Daycare Attendance, Adenoidectomy, and Tympanostomy
Abstract & Commentary
Synopsis: A 300% increase in daycare attendance as a result of legislation in Finland was followed by an increase in the rates of adenoidectomies and tympanostomies.
Source: Niemela M, et al. Changes in day care attendance rates and in the occurrence of adenoidectomies and tympanostomies. Acta Paediatr 1998;87:1003-1004.
Daycare attendance is a main risk factor for middle ear disease in young children. In 1990, a law was implemented in Finland to make daycare available for all children younger than 3 years of age. Niemela and colleagues, academic otolaryngologists and pediatricians, studied the number of adenoidectomies and tympanostomies performed in two towns, Oulu and Tempere, immediately before and after the daycare requirement was implemented. The numbers of adenoidectomies and tympanostomies between 1983 and 1993 were collected from computerized data bases at hospitals and manually from operating theater records in smaller private centers. The numbers of children attending daycare centers were ascertained from municipal statistics.
The rate of adenoidectomy in children increased in the two towns from 18.9% to 31.5%—an overall 67% increase. There were significant differences between the two towns. In Oulu, the increase was 17% (856 to 1003). In Tampere, the rate increased 90% (333 to 634). There was also an increased rate of tympanostomy tube placement from 9% to 14.3%. Again, there was a difference between the two towns: an increase in Oulu by 30%, but no change in Tampere.
Comment by David E. Karas, MD
The findings of this study are important and reinforce an association between daycare attendance and an increased risk for acute otitis media, chronic otitis media with effusion, and nasal obstruction. These diseases of the middle ear may require surgical treatments such as adenoidectomy and tympanocentesis with tube placement. Niemela et al point out that the rate of surgery is affected by several factors, including the clinical judgment and indications of the care givers. It is possible that there may have been other changes during the periods of the study, which could have affected these changes in practice; however, such changes are unlikely to have taken place as abruptly as the changes in daycare attendance. During the short interval between 1989 and 1990, there was an acute, 300% increase in daycare attendance!
Niemela et al also report corroborative data obtained from a survey of a multistage, random cluster national sampling involving 2052 families of second-grade children. This national questionnaire was returned by 94.3% of parents—most of whom gave information about adenoidectomy and daycare attendance. Attendance at a daycare center during the first three years of life increased the rate of adenoidectomy by 18% compared to children who had not attended daycare.
Niemela et al report what seems to me an extremely high rate of adenoidectomy—19% and 31% of their population underwent adenoidectomy. This is an incredibly high number and is about double the number of tympanostomy compared to tube placements. As a pediatric otolaryngologist, I find that I place many more tympanostomy tubes than I perform isolated adenoidectomies. Another issue is the local indications for surgery. The differences between the two towns suggest considerably different indications. In Oulu, there was only a 17% increase in adenoidectomies, where in Tampere there was a 90% increase. On the other hand, Oulu had an increase in tympanosomies while Tampere did not.
Despite some shortcomings, this is a valuable paper that corroborates previous reports of a positive correlation between middle ear disease and subsequent otolaryngological surgery and daycare attendance. These consequences should be taken into account by parents and governmental bodies when they consider making both individual and policy decisions concerning daycare. (Dr. Karas is Head of Pediatric Otolaryngology at Yale University School of Medicine, New Haven, CT.)
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