Objetivos: Caracterizar o perfil dos indivíduos com fissura labiopalatina e deficiência auditiva, adaptados com AASI, pela Divisão de Saúde Auditiva (DSA), HRAC/USP, Bauru e avaliar a efetividade e a satisfação da adaptação do AASI na amostra selecionada. Modelo: Análise dos prontuários, avaliação da efetividade do AASI pelo levantamento das características eletroacústicas, medidas com microfone sonda e teste de reconhecimento de sentenças no silêncio e no ruído e avaliação da satisfação pelo questionário QI-AASI. Local: Setor de AASI da DSA. Participantes: Para a caracterização do perfil, foram analisados os prontuários de 131 indivíduos e, destes, selecionados 8 com fissura labiopalatina, sem alterações associadas, deficiência auditiva condutiva e/ou mista e assíduos ao acompanhamento. Resultados: O perfil geral (n=131) caracterizou-se pela predominância de fissura transforame incisivo unilateral (27%), histórico de alterações de orelha média (56%) e intervenção cirúrgica (56%). Na amostra selecionada (n=8), a efetividade do AASI foi comprovada pelo melhor desempenho obtido com o aparelho, em comparação com as respostas sem ele, na avaliação proposta. A satisfação foi confirmada pelos escores elevados do questionário. Conclusões: O perfil geral dos indivíduos com fissura labiopalatina e deficiência auditiva, adaptados com AASI, caracterizou-se pela predominância do sexo masculino, fissura transforame incisivo unilateral, histórico positivo de alteração de orelha média, intervenção cirúrgica e deficiência auditiva sensorioneural bilateral de grau leve a profundo. Foi comprovada a efetividade e satisfação do AASI para os indivíduos com fissura labiopalatina e deficiência auditiva condutiva e/ou mista participantes deste estudo. É importante considerar a adaptação de AASI como alternativa para o tratamento desses indivíduos. / Aim: To characterize the profile and to assess efficacy and satisfaction of individuals with cleft palate and hearing loss that were hearing aids fitted at Divisão de Saúde Auditiva (DSA), Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Bauru. Model: Analysis of patients? files, assessment of the hearing aid efficacy by raising the electroacoustic characteristics, measurements with a probe tube and test of recognition of sentences in silence and noise and assessment of the satisfaction by questionnaire International Outcome Inventory for Hearing Aids. Local: Hearing aid division of the DSA. Participants: For the characterization of the profile, 131 files were analyzed from which 8 were selected with cleft palate, without associated alterations, conductive and/or mixed hearing loss, and assiduous to routine appointments. Results: The general profile (n=131) was characterized by the prevalence of the unilateral incisive transforamen cleft (27%), history of alterations of the middle ear (56%) and surgery intervention (56%). In the selected sample (n=8), the efficacy of the hearing aid was demonstrated by the better performance obtained with the hearing aid in comparison with those not using it in the proposed evaluation. The satisfaction was confirmed by the questionnaire elevated scores. Conclusions: The general profile of the individuals with cleft palate and hearing loss, adapted with hearing aid, was characterized by male predominance, unilateral incisive transforamen cleft, positive history of alteration of the middle ear, surgery intervention and moderate to profound bilateral sensorioneural hearing loss. It was possible to demonstrate the efficacy and satisfaction of the individuals with cleft palate and conductive and/or mixed hearing loss who participated in this work. It is important to consider the hearing aid fitting as an alternative to the treatment of such individuals.

