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Acute otitis media in children: Prevention of recurrence

Authors
Jerome
O
Klein,
MD
Stephen Pelton, MD
Section
Editors
Sheldon
L
Kaplan,
MD
Glenn C Isaacson, MD, FAAP
Deputy
Editor
Mary M Torchia, MD
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jan 2015. | This topic last updated: Dec 11, 2014.
INTRODUCTION Prevention is an important part of the management strategy for the child with
severe and recurrent acute otitis media (AOM) and the child who is at risk for severe and recurrent
AOM.
The prevention of AOM will be reviewed here. Other topics related to otitis media are presented
separately:
(See "Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and
complications" and "Acute otitis media in children: Diagnosis" and "Acute otitis media in
children: Treatment".)
(See "Otitis media with effusion (serous otitis media) in children: Clinical features and
diagnosis" and "Otitis media with effusion (serous otitis media) in children: Management".)
(See "External otitis: Pathogenesis, clinical features, and diagnosis" and "External otitis:
Treatment".)
(See "Malignant (necrotizing) external otitis".)
DEFINITIONS Recurrent acute otitis media (AOM) is usually defined as 3 distinct and welldocumented episodes of AOM within six months or 4 episodes within 12 months [1-3]. Infants who
have their first episode before six months of age or who have siblings with severe and recurrent
AOM are at highest risk for severe and recurrent AOM. It remains unresolved as to whether early
disease damages the Eustachian tube or middle ear leading to recurrent disease or selects those
with anatomic or genetic predisposition to recurrent disease or both.
PREVALENCE In a cohort of 698 children followed from shortly after birth until age three years,
17 percent had 3 episodes of acute otitis media (AOM) by one year of age and 46 percent had 3
episodes by three years [4]. These data precede the introduction of pneumococcal conjugate
vaccine. A 2014 report supports a decline in recurrent OM episodes and in tympanostomy tube
insertions in children <2 years of age following introduction of PCV13 [5].
OVERVIEW OF APPROACH

Interventions Specific interventions that may be used in the prevention of recurrent acute otitis
media (AOM) include [6-9]:
Identification and treatment of underlying predisposing conditions (eg, exposure to tobacco
smoke)
Parental education
Breast feeding
Administration of influenza virus and/or pneumococcal conjugate vaccines
Antibiotic prophylaxis
Surgery (myringotomy and placement of tympanostomy tubes)
These interventions, discussed below, are typically approached in a stepwise fashion, beginning
with identification of underlying conditions, parental education and vaccine administration, and then,
if indicated, chemoprophylaxisand/or surgery [6,7].
Factors influencing choice Decisions regarding strategies for prevention of recurrent AOM are
made on a case-by-case basis. Factors to be considered in the decision include [10]:
Age of the child Children younger than two years appear to receive the most benefit from
antibiotic prophylaxis.
Age at first episode Infants who have their first episode of AOM before six months of age
are at risk for severe and recurrent AOM.
Time of year The child who has already had several episodes of AOM by late fall (ie,
November in the northern hemisphere) is likely to have many more before the end of the
winter, whereas the child who has recurrent episodes by late spring (ie, May in the northern
hemisphere) could have fewer additional infections during the late spring and summer.
Attendance in large-group day care Children in this setting are likely to have more
respiratory infections, some of which will be accompanied by AOM.
Family history The risk of AOM is increased in children whose other family members have
AOM.
The developmental status of the child, particularly language development. Children with
permanent hearing loss, suspected or confirmed speech or language delay or disorder,
developmental delay, autism spectrum disorder, blindness or uncorrectable visual impairment,
are at increased risk for speech, language, or learning problems [11].
Underlying medical conditions that predispose to AOM (eg, cleft palate, immotile cilia
syndrome, IgG deficiency, Down syndrome).
The effects of recurrent AOM on the quality of life for the child and family.
Choice of intervention(s) When all factors are considered, the balance of risks and benefits will
favor less aggressive interventions for some children and more aggressive interventions for others.
