PAS 2009: AAP Guidelines for Acute Otitis Media May Encourage Overtreatment

Martha Kerr

May 11, 2009

May 11, 2009 (Baltimore, Maryland) — Investigators warned attendees here at the Pediatric Academic Societies 2009 Annual Meeting that the 2004 American Academy of Pediatrics (AAP) criteria for the diagnosis of acute otitis media (AOM) might lead pediatricians to prescribe antibiotics unnecessarily in a significant number of cases.

Results of a prospective longitudinal study of 40 children, aged 6 months to 3 years, were presented by Carlos E. Armengol, MD, from the Department of Pediatrics at the University of Virginia in Charlottesville. Children were seen for well-child visits in the physician's office in the 2 weeks prior to the onset of any symptoms and were examined between 6 and 10 times during the course of a cold.

Parents recorded symptoms daily during the illness. Healthcare providers performed tympanometry at each visit.

The researchers' only role was to perform pneumatic otoscopy and photography of the tympanic membranes at each study visit. There were no discussions of findings and they gave no advice. Children visited their primary physician for an acute-care visit at the discretion of the parent.

Of 31 colds recorded, AAP criteria for AOM were met at least once during 11 of the illnesses (35%). Of 200 study visits, AAP criteria for AOM were recorded at 28 visits (14%).

Antibiotics were prescribed by the primary physician for 4 (13%) of the 31 colds. Two of the 4 courses were prescribed during the first week of illness and 2 were prescribed during the second week.

Seven of the 12 children who had middle-ear effusions at baseline met AAP criteria for AOM at 21 (26%) of 81 study visits. In contrast, 4 of 19 children who had normal ears at baseline met AAP criteria at 7 (6%) of 119 study visits (P < .001).

Ten of 11 children with AOM met AAP criteria during the first 6 days of illness. Clinical status improved in 9 of the 10 cases. Three of the 11 met AAP criteria in the second week of the cold.

"Young children, especially those with pre-existing middle-ear effusion, will frequently meet AAP criteria for AOM during the natural course of a cold," the investigators said. "Most will resolve spontaneously without antibiotic treatment."

Coinvestigator J. Owen Hendley, MD, professor of pediatric infectious diseases at the University of Virginia, told Medscape Pediatrics that "a diagnosis of AOM frequently leads to treatment with antibiotics. . . . Ten of 11 children met the AAP criteria for AOM."

Although the guidelines do not recommend antibiotics for all cases of AOM, an increase in the diagnosis could be misinterpreted, the Virginia researcher cautioned.

Robert M. Jacobson, MD, chair of the Department of Pediatrics at the Mayo Clinic in Rochester, Minnesota, agreed with the investigators' conclusions.

"AOM will resolve without treatment in more than 90% of cases," he told Medscape Pediatrics. "The problem is that there is no measured approach to treatment. There are more and more children in daycare, more and more ear infections, and more and more antibiotics prescribed.

"Overtreatment of AOM is a big problem in children," Dr. Jacobson pointed out. "We need to avoid unnecessary use of antibiotics, and we also need to avoid treating middle-ear infusions with ear tubes. There are no long-term data to support their use either.

"We need to teach parents to manage their child's ear infections with symptom management, particularly the use of topical analgesics," Dr. Jacobson said. "In the vast majority of cases, [AOM] will resolve by itself."

Dr. Hendley and Dr. Jacobson have disclosed no relevant financial relationships.

Pediatric Academic Societies (PAS) 2009 Annual Meeting: Abstract 4315.4. Presented May 4, 2009.


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