ABSTRACT Thus far, literature is scant in assessing the ability of children with conductive hearing impairment to understand everyday speech. This assessment is important in determining the functional ability of children with conductive hearing impairment. In order to identify the hearing ability of children with conductive hearing impairment, many assessments to date have used speech stimuli, such as syllables, words and sentences, to measure how well children perform. In general, these tests are useful in measuring speech recognition ability, but are not adequate in measuring the functional ability of children to understand the conversations they encounter in their daily lives. In addition, many of these tests are not designed to be interesting or engage the children whom they are assessing. The University of Queensland Understanding of Everyday Speech (UQUEST) Test was developed to address the above issues by providing a stimulating speech perception assessment for children aged 5 to 10 years. This overall objectives of this thesis were to: (1) determine the applicability of a computer-based, self-driven assessment of speech comprehension, the UQUEST, (2) establish normative UQUEST data for school children, (3) compare the UQUEST results in children with and without histories of otitis media in understanding everyday speech, and (4) measure speech understanding in noise by children with minimal conductive hearing impairment. A total of 1094 children were assessed using the UQUEST. All children were native speakers of English and attended schools in the Brisbane Metropolitan and Sunshine Coast regions within the state of Queensland, Australia. All children were firstly assessed using otoscopic examination, pure tone audiometry testing and tympanometry. Children with sensorineural hearing impairment were excluded from the study. Following the initial audiological assessments, the UQUEST was administered to all participants. Three experiments were performed on three cohorts of children selected from the pool of 1094 children. Experiment 1 aimed to assess whether the UQUEST is a feasible speech perception assessment tool for school children and to establish normative data in a sample of normally hearing children. ix In this experiment, participants were a total of 99 children (55 boys / 44 girls), attending Grade 3 and grade 4 (41/58, mean age = 8.3 yr, range = 7 – 10 yr, SD = 0.7). The results showed that the UQUEST is a feasible test of speech understanding in children aged 7 to 10 years. In general, the UQUEST scores decreased as the signal-to-noise-ratio (SNR) decreased from 10 to 0 dB. Normative data based on the scores of six passages of equal difficulty were established for the 0 dB and 5 dB SNR conditions. In addition, the children appeared to be captivated with the UQUEST task and the attention of all the children was sustained throughout the duration of the test. Experiment 2 determined whether children with histories of otitis media (experimental group) performed worse on the UQUEST in comparison to those children without histories of otitis media (OM). A total of 484 children (246 boys / 238 girls), attending Grade 3 (272, mean age = 8.25 yr, SD = 0.43) and Grade 4 (212, mean age = 9.28 yr, SD = 0.41), were assessed. Children were grouped according to the number of episodes of otitis media as per parental report (control: < 4 episodes; mild history group: 4-9 episodes; and moderate history group: > 9 episodes OM). All children had normal hearing as determined by otoscopy, pure tone audiometry screening and tympanometry results. Results showed no significant difference in UQUEST scores between the control group in comparison to the experimental groups. However, children with a history of OM demonstrated varying speech comprehension abilities. Some children had severe difficulty with the speech comprehension task, suggesting that in cases with extensively reported episodes of OM, performance on the UQUEST was compromised. Experiment 3 determined the prevalence of conductive hearing loss in the Australian primary school population and investigated the ability of school children with minimal conductive hearing loss to understand everyday speech under noisy conditions. Based on a sample of 1071 children (mean age = 7.7 yr; range = 5.3 - 11.7 yr), 10.2% of children were found to have conductive hearing loss in one or both ears. To evaluate the binaural speech comprehension ability of children, a sample of 542 children were divided into four groups according to their audiological assessment results: Group 1: 63 children (34 boys, 29 girls, mean age = 7.7 yr, SD = 1.5) who failed the pure tone audiometry and tympanometry tests in both ears; Group 2: 38 children (17 x boys, 21 girls, mean age = 7.5 yr, SD = 1.2) who passed pure tone audiometry and tympanometry in one ear but failed both tests in the other ear; Group 3 (control group): 357 children (187 boys, 170 girls, mean age = 7.8 yr, SD = 1.3) who passed pure tone audiometry and tympanometry in both ears; Group 4: 84 children (41 boys, 43 girls, mean age = 7.2 yr, SD = 1.3) who passed pure tone audiometry in both ears, but failed tympanometry in one or both ears. The results showed that Group 1 had the lowest mean scores of 60.8% - 69.3% obtained under noise conditions. Their scores were significantly lower than the corresponding scores of 69.3% - 75.3% obtained by children in Group 4; 70.5% - 76.5% obtained by children with unilateral conductive hearing loss (Group 2); and 72.0% - 80.3% obtained by their normally hearing peers (Group 3). This study confirmed that young children, who are known to have poorer speech understanding in noise than adults, show further disadvantage when a bilateral conductive hearing loss is present In summary, the UQUEST has been found to be a useful tool to measure children‟s understanding of everyday speech. This test could be successfully used as a measure of speech comprehension in background noise in children. The UQUEST met expectations of being an interesting and engaging test for children aged 5-10 years. In addition, the UQUEST scores showed that children performed worse when challenged by the more difficult noise conditions incorporated in the test design. The findings from this thesis demonstrated that, at the group level, children with histories of OM did not perform any differently from those without significant histories of OM. However, at the individual level, children with significant OM histories had degraded functional performance with low UQUEST scores. Lastly, this thesis provided much needed speech comprehension data obtained from children with minimal conductive hearing impairment and provided evidence that young children were more affected by the co-occurrence of environmental noise and bilateral conductive hearing loss than their normally hearing peers in understanding everyday speech.