Less aggressive interventions (including no intervention) may be warranted for children older than
two years because the incidence of AOM declines after the second year of life. Children between
two and seven years with immature or defective immune function or persistent Eustachian tube
dysfunction may remain at increased risk for AOM after the second year of life. Less aggressive
interventions include treatment of predisposing conditions, education, and provision of

pneumococcal and influenza vaccines. (See 'Treatment of predisposing conditions' below

and 'Education' below and 'Vaccines' below.)
We suggest more aggressive interventions (eg, antibiotic prophylaxis or tympanostomy tube
placement) for children with recurrent otitis media and one or more of the following:
Age <2 years (when optimal hearing is necessary for acquisition of language skills)
Multiple risk factors, especially if the risk factor cannot be modified (eg, time of year, size of
day care) (see "Acute otitis media in children: Epidemiology, microbiology, clinical
manifestations, and complications", section on 'Risk factors')
Underlying medical conditions that predispose to recurrent AOM
Co-morbid conditions associated with developmental or language delays (the conductive
hearing loss associated with middle ear effusion may persist for weeks to months after the
acute signs of AOM have resolved and may add additional burden in children with existing
delays or deficits)
However, the ultimate decision about whether to use a more aggressive intervention and which
intervention to use is made on a case-by-case basis after discussion of the potential benefits and
risks with the caregivers.
The choice of antibiotic prophylaxis or tympanostomy tube placement is influenced by the level of
concern about antibiotic-resistant bacteria in the nasopharynx, language development, the risks of
surgery and anesthesia, and the values and preferences of the family. For children who have had
frequent breakthrough episodes of AOM while receiving antibiotic prophylaxis or who have multiple
drug allergies and continue to warrant more aggressive prevention strategies, we suggest
tympanostomy tube placement. (See 'Antibiotic prophylaxis' below and 'Tympanostomy
tubes' below.)
The 2013 American Academy of Pediatrics (AAP) and American Academy of Family Physicians
(AAFP) clinical practice guideline for the diagnosis and management of acute otitis media in
children 6 months through 12 years of age recommends that clinicians not prescribe prophylactic
antibiotics, but may offer tympanostomy tubes to prevent recurrent AOM [8]. The
2013 AAP/AAFP guideline does not apply to children with underlying conditions that may alter the
natural course of AOM (eg, anatomic abnormalities, genetic conditions with craniofacial
abnormalities, immune deficiencies, or cochlear implants), whereas this topic review does not make
such exclusions.
The 2013 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical
practice guideline on tympanostomy tubes in children recommends against tympanostomy tube
insertion for children with recurrent AOM unless they have unilateral or bilateral middle ear effusion
at the time of assessment for placement of tympanostomy tubes [11].
TREATMENT OF PREDISPOSING CONDITIONS The first step in the prevention of recurrent
acute otitis media (AOM) is identification, and treatment if warranted, of underlying conditions that
predispose
the
child
to
recurrent
AOM.
Such
conditions
include
immune
deficiencies and/or anatomic abnormalities.
Children who have had suppurative infections at multiple sites, including recurrent AOM, may have
immunologic deficiencies. The most commonly identified immune abnormality in children with

recurrent AOM is an IgG subclass deficiency. Children with recurrent AOM as their only
manifestation of recurrent infection rarely have severe immunologic abnormalities. However,
hypogammaglobulinemia, granulocyte defects, defective cell-mediated immunity, or HIV infection
may present with recurrent AOM as part of the spectrum of either increased infections or infections
that resolve more slowly than expected [12]. (See "Approach to the child with recurrent
infections" and "IgG subclass deficiency", section on 'Clinical manifestations' and "Primary humoral
immune deficiencies: An overview", section on 'Presentation of humoral immune deficiency'.)
Children with palatal clefts also are predisposed to the development of recurrent AOM. This
includes children with craniofacial abnormalities that are associated with submucous palatal clefts,
such as micrognathia and glossoptosis (seen in Robin sequence and similar syndromes).
