Question

• In children with a history of otitis media, will Xylitol help prevent recurrent infections?

Clinical Bottom Lines

1. Xylitol chewing gum is effective in preventing acute otitis media in children when used 8.4 gm total daily dose, divided 5 times a day.
2. Xylitol syrup is effective in preventing acute otitis media in children when used 10 gm/day divided 5 times a day.
3. Xylitol lozenges showed no significant benefit compared to control syrup.

Summary of Key Evidence

1. 857 healthy children were randomized into one of 5 different treatment groups to receive control syrup (n=165, mean age 2.2), xylitol syrup (n=159, mean age 2.2), control chewing gum (n=178, mean age 4.6), xylitol chewing gum (n=179, mean age 4.6), or xylitol lozenges (n=176, mean age 4.7).¹
2. 3 month randomized, controlled trial, blinded within chewing gum and syrup groups.
3. Comparison of xylitol syrup with control syrup showed an ARR of 12%, with an NNT of 8 to prevent one episode of AOM; ARR 26% and an NNT of 4 in preventing any episode of AOM.
4. Comparison of xylitol chewing gum with control chewing gum showed an ARR of 12%, with an NNT of 8 in preventing one episode of AOM. To prevent any episode of AOM, the ARR=15% with an NNT of 7.
5. No statistically significant difference with xylitol lozenges compared with control chewing gum.

Additional Comments

• Antimicrobial prophylaxis is problematic because of potential development of resistant strains.
• Xylitol is a 5-carbon polyol used as a sweetening substitute for sucrose; used widely in Europe. It is found in many plants such as raspberries, plums, strawberries (and Rowan berries?!).
• Xylitol inhibits growth of S. Mutans, and prevents dental caries.
• Xylitol can cause osmotic diarrhea in dosages of 30 - 40 gm/day.
• Bacteriologic studies show xylitol inhibits growth of S. Pneumoniae (no decrease in nasopharyngeal carriage was demonstrated in 1996 study).
• Mechanism of action is questionable: no decrease in nasopharyngeal carriage of S. Pneumoniae. Gum chewing itself is not the mechanism of action, as there was a difference between control and xylitol chewing gum.
• Peak age of AOM is 6 - 18 months, and the study population was a little older than this.
• Large percentage of the patient population had adenoidectomies, unlike U.S. Children. This may have had some effect.
• Where can we get xylitol in the U.S.? Not a component of major chewing gum brands. Our pharmacy doesn't carry it.
• Xylitol was dosed 5 times a day in this study - this could be difficult for families.
• Xylitol seems to be dose-dependent but the range of efficacy is unknown. Safety in different ages is also unknown.
• Range of adverse effects unknown.
• Allen Mitchell, M.D. and his group at Boston University are studying this, and hopefully will be able to answer these questions.

Citation

1. Uhari. Pediatrics 1998;102(4):879-884.
2. Uhari, L. BMJ, 1996;313(7066):1180-1183.

CAT Author: Lisa Sprague, MD

CAT Appraisers: Robert Schumacher, MD

Date appraised: June 18, 2001