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At the end of 2010, we faced a new phenomenon ofspontaneous ear drainage in very preterm infants. Overthe following two-and-a-half years, we saw 22 patients inour neonatal intensive care unit (NICU) with ear drain-age, with symptoms starting at a mean age of 20 days(range 4–101 days, standard deviation 21.8 days). Weconsulted a number of experts to help solve the problem,including paediatric infectious disease doctors, microbiol-ogists and infection control nurses from the hygienedepartment. The Rhinovirus was detected in two patients3–4 weeks before they showed symptoms of ear drainage.Bacterial cultures were obtained from all ear drainages,and the majority of these showed no growth (n = 4) ormixed flora (n = 11). The positive cultures showed strainsof Staphylococcus Aureus (n = 3), Acinetobacter Bau-mannii (n = 2), Klebsiella Oxytoca (n = 1) and coagulase-negative staphylococci (n = 1). Seven patients had alreadyreceived intravenous antibiotics when the ear drainagewas detected and the remaining 15 were given antibioticswhen they displayed symptoms. Seven of the patientsreceived intravenous cefuroxime, eleven were given acombination of intravenous cefuroxime and topical oflox-acine, three received a combination of intravenous clox-acillin, gentamycin and topical ofloxacine and one wasgiven a combination of oral amoxicillin and topicalofloxacine. The course of the disease was uneventful inall the patients, and the drainage was resolved during thecourse of their antibiotic treatment.Even though the issue was evaluated by several experts,there was no obvious explanation for this new problem inour unit. There was no increase in other nosocomialinfections, and no related changes in infection controlprocedures or equipment used in the NICU could beidentified.Nineteen of our cases had previously been intubated, andall of them had had a nasogastric tube before theydeveloped ear drainage. During mechanical ventilation,endotracheal tubes need to be securely fixed, usually withmedical adhesive tape, and tape is also used to fix nasogas-tric tubes. Upon extubation, or removal of the nasogastrictube, the adhesive tape needs to be gently removed to avoidskin damage. In our unit in Turku University Hospital, theuse of a commercial adhesive remover was recently intro-duced for this purpose.Then two of the authors (LL and KH) attended thePediatric Academic Societies’ meeting in Washington, DC,in May 2013, and were surprised to find a poster describingthe very same clinical problem. Dr Khattab had workedwith her staff and colleagues to identify the origin of theproblem,andwhentheycarriedoutasystematicinterventionprotocol, this showed that a commercial adhesive removerwas the toxic agent irritating the outer ear canal. The samecommercial adhesive remover was also routinely used forthis purpose in our unit, even though the manufacturer’sinstructions stated that the adhesive remover was notindicated for use on infants (1). As soon as Dr Khattabshared her findings with us, we banned the use of thecommercial adhesive remover in our NICU and no eardrainages cases occurred in our NICU during the following12-month period.This issue of the journal publishes the work of Dr Khattabet al. (2) to help all the units who have made the unfortu-nate choice of using off-label adhesive remover in preterminfants.There is a more general lesson to be learned about howcautious we need to be with all medical agents in preterminfants, even external ones. A number of medications areused in premature infants on an off-label basis, mainlybecause many drugs are not studied using this patient groupand, therefore, no clinical indications can be issued. Therisks of off-label prescribing need to be thoroughly balancedwith the potential benefits before introducing them intoclinical practice, as many medications behave differently inpremature infants (3). In this case, the off-label use of anadhesive removal patch was not considered criticallyenough, perhaps because it was used externally and not totreat a disease, and it proved to be harmful to prematureinfants. These ear drainage cases are a timely reminder thatwe need to perform critical analyses of all agents used inpreterm infants, even those used externally. We are gratefulto our colleagues from New Haven for sharing theirdiscovery, and we hope that their paper will raise awarenessof these issues.Kjell Helenius, Hanna Soukka, Liisa Lehtonen(lianle@utu.fi)Department of Pediatrics, Turku University Hospital andTurku University, Turku, FinlandReferences