INTERNATIONAL JOURNAL OF IMMUNOPATHOLOGY AND PHARMACOLOGY Vol. 23, no.

2, 567-575 (2010)

EFFECTIVENESS OF A PROPOLIS AND ZINC SOLUTION IN PREVENTING ACUTE

OTITIS MEDIA IN CHILDREN WITH A HISTORY
OF RECURRENT ACUTE OTITIS MEDIA

P. MARCHISIO, S. ESPOSITO, S. BIANCHINI, C. DESANTIS, C. GALEONEI, E. NAZZARI,

L. PIGNATAR02 and N. PRINCIPI

Department ofMaternal and Pediatric Sciences, University ofMilan, Fondazione IRCCS Ca'
Granda-Ospedale Maggiore Polie/inico, Milan; 1Department ofEpidemiology, Mario Negri
Pharmacological Research Institute, Milan; 'Department ofSpecialist Surgical Sciences, University
of Milan, Fondazione IRCCS Ca Granda-Ospedale Maggiore Policlinico, Milan, Italy

Received September 2, 2009 - Accepted January 11, 2010

Recurrent acute otitis media (rAOM) is frequently encountered in infants and children and the
lack of any definitive treatment has led parents and physicians to try complementary and alternative
therapies. We evaluated the efficacy of a propolis and zinc suspension in preventing AOM in 122 children
aged 1-5 years with a documented history of rAOM, who were prospectively, blindly, randomized 1:1
to receive the suspension plus elimination of environmental risk factors or elimination of environmental
risk factors only. AOM- and respiratory-related morbidity were assessed at study entry and every four
weeks. In the 3-month treatment period AOM was diagnosed in 31 (50.8%) children given the propolis
and zinc suspension and in 43 (70.5%) controls (p=0.04). The mean number of episodes of AOM per
child/month was 0.23 ± 0.26 in the propolis and zinc group and 0.34 ± 0.29 in controls (reduction 32.0%,
p=0.03). The administration of a propolis and zinc suspension to children with a history of rAOM can
significantly reduce the risk of new AOM episodes and AOM-related antibiotic courses, with no problem
of safety or tolerability, and with a very good degree of parental satisfaction. No effect can be expected
on respiratory infections other than AOM.

Recurrent acute otitis media (rAOM) is
frequently encountered in children in the first years
of life (1-2). Antibiotic prophylaxis has long been
considered the best means of reducing the incidence
of new episodes (3-4) but, although effective, it is
no longer recommended because it can contribute
to the emergence of resistant bacteria (5). Experts in
traditional medicine now indicate the elimination of
environmental risk factors and the use of influenza
and pneumococcal vaccines as methods that can be
used to try to prevent rAOM without any negative
impact (6-8). However, none of these methods lead
to optimal results and even when they are correctly
applied many otitis-prone children continue to suffer
from new episodes ofAOM (9-10).
As in the case of many other chronic or recurrent
diseases, the lack of any definitive therapeutic
solution for rAOM has induced many parents (and a
certain number of physicians) to try complementary
and alternative medicine (CAMs) (11-12), including

Key words: propolis, zinc, acute otitis media, recurrent acute otitis media, children

