In a blog for anyone interested in preventing and treating acuteA health condition (or episodes of a health condition) that comes on quickly and is short-lived. middle ear infections in children, Sarah Chapman from Cochrane UK looks at the Cochrane evidenceCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. on various approaches.
Page updated 20 November 2023
Take-home points
Acute middle ear infections, also called acute otitis media, are common in children and can cause earache, fever and occasionally a perforated ear drum (a hole or tear in your eardrum). These infections happen when bacteria from the upper part of the throat go to the middle ear. NHS advice is that you do not always need to see a GP for an ear infection as they often get better on their own within 3 days.
Preventing middle ear infections
‘Prevention is better than cure’ – true not just for you and your child but much more widely. Antibiotics are often given to treat middle ear infections, and overuse of antibiotics is a global problem as it makes them less effective (known as ‘antibiotic resistance’).
Guidance from the National Institute for Health and Care Excellence (NICE) says that avoiding exposure to passive smoking, use of dummies, and feeding lying down, can all help reduce the riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of ear infections, along with ensuring children have had a complete course of pneumococcal vaccinations (more about that below).
Here are some things that have been studied as possible ways to prevent middle ear infections in children:
Vaccination
Pneumococcal vaccine (PCV)
In the UK this is part of the routine vaccination programme for babies. Pneumococcal bacteria can cause many infections from meningitis to ear infections.
The Cochrane ReviewCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. Pneumococcal conjugate vaccines for preventing acute otitis media in children (November 2020) brought together the evidence on the effect of pneumococcal vaccines (PCV) in preventing acute ear infections in children under 12. The review authors found:
- PCV in babies may reduce the risk of acute ear infections caused by pneumococcal bacteria but it’s not clear whether there’s an effect on the risk of acute ear infections from any cause
- there may be no evidence of a beneficial effect on acute ear infections from any cause when PCV is given to high-risk infants, to infants aged over one year, or to older children with a history of respiratory illness
- mild local reactions to the vaccine, and fever, were common, while serious unwanted effects were rare
Flu vaccine
Although middle ear infections are caused by bacteria, they are often triggered by a viral infection. The Cochrane Review Influenza vaccines for preventing acute otitis media in infants and children (October 2017) has evidence that in infants and children under six years flu vaccination may slightly reduce the risk of acute middle ear infections. Side effects included an increase in fever, runny nose, and drowsiness. The evidence isn’t high quality, ten of the 11 trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. were funded by vaccine manufacturers (a potential source of biasAny factor, recognised or not, that distorts the findings of a study. For example, reporting bias is a type of bias that occurs when researchers, or others (e.g. drug companies) choose not report or publish the results of a study, or do not provide full information about a study.) and there was limited information on safetyRefers to serious adverse effects, such as those that threaten life, require or prolong hospitalization, result in permanent disability, or cause birth defects..
Probiotics
There are lots of health claims made about probiotics. Probiotics are live bacteria and yeasts which are thought to help restore the natural balance of bacteria in your gut after illness and may have other beneficial effects. They’re typically added to yogurts or taken as food supplements. You may see them marketed as ‘good’ or ‘friendly’ bacteria.
The Cochrane Review Probiotics for preventing acute otitis media in children (June 2019) finds that probiotics may prevent acute middle ear infections in children not prone to them, and probably reduces the number of children taking antibiotics for any infections. There may be little or no difference in unwanted effects between children taking probiotics and those taking a placeboAn intervention that appears to be the same as that which is being assessed but does not have the active component. For example, a placebo could be a tablet made of sugar, compared with a tablet containing a medicine..
The review authors say there are still lots of unanswered questions about the use of probiotics to protect children, including about the best type to take, when and how long to take them for, and about safety.
Xylitol
Xylitol, or birch sugar, is found in plums, strawberries, raspberries and rowan berries and is used as a sweetener in chewing gum, sweets, toothpaste and medicines. It doesn’t cause tooth decay. Xylitol has been reported to reduce the growth of some disease-causing bacteria and to reduce the ability of some of these to stick to the passageways of the nose and throat.
The Cochrane Review Xylitol for preventing acute otitis media in children up to 12 years of age (August 2016) has evidence from studies comparing xylitol with placebo or no treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes., mostly in healthy children attending daycare centres (three studies) while the other studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. looked at children with acute respiratory infections. It suggests that:
- giving xylitol in any form to healthy children probably reduces the number of children who get acute middle ear infections
- Xylitol probably doesn’t reduce the number of middle ear infections in children prone to them, or in children with respiratory illnesses
- there is probably little or no difference between those taking xylitol and those taking a placebo in unwanted effects (abdominal discomfort and rash)
Xylitol can be taken as syrup, chewing gum or lozenges. The review authors note that for children able to chew, xylitol taken in chewing gum seems to be more effective than in syrup form.
Treating acute middle ear infections
Drugs for pain relief
Despite recommendations in guidelines on the use of painkillers for children with acute middle ear infections, the authors of a 2023 Cochrane Review on this topic have found that there is not much evidence.
The evidence suggests that paracetamol or ibuprofen may be more effective than placebo in relieving short-term ear pain. But it’s not clear how the two drugs compare, nor how effective they are when combined versus using just paracetamol.
Drugs to treat the infection
Antibiotics
In high income countries like the UK, acute middle ear infections mostly resolve without drugs and without complications. Using antibiotics adds to the problem of antibiotic resistance and comes with the risk of unwanted effects for the person taking them, such as vomiting, diarrhoea or rash.
The authors of a Cochrane Review on Antibiotics for acute otitis media in children (November 2023) found that:
- by 24 hours from the start of treatment, 60% of the children had recovered whether or not they had placebo or antibiotics
- antibiotics had no effect on pain in the first 24 hours and only a slight effect on pain the following days
- antibiotics did not reduce the number of children with recurrence of infection or hearing loss at three months
- antibiotics slightly reduced the number of children with perforation of the eardrum
- it is unclear whether antibiotics reduced rare complications of ear infection
- unwanted effects such as vomiting happened more often in children taking antibiotics
- antibiotics seem to be most useful in children younger than two years old with infection in both ears and in children with both infection and discharge from the ear
Most of the evidence was judged to be high quality and the findings are unlikely to change.
Steroids
A Cochrane Review on Systemic corticosteroids for acute otitis media in children (March 2018) shows that the effects of corticosteroids given by mouth or injection for acute middle ear infection are uncertain.
Find out more
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