American Academy of Pediatrics and American Academy of Family Physicians

This evidence-based clinical practice guideline provides recommendations to primary care clinicians for the management of children from 2 months through 12 years of age with uncomplicated acute otitis media (AOM). The American Academy of Pediatrics and American Academy of Family Physicians convened a committee composed of primary care physicians and experts in the fields of otolaryngology, epidemiology, and infectious disease. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to AOM. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific definition of AOM. It addresses pain management, initial observation versus antibacterial treatment, appropriate choices of antibacterials, and preventive measures. Decisions were made based on a systematic grading of the quality of evidence and strength of recommendations, as well as expert consensus when definitive data were not available. The practice guideline underwent comprehensive peer review before formal approval by the partnering organizations. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decisionmaking. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem. ABBREVIATIONS. AOM, acute otitis media; OME, otitis media with effusion; AAP, American Academy of Pediatrics; AAFP, American Academy of Family Physicians; AHRQ, Agency for Healthcare Research and Quality; MEE, middle-ear effusion; CAM, complementary and alternative medicine. Acute otitis media (AOM) is the most common infection for which antibacterial agents are prescribed for children in the United States. As such, the diagnosis and management of AOM has a significant impact on the health of children, cost of providing care, and overall use of antibacterial agents. The illness also generates a significant social burden and indirect cost due to time lost from school and work. The estimated direct cost of AOM was $1.96 billion in 1995. In addition, the indirect cost was estimated to be $1.02 billion.1 During 1990 there were almost 25 million visits made to office-based physicians in the United States for otitis media, with 809 antibacterial prescriptions per 1000 visits, for a total of more than 20 million prescriptions for otitis media–related antibacterials. Although the total number of office visits for otitis media decreased to 16 million in 2000, the rate of antibacterial prescribing was approximately the same (802 antibacterial prescriptions per 1000 visits for a total of more than 13 million prescriptions).2–4 An individual course of antibacterial therapy can range in cost from $10 to more than $100. There has been much discussion recently as to the necessity for the use of antibacterial agents at the time of diagnosis in children with uncomplicated AOM. Although in the United States the use of antibacterial agents in the management of AOM has been routine, in some countries in Europe it is common practice to treat the symptoms of AOM initially and only institute antibacterial therapy if clinical improvement does not occur. For the clinician, the choice of a specific antibacterial agent has become a key aspect of management. Concerns about the rising rates of antibacterial resistance and the growing costs of antibacterial prescriptions have focused the attention of the medical community and the general public on the need for judicious use of antibacterial agents. Greater resistance among many of the pathogens that cause AOM has fueled an increase in the use of broader-spectrum and generally more expensive antibacterial agents. It is the intent of this guideline to evaluate the published evidence on the natural history and management of uncomplicated AOM and to make recommendations based on that evidence to primary care clinicians including pediatricians, family physicians, physician assistants, nurse practitioners, and emergency department physicians as well as otolaryngologists. The scope of the guideline is the diagnosis and management of uncomplicated AOM in children from 2 months through 12 years of age without signs or symptoms of systemic illness unreThe recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Academy of Pediatrics. PEDIATRICS Vol. 113 No. 5 May 2004 1451 by guest on October 22, 2017 http://pediatrics.aappublications.org/ Downloaded from lated to the middle ear. It applies only to the otherwise healthy child without underlying conditions that may alter the natural course of AOM. These conditions include, but are not limited to, anatomic abnormalities such as cleft palate, genetic conditions such as Down syndrome, immunodeficiencies, and the presence of cochlear implants. Also excluded are children with a clinical recurrence of AOM within 30 days or AOM with underlying chronic otitis media with effusion (OME).