The purpose of this study was to examine the effects of otitis media (OM) and the quality of child care on the social and communicative behaviors of toddlers, using a cumulative risk framework that included moderation. The study followed 72 children who began child care in infancy. Both process and structural aspects of the quality of 11 child care centers were measured and children received weekly ear examinations from the time they entered child care. At 24 months of age children were observed in their classrooms during free play when they were well. Children in the chronic OM, low quality care group exchanged more negative gestures with peers, initiated less verbally to teachers and peers and were talked to less by teachers and peers in comparison to all other children. The results suggest the importance of the moderating effect of the quality of child care in understanding the effects of OM on social/communicative development.