Acute Otitis Media

[Guest guest]

Some new guidelines by the American Assn. of Pediatrics and AAFamily Practice

for treatment of acute otitis media:

AOM is the most frequently occurring bacterial illness in children, and it

accounts for 50% of antibiotics prescribed for U.S. preschoolers. More than five

million AOM cases occur annually in U.S. children, resulting in more than 10

million annual antibiotic prescriptions. Although the number of office visits

for otitis media with effusion (OME) decreased from 25 million in 1990 to 16

million in 2000, there has been no decline in the number of antibiotic

prescriptions to treat AOM.

Prompted by concern about the significant increase in antibiotic resistance of

organisms causing AOM, the panel reviewed and graded available evidence and

drafted new guidelines defining diagnostic criteria and treatment standards for

AOM based on age and other clinical parameters. However, these guidelines are

intended only as recommendations and not as substitutes for clinical judgment.

The guidelines mandate accurate diagnosis of AOM versus OME, based on criteria

of recent, usually abrupt, onset of illness; presence of middle-ear effusion;

and signs or symptoms of middle-ear inflammation.

Pain relief in the first 24 hours should be achieved with ibuprofen or

acetaminophen, because antibiotics typically do not relieve pain in the first 24

hours, and they have only a minimal effect on pain subsequently. By 24 hours,

about 60% of children have pain relief, and this percentage increases to 80% to

90% within a few days.

" We want parents and doctors to first make the child comfortable with pain

relievers such as ibuprofen and acetaminophen, " says panel cochair Ted Ganiats,

MD, a family physician from San Diego, California. " Antibiotics do not relieve

pain during the first 24 hours and do not reduce fever any quicker or better

than pain medicines. "

Antibiotics should be prescribed for certain or suspected AOM in children aged

six months and younger, and for certain or suspected AOM with severe symptoms in

children aged six months to two years. The antibiotic of choice is amoxicillin,

80 to 90 mg/kg/day.

Approximately 80% of children with AOM improve without antibiotics, and those

not treated immediately with antibiotics are unlikely to develop serious

complications. However, children must be followed carefully and given

antibiotics if symptoms persist or get worse.

To minimize development of antibiotic resistance, parents and physicians may

therefore elect observation only for 48 to 72 hours in uncertain or suspected

AOM with nonsevere symptoms in children aged six months to two years, followed

by antibiotics if there is no improvement. Initial antibiotic treatment should

be reserved for those most likely to benefit. The panel suggests that using an

observation option could reduce the annual number of antibiotic prescriptions by

up to three million and could significantly reduce the prevalence of resistant

bacteria.

Because the benefit of using antibiotics for AOM is typically small, it must be

balanced against potential risks, including diarrhea or vomiting in about 15% of

patients and serious or life-threatening allergic reactions in up to 5%.

The panel warns that these guidelines apply only to otherwise healthy children,

and not to those with a clinical recurrence of AOM within 30 days, with

underlying chronic OME, or with underlying conditions that may alter the natural

course of AOM, such as cleft palate, Down syndrome, immune system disorders, and

cochlear implants. Antibiotics may also be appropriate if a child appears very

sick or has a high fever.

Prevention should include reducing risk factors by breast-feeding babies and

infants for at least six months, avoiding " bottle propping, " and eliminating

passive exposure to tobacco smoke.

The panel found insufficient evidence to recommend for or against complementary

or alternative medicine in AOM.

Pediatrics. Posted online March 9, 2004.