A number of alternatives to antibiotics and surgery?some helpful, some not?are being used to prevent and treat one of the most common childhood infections: otitis media.
Our continuing look at complementary and alternative medicine focuses on one of the most common childhood infections: otitis media. A number of alternatives to antibiotics and surgerysome helpful, some notare being used to prevent and treat the condition.
During a "meet and greet" prenatal visit with you, the parents-to-be mention that the father's 2-year-old nephew has been plagued by recurrent ear infections. He's received numerous courses of antibiotics and is now scheduled for surgery to place bilateral myringotomy tubes.
"We definitely want to avoid all those antibiotics and surgery," the parents tell you. "Is there something we could do from the time our baby is born? We heard that regular chiropractic adjustments help prevent early ear infections."
Your next patient is 3-year-old Charlie, whose chart notes a low-grade fever and possible right ear pain. Charlie has had recurrent otitis mediafour infections in his first year, three in the second year, and one so far this year. His language development has been normal and he has no other medical problems. His mother, a public health nurse, tells you she started him on a homeopathic remedy three months ago to prevent ear infections. After no episodes occurred for two months, she stopped giving him the remedy. But now he has a red, bulging right tympanic membrane with limited mobility. You tell her it looks like Charlie has acute otitis media again. The mother asks, "Can I give him the homeopathic remedy instead of antibiotics this time, at least for a couple of days to see if it works?"
Today's parents and prospective parents have a huge amount of health information available to them. Yet they still turn to trusted physicians for expert advice when management of a medical problem is not clear-cut. Case in point: ear infections. Although acute otitis media (AOM) is the most common bacterial infection of early childhood, treatment remains controversial. Most pediatricians in the United States recommend antibiotics, but many physicians in Britain and other European countries take a watchful- waiting approach, reserving antibiotic therapy for severe or complex cases and for young infants and children who have not improved on their own within 48 hours.1,2
As parents hear of different ways to treat otitis media and about the emergence and spread of antibiotic-resistant bacteria, they increasingly raise questions about alternatives to antibiotics and surgery for treating AOM. They also want to know about prevention. Physicians who encourage parents interested in nontraditional approaches for preventing and treating AOM must first become educated in this murky field. This review serves as a starting point for familiarizing yourself with alternatives to standard therapies.
Although antibiotics and myringotomy tubes may have a role in reducing the risk of recurrent otitis media, they are not indicated as primary preventive therapies and would not be part of your discussion with the prospective parents described in the first scenario. Instead, the conversation would focus on lifestyle choices that minimize the risk of developing otitis media in the first year of life (Table 1). These include breastfeeding and avoiding allergens, sick children, and tobacco smoke. Immunizations and xylitol syrup may also reduce the risk of otitis media. No scientific studies support the use of other professionally provided therapies, such as massage, chiropractic, and acupuncture, to prevent otitis media.
Breastfed babies have a substantially lower risk of otitis media than formula-fed babies.3 In one study, for example, the risk of recurrent otitis media in the first year of life was about 12% in infants exclusively breastfed for the first four months of life, compared with 20% in infants who were breastfed for less than four months.4
Breastfeeding confers well-known immunologic benefits and may exercise the oropharyngeal muscles that support optimal eustachian tube function. It also helps prevent food allergies in infantsallergies that may well contribute to the development of otitis media. In one study, children who had persistent middle ear fluid and documented food allergies went on a diet that eliminated those foods for 16 weeks; middle ear fluid resolved in nearly 90% of them. When they were re-challenged with the problem food, middle ear fluid recurred in 94% of children.5
Feeding solids to an infant before 4 to 6 months of age is linked to an increased risk of food allergies. Breastfeeding reduces the risk that the child will be directly exposed to potentially allergenic foods such as cow's milk, soy, wheat, and corn. Studies show that it can help prevent allergies in infants from atopic families, especially when parents are able to stop smoking and mothers minimize their intake of allergenic foods.68 Allergenic proteins in the maternal diet may be concentrated in breast milk; if a mother consumes, say, cow's milk, her nursing child is exposed to cow milk protein.9 Breastfeeding mothers who are allergic to cow's milk and who avoid it during pregnancy and while breastfeeding reduce the risk that their baby will become allergic to cow's milk by about 60%.10
Preventing otitis media and allergies are two more reasons to encourage mothers to breastfeed for at least the first 12 months of life. But for those who choose bottle-feeding instead, discourage bottle-propping or putting the baby to bed with a bottle, which increases the risk of both otitis media and dental caries. Putting the bottle in the baby's mouth when he is lying on his back allows milk to reflux into the eustachian tube, blocking drainage from the middle ear.