Mailing address: Professor Nicola Principi,

Department of Maternal and Pediatric Sciences,
Universita degli Studi di Milano,
Fondazione IRCCS Ca' Granda 0394-6320 (2010)
Ospedale Maggiore Policlinico Via Commenda 9, Copyright © by BIOLIFE, s.a.s.
20122 Milano, Italy This publication and/or article is for individual use only and may not be further
Tel: ++39 02 55032498; Fax: ++39 0250320206 reproduced without written permission from the copyright holder.
e-mail: Nicola.Principi@unimi.it
567 Unauthorized reproduction may result in financial and other penahies
568 P. MARCHISIO ET AL.
a mixture contammg echinacea, propolis and
vitamin C (13), Japanese herbal medicine (14),
xylitol (15-16), probiotics (17-18) and osteopathy
(19-20). These have sometimes led to similar results
to those obtained using traditional prophylaxis,
but most of the studies that have evaluated CAMs
in the prevention of rAOM have considerable
methodological limitations that prevent any firm
conclusions concerning their real efficacy (21-22).
Propolis is a natural product collected by bees
from the exudates ofplants to which a number ofanti-
inflammatory, antimicrobial and antiviral activities
and anticancer properties have been attributed (23-
25). It is widely used in the prevention and treatment
of respiratory infections (21). However, there are no
definitive data concerning its efficacy in preventing
AOM in children with a history of rAOM. Zinc is a
mineral that has an important function in regulating
the immune system, and its administration in
subjects with zinc deficiency leads to a significant
reduction in the development of infectious diseases
(26-27), but once again there are no data concerning
its use in children with rAOM. The aim ofthis study
is to evaluate the effectiveness of a propolis and
zinc suspension in preventing acute otitis media in
children with a documented history of rAOM.
MATERIALS AND METHODS
Population and eligibility criteria
One hundred thirty children were assessed for eligibility,
8 refused to participate and therefore 122 were randomly
divided into two groups. The study involved children
aged 1-5 years with a history of rAOM, defined as ~3
episodes in the preceding six months or ~4 episodes in
the preceding 12 months (6, 10), who had experienced
their most recent episode in the previous 2-8 weeks. The
episodes were documented by medical records, with ~2
episodes documented by symptoms as well as otoscopy and
tympanometric findings. The children had to be currently
free of AOM, but they could have otitis media with effusion
(OME). The exclusion criteria were antibiotic treatment in
the preceding 2 weeks, severe atopy, acquired or congenital
immunodeficiency, recent administrationof blood products,
cleft palate, persistent tympanic membrane perforation,
obstructive adenoids, sleep apnea syndrome, and the
placement oftympanostomy tubes.
Study design
This single-centre, prospective, randomized, single-
blind study was conducted in Italy between 1 December,
2004 and 31 March, 2005. The study protocol was
approved by the Ethics Committee of the University of
Milan, the research was conducted in accordance with
the guidelines for human experimentation specified by
the authors' institutions, and a parent or legal guardian
was required to provide written informed consent for
each child. A single-blind design was chosen because the
preparation of a placebo containing all the components of
the formulation except propolis and zinc was not possible
for technical reasons and a vitamin supplement without
zinc was not considered a suitable placebo because of the
possible influence of the course of respiratory diseases
(28-29).
Intervention
During one month (December) consecutive eligible
children were randomly assigned 1:I to the treatment
group (propolis and zinc suspension plus elimination
of environmental risk factors) or the control group
(elimination of environmental risk factors only).
Group allocation was made according to a computer-
generated randomization list in blocks of 4. Each child
in the treatment group would receive 0.3 mL/kg/day of
a suspension containing propolis (30% hydroglyceric
extract) and zinc sulfate (1.2%) (Flogoflu, Pharbenia,
Bayer, Italy) for three months, a dose that assured 3 mg/
kg/day of total f1avonoids (1 mg galangin) from propolis
and 0.15 mg/kg/day of elemental zinc. Elimination
of environmental risk factor included elimination of
exposure to passive smoking, of pacifier, and of full time
day-care attendance in the two treatment groups. A leaflet
with information about the effects on the occurrence of
AOM of passive smoking, pacifier suckling, and full-time
day-care attendance was given to all the parents and the
content was explained to parents during a 15-minute talk.
In order to ensure investigator blinding, the assignment
and treatment administration was performed by a single
investigator (SB), and the parents were instructed not to
discuss the assignment with the investigators (PM and
SE) responsible for clinical and otological follow-up,
who remained blinded to group assignment until the end
of follow-up period.
A nasopharyngeal specimen to evaluate the carriage of
bacterial pathogens was collected from all of the children
at the time of enrolment and at the final visit after three
months of treatment. Throughout the three months of the
study, the parents of all the enrolled children were asked
to keep a daily record on a diary card of the occurrence
