An infant who has clinical manifestation of acute otitis media is brought to the emergency room by their parent. The nurse recognizes which of the following factors places the child at increased risk for otitis media? (Select the 3 that apply)

Rationale: A. Exclusive breastfeeding: Exclusive breastfeeding is actually protective against otitis media because it provides antibodies that help prevent infections, reducing the risk rather than increasing it. B. Recent upper respiratory infection: Upper respiratory infections can cause inflammation and blockage of the eustachian tubes, which increases the risk for fluid buildup and subsequent middle ear infections like otitis media. C. Immature sinuses and eustachian tube anatomy: Infants have shorter, more horizontal eustachian tubes that drain poorly, making them more prone to infections like otitis media due to fluid accumulation and bacterial growth. D. Limited vaccination: Incomplete immunization, especially against pathogens like Streptococcus pneumoniae and Haemophilus influenzae, increases susceptibility to infections including otitis media. E. Smoke-free household: A smoke-free environment reduces the risk of respiratory infections and otitis media; exposure to secondhand smoke increases the risk of ear infections in children.