Comparative efficacy of different probiotic strains and preparations for prevention of acute otitis media in children: a systematic review and network meta-analysis

Why clinicians should know about it

• Picked for Otorhinolaryngology (top studies of the week, 26 July 2026): Probiotic strains for AOM prevention, pediatric focus not ENT surgical

Abstract

BACKGROUND: Probiotics are established candidates for preventing acute otitis media (AOM) in children, yet existing meta-analyses treat all probiotic interventions as a single class, precluding strain-specific clinical guidance. This network meta-analysis (NMA) compared the efficacy and safety of individual probiotic strains for pediatric AOM prevention. METHODS: We systematically searched PubMed, Embase, the Cochrane Library, Web of Science, CNKI, WanFang, and CBM from inception to 15 March 2026. Eligible studies were RCTs evaluating probiotic interventions for AOM prevention in children aged 0-18 years. The primary outcome was AOM incidence; secondary outcomes included antibiotic prescription rates, tympanostomy tube placement rates, and adverse events. NMAs were performed using a multivariate random-effects frequentist framework (Stata 17.0). Treatment ranking was estimated using SUCRA values. RESULTS: Eighteen RCTs (reported in 20 publications) enrolling 4,462 children were included, evaluating seven probiotic nodes (SS-K12, SS-24SMB, BB-12, CBA-L74, LGG, Multi-strain, α-Strep) against placebo. For AOM incidence, only CBA-L74 (OR = 0.27, 95% CI: 0.11-0.68; SUCRA = 89.3%) and SS-K12 (OR = 0.44, 95% CI: 0.20-0.94; SUCRA = 71.8%) achieved statistically significant reductions vs. placebo. Sensitivity analyses excluding two high risk-of-bias trials showed that SS-K12's effect was substantially attenuated and lost significance, whereas CBA-L74 remained robustly effective (OR = 0.28, 95% CI: 0.14-0.56). For antibiotic prescription rates, Multi-strain (OR = 0.45; SUCRA = 87.1%) and LGG (OR = 0.69; SUCRA = 65.3%) demonstrated significant reductions; both were superior to SS-K12 in direct pairwise comparisons. No intervention significantly reduced tympanostomy tube placement rates, though Multi-strain showed the most favorable numerical trend (SUCRA = 93.2%). Among exploratory outcomes, SS-K12 and LGG significantly reduced RTI incidence, while CBA-L74 and LGG significantly reduced AGE incidence, with CBA-L74 ranking first for AGE (SUCRA = 95.9%). CONCLUSIONS: Probiotic efficacy for AOM prevention is highly strain-specific. CBA-L74 demonstrated the most robust and consistent protection across AOM and gastrointestinal outcomes; Multi-strain combinations and LGG were most effective for antibiotic stewardship. These findings provide the first strain-level evidence base to guide rational probiotic selection in pediatric AOM prevention. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420261360351, identifier CRD420261360351.

Abstract as published, via PubMed.