of any systemic symptoms (including a rectal temperature
~38.1 DC, earache, cough, vomiting, diarrhea, rash), nasal
symptoms (including an itchy, stuffy or runny nose, and
sneezing), any problems with palatability and compliance.
 Int. J. Immunopathol. Pharmacol.
Adherence to suggestions regarding elimination of risk
factors was also recorded.
Study procedures
The children were examined at study entry and every
four weeks for three months. To overcome possible disease
under-reporting in the treated children due to the parents'
feeling that the treatment was providing protection, all of
the families were telephoned once a week to inquire about
the child's day-to-day status and remind parents of the
possibility of freely contacting an investigator at any time
of the day to arrange an extra visit within 24 hours if the
child developed respiratory symptoms. Moreover, during
the telephone calls, information regarding the apparent
safety and tolerability, as well as palatability of the
mixture was collected, paying particular attention to the
compliance with the administration ofthe prescribed doses
and, finally, the elimination of risk factors. Any negative
health episode occurring in the controls was recorded
in the same way. The investigators responsible for the
telephone calls were blinded to the group assignment until
the end of follow-up period.
At each visit, a history of infections since the previous
visit was obtained, and the subjects underwent pneumatic
otoscopy (Welch Allyn, model 20200) and tympanometry
(MicroTymp2, Welch Allyn or MTlO, Interacoustics),
together with a complete physical examination. The
procedures were always carried out by the same blinded
investigators validated in the use of the instruments.
A diagnosis of ADM was made on the basis of the
presence of any combination of fever, earache, irritability
and hyperemia or opacity accompanied by bulging or
immobility of the tympanic membrane; tympanometry
assisted in establishing the presence ofeffusion in doubtful
cases. Whenever ADM was diagnosed, amoxicillin plus
c1avulanic acid (80 mglkglday of amoxicillin) was given
for 10 days. No other treatment was allowed for ADM,
except for acetaminophen in the case of fever. Relapses or
recurrences were respectively defined as the reappearance
of any signs and symptoms of ADM ~ days or 5-14 days
after the end of therapy.
The nasopharyngeal samples collected at enrolment
and after three months of treatment were always obtained
by the two investigators responsible for the clinical and
ontological follow-up (PM and SE). A mini-culturette
extra-thin flexible wire swab (Becton Dickinson,
Cockeyville, MD, USA) with the tip bent at an angle of
30° was inserted through the child's mouth and placed
1-1.5 inches into the nasopharynx without touching
the uvula or tongue. The nasopharyngeal cultures were
inoculated into Stuart transport medium tubes (Venturi
Transystem, Italy), taken to the microbiology laboratory
and immediately processed. Streptococcus pneumoniae,
569
Haemophilus influenzae, Moraxella catarrhalis, and
Streptococcus pyogenes were isolated and identified using
standard laboratory procedures.
Compliance with the study regimen was encouraged
by asking parents to affix a written reminder of the
protocol to the refrigerator door. Parents were also asked
to bring the medication bottles with them at follow-up
visits, and compliance was evaluated on the basis of
the amount of drug remaining in the bottle. Failure to
administer two or more doses of the suspension solution
was considered poor compliance, but this was not a reason
for interrupting prophylaxis.
At the end of the study, one parent per child rated
his/her satisfaction with his/her child's participation:
"unsatisfied" (if he/she thought that something better
could have been done to prevent ADM), "satisfied" (if he/
she thought the approach to preventing ADM was good)
or "very satisfied" (if he/she thought that the best possible
approach had been adopted).
Statistical analysis
The data were compared using SAS software, version
9.1 (SAS Institute, Cary, NC, USA). The continuous
variables are given as mean values ± standard deviation
(SD), and were analyzed using a t test for approximately
normal variables (based on the Shapiro-Wilk statistic)
and Wilcoxon's rank-sum test otherwise; the categorical
variables are given as numbers and percentages, and were
analyzed by means of contingency tables and the chi-
squared or Fisher's test, as appropriate.
The primary outcome measure was the occurrence of
ADM within the 3-month treatment period; the secondary
outcome measures were any change in the frequency of
carriage of respiratory pathogens, the proportion of time
with bilateral DME, the occurrence of febrile respiratory
illnesses, and the use of antibiotics or antipyretics. The
analyses were made in relation to the intent-to-treat
population.
The sample size was determined on the basis of
published data regarding the efficacy of eliminating the
use ofa pacifier in reducing the incidence ofrADM (30).
Assuming a 20% case loss, a sample size of 120 subjects
was calculated, with a beta error margin of 0.20, an alpha
value of 0.05, and a power of 80%.
RESULTS
Table I summarizes the demographic
characteristics of the 122 children, 61 of whom
received the suspension of propolis and zinc, and
61 were assigned to the control group; there was no
significant between-group difference in relation to
570 P. MARCHISIO ET AL.