<p>Acute otitis media (AOM) is a common disease in childhood and is one of the most common causes for outpatient antibiotic treatment. The major aetiological agents of AOM have varied over the decades. Now the three most common pathogens are <i>Streptococcus pneumoniae</i>, <i>Haemophilus influenzae</i> and <i>Moraxella catarrhalis</i>. The resistance patterns of these organisms have also varied from the beginning of the antibiotic era to the situation we have today with an increasing incidence of penicillin-resistant <i>S. pneumoniae</i> and a moderate to high frequency of beta-lactamase production in <i>H. influenzae</i> and <i>M. catarrhalis</i>. In Sweden we have continued to use the Scandinavian treatment policy of penicillins as the first-line antibiotic treatment of AOM, which has been implemented with good results in the past. The question is if this policy will continue to have acceptable treatment results.</p><p>In order to investigate aspects of treatment, protection and structural changes in AOM, an animal model was used.</p><p>Amoxicillin treatment of AOM caused by <i>H. influenzae</i> was studied. Amoxicillin treatment was shown to shorten the duration of the infection and to reduce the morphological changes normally observed after an untreated AOM. The influence of antibiotic treatment on recurrent AOM was evaluated. Amoxicillin treatment did not lead to less protection against reinfection. Abstaining from antibiotics did not improve the levels of serum IgG antibodies. The IgG levels were significantly higher in treated animals after rechallenge. AOM caused by <i>H</i>. <i>influenzae</i> with a non-beta-lactamase-mediated resistance to beta-lactams was investigated and it was observed that during amoxicillin treatment the chromosomal changes mediating resistance were possibly advantageous for the bacterium. In cultures from children with AOM, there is sometimes growth of several bacteria. The possibility of a sheltering effect of beta-lactamase-producing <i>H. influenzae</i> on a penicillin-sensitive <i>S. pneumoniae</i> in a mixed infection was investigated, and amoxicillin was shown to eradicate the pneumococci from the middle ear despite the presence of beta-lactamase. An increasingly cultured bacterium in nasopharynx and in AOM is <i>M. catarrhalis</i>. It is now beta-lactamase-producing in almost 100% of cases and is thus not eradicated by penicillins. An animal model of AOM caused by beta-lactamase-producing <i>M. catarrhalis</i> was established to study the course of this infection with the possibility of evaluating aspects of virulence between AOM pathogens. The AOM observed was a self-limiting disease.</p><p>The results obtained in this study in a rat model support the continuing use of penicillins as first-line drugs in the treatment of AOM. Penicillins are not sufficient to treat all causative agents, but the majority of pathogens including the most virulent bacteria are eradicated from the middle ear. </p>

<p>Otitis media with effusion (OME) is the major form of chronic relapsing inflammatory disease of the middle ear, constitutes the most common diagnosis for children under 15 years old and is the major cause of auditory dysfunction in pre-school children. OME is a disease more commonly found in allergic children. These studies sought to investigate the inflammatory response in the middle ear of patients and test the hypothesis that an allergic-like response might occur in the ear. Atopy was diagnosed by standard in vitro tests. Immunochemical techniques used to study classic allergic rhinitis and asthma were extrapolated to the evaluation of OME children whose effusion persisted beyond 2 months. Not only eosinophil cationic protein (ECP), tryptase, CD3-positive and IL-5 producing cells, but also myeloperoxidase (MPO) was found in middle ear fluid and/or mucosa in the majority of patients with OME and atopy. </p><p>Initially, levels of ECP, MPO, and tryptase were measured in effusions from 97 random OME patients whose atopic status was determined by in vitro testing to 12 inhalants and 5 foods. The response of eosinophils, neutrophils and mast cells in the middle ear was distinctly different between atopic and non-atopic patients (p<0.001) with higher levels of the cell markers in the atopic group of patients. This suggested that 1) perhaps OME was predominantly a disease of atopics and that 2) they differed in their response from non-atopics.</p><p>Tryptase was measured in middle ear effusions from 38 patients with OME, 94.7% of whom were atopic by in vitro testing. Tryptase was elevated only in the effusion of atopic patients as compared to 5 controls (p<0.01). Biopsies stained histochemically for tryptase showed evidence of mast cells in the mucosa and submucosa from 6 of 8 OME ears but absent in 4 normals.