- Design
- Systematic review and meta-analysis
- Population
- 2,070 children with chronic or recurrent otitis media in 28 studies
- Primary outcome
- Pepsin detection in middle ear effusion
- Effect
- Pooled detection 72.5% (95% CI 53.7% to 88.0%); Hedges' g 1.92 vs controls
This meta-analysis gathered 28 studies, 2,070 children, on the link between reflux and chronic or recurrent otitis media with effusion. In 15 studies measuring pepsin in the effusion, it was detected in about 72.5% (95% CI 53.7% to 88.0%), and concentrations were much higher than in controls.
Detection depended heavily on the assay: 85.6% with ELISA against 17.9% with enzymatic methods. Diagnostic criteria for reflux and otitis media varied widely across studies, and heterogeneity was substantial.
The presence of gastric enzymes in the middle ear supports a role for reflux in some children. It does not show that treating reflux helps the ear.
Acid-suppressing drugs are not a proven treatment for otitis media with effusion, and they carry their own risks in children. Management should continue to follow current guidance on watchful waiting and grommets.
- Do not start proton pump inhibitors for otitis media with effusion on the strength of this association
- Ask about reflux symptoms in children with persistent effusion as part of the history
- Continue to manage otitis media with effusion with watchful waiting and grommets per current guidance
- Pepsin testing of effusions is a research tool, not a routine test
Why it matters
It raises a plausible mechanism for persistent effusion that has not yet been tested with treatment.
Don't overread it
Finding pepsin in the ear does not show that reflux treatment improves otitis media.
The statistics, in plain English
The wide confidence interval for pepsin detection, 54% to 88%, and the big difference between assays show how much the studies disagreed. High heterogeneity means the pooled figure is a rough guide only.
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