Table I. Demographic characteristics ofstudy participants.

Characteristic Propolis and zinc Controls Pvalue
suspension (n=6I) (n=6I)
Males 37 (60.6) 38 (62.3) 1.00
Age, mean (± SO), months 30.37 (± 13.75) 37.20 (± 15.50) 0.19
:524 months 24 (39.3) 19(31.1) 0.44
Caucasians 59 (96.7) 58 (95.1) 1.00
Breastfeeding 42 (68.9) 48 (78.7) 0.30
Urban residence 61 (100.0) 61 (100.0) n.e.
At least one older sibling 32 (52.4) 35 (57.4) 0.71
Exposure to passive smoking 13 (21.3) 15 (24.6) 0.83
Regular use of pacifier 36 (59.0) 38 (62.3) 0.85
Full-time childcare attendance" 39 (63.9) 42 (68.8) 0.70
Hospitalization in previous 3 months 0(0.0) 3 (4.9) 0.24
Presence of middle ear effusion 57 (93.4) 55(90.1) 0.74
Unilateral middle ear effusion 5 (8.2) 8(13.1) 0.51
Bilateral middle ear effusion 52 (85.2) 47 (77.0) 0.35
Mean number of AOM episodes per 0.66 (± 0.18) 0.64 (± 0.17) 0.34
child/month in previous 6 months (± SO)

Numbers in parentheses = percentages

ADM' acute otitis media; DME: otitis media with effusion; SD: standard deviation; n.e.: not evaluable. *5-6 days/week,
6-8 hrs/day

any of the epidemiological variables likely to affect
the history of rAOM. All of the children completed
the study, the overall follow-up period being 183
child-months for both groups. The compliance
with treatment regimens was very good: a total of
98.2% of propolis and zinc solution were correctly
administered. As regards elimination of risk factors,
passive smoking was eliminated in 60 (98.3%)
treated children and in 100% controls, pacifier was
reduced in 58 (95.1%) treated children and in 60
(98.3%) controls, and all the children in both groups
were able to attend day-care only in the morning.
Table II shows the occurrence of AOM
episodes, febrile respiratory illnesses, and antibiotic
administration during the study period. Thirty-one
treated children developed 43 episodes of AOM,
whereas 43 controls developed 63 episodes. No
relapses were diagnosed. The number of children
with at least one episode of AOM (50.8% vs 70.5%;
p=0.04), the mean number ofAOM episodes (0.70 vs
1.03; p=0.03), the number of patients treated with at
least one antibiotic course because of AOM (49.2%
vs 75.4%; p=0.005), and the mean number ofAOM-
related antibiotic courses (0.64 vs 0.98; p=0.0005)
were all significantly lower among the children
treated with the propolis and zinc suspension. In
comparison with the 6 months preceding enrollment,
there was a greater reduction in the incidence density
(AOM episodes per child/month) in treated children
(from 0.66 to 0.23) than in controls (from 0.63 to
0.34). There was no significant between-group
difference in the mean duration of bilateral OME,
the occurrence of febrile respiratory tract infection,
or the number of antibiotic courses administered
because of respiratory tract infections.
Table III shows the characteristics of
nasopharyngeal colonization at baseline and after
three months. About 50% of the children in both
groups were carrying respiratory bacterial pathogens
at baseline; after three months, this had significantly
decreased in the treated group but not in the control
group (p<O.OOOI). The suspension of propolis and
zinc was associated with a significant reduction
in the carriage of S. pneumoniae (p=0.02) and
H. irfiuenzae (p=O.OI). No change in any of the
bacterial pathogens was found in the control group.
Table IV shows the number and types of adverse
events recorded by the parents, and their satisfaction
 Int. J. Immunopathol. Pharmacol. 571

Table II. Occurrence ofacute otitis media. febrile respiratory illnesses. and antibiotic prescriptions during the 3-month
study period according to treatment group.