</p><p>Middle ear biopsies, embedded in a plastic resin to improve the structural preservation, from 5 patients with OME and 5 normals were evaluated for the presence of eosinophils and neutrophils with monoclonal antibodies against 4 specific granule proteins. Eosinophils and neutrophils were present in the mucosa and mucus in significantly higher numbers than in the control group.</p><p>In an effort to determine whether the middle ear itself might be involved in allergic disease, evidence that some of the cells, mediators and cytokines associated specifically with a Th-2 response were sought for in the middle ear mucosa of these children. Middle ear biopsies from 7 atopic patients with OME and 4 controls demonstrated the presence of activated eosinophils, CD-3+ T cells and IL-5 mRNA cells only in the mucosa from atopic OME children. </p><p>Conclusion: Effusion and mucosal biopsies containing ECP, tryptase, and/or IL-5 mRNA cells, CD3+ T cells, eosinophils, and mast cells indicate that many of the mediators and cells essential to the production of a Th-2 immune mediated response are present in ears with chronic effusion. The increased levels of MPO in atopic patients further suggest that the general inflammatory response to putative inciting agents such as bacterial and viral products may be altered in atopy. These studies support the hypothesis that the exaggerated inflammation within the middle ear associated with most cases of OME is possibly the result of an atopic response within the middle ear itself.</p>

Otitis media with effusion (OME) is the major form of chronic relapsing inflammatory disease of the middle ear, constitutes the most common diagnosis for children under 15 years old and is the major cause of auditory dysfunction in pre-school children. OME is a disease more commonly found in allergic children. These studies sought to investigate the inflammatory response in the middle ear of patients and test the hypothesis that an allergic-like response might occur in the ear. Atopy was diagnosed by standard in vitro tests. Immunochemical techniques used to study classic allergic rhinitis and asthma were extrapolated to the evaluation of OME children whose effusion persisted beyond 2 months. Not only eosinophil cationic protein (ECP), tryptase, CD3-positive and IL-5 producing cells, but also myeloperoxidase (MPO) was found in middle ear fluid and/or mucosa in the majority of patients with OME and atopy. Initially, levels of ECP, MPO, and tryptase were measured in effusions from 97 random OME patients whose atopic status was determined by in vitro testing to 12 inhalants and 5 foods. The response of eosinophils, neutrophils and mast cells in the middle ear was distinctly different between atopic and non-atopic patients (p&lt;0.001) with higher levels of the cell markers in the atopic group of patients. This suggested that 1) perhaps OME was predominantly a disease of atopics and that 2) they differed in their response from non-atopics. Tryptase was measured in middle ear effusions from 38 patients with OME, 94.7% of whom were atopic by in vitro testing. Tryptase was elevated only in the effusion of atopic patients as compared to 5 controls (p&lt;0.01). Biopsies stained histochemically for tryptase showed evidence of mast cells in the mucosa and submucosa from 6 of 8 OME ears but absent in 4 normals. Middle ear biopsies, embedded in a plastic resin to improve the structural preservation, from 5 patients with OME and 5 normals were evaluated for the presence of eosinophils and neutrophils with monoclonal antibodies against 4 specific granule proteins. Eosinophils and neutrophils were present in the mucosa and mucus in significantly higher numbers than in the control group. In an effort to determine whether the middle ear itself might be involved in allergic disease, evidence that some of the cells, mediators and cytokines associated specifically with a Th-2 response were sought for in the middle ear mucosa of these children. Middle ear biopsies from 7 atopic patients with OME and 4 controls demonstrated the presence of activated eosinophils, CD-3+ T cells and IL-5 mRNA cells only in the mucosa from atopic OME children. Conclusion: Effusion and mucosal biopsies containing ECP, tryptase, and/or IL-5 mRNA cells, CD3+ T cells, eosinophils, and mast cells indicate that many of the mediators and cells essential to the production of a Th-2 immune mediated response are present in ears with chronic effusion. The increased levels of MPO in atopic patients further suggest that the general inflammatory response to putative inciting agents such as bacterial and viral products may be altered in atopy. These studies support the hypothesis that the exaggerated inflammation within the middle ear associated with most cases of OME is possibly the result of an atopic response within the middle ear itself.