Environmental changes can also reduce a child's risk of otitis media. Pediatricians should counsel all parents to stop smoking and to not allow anyone to smoke in the child's presence. Children whose parents smoke get approximately 50% more ear infections than children whose parents do not smoke.11
Children who are regularly in contact with many other children are exposed to numerous viral and bacterial infections. For this reason, day care attendance is a well-known risk factor for otitis media. The more children the child has contact with, the higher the risk. American public policy, economics, and culture strongly encourage mothers to return to work outside the home six to 12 weeks postpartum, putting the infant into day care. In contrast, some European countries have made public policy choices that more clearly support families and children by giving mothers the economic option of staying home with the infant for six to 12 months. These policies promote maternal-child bonding, support breastfeeding, and minimize early exposure to day careall of which reduce the risk of otitis media developing early in childhood.
Preliminary evidence implicates pacifiers as a risk factor for recurrent ear infections.12,13 Pacifiers may also interfere with breastfeeding. Additional research is needed to better understand the long-term benefits and risks associated with pacifiers and their role in otitis media. Non-nutritive sucking clearly helps infants and young children cope with painful procedures, but for parents who are looking for support in weaning their child from the pacifier, the association between otitis media and pacifier use may be helpful information.
Two types of biochemical therapies other than antibiotics reduce the risk of otitis media: immunizations and xylitol sugar. The seven-valent pneumococcal conjugate vaccine and the influenza vaccine offer significant protection against infections caused by these microorganisms. The pneumococcal vaccine is available for children beginning at 2 months of age, and the influenza vaccine is available starting at 6 months of age. Both are particularly beneficial for children in day care because of their heightened exposure to infectious agents. I have found that even parents who resist using antibiotics or other drugs are amenable to providing immunizations that "boost" the body's natural immune function and build resilience.
Xylitol, a sugar found in fruits and the bark of birch trees, was used as a sucrose substitute during World War II. Subsequently, dentists noticed fewer dental caries among those who consumed xylitol than they observed in those who consumed sucrose; controlled trials have confirmed the caries-preventing effects of the compound.14,15 In vitro, xylitol has bacteriostatic effects against Streptococcus pneumoniae and interferes with bacterial adhesion to mucous membranes, preventing pathogenic bacteria from sticking to cells that line the eustachian tube and middle ear.16
In two studies of nearly 1,200 Finnish preschoolers, those who received gum (limited to children who were old enough to chew gum) or syrup sweetened with xylitol (89 g divided into five doses daily) had 30% to 40% fewer ear infections than children who received standard (no xylitol) gum or syrup.17,18 Giving xylitol five times a day may be impractical for many families; future studies need to address the optimal dose and frequency of administrationone 6-year-old boy in my practice developed jaw pain and refused to chew gum anymore! Dosages greater than 30 grams daily may be associated with diarrhea. For many children, however, xylitol is a safe and inexpensive way to reduce the risks of both AOM and caries. It is readily available over the World Wide Web and in health food stores.
The goals of therapy for AOM are to relieve symptoms, reduce complications such as mastoiditis and perforation, and minimize the risk of long-term sequelae such as hearing loss, speech delay, and behavioral problems. Although antibiotics are routinely prescribed for AOM in the United States, most children (70% to 80%) recover without specific antimicrobial therapy.19,20 Physicians should still consider strongly encouraging antibiotics for children who are less likely to recover spontaneously: those who are immunosuppressed, are younger than 18 months, or have severe or recurrent infections.
Medicine's basic tenet, "First, do no harm," reminds us that, regardless of our therapeutic goals, the potential benefit of a therapy must outweigh its risk. This means balancing the benefits of analgesic and antibiotic medications against the risks of allergic reaction, diarrhea, diaper rash, thrush, abdominal discomfort, and the development and spread of antibiotic-resistant bacteria. It also means being aware that the way we offer and frame treatment options may have a subtleor powerfuleffect on psychosocial outcomes.
Is, for example, the pediatrician perceived as supporting or belittling home remedies (and, in turn, the family's cultural identity)? What effect does promoting parents' ability to select and administer nonprescription remedies have on parenting competence? What effect does relying on medications rather than the child's immune system to combat illness episodes have on the child's self-esteem?
