the purpose of the present study was to design and administer a questionnaire directed at parents of children aged younger than 6 years in preschool and kindergarten settings, with and without previous knowledge of xylitol, to assess whether they were aware of xylitol products and would use them with their children to prevent AOM. We hypothesized that most parents would be unaware that xylitol can reduce AOM in children; that few parents would be willing to comply with the strict protocols and regimens of xylitol that are necessary for preventing AOM in their children; and that parental education would be necessary before establishing ear infection prevention programs using xylitol with children that could be implemented in home, preschool, and kindergarten settings. Thus, a goal of the present study was to determine obstacles to and solutions for using xylitol in ear infection prevention programs with families. The questions posed in the present study included the following: 1.

Do parents know about xylitol and its use in preventing ear infections in children?

2.

Would parents be willing to do their part at home and use xylitol on their children and comply with dosages/regimens necessary for preventing AOM?

3.

Would parents participate in ear infection prevention programs using xylitol with their children and consent to having teachers administer necessary dosages while at school?

4.

Are there differences in responses from parents of children across private audiology practice (PP), nursery school (NS), preschool (PS), or kindergarten class (KC) settings?

5.

Would parents with children aged ≤3 years be more likely to use xylitol nasal spray on their children and comply with ear infection prevention programs than those with older children?

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Do parents with prior knowledge of xylitol respond differently than those having no prior knowledge?

This study was approved by the University of California, Santa Barbara, Institutional Review Board.

Method Questionnaire, Participants, and Procedure Because no questionnaires were found in the literature that met the needs of this study, we created a new questionnaire, as shown in the Appendix, according to procedures recommended by Cummings and Hulley (2007). The 34-item Internet survey was designed to be completed in less than 10 min and included sections on demographics (gender, age, marital status, number of children and their ages, and relationships to the child), factors related to AOM (bottle propping, day care attendance, smokers in household, number of bouts of AOM, and previous treatments), communication disorders (speech/language delays and/or hearing loss and effects on quality of life), preventative measures for AOM (willingness to have children use chewing gum,

pacifier, or nasal spray 3–5 times/day for 3 months), and willingness to participate in ear infection prevention programs administered in school and preschool settings with or without student mentors. The potential participants in the present study were from a convenience sample in southern California consisting of parents having children in PP, NS, PS, and KC settings who were invited to participate in the survey. All of the parents in these groups were known to have children aged between 0 and 5 years, when AOM is most prevalent. The survey was conducted with these particular families at a local level with the intent of establishing ear prevention programs designed specifically for them. The teachers from the NS, PS, and KC settings in the Santa Barbara area were associates of the first author, and all of the families in the PP group had children who were seen by the first author for audiologic evaluations in the previous 6 months and had documented cases of AOM. Thus, we knew that the parents in the PP group had some basic previous knowledge about hearing loss and about ear infections and how to prevent them, especially through the use of xylitol products, because the first author had personally counseled them about these issues. We assumed that the parents from the NS, PS, and KC groups had little or no prior knowledge about ear infections and xylitol. E-mails were sent to all of the parents in each group with a link to the questionnaire on SurveyMonkey.com. For confidentiality reasons, the teachers in the NS, PS, and KC groups were given the link to the survey, which they in turn e-mailed to 174 parents. Similarly, 23 e-mails were sent to the parents of the children in the PP group with documented cases of AOM and who had been counseled on the possible benefits of xylitol in preventing middle ear infections. Thus, a total of 198 e-mails were sent, and data were collected over a 3-week period during February 2013; potential participants were contacted only once. The families were generally representative of the local area and were specifically being considered for future xylitol prevention programs in their community and schools. All of the potential participants were known to have e-mail addresses and Internet access. Thus, no parents should have been excluded due to a lack of access to the Internet. Participants selfselected their involvement by completing the questionnaire and received a $20 gift card or donation to the schools (except for the PS, which could not accept them) as incentives for their participation. We hypothesized that parents who had prior knowledge of or used xylitol and/or had children with a history of AOM would be more willing to comply with ear infection prevention programs administered at home and through the schools than the others, but that most parents would be unwilling to comply with the protocols necessary to prevent ear infections in children.

Results Demographics A total of 136 parents answered the survey (PP = 23, KC = 20, NS = 34, and PS = 59), which produced response

Danhauer et al.: Xylitol for Preventing AOM in Children

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rates that ranged from 57% to 100% across the groups (NS = 57%, PS = 66%, KC = 77%, PP = 100%). In nearly all cases, the mothers completed the surveys (86%). Due to space limitations, the participants’ responses are not reproduced here, but they are available from the authors. The numbers of parents having a child in each of the following age groups were as follows: 75 (4–6 years), 44 (2–3 years), and 17 (≤1 year). Of all of the parents, only two (

Will parents participate in and comply with programs and regimens using xylitol for preventing acute otitis media in their children?

Antiadhesive properties in xylitol, a natural sugar alcohol, can help prevent acute otitis media (AOM) in children by inhibiting harmful bacteria from...
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