(See "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx", section on 'Jaw
anomalies'.)
EDUCATION Educating parents about ways to decrease exposure to risk factors and increase
exposure to protective factors is an appropriate prevention strategy for all children with recurrent
acute otitis media (AOM) [8]. Although the effectiveness of parental education in preventing
recurrent AOM has not been proven, there is little risk of harm. The risk factors for AOM are
discussed in detail separately. (See "Acute otitis media in children: Epidemiology, microbiology,
clinical manifestations, and complications", section on 'Risk factors'.)
Specific risk/protective factors to be discussed include [1,7]:
Day care The fewer children in the day care group, the lower the exposure to respiratory
pathogens and risk for AOM.
Exposure to smoke Children exposed to cigarette smoke in the home have more episodes
of AOM than children in smoke-free homes; methods of home heating, such as wood or coal
burning stoves, also may be a risk factor. A suggested mechanism is increased colonization
with bacterial otopathogens leading to greater risk for development of bacterial OM following
viral respiratory tract infection. (See "Control of secondhand smoke exposure".)
Breastfeeding Breastfeeding for at least three months protects against AOM during the first
year of life. Although this knowledge may not prevent recurrent AOM in the index case, when
family history suggests an increased risk of recurrent AOM, breastfeeding may help prevent
recurrent AOM in subsequent children.
Pacifiers The use of pacifiers after six months of age increases the risk of recurrent AOM
[13].
VACCINES The routine administration of pneumococcal conjugate vaccine and influenza
vaccine during infancy provides only a modest reduction in the frequency of acute otitis media
(AOM), but appears to decrease the need for placement of tympanostomy tubes. These
observations are consistent with the hypothesis that prevention of early episodes has downstream
benefit in prevention of subsequent recurrences.
Pneumococcal conjugate vaccine We recommend that infants and children be immunized with
the 13-valent pneumococcal conjugate vaccine (PCV13) according to the routine childhood
immunization schedule at ages 2, 4, 6 and 12 months [8,14]. Although AOM is not specifically
identified as "an underlying medical condition" requiring the supplemental dose of PCV13 through
71 months of age, we also suggest PCV13 for children younger than six years who continue to

have recurrent episodes of AOM and have not previously received PCV13. The catch-up dose of
PCV13 should be administered as soon as possible (provided that at least 8 weeks have passed
since the last dose of PCV7). (See "Pneumococcal (Streptococcus pneumoniae) conjugate
vaccines in children", section on 'Supplemental dose'.)
In randomized trials, administration of the 7-valent pneumococcal conjugate vaccine (PCV7)
beginning at age two months was associated with a modest reduction in AOM (6 to 8 percent) [1517]. However, the efficacy of prevention of culture-confirmed pneumococcal AOM caused by a
vaccine serotype was 57 to 65 percent. In these and other randomized and observational studies,
receipt of PCV7 was associated with fewer medical visits for AOM and fewer tympanostomy tube
placements [15,16,18-23]. Several studies have noted an increase in AOM caused by
pneumococcal serotypes not included in the vaccine (ie, replacement serotypes) [15,24,25].
It is assumed that the additional serotypes (particularly serotype 19A) in PCV13 will provide
additional protection against AOM and recurrent AOM (table 1) [26]. Initial reports from Israel have
demonstrated declines in otitis media due to PCV13 vaccine serotypes and overall otitis media [27].
Continued monitoring is necessary to characterize the efficacy for prevention of vaccine serotype
AOM and monitor for replacement serotypes.
In countries where the pneumococcal conjugate vaccine is not part of the routine immunization
schedule, we suggest pneumococcal conjugate vaccine for infants and young children at high-risk
for recurrent AOM (ie, first episode of AOM at <6 months of age, older siblings with severe and
recurrent AOM). In a randomized trial, 96 infants with AOM onset at <6 months of age were
assigned to receive or not receive PCV7 [28]. Receipt of PCV7 was associated with a 26 percent
reduction in AOM, a 36 percent reduction in emergency visits for suspected AOM, and a 50 percent
reduction in placement of ventilation tubes.
