New AOM treatment guidelines emphasize watchful waiting

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New AOM treatment guidelines emphasize watchful waiting
New AOM treatment guidelines emphasize watchful waiting

HealthDay News -- The American Academy of Pediatrics (AAP) has released new guidelines for managing acute otitis media (AOM) that provide more stringent criteria to limit unnecessary antibiotic prescriptions, and advise against prophylactic antibiotics for children with recurrent infections.

About 70% of children who present with ear infections get better on their own within two or three days, and about 80% are better within a week to 10 days, according to Allen S. Leiberthal, MD, FAAP, and colleagues from the AAP's Subcommittee on Diagnosis and Management of Acute Otitis Media.

The committee's latest recommendations, published online in Pediatrics, are the first revisions issued since 2004, and are based on age and symptom severity.

The 2004 recommendations stated three diagnositic criterion for AOM-- acute symptom onset, middle ear effusion and signs of acute middle ear inflammation -- and have been criticized as being too broad to distinguish AOM from other causes of ear pain that do not require antibiotics. The authors stated overdiagnosis, "often without adequate visualization of the tympanic membrane," as another concern prompting the revisions.

The 2013 guidelines specifically address uncomplicated acute otitis media at ages 6 months to 12 years in otherwise healthy children without tympanostomy tubes, anatomic abnormalities such as cleft palate or Down syndrome, immune deficiencies or cochlear implants.

The new guidelines state that in order to make an AOM diagnosis, children must present with moderate-to-severe bulging of the tympanic membrane (TM) confirmed by tympanometry or pneumatic otoscopy, or new onset otorrhea not due to acute otitis externa.

"The current guideline endorses stringent otoscopic diagnostic criteria as a basis for management decisions," Lieberthal and colleagues wrote. "As clinicians use [these criteria], they should be aware that children with AOM may also present with recent onset of ear pain and intense erythema of the TM as the only otoscopic finding."

AOM management should include a pain assessment, and if present, clinicians should recommend pain reducing treatment, the guideline states.

Although many children with infection improve without any antibiotics, there are some patients with AOM in whom antibiotics continue to be recommended. These include children aged 6 months and older with severe signs or symptoms, including moderate or severe otalgia, or otalgia for at least 48 hours accompanied by a fever of 102.2° F or higher, and any child with a ruptured eardrum.

Amoxicillin should be prescribed if the child has not received amoxicillin in the past 30 days, does not have concurrent purulent conjunctivitis, and/or  is not allergic to penicillin, the guideline states. 

Prophylactic antibiotics to reduce the frequency of recurrent AOM, defined as three episodes in 6 months or four in the prior year with one in the past 6 months, are not recommended. However, these children may be offered the option of tympanostomy tubes.

Breastfeeding, recommendingchildren be immunized with the pneumococcal conjugate vaccine and annual influenza vacccine, and limiting exposure to cigarette smoke are important strategies in AOM prevention, the committee wrote.

References

  1. Lieberthal AS et al. "The Diagnosis and Management of Acute Otitis Media." Pediatrics. 2013; doi: 10.1542/peds.2012-3488.
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