Efficacy measure Propolis and zinc Controls Propolis and Pvalue Difference between
suspension (n=61) (n=6l) zinc efficacy* the groups
(95% CI)
Children with 2: I 31 (50.8) 43 (70.5) 28.0% 0.04 19.7 (2.7 to 36.7)
AOM episode (%)
Mean number of 0.23 (± 0.26) 0.34 (± 0.29) 32.0% 0.03 0.11 (0.01 to 0.21)
episodes per
child/month (± SO)
Children given 2: I 30 (49.2) 46 (75.4) 35.1 % 0.005 26.2 (9.6 to 42.8)
antibiotic course
forAOM (%)
Mean number of 0.64 (± 0.69) 0.98 (± 0.73) 34.7% 0.005 0.34 (0.09 to 0.59)
antibiotic courses
for AOM per child
(± SO)
Mean duration of 8.62 (± 3.73) 9.50 (± 4.06) 9.3 % 0.24 0.88 (-0.50 to 2.26)
bilateral OME per
child ( ± SO),
months
Children with 2: I 45 (73.8) 47 (77.0) 4.3 % 0.84 3.3 (-12.1 to 18.5)
febrile RTI (%)
Mean number of 1.20 (± 0.94) 1.36 (± 1.26) 11.8 % 0.43 0.16 (- 0.23 to 0.55)
febrile RTI
episodes per child
(± SO)
Children given 2: I 46 (75.4) 50 (81.9) 8.0% 0.51 6.5 (- 8.0 to 21.0)
antibiotic course
for RTI (%)
Mean number of 1.29 (± 1.15) 1.31 (± 0.96) 1.6% 0.92 0.02 (-0.36 to 0.40)
antibiotic courses
for RTI per child (±
SO)

*Propolis and zinc efficacy = 1 minus attack rate (defined as the event rate divided by the total population) among the
treated children divided by the attack rate among controls (13).
AOM' acute otitis media; OME: otitis media with effusion; RTl: respiratory tract infection; SD: standard deviation

with their children's participation in the study.
Adverse events were very rare, mild, transient and
never required study discontinuation. Judgments of
"very satisfied" were significantly more frequent
in the treated group (p=O.002), and judgments of
"unsatisfied" were significantly more frequent in
the control group (p<O.OOOI) whereas none of the
parents of the treated children declared themselves
"dissatisfied".
DISCUSSION
The results of the study show that the
administration of a suspension containing propolis
and zinc to children with a history of rAOM can
significantly reduce the incidence of new episodes
of AOM and AOM-related antibiotic use, thus
enhancing the natural time-linked decline in the
occurrence of AOM and reducing the possible
increase in antibiotic-resistant pathogens. The
efficacy of the mixture was significantly better than
that obtained with eliminating environmental risk
factors, although less than that usually obtained
with antibiotic prophylaxis (3, 5). However, as
the mixture was safe and well tolerated, it can be
suggested that it be included in the list of remedies
capable of reducing the risk of new episodes of
AOM in children with a history of rAOM.
The mixture was effective in preventing only
AOM because the incidence of new episodes of
all the other respiratory infections was similar in
both groups during the study period. As respiratory
infections other than AOM are often due to viruses
in the first years of life and, although frequently
572 P. MARCHISIO ET AL.

Table III. Nasopharyngeal colonization ofrespiratory pathogens at baseline and after 3 months according to treatment
group.

Baseline After 3 months Pvalue

Propolis and zinc suspension 61 61
Carriers of respiratory pathogens 35 (57.4) 13 (21.3) <0.0001
S. pneumoniae 12 (19.7) 3 (4.9) 0.02
H. influenzae 18 (29.5) 6 (9.8) 0.01
M catarrha/is 1 (1.6) 1 (1.6) 1.00
S.pyogenes 4 (6.6) 2 (3.3) 0.68
Controls 61 61
Carriers of respiratory pathogens 33(54.1) 27 (44.3) 0.36
S. pneumoniae 11 (18.0) 9 (14.7) 0.80
H. influenzae 16 (26.2) 13 (21.3) 0.67
M catarrhalis 2 (3.3) 2 (3.3) 1.00
S.pyogenes 4 (6.6) 3 (4.9) 1.00

Numbers in parentheses = percentages

P values were calculated using the chi-squared or Fisher s test, as appropriate.