Pneumococcal polysaccharide vaccine For children older than two years who continue to
have recurrent episodes of AOM, we suggest administration of the 23-valent pneumococcal
polysaccharide (PPSV23) after completion of immunization with PCV13 to provide coverage for as
broad a range of pneumococcal serotypes as possible (table 1). PPSV23 should be administered at
least 8 weeks after PCV13 [14].
A systematic review of randomized controlled trials evaluating pneumococcal vaccination for AOM
in children younger than 12 years found a moderate effect of pneumococcal polysaccharide
vaccine in the prevention of AOM in children older than 24 months who had documented AOM
before vaccination (relative risk 0.74, 95% CI 0.62 to 0.90) [29]. No overall reduction in AOM is
observed when immunization is initiated after the development of recurrent otitis media [29-32].
Influenza vaccine In the United States, annual influenza immunization is recommended for all
children 6 months [33]. In countries where universal influenza immunization of infants is not
routine, we suggest annual influenza vaccination for children who had recurrent episodes of AOM
during the preceding winter [34]. (See "Seasonal influenza in children: Prevention with vaccines",
section on 'Indications'.)
In a meta-analysis of randomized studies, the efficacy of influenza vaccination against AOM (of any
cause) in healthy children younger than 18 years was 51 percent (95% CI 21-70 percent) [35]. It is
not surprising that influenza vaccine has only a modest impact on AOM episodes, because infection
with other respiratory viruses, such as respiratory syncytial virus, parainfluenzae, and human

metapneumovirus, appear to have a much greater association with AOM. (See "Acute otitis media
in children: Epidemiology, microbiology, clinical manifestations, and complications", section on
'Viruses'.)
The inactivated influenza vaccine (IIV) may be given to children 6 to 24 months of age, whereas
either IIV or live attenuated influenza vaccine (LAIV) may be given to children 24 months. For
children 24 months with recurrent AOM, LAIV may be more beneficial than IIV [36-38]. In pooled
analysis of two randomized trials, the relative efficacy of LAIV versus IIV in preventing influenzaassociated AOM was 54 percent (95% CI 27-72 percent) [37]. (See"Seasonal influenza in children:
Prevention with vaccines", section on 'Choice of vaccine'.)
ANTIBIOTIC PROPHYLAXIS Prophylaxis with a modified dose of an antimicrobial agent can be
helpful in preventing recurrent acute otitis media (AOM) [39,40]. However, the protection afforded
by prophylaxis is not sustained after discontinuation [41].
Indications Antibiotic prophylaxis may be warranted for children who have had 3 distinct and
well-documented episodes within six months or 4 episodes within 12 months [3,42]. However,
decisions regarding the use of antibiotic prophylaxis should be made on a case-by-case basis. The
potential benefits (20 to 50 percent fewer episodes) must be balanced with the risk of development
of nasopharyngeal colonization with antibiotic-resistant organisms [40,43]. Additional factors that
influence the decision to use antibiotic prophylaxis are discussed above. (See 'Factors influencing
choice' above.)
Potential benefits In a meta-analysis, of 14 randomized trials (1461 children) comparing longterm antibiotics (>6 weeks) with placebo or no treatment for the prevention of acute and chronic
suppurative otitis media, antibiotic prophylaxis [40]:
Reduced the occurrence of any episode of AOM (37 versus 56 percent; pooled risk ratio
0.65, 95% CI 0.53-0.79); approximately five children would need to be treated to prevent one
child from experiencing AOM while on treatment.
Reduced the number of episodes of AOM while on antibiotics from 3 to 1.5 per year
(incidence rate ratio 0.51, 95% CI 0.39-0.66).
The protection afforded by prophylaxis does not persist after discontinuation of chemoprophylaxis.
Many children in whom antibiotic prophylaxis is discontinued will have recurrence of frequent AOM
[41].