Whether or not the choice is made to prescribe antibiotics, the immediate therapeutic goal is to make the child comfortable (Table 2). Antihistamines and decongestants have no role in the treatment of acute otitis mediathey are not effective and may have substantial side effects.21 Parents can provide nonprescription analgesics such as acetaminophen or ibuprofen. Although ear drops such as Auralgan (antipyrine, benzocaine, glycerin) have proven more effective than placebo in relieving otalgia,22 a substantial number of children also benefit from home remedies such as olive oil or olive oil mixed with garlic or mullein. These drops do not hasten healing, but they do help children feel more comfortable while their immune system tackles the infection. Other home ear drop remedies include supersaturated solutions of sugar or epsom salts. As long as common- sense safety precautions are used (the drops are not too hot and do not contain any vegetable matter that might become lodged in the ear canal; the ear drum is not perforated; and so on), there is little reason to discourage use of such remedies.
Cold or hot packs
Comforting and distracting the child
Ice packs are helpful for some children (a bag of frozen peas or carrots held against the ear, for example) while others prefer heat (a hot water bottle or heating pad). Because many children experience more pain lying down (decreased venous return from the middle ear), positioning the child for sleep with the head propped up may be very helpful.23 Cuddling, holding, carrying, reassuring, singing to, and distracting the child are all time-honored techniques that can be safely encouraged.
Some pediatricians recommend gum chewing and bubble blowing as methods to "pop" open the eustachian tube and allow the ear to drain. This rationale is appealing, and the methods appear safe, but no studies have evaluated their effectiveness in enhancing comfort or healing in AOM. Similarly, no studies have specifically evaluated the benefits of parentally provided back rubs or massage of the head, neck and shoulders, hands, or feet. Massage is, however, benign, culturally acceptable, enhances parents' sense of competence and efficacy, and has proven effective for treating pain of more serious conditions.24 For these reasons, I do not hesitate to recommend it.
Herbal remedies have become very popular in the last 20 years.25 Scientific studies support the use of Echinacea to treat adult upper respiratory infections.26 The independent ConsumerLab.com reported that the highest quality Echinacea products were Herbal Authority Echinacea, Nature's Bounty Natural Echinacea, Nutrilite Triple Guard, and Tom's of Maine Natural Echinacea Tonic with Green Tea Liquid Herbal Supplement. Echinacea has not been evaluated as a treatment for pediatric otitis media, however. Similarly, elderberry (Sambucol) may help adults seeking relief from influenza but has not been studied for pediatric conditions.
High dosages of zinc have been shown not to help children recover more quickly from upper respiratory infections,27 although some studies of zinc use in adults do show some benefit for treating colds.28,29 There are no data evaluating the efficacy of high dosages of vitamin C in speeding recovery from otitis media.
Because herbs and other dietary supplements are not regulated by the Food and Drug Administration as stringently as medications are, consumers must be aware of the risks of misidentified herbs, lack of quality control that results in inconsistent concentrations, and the potential for contamination with pesticides, heavy metals, and pharmaceuticals in some products.
Dietary home remedies for otitis media and other upper respiratory infections include chicken soup, increased intake of garlic, ginger, and other spicy foods, and increased amounts of fruit juice and other liquids. No data show that withholding milk products enhances healing from upper respiratory infection in patients who do not have an underlying milk allergy. I support families who choose to follow their cultural traditions as long as they meet the test of common sense (for instance, no fasting for a child younger than 6 years).
A few years back, special hollow "ear" candles were a popular home remedy for otitis media. The bottom of the candle was placed in the ear canal (violating the old rule of never putting anything smaller than your elbow in your ear!) and the top was lighted. The heat, theoretically, would "draw out toxins." The problem was, they didn't workcandle wax dripped into the ear instead, some children got burned and suffered other injuries, and, overall, they were much more trouble than they were worth.30 I do not recommend them.
Studies are under way to evaluate the effectiveness of chiropractic as a preventive and therapeutic option for otitis media. Because of its significant cost, I would not recommend chiropractic unless strong data arrive to suggest a positive benefit/cost ratio. Similarly, no study shows that acupuncture offers significant benefit for children suffering otitis media. Because acupuncture must be administered by a professional, the benefit would have to be great to justify the cost of care.
