Acute Otitis Media in Children

Updated Guidelines for Diagnosis and Management of Acute Otitis Media in Infants and Children

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Acute otitis media (AOM) was the third most frequent diagnosis in ambulatory care for patients under age 15 in the most recent National Ambulatory Medical Care Survey  and is the most common cause of antibiotic prescriptions for infants and children.[1] The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) have updated evidence-based guidelines for the diagnosis and management of uncomplicated AOM in children ages 6 months to 12 years.[2,3] I will attempt herein to summarize both the initial guideline published in 2004 and the current update. This summary will include the guideline’s assessment of quality of evidence and strength of conclusion, but will omit the supporting evidence reviewed by the guideline developers. Free full text of both is available online from the AAP containing summaries of the supporting evidence for each recommendation.

(http://pediatrics.aappublications.org/content/113/5/1451.full for the initial and http://pediatrics.aappublications.org/content/131/3/e964.full for the current update).

Here are the stated 2004 Recommendations:
1. To diagnose AOM the clinician should confirm a history of acute onset, identify signs of middle-ear effusion (MEE), and evaluate for the presence of signs and symptoms of middle-ear inflammation.
2. The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain.
3A. Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up.
3B. If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children.
4. If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent, the clinician should change the antibacterial agent.
5. Clinicians should encourage the prevention of AOM through reduction of risk factors.
6. No recommendations for complementary and alternative medicine (CAM) for treatment of AOM are made based on limited and controversial data.
The current update to the guidelines contain the following “key action statements” which correlate to the previous recommendations:AOM

I think it is noteworthy to mention some of the recommendations of the initial guideline, notably an option of “watchful waiting” while withholding antibiotics, has not been embraced by the practitioner community and remains unchanged. [4] I believe it is not that we do not appreciate the risks of prescribing unnecessary antibacterials or that we are unwilling to share informed decision-making with the parents and caretakers of our pediatric patients, but rather the burden of additional time and visits for the patients, families, as well as the healthcare system is substantial for a condition in which precise diagnosis by identification of bacterial antigens in the middle ear fluid is impractical in a primary care setting. The option of “observation with close follow-up” increases the possibility of error of omission of necessary observations and actions by a complex triad involving patients, caregivers, and clinicians. The existing healthcare system challenges coordinated communication even in the best of circumstances. If a toddler is holding his ear in day care, but is afebrile because he was prescribed acetaminophen or ibuprofen for otalgia the night before, will that information get processed into a decision process to trigger a re-evaluation?
Applying the revised guideline which requires proof of middle ear effusion (MEE) for diagnosis increases the necessity for additional diagnostic testing with associated time and expense.  Pneumatic otoscopy is a clinical procedure challenging to perform even in a cooperative patient. Tympanometry, even when available, is not reliable as an independent assessment of middle ear disease and must be combined with the clinical assessment. [5] Tympanometric systems cost over $2000, testing is often not reimbursed by third party payers, and importing the data into electronic records systems is not easy.

The recommendation to initiate antimicrobial therapy with amoxicillin (80–90 mg/ kg per day in 2 divided doses) unless contraindicated, remains in the revised guidelines.  Although I hear complaints from parents who claim “it never works in my child” and presentations from pharmaceutical manufacturers encouraging me to prescribe their branded products, I am comfortable with this practice. I believe this recommendation is based on evidence derived from sufficient microbiological studies including studies of the effect of the recent adoption of infant immunization with polyvalent pneumococcal conjugate vaccine (PCV). I find flavored amoxicillin chewable tablets are appreciated by those children who can use them and avert substantial inconvenience in transporting refrigerated suspensions in our highly mobile society.

The updated guidelines also have specific recommendations for initial treatment failure and a recommendation against antimicrobial prophylaxis to prevent episodes of recurrent otitis media.

Charles Sneiderman MD PhD DABFP
Family Physician and Medical Director
Culmore Clinic, Falls Church, VA

Published on May 7, 2013

Biosketch
Charles Sneiderman, MD PhD, retired in 2010 after a 31-year career in medical informatics at the Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health. His work included research and development in telemedicine, distance learning, and medical language and image processing. Since leaving federal service, he has developed a computerized clinical decision support system to assist primary healthcare practices in the recognition and management of post-traumatic stress syndromes with support from the NLM Disaster Information Management Research Center. Dr. Sneiderman received a B.S. with high honors from the University of Maryland in 1969, and M.D. and Ph.D. degrees from Duke University in 1975. He completed residency training in family medicine at the Medical University of South Carolina in 1979. He has authored numerous scientific reports, book chapters, and medical educational media. He was a Clinical Assistant Professor of Family Practice at the Uniformed Services University of the Health Sciences. He maintains certification by the American Board of Family Medicine and has practiced family medicine part-time in the Washington, DC area since 1980. He has assisted wounded warriors with adaptive snowsports since 2005.

References

  1. National Ambulatory Medical Care Survey. Top 5 diagnoses at visits to office-based physicians and hospital outpatient departments by patient age and sex: United States, 2008.  http://www.cdc.gov/nchs/ahcd/web_tables.htm
  2. Lieberthal AS, Carroll AE, Chonmaitree T, et al.  The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar;131(3):e964-999.
  3. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004 May;113(5):1451-1465.
  4. Coco A, Vernacchio L, Horst M, Anderson A.. Management of acute otitis media after publication of the 2004 AAP and AAFP clinical practice guideline. Pediatrics. 2010 Feb;125(2):214–220.
  5. Onusko E. Tympanometry. Am Fam Physician. 2004 Nov 1;70(9):1713-1720.

 


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