The findings of the meta-analysis must be interpreted with caution because the studies that were
included had different entry criteria, used different drugs for different durations, and observed
patients for various lengths of time. Most were conducted before the era of widespread penicillinresistant pneumococci and the recommendation for routine immunization of infants with the
pneumococcal conjugate vaccine.
Antibiotic prophylaxis compared with tubes In the only trial comparing antibiotic prophylaxis
and tympanostomy tube placement that excluded children with otitis media with effusion (OME),
antibiotic prophylaxis was more effective [2]. In this trial, 264 children 7 to 35 months of age with
recurrent AOM (3 episodes within six months or 4 episodes within 12 months) were randomly
assigned to three groups: amoxicillin prophylaxis, myringotomy and tympanostomy tube placement,
or placebo, and followed for two years [2]. The average rate of new episodes of AOM was

decreased in the amoxicillin group compared with the tympanostomy and placebo groups (0.6,
1.02, and 1.08 new episodes of AOM or otorrhea per child per year, respectively).
Adverse effects Prolonged use of antibiotic prophylaxis for AOM may result in the selection of
resistant bacteria in the nasopharynx and subsequent respiratory tract infection with resistant
pathogens [40,43]. The treatment of AOM and other upper respiratory infections caused by
antibiotic-resistant organisms is discussed separately. (See "Acute otitis media in children:
Treatment", section on 'Initial antimicrobial therapy' and "Acute bacterial rhinosinusitis in children:
Microbiology and treatment", section on 'Empiric antibiotic therapy'.)
Additional risks of prolonged antibiotic use include allergic reactions and diarrhea, as well
as Clostridium difficile-associated diarrhea (on rare occasions). (See "Clostridium difficile infection
in children: Microbiology, pathogenesis, and epidemiology", section on 'Risk factors'.)
Antibiotic choice and regimen When the decision is made to use antibiotic prophylaxis, we
typically use amoxicillin 40 mg/kg orally once per day unless the child has a penicillin allergy
(see "Allergy to penicillins"). Sulfisoxazole 50 mg/kg orally once per day is an alternative.
Cephalosporins usually are not used for prophylaxis because they have a broader spectrum and
are more expensive.
Antibiotic prophylaxis should be provided during the fall, winter, and early spring months, when
respiratory infections are most prevalent, but for no longer than six months [42]. In a small
randomized trial, administration every day was more effective than administration only during upper
respiratory infections [44].
Breakthrough AOM Breakthrough episodes of AOM in the child who is currently
on amoxicillin prophylaxis increases the likelihood of a beta-lactamase producing nontypeable H.
influenzae or a penicillin-resistant pneumococcus. Our initial choice is amoxicillinclavulanate 90 mg/kg per day amoxicillin and 6.4 mg/kg per day of clavulanate in two divided
doses. Ceftriaxone 50 mg/kg intramuscularly once per day is an alternative. A single dose of
ceftriaxone may be sufficient, but often a two- or three- dose regimen is necessary [45,46].
(See "Acute otitis media in children: Treatment", section on 'Initial antimicrobial therapy'.)
Follow-up During chemoprophylaxis, children should be examined whenever they have signs or
symptoms of AOM. (See "Acute otitis media in children: Diagnosis", section on 'Diagnosis'.)
Children without signs of AOM should be examined approximately every two months to determine
the presence and duration of middle ear effusion [7]. The management of persistent middle ear
effusion is discussed separately. (See "Otitis media with effusion (serous otitis media) in children:
Management", section on 'Overview of management'.)
SURGERY
Tympanostomy tubes Myringotomy with placement of tympanostomy tubes permits drainage of
the middle ear fluid, aeration of the middle ear space, and return of the middle ear mucosa to
normal. An abscess does not form because the tube allows drainage of accumulated middle ear
fluid. Nevertheless, recurrent infection may result in a mucositis that is usually identified by systemic
signs and/or otorrhea. (See "Overview of tympanostomy tube placement, postoperative care, and
complications in children", section on 'Tube otorrhea' and "Tympanostomy tube otorrhea in children:
Causes, prevention, and management", section on 'Acute tympanostomy tube otorrhea'.)