Table IV. Adverse events and degree ofparental satisfaction according to treatment group.

Characteristic Propolis and zinc Controls Pvalue

suspension (n=61)
(n=6I)
Adverse events
Vomiting 1 (1.6) 1 (1.6) 1.00
Rash I (1.6) 0(0.0) 1.00
Degree of parental satisfaction
Unsatisfied 0(0.0) 17 (27.9) <0.0001
Satisfied 40 (65.6) 38 (62.3) 0.85
Very satisfied 21 (34.4) 6 (9.8) 0.002

Numbers in parentheses = percentages

s
P values were calculated using the chi-squared or Fisher test, as appropriate.

preceded by a respiratory viral infection, AOM is
mainly caused by bacteria (31), this finding may
have been due to direct antimicrobial activity.
Further support to this hypothesis is given by the data
regarding the nasopharyngeal carriage of bacterial
respiratory pathogens: at the end of the study period,
the total number of children carrying S. pneumoniae
and H. influenzae was significantly lower only in the
group of subjects receiving the mixture of propolis
and zinc; no change was found among the controls.
Given the biological effects of propolis and zinc,
it is reasonable to assume that propolis was more
 Int. J. Immunopathol. Pharmacol.
relevant microbiologically. A number of authors have
demonstrated that propolis has in vitro bacteriostatic
and (at high contractions) bactericidal activity
against many pathogens, including all of the most
common causes ofAOM such as S. pneumoniae and
H. inf/uenzae (23-25). Zinc does not have any direct
antimicrobial activity (24) and, when given to zinc-
deficient children, reduces the risk of respiratory
infections by increasing host defenses rather than
by interfering with nasopharyngeal carriage (27);
furthermore, zinc is effective in reducing the risk of
infections only when administered to zinc-deficient
children, whereas its use in normal subjects is not
followed by any significant change in immune
function (26). As the children enrolled in this study
had never reported any nutritional problems, it is
likely that the zinc component of the mixture had
little or no effect in reducing the recurrence ofAOM.
In addition to its direct antimicrobial activity, propolis
has been attributed with other biological properties
(32), and its anti-oxidant and anti-inflammatory
activity may have contributed to its positive effect on
AOM recurrences.
Our data only partially agree with those reported
by Cohen et al. (13), who found that the incidence
of AOM and other respiratory infections could
be significantly reduced by the use of a herbal
preparation containing propolis together with
echinacea and vitamin C. One possible explanation
for this difference could be the fact that the benefits in
terms of the prevention of respiratory tract infections
in their study may have been due to the presence of
echinacea, which is known to prevent respiratory
tract infections (33-34).
Our study has a few limitations. The first is
that it was not double-blind or placebo-controlled;
however, we believe that the absence of a placebo
was compensated for by the fact that all ofthe parents
were contacted once a week to inquire about their
child's day-to-day status and remind them that they
could freely contact the investigators responsible
for the follow-up, and they were also instructed at
study entry and reminded at each visit not to discuss
group assignment with the only 2 investigators
responsible for clinical and otological follow-up.
The second limitation is that the suspension we
used is no longer marketed, but has been replaced
by a different suspension of the same composition
573
and with the same content of propolis and zinc
(Defenflu-S, Pharbenia, Bayer, Italy), in which
the active components of propolis are treated by
means of a procedure that leads to greater solubility
and bioavailability; consequently, it may be more
