While reading the article by Ah-Tye et al,1 which appeared in the June 2001 issue of Pediatrics, I was reminded of an incident early in my career when I was asked by a pediatric infectious disease specialist to look in the ears of a child who was being seen for recurrent acute otitis media with effusion (OME). In the corridor consultation, I was told that the 16-month-old child had recurrent acute otitis media and middle ear effusion that had been present almost constantly since 2 months of age. The child had been seen by several primary care physicians as well as 2 otolaryngologists and was now on his third set of tympanostomy tubes. Otorrhea had been almost continuously present since the first set of tubes was placed at 5 months of age. Aside from history of OME, the child was generally healthy with normal growth and development and absence of diarrhea or skin lesions. Laboratory tests had included normal complete blood counts, erythrocyte sedimentation rate, and immunoglobulins, including IgG subclasses.
As I examined the child’s ears with my pneumatic otoscope, I noted the presence of tympanostomy tubes and a light-colored fluid behind the eardrums. Upon creating negative ear-canal pressure with the pneumatic otoscope, a white fluid came through the tympanostomy tube into the ear canal.
After seeing the white fluid, I turned to the parents and asked whether they were accustomed to putting the child to bed supine with a bottle of milk. They answered “yes.” When I asked them whether anyone had previously inquired about bedtime bottle-feeding, they said “no.”
We then discussed “positional otitis media,” which was described by Beauregard2,3 and others.4–6 At first, they were concerned about being able to stop the bedtime bottle; however, they succeeded and, at telephone follow-up 6 months later, they reported that the otorrhea had stopped shortly after the visit and the child subsequently had no additional episodes of otitis media.
Since that time, I have seen many children with recurrent OME who, upon stopping the bedtime bottle, had a marked reduction or elimination of episodes of OME. I hope this letter serves as a reminder for physicians to inquire about bottle-propping. I also wonder whether Ah-Tye et al had information on the feeding position and type7 for the group of infants in which they reported otorrhea.
Dr Katcher’s observations are interesting. We too have seen repeated reflux of ingested milk through a tympanostomy tube, but only in an infant with cleft palate, a phenomenon that was also described by Braganza and colleagues.1 In infants with normal palates the phenomenon must be rare indeed, despite the likelihood that many infants with tubes in place continue to be fed, at least some of the time, in the supine position. On the other hand, in roentgenographic studies 3 decades ago in infants with normal palates and tympanostomy tubes in place, Bluestone and colleagues2 described retrograde reflux of liquid from the nasopharynx through the eustachian tube and into the middle-ear cavity in certain of the infants. It seems likely that the occurrence of such reflux depends on loss of the middle-ear air cushion as the result of tube placement or tympanic membrane perforation.
It is tempting to assume that feeding position may play a role in the pathogenesis of otitis media, but the evidence remains anecdotal. Nonetheless, stopping the bedtime bottle certainly seems worth a try in children with persistent or recurrent problems.
Unfortunately, we do not have information about feeding methods in the infants in whom we reported otorrhea. However, as we reported, the extent of otorrhea was inversely related to the family’s socioeconomic status3 (as is the extent of otitis media in general4), and it seems likely that the same inverse relation holds regarding the extent of bottle-propping. What factor might be primary in all these relations remains a matter of speculation.
- ↵Ah-Tye C, Paradise JL, Colborn DK. Otorrhea in young children after tympanostomy-tube placement for persistent middle-ear effusion: prevalence, incidence, and duration. Pediatrics.2001;107 :1251– 1258
- ↵Paradise JL, Rockette HE, Colborn DK, et al. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics.1997;99 :318– 333
- Copyright © 2002 by the American Academy of Pediatrics