A new, more stringent definition of acute otitis media that focuses on tympanic membrane appearance on otoscopy and downplays the diagnostic role of symptoms highlighted the new acute otitis media diagnosis and management guidelines released by the American Academy of Pediatrics on Feb. 25.
The new guidelines, the first revision since 2004, also reaffirmed and expanded the option of observation without treatment for selected children with acute otitis media (AOM) as an alternative to immediate prescription of an antibiotic. Introduction of observation as a viable alternative to antibiotics had been the major feature of the 2004 guidelines.
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New guidelines released by the AAP stress the stringent definition of acute otitis media that focuses on tympanic membrane appearance on otoscopy.
"The most important change from 2004 is the working definition of AOM. The appearance of the tympanic membrane [TM] is the key to an accurate diagnosis," said Dr. Allan S. Lieberthal, a pediatrician with Kaiser-Permanente in Panorama City, Calif., who chairs the AAP subcommittee on diagnosis and management of acute otitis media, which wrote the new guidelines revision (Pediatrics 2013;131;e964-e99).
"Fever, fussiness, ear pain, or a combination may be the usual reason for a doctor visit, but research done in the last several years has shown that symptoms do not differentiate AOM from an upper respiratory infection or other minor illnesses. With the requirement of a bulging TM, there should no longer be uncertainty in diagnosis," Dr. Lieberthal said.
The guidelines also emphasize pneumatic otoscopy to ensure the presence of a middle-ear effusion, calling the pneumatic otoscope the "standard tool" for diagnosing otitis media. Despite that, "relatively few physicians consistently use pneumatic otoscopy, and they may be resistant to changing their practice," Dr. Lieberthal said in an interview.
The second major change of the new guidelines is expansion of the observation option to selected children aged 6-24 months if they have unilateral AOM without otorrhea and if the child’s parent or caregiver understands and agrees with the option. Children this young with bilateral AOM, severe symptoms, or otorrhea are not recommended as candidates for deferred treatment and observation. The new guidelines also reaffirmed the observation option first recommended in 2004 for selected children older than 2 years if they have either unilateral or bilateral AOM but without otorrhea or severe symptoms.
Recent research results "reinforced the success of observation, especially in children older than 24 months who are not severely ill," said Dr. Lieberthal. "In most studies, 70% of children treated with initial observation did not require subsequent antibiotic treatment."
The guidelines also stress two important caveats: The family should be included in decisions regarding the use of observation for initial therapy, and a mechanism must be in place to ensure follow-up so that an antibiotic regimen can start if the child worsens or fails to improve within 48-72 hours after symptom onset.
Results from "two major studies using a highly specific definition of AOM in younger children showed significant improvement in patients treated with antibiotics, compared with those who were observed. The panel acknowledged this by continuing to recommend initial antibiotic treatment in children younger than 24 months who have a bulging TM. However, if the bulging is minor and the child does not appear ill, then initial observation may be used if the family agrees, and if a mechanism is in place to ensure follow-up," he said.
"Due to widespread discussion [about the observation option] in consumer media after the 2004 guidelines, parents now often ask if observation is recommended, and a growing number of pediatricians use observation," Dr. Lieberthal said, adding that "family and emergency physicians have been more resistant" to applying the observation option.
The new guidelines made no change in the recommended antibiotic regimens, with amoxicillin the top choice and amoxicillin-clavulanate an alternative for either initial or delayed treatment. For children who fail to improve after 48-72 hours of treatment, the guidelines call for switching to amoxicillin-clavulanate or ceftriaxone. The guidelines also include recommended options for children with penicillin allergy.
The new guidelines also made no changes from the 2004 recommendations for pain management, with acetaminophen and ibuprofen flagged as the "mainstays" for treating AOM pain.
This year’s guidelines also include recommendations that physicians check that their patients are up to date on their pneumococcal conjugate and influenza vaccines, that mothers are encouraged to breastfeed their infants for at least 6 months, and that physicians encourage tobacco smoke avoidance.
The guidelines also address dealing with children who develop recurrent AOM, a topic not included in the 2004 version. Recurrent AOM is defined as three episodes in 6 months or four episodes in 1 year, with one episode in the preceding 6 months. The new guidelines specifically say that clinicians should not prescribe any prophylactic antibiotics but may offer tympanostomy tubes. "Many physicians no longer use prophylactic antibiotics," Dr. Lieberthal noted. "Hopefully, the guidelines will reduce the use of unnecessary tubes," he added.