Plasmin has been suggested to be involved in degradation of extracellular matrix (ECM) and tissue remodeling during a number of physiological and pathological processes. The aims of this thesis were to study the functional roles of plasmin during pathological inflammation in autoimmune and nonautoimmune disease models of rheumatoid arthritis (RA), multiple sclerosis (MS), wound healing and infection. In order to explain the obtained results in our functional studies as well as some previous results on the functional roles of plasmin during different tissue remodeling processes, I propose that there is a functional correlation between absence of plasmin and an inability to activate complement. The role of plasminogen during autoimmune collagen type II-induced arthritis (CIA) was studied first. The data revealed that whereas 83% of wild-type (plg+/+) mice developed CIA, none of the plasminogendeficient (plg-/-) mice got arthritis within a 40-day period. When plg+/+ mice were injected with a mixture of monoclonal antibodies against collagen type II they developed arthritis within a 5-day period, whereas no arthritis could be seen in plg-/- mice, although these mice had normal binding of antibody to the cartilage surface. These data suggest that plasmin plays an essential role in the step between antibody binding and inflammatory cell infiltration during CIA, probably during the step of complement activation. When plg+/+ and plg-/- mice were injected intra-articularly with collagen type II or 0.9% NaCl following CIA induction, plg-/- mice developed typical CIA, but the disease was less severe than in the plg+/+ mice and restricted to the injected joints. Sustained tissue necrosis was found only in the plg-/- mice after the local injection. When the antigen-induced arthritis (AIA) model was used, plg-/- mice developed a much more severe arthritis than the plg+/+ mice. These results indicate that different forms of pathogenesis exist for CIA and AIA, and further emphasize the importance of trauma in the induction of CIA in plg-/- mice. We further investigated the role of plasmin in experimental autoimmune encephalomyelitis (EAE), which is an autoimmune disease model for MS. During a 2-month period, the severity, incidence, mean onset day, mean maximal score and mean accumulative score of EAE were essentially identical in plg-/- and plg+/+ mice of B10.Q background. Histopathological studies revealed similar levels of inflammation and demyelination in plg-/- and plg+/+ mice. These data indicate that plasmin does not play an essential role in the development of EAE. The findings that plasmin is essential for the development of CIA but not needed for the development of EAE suggest that plasmin may play a pivotal role in autoimmune diseases where complement activation is critically involved in the pathogenesis. The role of plasmin was also studied in a tympanic membrane (TM) wound healing model. After TM perforations were performed, the plg+/+ TMs had all healed by day 11, whereas TM healing was completely arrested in plg-/- mice even as late as day 143. Immunohistochemical studies revealed a disturbed inflammation and tissue remodeling pattern in plg-/- mice. These data indicate that plasmin plays a central role in the healing of TM perforations. The involvement of plasminogen in ear infections was also investigated in plg-/- mice. During an 18-week experimental period, spontaneous otitis media (OM) was essentially developed in all of the plg-/- mice, whereas all of the plg+/+ mice kept a normal TM status. Positive bacterial growth was found in 5 out of 6 plg-/- mice, but only in 1 out of 6 plg+/+ mice. Immunohistochemical studies showed an accumulation of inflammatory cells, fibrin and also other extracellular matrix in the middle-ear cavity and the external-ear canal of plg-/- mice. These results show a spontaneous development of OM in plg-/- mice, but not in plg+/+ controls, suggesting that plasmin plays a critical role in the defense mechanisms during ear infections. Taken together, plasmin appears to play essential roles during autoimmune and non-autoimmune diseases in which complement activation is critical in the pathogenesis.

