April 12, 2004
Recently a subcommittee representing the American Academy of Pediatrics and the American Academy of Family Physicians published new clinical practice guidelines for the diagnosis and management of acute otitis media (AOM). These guidelines provided six recommendations to primary care clinicians for the management of uncomplicated acute otitis media in children ages 2 months to 12 years. Within this document a number of recommendations were made ranging from diagnosis of AOM to alternative medicine treatments for the condition. The following provides a brief synopsis of the published guidelines.
To properly diagnose AOM there are three key elements that must be present. These elements are a history of acute onset of signs and symptoms, the presence of middle-ear effusion and signs and symptoms of middle-ear inflammation. In the diagnosis process it is very important to visualize the tympanic membrane. Therefore it is very important to remove cerumen that is blocking the tympanic membrane (Safe Ear Curettes, The Lighted Ear Curette and OtoClear® Safe Irrigation Tips). Inability to sufficiently clear the ear canal of cerumen leads to an increase in uncertainty when diagnosing.
The assessment and treatment of pain that the patient is experiencing is an important
part of the proper management of AOM.
Observation without the use of antibacterial treatment is becoming a more popular
option for managing AOM. This comes about from the growing evidence of antibacterial resistance that is occurring due to the overuse of antibacterial prescriptions in treatment. Observation is commonly used in Europe as they initially only treat the symptoms of AOM. If improvement in the patient’s condition is not seen within 48-72 hours then antibacterial prescriptions are used.
When using observation it is important that the parent have regular communication with the clinician and that there is a system of re-evaluation in place. This option is also only suggested for healthy children within the ages of 6 months to 2 years.
If the decision is made to treat AOM with an antibacterial prescription it is recommended that amoxicillin be used. Amoxicillin is the first choice due to its general effectiveness, safety, low cost and acceptable taste.
Once the clinician has decided between observation and the use of an antibacterial
agent for initial treatment the patient must be monitored for the first 48 to 72 hours by the
parent or caregiver. If the patient does not respond to this initial treatment they must be reassessed to ensure proper diagnosis. If AOM is confirmed the clinician must then alter the treatment. Therefore a patient managed with observation should then be given an antibacterial agent and a patient that was initially given an antibacterial agent should be prescribed a different antibacterial agent.
A reduction in risk factors should always be encouraged by the clinicians to assist in the prevention of AOM. Factors that should be considered are lowering the attendance in a day care setting, using breast feeding for at least the first 6 months of a child’s life, avoid supine bottle feeding and reducing or eliminating the use of a pacifier after 6 months of age.
There are a growing number of people that are utilizing nonconventional methods of treatment for their children. However, there is insufficient evidence to support a recommendation for the use of complementary and alternative medicine for the management of AOM.
(Clinical Practice Guideline, AAP & AAFP, 2003)
The complete Clinical Practice Guideline can be found by visiting the American Academy of Pediatrics website at http://aappolicy.aappublications.org.