Environmental determinants associated with acute otitis media in children: a longitudinal study



Acute otitis media (AOM) is a common pediatric disease and frequent reason for antibiotic treatment. We aimed to identify environmental and host factors associated with AOM and assess which determinants were associated with AOM at specific ages.


This study among 7863 children was embedded in the Generation R Study: a population-based prospective cohort study from fetal life onwards. Data on outcome and possible determinants were collected using questionnaires until 6 years. We used generalized estimating equation models to examine associations with AOM with longitudinal odds at different ages, considering correlations between repeated measurements.


Male gender increased odds of AOM in children at 2, 3, and 4 years but not at other ages. Postnatal household smoking, presence of siblings, and pet birds increased odds of AOM. Breastfeeding decreased AOM odds, most notably in the first 2 months of life. No association was found for season of birth, maternal age, ethnicity, aberrant birth weight for gestational age, prenatal smoking, furry pets, and daycare attendance.


Risk of childhood AOM varies with age. Significant association with AOM was found for gender and breastfeeding at specific ages and for household smoking, presence of siblings, and pet birds at all the studied ages.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1
Fig. 2
Fig. 3

Data availability

The data are available from the corresponding author upon request.


  1. 1.

    Coker, T. R. et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA 304, 2161–2169 (2010).

  2. 2.

    Kaur, R., Morris, M. & Pichichero, M. E. Epidemiology of acute otitis media in the postpneumococcal conjugate vaccine era. Pediatrics 140, e20170181 (2017).

  3. 3.

    de Hoog, M. L. A. et al. Impact of early-onset acute otitis media on multiple recurrences and associated health care use. J. Pediatr. 177, 286.e1–291.e1 (2016).

  4. 4.

    Ilia, S. & Galanakis, E. Clinical features and outcome of acute otitis media in early infancy. Int. J. Infect. Dis. 17, e317–e320 (2013).

  5. 5.

    Sidell, D., Shapiro, N. L. & Bhattacharyya, N. Demographic influences on antibiotic prescribing for pediatric acute otitis media. Otolaryngol. Head Neck Surg. 146, 653–658 (2012).

  6. 6.

    Daly, K. A. Epidemiology, natural history, and risk factors: Panel report from the Ninth International Research Conference on Otitis Media. Int. J. Pediatr. Otorhinolaryngol. 74, 231–240 (2010).

  7. 7.

    van Ingen, G. et al. Genome-wide association study for acute otitis media in children identifies FNDC1 as disease contributing gene. Nat. Commun. 7, 12792 (2016).

  8. 8.

    Kooijman, M. N. et al. The Generation R Study: design and cohort update 2017. Eur. J. Epidemiol. 31, 1243–1264 (2016).

  9. 9.

    Winkleby, M. A., Jatulis, D. E., Frank, E. & Fortmann, S. P. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am. J. Public Health 82, 816–820 (1992).

  10. 10.

    Silva, L. M. et al. Children of low socioeconomic status show accelerated linear growth in early childhood; results from the Generation R Study. PLoS ONE 7, e37356 (2012).

  11. 11.

    Damoiseaux, R. A., Rovers, M. M., Van Balen, F. A., Hoes, A. W. & de Melker, R. A. Long-term prognosis of acute otitis media in infancy: determinants of recurrent acute otitis media and persistent middle ear effusion. Fam. Pract. 23, 40–45 (2006).

  12. 12.

    Korvel-Hanquist, A. et al. Risk factors of early otitis media in the Danish National Birth Cohort. PLoS ONE 11, e0166465 (2016).

  13. 13.

    Sillanpaa, S. et al. Human parechovirus as a minor cause of acute otitis media in children. J. Clin. Virol. 62, 106–109 (2015).

  14. 14.

    MacIntyre, E. A. Otitis media incidence and risk factors in a population-based birth cohort. Paediatr. Child Health 15, 437–442 (2010).

  15. 15.

    Lundgren, K. & Ingvarsson, L. Epidemiology of acute otitis media in children. Scand. J. Infect. Dis. Suppl. 39, 19–25 (1983).

  16. 16.

    Salah, M., Abdel-Aziz, M., Al-Farok, A. & Jebrini, A. Recurrent acute otitis media in infants: analysis of risk factors. Int. J. Pediatr. Otorhinolaryngol. 77, 1665–1669 (2013).

  17. 17.

    Thornton, D. et al. Chronic suppurative otitis media in Nepal: ethnicity does not determine whether disease is associated with cholesteatoma or not. J. Laryngol. Otol. 125, 22–26 (2011).

  18. 18.

    Teele, D. W., Klein, J. O. & Rosner, B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J. Infect. Dis. 160, 83–94 (1989).

  19. 19.

    Duffy, L. C., Faden, H., Wasielewski, R., Wolf, J. & Krystofik, D. Exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media. Pediatrics 100, E7 (1997).

  20. 20.

    Bowatte, G., Tham, R. & Allen, K. J. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatr. 104, 11 (2015).

  21. 21.

    Uhari, M., Mantysaari, K. & Niemela, M. A meta-analytic review of the risk factors for acute otitis media. Clin. Infect. Dis. 22, 1079–1083 (1996).

  22. 22.

    den Dekker, H. T. Breastfeeding and asthma outcomes at the age of 6 years. The Generation R Study. Pediatr. Allergy Immunol. 27, 486–492 (2016).

  23. 23.

    Boland, M. R., Shahn, Z. & Madigan, D. Birth month affects lifetime disease risk: a phenome-wide method. J. Am. Med. Inf. Assoc. 22, 11 (2015).

  24. 24.

