PEDIATRICIAN Spring 2003 - AAP-CA

Preventing Ear Infections in Children
Harry Pellman, M.D.
Acute Otitis Media (AOM) is the
most common bacterial infection
diagnosed in children and the most
common reason antibiotics are prescribed in
this age group. Despite these facts, there is still
quite a bit of controversy on how to best make
the diagnosis of AOM and a good strategy for
treating these infections. The American Academy
of Pediatrics is intently working on new
guidelines for the diagnosis and treatment of
acute otitis media (AOM) in children.
There are a variety of strategies known to
reduce the frequency of middle ear problems.
Implementing as many of these strategies as
possible may be like closing the barn door
before the cows get out.
Breast feeding has been clearly shown to
reduce both the incidence of AOM and
otitis media with effusion (OME) in
multiple studies. The protective effect is
related to the duration and exclusivity of
breast feeding and is most prevalent in
infancy.
Avoid environmental tobacco poisoning
(aka cigarette smoking). This type of air
pollution is clearly related to more AOM
and OME.
When bottle feeding, use fully vented bottles.
Fully vented bottles allow air inflow
as the milk exits the bottle and prevents
negative middle ear pressure. Negative
pressure in the middle ear promotes the
entrance of nasopharyngeal contents into
the middle ear chamber. Children using
fully vented bottles have middle ear pressures
that appear to be similar to infants
breast feeding.
Use of pacifiers beyond 18-24 months of age
has been associated with more middle ear
disease. The reason for this association is
not clear. Whether this occurs because
of abnormal pressures generated in the
middle ear, more viral infections associated
with pacifier use, or another mechanism
is unknown.
There are a variety of strategies known to reduce the frequency
of middle ear problems. Implementing as many of these
strategies as possible may be like closing the barn door before
the cows get out.
There is a suggestion that babies that have gastroesophageal
reflux disease (GERD)
have a higher incidence of middle ear
disease. In one study, middle ear fluid
obtained from children having myringotomy
and tube insertion revealed pepsin
and pepsinogen levels 1000 times higher
than serum levels in more than 80% of
children. Ongoing investigations will help
clarify this issue.
Daycare is associated with both an increased
incidence of middle ear disease and the
presence of more resistant bacteria when
infections occur. Of course, daycare
is essential for many working parents.
Training daycare workers to wash hands
frequently and employ hygienic measures
is a Herculean task.
Vaccines will have a dramatic impact on
AOM. Prevnar vaccine provides significant
protection against the seven strains of
streptococcus pneumonia (in the past, the
most common bacteria isolated in AOM)
in the vaccine plus five cross-reacting
strains. The vaccine has only reduced the
overall incidence of AOM about 5-10%.
However, the serotypes of streptococcus
pneumonia present in the vaccine are both
some of the most common bacteria present
in AOM and the most resistant and
difficult to treat bacteria we encounter.
This vaccine has reduced the necessity
for ear tubes about 20%, the frequency
of having multiple episodes of AOM in
an infection-prone child up to 20%, and
changed the bacteriology of AOM so that
non-typable hemophilus influenza bacteria
is now the most common bacteria isolated
in AOM in children vaccinated with
prevnar. Work is presently being done
on a nine-valent pneumococcal vaccine
and a non-typable hemophilus influenza
vaccine. Their impact on reducing AOM
remains to be seen.
Since most episodes of AOM follow viral
respiratory illnesses, it appears that
reducing these illnesses will lessen the
frequency of AOM. Influenza vaccine,
especially the newly released coldadapted
live influenza vaccine, has been
shown to effectively lessen the incidence
of AOM. If a safe, effective RSV vaccine
is ever approved by the FDA, we should
expect a further reduction in AOM episodes.
Xylitol is a natural, non-absorbable sugar most
commonly harvested from birch trees.
Xylitol chewing gum has been used in
Finland for many years to reduce the
incidence of dental caries, an infectious
disease caused by strep mutans. Children
on long term xylitol chewing gum were
found to have as much as 40% fewer
episodes of AOM. However, if used only
during a high risk period, such as a viral
respiratory infection, xylitol may not be
protective. The usefulness of xylitol in
other forms (syrup, lozenges, etc.) is still
being investigated.
There is a suggestion that iron deficiency
anemia may be associated with an
increased risk of AOM.
It sounds like the ideal situation for maximum
middle ear health is an infant exclusively
breast fed for at least six months, living in a
healthful environment without daycare, no
pacifiers, bottles (if used) should be fully
vented, kept on an iron rich diet, fully vaccinated,
properly positioned to lessen GERD,
and chewing xylitol chewing gum when old
enough to do so.
If employing the above strategies fails to
reduce the incidence of ear infections, since
frequent AOM seems to have some kind of
genetic link, the child should consider choosing
different parents!
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 9