The use of tympanostomy tubes in the prevention of recurrent acute otitis media (AOM) in otherwise
healthy children has increased as the popularity of chemoprophylaxis has decreased due to
concerns about antibiotic resistance among otopathogens. (See 'Adverse effects' above.)
Indications Tympanostomy tube placement may be warranted for children who have had 3
distinct and well-documented episodes within six months or 4 episodes within 12 months [3,42].
Decisions regarding the placement of tympanostomy tubes for recurrent AOM must be
individualized after consideration of the risks and benefits. (See 'Factors influencing choice' above.)
We suggest tympanostomy tube placement for children who warrant more aggressive prevention
strategies and:
Have had breakthrough episodes of AOM while receiving prophylaxis, or
Have declined antibiotic prophylaxis (because of parental concerns), or
Have multiple drug allergies
Potential benefits A meta-analysis of five randomized trials of tympanostomy tubes versus no
surgery in children with AOM or otitis media with effusion (OME) showed a mean absolute decrease
in AOM incidence of 1.0 episode per child-year (95% CI 0.4-1.6) [47]. When the analysis was
limited to trials of children with recurrent AOM, the mean absolute decrease in the incidence of
AOM was 1.75 episodes per child-year (95% CI -0.44-3.93).
A subsequent systematic review [48] that included only two trials (both of which included children
with OME) [49,50] found that insertion of tympanostomy tubes was associated with a mean of 1.5
fewer episodes of AOM in the six months after surgery.
In a randomized trial published after the systematic review, 300 children (10 months to 2 years of
age) with recurrent AOM (3 episodes in the previous six months) were randomly assigned to
tympanostomy tubes, tympanostomy tubes plus adenoidectomy, or neither [51]. Treatment failure
(defined as two episodes of AOM in two months, three episodes in six months, or effusion for longer
than two months) occurred in fewer patients in the tympanostomy tube groups (21 and 16 percent
in the tympanostomy tube and tympanostomy tube/adenoidectomy groups, respectively, versus 34
percent in controls). More children in the tympanostomy tube groups were AOM-free during the one
year
of
follow-up
(48
and
49
percent
in
the
tympanostomy
tube
and
tympanostomy tube/adenoidectomy groups, respectively, versus 34 percent in controls). As
discussed below, the combination of adenoidectomy and tympanostomy tubes did not provide any
advantage over tympanostomy tubes alone. (See 'Adenoidectomy or adenotonsillectomy' below.)
Two trials included in the first meta-analysis compared tympanostomy tube placement with
chemoprophylaxis and placebo [2,52]. However, only one excluded children with OME [2]. This
study, which is described in greater detail above, found antibiotic prophylaxis with amoxicillin to be
more effective than tympanostomy tube placement or placebo. (See 'Antibiotic prophylaxis
compared with tubes' above.)
Adverse effects Myringotomy and placement of tympanostomy tubes are surgical procedures
and parents should be informed about the potential adverse events associated with anesthesia and
surgery. Complications and sequelae of tympanostomy tubes include otorrhea, persistent
perforation of the tympanic membrane, tympanosclerosis, focal atrophy of the tympanic membrane,

and cholesteatoma. (See "Overview of tympanostomy tube placement, postoperative care, and
complications in children", section on 'Complications and sequelae'.)
Adenoidectomy or adenotonsillectomy When the decision is made to proceed with a first set
of tympanostomy tubes, concurrent adenoidectomy is indicated only for patients with moderate to
severe nasal obstruction [1]. (See "Tonsillectomy and adenoidectomy in children: Indications and
contraindications", section on 'Nasal obstruction'.)
Adenoidectomy, with or without tonsillectomy, does not appear to be an effective primary preventive
measure for children with recurrent AOM [51,53-55]. Two randomized clinical trials run in parallel
failed to demonstrate a substantial effect of adenoidectomy or adenotonsillectomy on the
occurrence of AOM in patients 3 to 15 years of age with recurrent otitis media and no previous
history of tympanostomy tubes, whether or not they had evidence of enlarged tonsils or adenoids
[53].