    Homoe, P., Christensen, R. B. & Bretlau, P. Acute otitis media and season of birth. Int. J. Pediatr. Otorhinolaryngol. 69, 487–491 (2005).

  25. 25.

    Pettigrew, M. M., Gent, J. F. & Triche, E. W. Infant otitis media and the use of secondary heating sources. Epidemiology 15, 8 (2004).

  26. 26.

    Kvaerner, K. J. The relationship between otitis media and intrauterine growth: a co-twin control study. Int. J. Pediatr. Otorhinolaryngol. 37, 217–225 (1996).

  27. 27.

    Burr, M. L. et al. Respiratory symptoms and home environment in children: a national survey. Thorax 54, 27–32 (1999).

  28. 28.

    Hatakka, K. et al. Factors associated with acute respiratory illness in day care children. Scand. J. Infect. Dis. 42, 704–711 (2010).

  29. 29.

    Celedon, J. C., Litonjua, A. A., Weiss, S. T. & Gold, D. R. Day care attendance in the first year of life and illnesses of the upper and lower respiratory tract in children with a familial history of atopy. Pediatrics 104(3 Pt 1), 495–500 (1999).

  30. 30.

    Bornehag, C. G., Sundell, J., Hagerhed, L. & Janson, S., Group DBHS. Pet-keeping in early childhood and airway, nose and skin symptoms later in life. Allergy 58, 939–944 (2003).

  31. 31.

    Lieu, J. E. & Feinstein, A. R. Effect of gestational and passive smoke exposure on ear infections in children. Arch. Pediatr. Adolesc. Med. 156, 147–154 (2002).

  32. 32.

    Jones, L. L., Hassanien, A., Cook, D. G., Britton, J. & Leonardi-Bee, J. Parental smoking and the risk of middle ear disease in children: a systematic review and meta-analysis. Arch. Pediatr. Adolesc. Med. 166, 18–27 (2012).

  33. 33.

    Amani, S. & Yarmohammadi, P. Study of effect of household parental smoking on development of acute otitis media in children under 12 years. Glob. J. Health Sci. 8, 50477 (2015).

  34. 34.

    Prins-van Ginkel, A. C. et al. Acute otitis media during infancy: parent-reported incidence and modifiable risk factors. Pediatr. Infect. Dis. J. 36, 245–249 (2017).

  35. 35.

    Vernacchio, L. et al. Racial/ethnic disparities in the diagnosis of otitis media in infancy. Int. J. Pediatr. Otorhinolaryngol. 68, 795–804 (2004).

  36. 36.

    Fortanier, A. C. et al. Parent-reported symptoms of acute otitis media during the first year of life: what is beneath the surface? PLoS ONE 10, e0121572 (2015).

  37. 37.

    Shaikh, N. et al. Development and preliminary evaluation of a parent-reported outcome instrument for clinical trials in acute otitis media. Pediatr. Infect. Dis. J. 28, 5–8 (2009).

  38. 38.

    Uitti, J. M., Laine, M. K., Tahtinen, P. A., Ruuskanen, O. & Ruohola, A. Symptoms and otoscopic signs in bilateral and unilateral acute otitis media. Pediatrics 131, e398–e405 (2013).

  39. 39.

    Laine, M. K., Tahtinen, P. A., Ruuskanen, O., Huovinen, P. & Ruohola, A. Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age. Pediatrics 125, e1154–e1161 (2010).

  40. 40.

    Rovers, M. M. Heritability of symptom domains in otitis media: a longitudinal study of 1,373 twin pairs. Am. J. Epidemiol. 155, 958–964 (2002).

Download references


The Generation R Study is being conducted by the Erasmus Medical Center in close collaboration with the School of Law and Faculty of Social Sciences of the Erasmus University Rotterdam, the Municipal Health Service Rotterdam area, Rotterdam, the Rotterdam Homecare Foundation, Rotterdam, and the Stichting Trombosedienst & Artsenlaboratorium Rijnmond (STAR-MDC), Rotterdam. We gratefully acknowledge the contributions of children and parents, general practitioners, hospitals, midwives, and pharmacies in Rotterdam. The general design of the Generation R Study was made possible by financial support from Erasmus MC, Rotterdam; Erasmus University, Rotterdam; the Netherlands Organization for Health Research and Development (ZonMw); the Netherlands Organization for Scientific Research (NWO); the Ministry of Health, Welfare, and Sport; and the Ministry of Youth and Families. The funders were not involved in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author information




G.v.I. conceptualized and designed the study, performed the statistical analyses, and drafted the manuscript; C.M.P.l.C. assisted in conceptualizing and designing the study, assisted in data collection, supervised the statistical analyses, and reviewed the manuscript; C.E.T. coordinated and performed statistical analyses and assisted in drafting the manuscript; L.D. provided comments and consultation regarding statistical analyses and the manuscript; H.A.M. contributed to the original data collection of the Generation R Study and reviewed the manuscript for intellectual content; V.W.V.J. initiated and designed the Generation R Study, supervised data collection for the Generation R Study, and reviewed the manuscript; H.R. made important contributions the design of the Generation R study and reviewed the manuscript for important intellectual content; R.J.B.d.J. critically revised the manuscript and was responsible for the infrastructure of the study; M.P.v.d.S. conceptualized and designed the study, supervised analyses, and drafting of the manuscript; and all authors approved the final manuscript as submitted.

Corresponding author

Correspondence to Gijs van Ingen.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

van Ingen, G., le Clercq, C.M.P., Touw, C.E. et al. Environmental determinants associated with acute otitis media in children: a longitudinal study. Pediatr Res 87, 163–168 (2020). https://doi.org/10.1038/s41390-019-0540-3

Download citation

Further reading