Homeopathy offers a noteworthy contrast. Homeopathic remedies, sold over the counter, are carefully regulated and unlikely to contain hazardous contaminants or any compound other than lactose. Although there is no known biochemical mechanism by which a homeopathic remedy can cure an infectious illness, the results of a single small, double-blind, controlled trial suggest that homeopathy may offer benefit beyond placebo in treating AOM.31 It is premature to recommend that every child with otitis media be treated with a homeopathic remedy, but this pilot study does offer scientific support for parents who wish to try the drug Pulsatilla or another homeopathic remedy for 24 to 48 hours while providing comfort measures.32
A wide variety of complementary therapies are available to parents who want to prevent or treat otitis media without antibiotics or surgery. Clinicians should be aware of commonly used alternative approaches and published data that describe their benefits and risks (Table 3). Benefits include a healthier lifestyle; stronger cultural identity for the family; stronger sense of parenting competence; avoidance of the side effects of antibiotics; and, for society broadly, an obstacle to the rise of resistant bacterial pathogens. Negatives associated with reliance on complementary therapy may include the cost of professionally provided care, the medical risks of side effects, the risks of inappropriately administered remedies, and a delay in starting effective therapy for the minority of children who require an antibiotic.
Healthier lifestyle (breastfeeding; avoiding allergens, tobacco smoke, and crowded day care)
Stronger cultural identity for family (use of home or cultural remedies)
Stronger sense of parenting competence (use of over-the-counter medical and homeopathic remedies, distraction, positioning, heat, cold, parent-provided massage)
Avoidance of side effects of antibiotics (allergies, diarrhea, development and spread of antibiotic-resistant organisms)
Cost of professionally provided care (chiropractic, acupuncture)
Medical risks of side effects (unregulated herbs, ear candles)
Risks of inappropriately administered remedies (failing to cool or strain oil before putting it in the ear)
Delay in starting effective therapy
The growing use of CAM makes it necessary for clinicians to expand their focus beyond antibiotics. Better understanding of the benefits and costs of all therapeutic options will enhance your ability to provide comprehensive, patient-focused, culturally competent care.
1. Van Buchem FL, Peeters MF, van't Hof MA: Acute otitis media: A new treatment strategy. BMJ 1985;290:1033
2. Bollag U, Bollag-Albrecht E: Recommendations derived from practice audit for the treatment of acute otitis media. Lancet 1991;338:96
3. Duffy LC, Faden H, Wasielewski R, et al: Exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media. Pediatrics 1997; 100(4):e7
4. Duncan B, Ey J, Holberg C, et al: Breastfeeding and recurrent otitis media in the first year of life. Am J Dis Child 1992;146:482
5. Nsouli TM, Nsouli SM, Linde RE: Role of food allergy in serous otitis media. Ann Allergy 1994;73(3):215
6. Marini A, Agosti M, Motta G, et al: Effects of a dietary and environmental prevention programme on the incidence of allergic symptoms in high atopic risk infants: Three year follow-up. Acta Paediatr Scand 1996;Suppl 414:1
7. Vadas P, Wai Y, Burks W, et al: Detection of peanut allergens in breast milk of lactating women. JAMA 2001; 285:1746
8. Saarinen UM, Kajosaaari M: Breastfeeding as prophylaxis against atopic disease: Prospective follow-up study until 17 years old. Lancet 1995;346:1065
9. Jarvinen KM, Makinen-Kiljunen S, Suomalainen H: Cow's milk challenge through human milk evokes immune response in infants with cow's milk allergy. J Pediatr 1999;125:506
10. Lovegrove JA, Morgan JB, Hampton SM: Dietary factors influencing levels of food antibodies and antigens in breast milk. Acta Paediatr 1996;85:778
11. Adair-Bischoff CE, Sauve RS: Environmental tobacco smoke and middle ear disease in preschool-age children. Arch Pediatr Adolesc Med, 1998;152:127
12. Jackson JM, Mourino AP: Pacifier use and otitis media in infants twelve months or younger. Pediatr Dent 1999;21:255
13. Niemela M, Uhari M, Mottonen M: A pacifier increases the risk of recurrent otitis media in children in day care centers. Pediatrics 1995;96:884
14. Makinen KK, Hujoel PP, Bennett CA, et al: Polyol chewing gums and caries rates in primary dentition: A 24 month cohort study. Caries Res 1996;30:408
15. Hujoel PP, Makinen KK, Bennett CA, et al: The optimum time to initiate habitual xylitol gum-chewing for obtaining long-term caries prevention. J Dent Res 1999; 78(3):797
16. Kontiokari T, Uhari M, Koskela M: Antiadhesive effects of xylitol on otopathogenic bacteria. J Antimicrob Chemotherapy 1998;41:563
17. Uhari M, Kontiokari T, Koskela M: Xylitol chewing gum in prevention of acute otitis media: Double blind randomised trial. BMJ 1996;313:1180
18. Uhari M, Kontiokari T, Niemela M: A novel use of xylitol sugar in preventing acute otitis media. Pediatrics 1998; 102(4):879
19. Del Mar C, Glaszious P, Hayem M: Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ, 1997;314:1526