The relative merits of adenoidectomy at the time of tympanostomy tube placement in children with
recurrent AOM (more than three episodes in the past six months) or chronic otitis media with
effusion were evaluated in a prospective trial [56]. A total of 217 children with no previous surgery
(aged 12 to 48 months) were randomly assigned to adenoidectomy with insertion of tympanostomy
tubes or insertion of tympanostomy tubes alone. There was no difference in the incidence of
subsequent AOM between the two groups [56].
In contrast, adenoidectomy with or without tonsillectomy may be helpful in reducing the number of
episodes of AOM in children who have recurrences after an initial placement of tympanostomy
tubes [57]. A retrospective study suggested that adenoidectomy or adenoidectomy plus
tonsillectomy at the time of tube reinsertion substantially reduced the incidence of subsequent
hospitalizations and repeat tympanostomy tube insertion in patients 2 years of age [58].
(See "Tonsillectomy and adenoidectomy in children: Indications and contraindications", section on
'Otitis media'.)
OTHER INTERVENTIONS
Xylitol We do not suggest the use of xylitol to prevent recurrent acute otitis media in children.
Although there is some evidence to suggest that xylitol may be beneficial, additional information is
necessary before it can be routinely recommended [59].
Xylitol is a five-carbon sugar alcohol that is used in place of sucrose as a sweetener. It has been
shown to prevent dental caries by inhibiting the growth of Streptococcus mutans and has been
studied as a means of preventing AOM in children attending day care [60-62].
In a 2011 meta-analysis of three randomized trials [63-65], two to three months of xylitol chewing
gum, syrup, or lozenges prevented recurrent AOM among healthy children (mean age two to five
years) attending day care (risk ratio 0.75, 95% CI 0.65-0.88) [62]. In individual studies,
administration of xylitol five times per day was effective [63,64], but three times per day was not
[65]. In a separate randomized trial, xylitol syrup administered only during respiratory infections did
not prevent AOM among children attending day care [66].
Although the results of the meta-analysis are promising, it has several limitations. The mean ages in
the study populations were older than the age of peak incidence of AOM (2 to 5 years versus 6 to
18 months). In addition, it is not clear that the study conditions (eg, administration of xylitol five

times per day) could be replicated in "the real world". A subsequent randomized trial in children six
months to five years (mean age approximately 22 months) found no benefit of a three-times-daily
dosing regimen of xylitol in preventing recurrent otitis media [67].
The optimal dose, dosing regimen, long-term benefits, and full range of adverse effects must be
determined before xylitol can be recommended to prevent AOM [59].
Antiadhesive oligosaccharide Administration of oligosaccharides may be helpful in the
prevention of infection by inhibiting the binding of bacteria to epithelial cells [68-70]. In an animal
study, intratracheal administration of antiadhesive oligosaccharides was effective in decreasing
pneumococcal load and subsequent bacteremia [71]. However, in a randomized controlled trial,
nasopharyngeal administration of oligosaccharides to children for three months did not affect
nasopharyngeal carriage of S. pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis or
prevent AOM [72]. We do not suggest the administration of oligosaccharides to prevent recurrent
AOM in children.
Probiotics We do not suggest the administration of probiotics to prevent recurrent AOM in
children. In theory, administration of probiotics after treatment of AOM recolonizes the nasopharynx
with bacteria that can hinder the growth of pathogenic bacteria. However, studies evaluating
probiotic for the prevention of recurrent AOM have inconsistent results.
Two randomized trials, each including >200 children, found no benefit of oral probiotics in the
prevention of recurrent AOM [73,74]. In another randomized trial, more children who received
alpha-streptococcal nasal spray than placebo nasal spray remained AOM-free for three months (42
versus 22 percent) [75]. Alpha-streptococcal nasal spray is not commercially available.
