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© 2004 American Academy of Pediatrics
AOM guideline addresses use of antibiotics and analgesics
by Trisha Korioth Before writing that next prescription for antibiotics, pediatricians first should be certain their patient has acute otitis media (AOM) and then treat associated pain with analgesic medications. This recommendation is part of the Clinical Practice Guideline Diagnosis and Management of Acute Otitis Media), by the Academy and the American Academy of Family Physicians Subcommittee on Management of Acute Otitis Media. The guideline, which will be published in the May Pediatrics, addresses appropriate management of AOM in children ages 2 months through 12 years.
Is it AOM or OME? "The management of AOM and OME are completely different. It is important to diagnose AOM accurately in order to manage it correctly" he said. AOM is the most common infection for which antibacterial agents are prescribed for U.S. children. The definition developed by the subcommittee defines AOM is:
But surveys find that only a minority of pediatricians use pneumatic otoscopy routinely when diagnosing AOM, and many pediatric training programs do not routinely teach pneumatic otoscopy, Dr. Lieberthal said.
Consider observation "Selected children may be considered for observation. This does not apply to all children and there are pretty stringent criteria for who would qualify for this option," said Dr. Lieberthal. The observation option is limited to otherwise healthy children ages 6 months to 2 years of age with non-severe illness at presentation and an uncertain diagnosis and to children 2 years and older without severe symptoms at presentation or with an uncertain diagnosis. The guideline encourages clinicians to consider the observation option, taking into account patient preference. "With the new guideline, we are pointing out the importance of accurate diagnosis. An abnormal ear without AOM does not necessarily need antibiotics," Dr. Lieberthal said. If the patient fails to respond to initial care after 48-72 hours, reassessment and confirmation of AOM must be made. If the patient was not initially treated with an antibiotic, one should be started. If the patient initially received an antibacterial agent, the antibacterial agent should be changed, according to the guideline.
Analgesics and antibiotics "Pediatricians tend to under-treat pain as a specific symptom and tend not to treat the symptom of pain perhaps as aggressively as they should," said Dr. Lieberthal. According to the guideline, the choice of first-line antibacterial treatment should be based on anticipated clinical response. Amoxicillin generally is effective when used in sufficient doses against susceptible and intermediate resistant pneumococci. It also is safe, low in cost, has an acceptable taste and narrow microbiologic spectrum. The recommended dose is 80 to 90 mg/kg/day for 10 days. For older children, a shorter course can be considered. For patients with severe illness and those for whom additional coverage for beta-lactamase positive Haemophilus influenzae and Moraxella catarrhalis is desired, the guideline recommends high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component, with 6.4 mg/kg/day of clavulanate in two divided doses).
Resistance from parents, child care providers "(Not writing a prescription for antibiotics) should not have an impact on days missed from work," said Dr. Lieberthal. "To exclude a child from day care for an ear infection is not really necessary. "The evidence is that symptoms, primarily pain, are only shortened by approximately 1 day in children who are treated with antibiotics, and those symptoms can be relieved by pain medications." He suggests pediatricians implement strategies for the observation option, such as a parent-initiated visit and/or phone contact for worsening symptoms or no improvement at 48-72 hours, routine follow-up phone contact or use of a safety-net antibiotic prescription to be filled if illness does not improve in 48-72 hours.
Preventive practices
A Q&A about AOM diagnosis and treatment is available on the Members Only Channel of the AAP Web site.
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