20. Damoiseaux RA, van Balen FA, Hoes AW, et al: Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years. BMJ 2000;320(7231):350
21. Cantekin EI, Mandel EM, Bluestone CD, et al: Lack of efficacy of a decongestant-antihistamine combination for otitis media with effusion ("secretory" otitis media) in children: Results of a double-blind, randomized trial. N Engl J Med 1983;308:297
22. Hoberman A, Paradise JL, Reynolds EA, et al: Efficacy of Auralgan for treating ear pain in children with acute otitis media. Arch Pediatr Adolesc Med 1997;151:675
23. Rundcrantz H: The effects of position change on eustachian tube function. Otolaryngol Clin N Am 1970; 3:103
24. Field T: Massage therapy: More than laying on of hands. Contemporary Pediatrics, 1999;16(5):77
25. Gardiner P, Kemper KJ: Herbs in pediatric and adolescent medicine. Pediatr Rev 2000;21(2):44
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27. Macknin ML, Piedmonte M, Calendine C, et al: Zinc gluconate lozenges for treating the common cold in children. JAMA 1998;279:1962
28. Farr BM, Conner EM, Betts RF, et al: Two randomized controlled trials of zinc gluconate lozenge therapy of experimentally induced rhinovirus colds. Antimicrob Agent Chemother 1987;31:1183
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31. Jacobs J, Springer DA, Crothers D: Homeopathic treatment of acute otitis media in children: A preliminary randomized placebo-controlled trial. Pediatr Infect Dis J 2001;20(2):177
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This article makes clear that pediatricians need to listen to parents' beliefs about therapiessomething that often requires an unconventional, nonjudgmental approach. It also highlights the fact that the outcome of most cases of otitis media is the same whether the child is treated or not and that, in an era of increasing antibiotic resistance, alternatives to broad-spectrum antibiotics must be considered.
Dr. Kemper's useful and interesting review may serve to encourage the use of worthwhile alternatives. Primary care physicians may, however, have some concerns about the approach discussed in this article:
Can they afford the time it takes to learn about, explain, and listen to alternatives for a specific entity such as otitis media, which is usually treated much more quickly with a standard prescription for antibiotics?
How much should patients be encouraged to assume responsibility for their own therapies, especially nonstandard ones? (Some physicians "train" parents to call frequently for advice; others encourage a less dependent relationship.) How does the parent know whether the child has otitis media again rather than another condition? Should the pediatrician examine the child each time to be certain of the diagnosis before agreeing with the use of complementary and alternative medicine (CAM)? Should the criteria be that the physician knows for sure that the child has otitis media, that antibiotics are not needed, and that the family prefers alternative therapies to conventional approaches, before CAM is used?
Once encouraged to use alternative therapies, will the parent apply these to other medical conditions?
The author replies: As Dr. Hall points out, it is our responsibility and privilege as pediatricians to listen to, support, and encourage families to creatively care for their children. Often, taking the time to listen seems like a luxury, but it is truly a necessity for understanding the child, the child's environment, and the family's values. It is also the key to developing the most useful of all our treatment toolsthe therapeutic relationship. Plus, learning about the diverse ways parents solve common problems is just plain fun!
Parents are responsible for the care they provide to their children. Pediatricians are responsible for helping parents by providing complete and accurate information, covering the pros and cons of different treatment alternatives. By supporting parents' wisdom in deciding when and how to seek medical care, by empowering them and encouraging them, we facilitate the growth and development of parents' sense of competence and their appropriate use of medical care. In the old days, we encouraged parents to bring their child to the emergency department in the middle of the night so that a case of acute otitis media could be immediately treated with antibiotics; nowadays, we talk over the phone and advise analgesic strategies, waiting until the next morning or afternoon for an office visit. Perhaps five years from now we will advise analgesics and home remedies for 24 to 48 hours before visualizing the tympanic membranes of low-risk children with ear pain. There may even be a parent-held electronic device that assesses the middle ear, applies an algorithm, and transmits the relevant information to the pager or personal digital assistant of the physician, who then sends the appropriate advice and prescription to the family and pharmacy electronically!
The topics of complementary therapies and modern technologies raise an enormous number of research and policy questions. I look forward to seeing studies addressing the questions raised by Dr. Hall. Such work is vital to our progress toward truly evidence-based, cost-effective medicine.
Kathi Kemper. Otitis media: When parents don't want antibiotics or tubes. Contemporary Pediatrics 2002;4:47.