Other complementary therapies Nearly one-half of families of children with recurrent AOM may
try complementary, holistic, or integrative therapies (eg, herbal remedies, homeopathy, nutritional
supplements, such as zinc) to prevent recurrent AOM [76]. Although some of these interventions
have been evaluated in clinical trials, methodologic limitations preclude definitive conclusions about
their safety or efficacy [8,77,78].
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The
Basics and Beyond the Basics. The Basics patient education pieces are written in plain language,
th
th
at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
th
th
more sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on patient info and the keyword(s) of interest.)
Basics topic (see "Patient information: Ear tubes (The Basics)")
Beyond the Basics topic (see "Patient information: Ear infections (otitis media) in children
(Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS

Recurrent acute otitis media (AOM) is defined as 3 distinct and well-documented episodes
within six months or 4 episodes within 12 months. Infants who have their first episode of
AOM before six months of age or who have siblings with severe and recurrent AOM are at risk
for severe and recurrent AOM. (See 'Definitions' above.)
Prevention strategies include identification and treatment of underlying conditions that
predispose to recurrent AOM, parental education about the risk factors for AOM, vaccine
administration,
chemoprophylaxis,
and
tympanostomy
tube
placement.
(See 'Interventions' above.)
Factors that influence the choice of prevention strategy include the age of the child, the age
at first episode of AOM, the time of year, day care attendance, family history, cognitive and
language status, underlying conditions that predispose to AOM, and the effects of recurrent
AOM on the quality of life for the child and family. (See 'Factors influencing choice' above.)
Treatment of predisposing conditions and parental education are reasonable strategies for all
children with recurrent AOM. (See 'Treatment of predisposing conditions' above
and 'Education' above.)
We recommend administration of the pneumococcal conjugate vaccine (PCV) and annual
influenza vaccine according to the routine childhood immunization schedule (Grade 1A). We
suggest that children with recurrent AOM who are between two and six years of age and have
not received any doses of the 13-valent PCV (PCV13), receive a dose of PCV13 (Grade 2C).
We also suggest that children older than two years of age with recurrent AOM receive a dose
of the 23-valent pneumococcal conjugate vaccine at least eight weeks after PCV13 (Grade
2C). (See 'Vaccines' above and "Pneumococcal (Streptococcus pneumoniae) conjugate
vaccines in children", section on 'Supplemental dose' and "Seasonal influenza in children:
Prevention with vaccines", section on 'Indications'.)
We suggest antibiotic prophylaxis or tympanostomy tube placement for children who are
younger than two years of age, have multiple risk factors for recurrent AOM, have underlying
medical conditions that predispose to AOM, or have known or suspected developmental or
language delays (Grade 2B). However, the ultimate decision about whether to use one of
these more aggressive interventions and which intervention to use is made on a case-by-case
basis after discussion of the potential benefits and risks with the caregivers. (See 'Choice of
intervention(s)' above.)
When the decision is made to use antibiotic prophylaxis, we typically
use amoxicillin 40 mg/kg orally once per day. Sulfisoxazole 50 mg/kg orally once per day is an
alternative. Antibiotic prophylaxis should be provided every day during the fall, winter, and
early spring months. Children receiving chemoprophylaxis should be examined approximately
every two months to determine the presence and duration of middle ear effusion.
(See'Antibiotic prophylaxis' above.)
Tympanostomy tube placement is an alternative to antibiotic prophylaxis for children who
warrant more aggressive prevention strategies and an option for those who have had
breakthrough episodes of AOM while receiving antibiotic prophylaxis. (See 'Choice of
intervention(s)' above and 'Tympanostomy tubes' above.)
Adenoidectomy is not an effective primary preventive measure for children with recurrent
AOM but may be beneficial in those who continue to have recurrent AOM after extrusion of
tubes and are undergoing repeat tympanostomy tube placement. (See 'Adenoidectomy or
adenotonsillectomy' above.)

We do not suggest xylitol, antiadhesive oligosaccharide, or probiotics for the prevention of

recurrent AOM in children (Grade 2C). (See 'Other interventions' above.)
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Topic 5998 Version 21.0