tolerable with a probable higher efficacy (35). The
third could be represented by the high number of
comparisons, which could imply that some of the
associations we found could be due to chance alone.
However, selected findings were significant at the
99% level, reassuring on their validity.
In conclusion, our data show that adequate
amounts of propolis and zinc can be administered
to children with rAOM to reduce the risk of new
AOM episodes and AOM-related antibiotic courses,
with no problem of safety and tolerability, and with
a very good degree ofparental satisfaction. No effect
can be expected on respiratory infections other than
AOM.
ACKNOWLEDGEMENTS
This study was supported in part by an unrestricted
grant from Pharbenia, Bayer, Italy.
Appropriate informed consent was obtained,
and the study was conducted in accordance with the
guidelines for human experimentation specified by
the authors' institution. None of the authors has any
commercial or other association that might pose a
conflict of interest.
REFERENCES
1. Paradise JL, Rockette HE, Colborn DK, Bernard BS,
Smith CG, Kurs-Lasky M, Janosky JE. Otitis media
in 2253 Pittsburgh-area infants: prevalence and risk
factors during the first two years of life. Pediatrics
1997; 99:318-33.
2. Sox CM, Finkelstein JA, Yin R, Kleinman K, Lieu
TA. Trends in otitis media treatment failure and
relapse. Pediatrics 2008; 121:674-9.
3. Leach AJ, Morris PS. Antibiotics for the prevention
of acute and chronic suppurative otitis media in
children. Cochrane Database of Systematic Reviews
2006, Issue 4. Art. No.: CD004401. DOl: 10.1002/
14651858.CD004401.pub2.
4. Meropol SB. Valuing reduced antibiotic use for
574 P. MARCHISIO ET AL.
pediatric acute otitis media. Pediatrics 2008; 121:
669-73.
5. American Academy of Pediatrics Subcommittee on
Management of Acute Otitis Media. Diagnosis and
management of acute otitis media. Pediatrics 2004;
113:1451-65.
6. Marchisio P, Cavagna R, Maspes B, Gironi S,
Esposito S, Lambertini L, Massimini A, Herzog C,
Principi N. Efficacy of intranasal virosomal influenza
vaccine in the prevention of recurrent acute otitis
media in children. Clin Infect Dis 2002; 35:168-74.
7. Jansen AG, Sanders EA, Hoes AW, van Loon AM,
Hak E. Effects of influenza plus pneumococcal
conjugate vaccination versus influenza vaccination
alone in preventing respiratory tract infections in
children: a randomized, double-blind, placebo-
controlled trial. J Pediatr 2008; 153:764-70.
8. Haggard M. Otitis media: prospects for prevention.
Vaccine 2008; 26S:G20-G24
9. Leibovitz E. The challenge of recalcitrant acute otitis
media: pathogens, resistance, and treatment strategy.
Pediatr Infect Dis J 2007; 26(S):8-ll.
10. Marchisio P, Esposito S, Bianchini S, Dusi E, Fusi
M, Nazzari E, Picchi R, Galeone C, Principi N.
Efficacy of injectable trivalent virosomal-adjuvanted
inactivated influenza vaccine in preventing acute
otitis media in children with recurrent complicated
or non-complicated acute otitis media. Pediatr Infect
Dis J 2009; 28:855-9.
II. Carr RR, Nahata Me. Complementary and alternative
medicine for upper respiratory tract infection in
children. Am J Health Syst Pharm 2006; 63:33-9.
12. Bukutu C, Deol J, Vohra S. Complementary, holistic,
and integrative medicine: therapies for acute otitis
media. Pediatr Rev 2008; 29:193-9.
13. Cohen HA, Varsano I, Kahan E, Sarrell EM, Uziel
Y. Effectiveness of an herbal preparation containing
echinacea, propolis, and vitamin C in preventing
respiratory tract infections in children. Arch Pediatr
Adolesc Med 2004; 158:217-21.
14. Maruyama Y, Hoshida S, Furukawa M, Ito M.
Effects of Japanese herbal medicine, Juzen-taiho-to,
in otitis-prone children - a preliminary study. Acta
Otolaryngol 2009; 129:14-18.
15. Uhari M, Tapiainen T, Kontiokari T. Xylitol in