Acute otitis media (AOM) is a common disease in childhood and is one of the most common causes for outpatient antibiotic treatment. The major aetiological agents of AOM have varied over the decades. Now the three most common pathogens are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. The resistance patterns of these organisms have also varied from the beginning of the antibiotic era to the situation we have today with an increasing incidence of penicillin-resistant S. pneumoniae and a moderate to high frequency of beta-lactamase production in H. influenzae and M. catarrhalis. In Sweden we have continued to use the Scandinavian treatment policy of penicillins as the first-line antibiotic treatment of AOM, which has been implemented with good results in the past. The question is if this policy will continue to have acceptable treatment results. In order to investigate aspects of treatment, protection and structural changes in AOM, an animal model was used. Amoxicillin treatment of AOM caused by H. influenzae was studied. Amoxicillin treatment was shown to shorten the duration of the infection and to reduce the morphological changes normally observed after an untreated AOM. The influence of antibiotic treatment on recurrent AOM was evaluated. Amoxicillin treatment did not lead to less protection against reinfection. Abstaining from antibiotics did not improve the levels of serum IgG antibodies. The IgG levels were significantly higher in treated animals after rechallenge. AOM caused by H. influenzae with a non-beta-lactamase-mediated resistance to beta-lactams was investigated and it was observed that during amoxicillin treatment the chromosomal changes mediating resistance were possibly advantageous for the bacterium. In cultures from children with AOM, there is sometimes growth of several bacteria. The possibility of a sheltering effect of beta-lactamase-producing H. influenzae on a penicillin-sensitive S. pneumoniae in a mixed infection was investigated, and amoxicillin was shown to eradicate the pneumococci from the middle ear despite the presence of beta-lactamase. An increasingly cultured bacterium in nasopharynx and in AOM is M. catarrhalis. It is now beta-lactamase-producing in almost 100% of cases and is thus not eradicated by penicillins. An animal model of AOM caused by beta-lactamase-producing M. catarrhalis was established to study the course of this infection with the possibility of evaluating aspects of virulence between AOM pathogens. The AOM observed was a self-limiting disease. The results obtained in this study in a rat model support the continuing use of penicillins as first-line drugs in the treatment of AOM. Penicillins are not sufficient to treat all causative agents, but the majority of pathogens including the most virulent bacteria are eradicated from the middle ear.

Introduktion: Sekretorisk media otit (SOM) är den vanligaste öronsjukdomen och uppkommer oftast i efterförloppet till akut media otit (AOM). Om barnet får SOM leder det till hörselnedsättning som kan påverka språklig utveckling och ge beteendeproblem. Etiologin bakom SOM anses vara multifaktoriell. Barnets tryck i mellanörat kan påverkas vid flaskmatning. Allergier, bakteriella/virus infektioner och inflammationer har också betydelse för utvecklandet av SOM. Syfte: att studera frekvensen av att använda nappflaska och liggande position vid flaskmatning relaterat till sekretorisk media otit och akut media otit i samband med rörbehandling. Metod: En deskriptiv tvärsnittsstudie med kvantitativ ansats. Datainsamling skedde via enkäter som besvarades av närstående till barn 2- 5 år som genomgått rörinsättning på öronoperation. Resultat: 103 barn med närstående deltog i studien. 87% av barnen som genomgick rörinsättning använde eller hade använt nappflaska och av dessa barn låg 55% i planläge. Hereditet gällande SOM kunde skönjas. Konklusion: Studien visade hög frekvens av flaskmatning där lite mer än hälften, 55% låg i planläge men studiens begränsning kunde inte åskådligöra samband med planläge och SOM. Det är av vikt att belysa faktorer som har betydelse för utveckling av SOM för att minska behov av rörbehandling. Dessa faktorer kan sjuksköterskan informera närstående om via hälsoundervisning för att öka barn och närståendes empowerment. / Introduction: Otitis Media with Effusion (OME) is the most common ear disease and arises mostly in the end of akut media otit (AOM). If a child contracts OME, it will result in a hearing loss which can affect the verbal development and may lead to behavior difficulties. The etiology behind OME is considered to be multifactorial. A child’s middle ear pressure may be affected by bottle nursing. Furthermore, the development of OME may be caused by allergies, bacterial/virus infections and inflammations. Purpose: To study the frequency of using a feeding bottle while the child is lying down related to OME and AOM when tube insertion. Method: A descriptive cross-sectional study with a quantitative approach. A survey data collection was used wherein the people who were surveyed were close family to two to five year old children, who have had ear tubes inserted. Result: 103 children with their close family participated in the study. 90% of these children who went through an ear tube insertion used or had used a feeding bottle and 50% of them lied down as they were fed. The heredity regarding SOM could be picked out. Conclusion: The study showed a high frequency of bottle nursing where just over the half (55%) lied down, but the restriction of the study could however not visualize the relation between lying down and SOM. Moreover, it is important to bring up the factors that are significant for the development of SOM to decrease the need of ear tube treatment/insertion. The nurse can inform close family about these factors through health education in order to increase children and close family´s empowerment.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 5 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2010.