Clinical Question What is the bes...

Clinical Question

What is the best way to manage uncomplicated acute otitis media (AOM) in otherwise healthy children?

Evidence Summary

The American Academy of Pediatrics and the American Academy of Family Physicians freshly released an evidence-based practice guideline to help physicians provide the principally up-to-date care for children with AOM. (1) The subcommittee that exhibited the guideline included primary care physicians, pediatricians, and skilled hands in the fields of infectious disease, epidemiology, and otolaryngology. The subcommittee reviewed the best available evidence before making its recommendations. All recommendations have been substantiated by way of research evidence and have been assigned a rating for the hardness of the evidence.

The guideline applies to otherwise healthy children between pair months and 12 years of age with uncomplicated AOM. A specific definition of AOM is provided: "a diagnosis of acute otitis media requires a history of acute first brunt of signs and symptoms, the port of middle-ear effusion, and signs and symptoms of middle ear inflammation." (1) Children suspected of having AOM who do not encounter all three criteria are described as having an uncertain diagnosis of AOM. It also is important to distinguish AOM from otitis media with effusion, because merely patients with AOM have the potential to benefit from antibiotics.

The guideline (1) vehemently recommends assessment of the child's pain. Too oftentimes an antibiotic is prescribed, if it be not that no recommendation for analgesia is provided. Use of acetaminophen or ibuprofen is commended although topical and naturopathic agents also have evidence of efficacy. The choice of analgesic should be based upon an evaluation of risks and benefits, with consideration of the choice of the parent/ caregiver and patient.

The decision to prescribe an antibiotic hangs on the child's age, the certainty of the diagnosis, and the severity of the symptoms. inexorable AOM is characterized by plain otalgia and/or a temperature of at least 39[degrees]C (1022[degrees]F) Observation without antibiotic therapy is an option in a certain children, provided that follow-up in 48 to 72 hours can be assured and analgesia is provided. Observation should be considered in children six month to sum of two units years of age with an uncertain diagnosis and nonsevere symptoms, children older than pair years with a certain diagnosis moreover nonsevere symptoms, and children older than sum of two units years with an uncertain diagnosis. The guideline (1) cites studies demonstrating that the majority of children improve within three days of presentation, smooth without antibiotics, (2,3) and that the risk of complications is no higher when antibiotic therapy is delayed. (4) If antibiotics are necessary for initial management, the commited agents are amoxicillin (40 to 45 mg by kg orally twice daily) for children with nonsevere illness and amoxicillin-clavulanate (45 mg for kg/3.2 mg per kg orally twice daily) for children with exact symptoms or children in whom additional coverage for beta-lactamase-positive Haemophilus influenzae and Moraxella catarrhalis is desired.

The accompanying patient fight form for children two month to 12 years of age who not past nor future with earache includes an assessment of pain, the definition of AOM, clinical decision support for the use of an antibiotic, guidance forward selection of the most appropriate antibiotic, and a reminder to commit analgesia.

Applying the Evidence

A two-year-old stripling presents with one day of tugging at his right ear, a runny nose, and a temperature of 379[degrees]C (1002[degrees]F) His appetite and fluid intake are proper Although the child is a bit irritable, he is not lethargic or toxic-appearing. forward examination, the tympanic membrane is inactive but not erythematous; the membrane has limited mobility. What is the diagnosis, and in what way should the patient be managed?

Answer: This patient has an uncertain diagnosis of AOM. Although there is evidence of effusion and an acute storming of symptoms, there is no evidence of inflammation. Furthermore, the illness is not censorious (i.e., low-grade fever, nonspecific tugging at the right ear). It would be reasonable to provide analgesia in the form of acetaminophen and to have the parents perceive the child carefully for 48 to 72 hours. If the child does not improve or indicates signs of worsening, he should be reevaluated. If an antibiotic is required on the other hand symptoms are not severe, amoxicillin in a dosage of 45 mg by means of kg per day orally twice daily is the best choice if the patient is not allergic to penicillin.