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Diagnosis and Management of AOM

The joint clinical practice guideline from the American Academy of Pediatrics and the American Academy of Family Physicians

Acute otitis media (AOM) continues to occupy the pages of pediatric journals, and JW Pediatrics and Adolescent Medicine has published many summaries on this topic. Why? An obvious answer is that AOM is the most common illness for which children receive antibiotics. More to the point may be the uncertainty, complexity, and variability that accompany the diagnosis and management of this condition. After many years of struggle, the American Academy of Pediatrics and the American Academy of Family Physicians have released a joint clinical practice guideline for AOM. Interestingly, their recommendations echo those promulgated by "ear experts" in a recent review (see JW Pediatr Adolesc Med Mar 29 2004).

Two important themes emerge:

• Accurate diagnosis is imperative, and middle-ear effusion (MEE) must be present to make the diagnosis. MEE can be confirmed by pneumatic otoscopy. The clear intent is to improve diagnostic accuracy by regular use of insufflation bulbs or other tests of middle-ear mobility.
  
• In practice, certain diagnosis (rapid onset, signs of MEE, signs and symptoms of middle-ear inflammation) is not always possible, and, depending upon the child's age and the clinician's confidence in the diagnosis, therapeutic options vary. Observation is a reasonable alternative to antibiotics in children who are older and relatively well.
  

Specific recommendations include:

• Children younger than 6 months should receive antibiotics.
  
• Children aged 6 months to 2 years should receive antibiotics if diagnosis is certain or disease is severe (moderate-to-severe ear pain or temperature 39°C); observation is appropriate if the diagnosis is uncertain and the illness is mild or moderate.
  
• Children older than 2 years should receive antibiotics if the diagnosis is certain and the illness is severe; others can be observed with follow-up. Whenever observation is the chosen approach, follow-up must be assured and antibiotics started if necessary.
  
• Pain relief, including acetaminophen, ibuprofen, and topical agents, is an important part of management. Few data are available about the effectiveness of such home remedies as application of heat or cold oil or homeopathic agents. Codeine is effective for moderate or severe pain. I vividly recall a parent calling the day after I had diagnosed AOM in her 4-year-old child and given her a prescription for three doses of codeine. She was profusely thankful that both she and her child had slept through the night. Antibiotics may help to clear the infection, but they do little for pain.
  
• When an antibiotic is prescribed, most children should receive amoxicillin (80 mg to 90 mg/kg/day). Amoxicillin is recommended for its safety, low cost, acceptable taste, and general effectiveness against susceptible and intermediate resistant pneumococci. In children with severe illness and when effectiveness against Haemophilus influenzae and Moraxella catarrhalis is desired, therapy should start with high-dose amoxicillin plus clavulanate (90 mg/kg/day of amoxicillin + 6.4 mg/kg/day of clavulanate).
  
• In children with a history of amoxicillin allergy but no type 1 reaction, cefdinir, cefpodoxime, or cefuroxime can be used. If there is a history of type 1 reaction, azithromycin or clarithromycin are acceptable alternatives.
  
• Regardless of whether the initial decision is for antibiotics or observation, a system for appropriate follow-up must be in place. Symptoms should resolve in most children in 48-72 hours.
  

Comment: I applaud these guidelines. Withholding antibiotics but providing pain relief is an option, depending on the age and condition of the patient. I would find it difficult to withhold antibiotics from a febrile infant with AOM or consider such a patient to have mild-to-moderate disease. Data consistently show that infants with AOM get better more quickly if they are given antibiotics.

— Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 26, 2004

Citation(s):

American Academy of Pediatrics and American Academy of Family Physicians. Subcommittee on Management of Acute Otitis Media. Clinical Practice Guideline. Diagnosis and Management of Acute Otitis Media. http://www.aap.org/policy/aomfinal.pdf