preventing acute otitis media. Vaccine 2000; 19(5) 1:
144-7.
16. Hautalahti 0, Renko M, Tapiainen T, Kontiokari
T, Pokka T, Uhari M. Failure of xylitol given three
times a day for preventing acute otitis media. Pediatr
Infect Dis J 2007; 26:423-7.
17. Hatakka K, Blomgren K, Pohjavuori S, Kaijalainen
T, Poussa T, Leinonen M, Korpela R, Pitkaranta
A. Treatment of acute otitis media with probiotics
in otitis-prone children - a double-blind, placebo-
controlled randomized study. Clin Nutr 2007; 26:
314-21.
18. Rautava S, Salminen S, Isolauri E. Specific probiotics
in reducing the risk of acute infections in infancy - a
randomized, double-blind, placebo-controlled study.
Br J Nutr 2009; 101:1722-6.
19. Degenhardt BF,Kuchera ML. Osteopathic evaluation
and manipulative treatment in reducing the morbidity
of otitis media: a pilot study. J Am Osteopath Assoc
2006; 106:327-34.
20. Wahl RA, Aldous MB, Worden KA, Grant KL.
Echinacea purpurea and osteopathic manipulative
treatment in children with recurrent otitis media:
a randomized controlled trial. BMC Complement
Altern Med 2008; 8:56.
21. Carr RR, Nahata Me. Complementary and
alternative medicine for upper respiratory tract
infection in children. Am J Health Syst Pharm 2006;
63:33-9.
22. Altunc U, Pittler MH, Ernst E. Homeopathy for
childhood and adolescence aliments: systematic
review of randomized clinical trials. Mayo Clin Proc
2007; 82:69-75.
23. Drago L, Mombelli M, De Vecchi E, Fascina MC,
Tocalli L, Gismondo MR. In vitro antimicrobial
activity of propolis dry extract. J Chemother 2000;
12:390-5.
24. Sforcin JM. Propolis and the immune system: a
review. J Ethnopharmacol2007; 113:1-14.
25. Schnitzler P, Neuner A, Nolkemper S, Zundel C,
Nowack H, Sensch KH, Reichling J. Antiviral
activity and mode of action of propolis extracts and
selected compounds. Phytother Res 2009; May 27
Epub.
26. Fischer Walker C, Black RE. Zinc and risk of
infectious disease. Ann Rev Nutr 2004; 24:255-75.
27. Coles C, Sherchand 18, Khatry SK, Katz J, Leclerq
 Int. J. Immunopathol. Pharmacol.
SC, Mullany LC, Tielsch JM. Zinc modifies the
association between nasopharyngeal Streptococcus
pneumoniae carriage and risk of acute lower
respiratory infection among young children in rural
Nepal. J Nutr 2008; 138:2462-7.
28. Heimer Ka, Hart Am, Martin LG, Rubio-Wallace S.
Examining the evidence for the use of vitamin C in
the prophylaxis and treatment of the common cold. J
Am Acad Nurse Pract 2009; 21:295-300.
29. Hughes DA, Norton R. Vitamin D and respiratory
health. Clin Exp Immunol2009; 158:20-25.
30. Niemela M, Pihakari 0, Pokka T, Uhari M. Pacifier
as a risk factor for acute otitis media: a randomized,
controlled trial of parental counseling. Pediatrics
2000; 106:483-8.
31. Chonmaitree T, Reval K, Grady 11, Clos A, Patel JA,
Nair S, Fan J, Henrickson KJ. Viral upper respiratory
infection and otitis media complication in young
children. Clin Infect Dis 2008; 46:815-23.
575
32. Viuda-Martos M, Ruiz-Navajas Y, Fernandez-Lopez
J, Perez-Alvarez JA. Functional properties of honey,
propolis, and royal jelly. J Food Sciences 2008, 73:
R1l7-24.
33. Schoneberger D. Influence ofthe immunostimulating
effect of the pressed juice of Echinacea purpureae
on the duration and intensity of the common cold:
results of a double blind clinical trial (in German).
Forum Immunol1992; 2:18-22.
34. Schmidt U, Albrecht M, Schenk N. Plankliches
immunostimulans senkt haufigkeit grippaler infekte:
plazebokontrollierte doppelblindstudie mit einem
kombinierten Echinacea-praparat mit 646 studenten
der Kolner Universitate. Nat Ganzheits Med 1990; 3:
227-81.
35. Drago L, De Vecchi E, Nicola L, Gismondo MR.
In vitro antimicrobial activity of a novel propolis
formulation (Actichelated propolis). J Appl
Microbiol2007; 103:1914-21