Pepsin turned up in most children's middle ear effusions

Design

Systematic review and meta-analysis

Population

2,070 children with chronic or recurrent otitis media, 28 studies

Primary outcome

Pepsin detection in middle ear effusion

Effect

Pooled detection 72.5% (95% CI 53.7% to 88.0%)

A meta-analysis pooled 28 studies of 2,070 children with chronic otitis media with effusion or recurrent acute otitis media, looking for evidence of reflux.

Pepsin was detected in middle ear effusions in a pooled 72.5% (95% CI 53.7% to 88.0%), rising to 85.6% with ELISA methods. Pepsin concentrations were much higher than in controls (Hedges' g 1.92). Diagnostic criteria for reflux and otitis media varied widely between studies.

The finding supports reflux as a possible contributor in some children, but it does not show that treating reflux helps the ears. Acid-suppressing drugs are not a substitute for standard otitis media management on this evidence.

• Ask about reflux symptoms in children with persistent middle ear effusion
• Do not start acid suppression for otitis media on this evidence alone
• Continue standard watchful waiting and grommet criteria for effusion
• Consider paediatric gastroenterology review where reflux symptoms are prominent

Why it matters

It strengthens a biological link between reflux and middle ear disease without yet giving a treatment target.

Don't overread it

Detection of pepsin shows exposure, not that reflux causes the effusion or that reflux treatment would clear it.

The statistics, in plain English

The wide interval for prevalence (54% to 88%) and the dependence on test method show how variable the underlying studies were.

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