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• There is relatively higher bacterial colonisation in Indigenous infants, which isstrongly correlated with the onset of middle ear effusion (this tended to occurwithin the first 12 weeks of life in 66 per cent of Indigenous infants). Nocorrelation is found between colonisation and the onset of otitis media innon-Indigenous infants. Further, once established, it is significantly less likelyfor an Indigenous infant compared with a non-Indigenous infant to clear thebacterial pathogens (Morris et al. 2006). The early bacterial colonisation inIndigenous infants might be linked to the fact that Indigenous communities aremore exposed to factors such as a greater number of siblings in an overcrowdedhousehold, which increases the risk factors for bacterial colonisation and acuteotitis media.• Some studies have found a link between the early first onset of otitis media andthe increased risk of recurrent infections (that is, ‘early and often appears to bethe rule’). Indigenous infants tend to have persistent acute otitis media and otherear infections that are rarely resolved (Boswell and Nienhuys 1996;Morris et al. 2006).• The incidence of acute otitis media in other family members may significantlyincrease the risk of ear infection, especially in children.• Although few studies have evaluated this relationship, malnutrition inIndigenous children might be associated with the development of chronic otitismedia (Jones and Smith 2006).• High rates of smoking within the Indigenous population might contribute to theprevalence of otitis media among Indigenous children (see section 8.2 for moreinformation on tobacco use).Box 5.4.3 provides examples of programs that have improved health outcomes forIndigenous children.5.28 OVERCOMINGINDIGENOUSDISADVANTAGE 2007