Pediatric Ear Infections: Watchful Waiting May Be the Best Strategy

The American Academy of Pediatrics and American Academy of Family Physicians Clinical Practice Guideline for Diagnosis and Management of Acute Otitis Media, published in Pediatrics in 2004, calls for “judicious use of antibacterial agents” (Pediatrics 2004;113:1451–1465). These guidelines endorse the option of observation without the use of antibacterial agents in a child with uncomplicated AOM based on diagnostic certainty, age, illness severity, and assurance of follow-up. This option refers to delaying the use of antibiotics for 48 to 72 hours for selected children. The guidelines cite studies over the past three decades consistently showing that between 7 and 20 children must be treated with antibacterial agents for one child to derive benefit. In placebo-controlled trials, 61% of children have decreased symptoms at 24 hours whether or not they received antibiotics.

In September of this year, JAMA published a study entitled, “Wait-and-See Prescription for the Treatment of Acute Otitis Media” by David M. Sprio, MD, et al. (JAMA 2006;296:1235–1241). Participants in the study were children between the ages of 6 months and 12 years who were diagnosed in an emergency department with AOM. The participants’ parents were given an antibiotic prescription that would expire three days following the child’s visit to the emergency department. Parents were instructed to fill the prescription if their child was not better, or was worse, 48 hours after their visit to the emergency department. Prescriptions were not filled for 62% of patients. The parents who did fill the prescription reported that they did so because of fever, otalgia, or fussy behavior. Follow-up at 4, 6, 11, and 14 days found that the rates of otalgia were not significantly different between patients who took antibiotics and those who did not. Furthermore, reported rates of diarrhea were two- to threefold higher in patients who took antibiotics immediately compared with patients in the “wait-and-see” group.

In the same issue of JAMA, Paul Little, MD, of the Community Clinical Sciences Division, University of Southampton, Southampton, UK, wrote an editorial on the subject entitled, “Delayed Prescribing—A Sensible Approach to the Management of Acute Otitis Media” (JAMA 2006;296:1290–1291). Dr. Little lists several potential advantages to delayed prescribing of antibiotics:

• Delayed prescribing rationalizes antibiotic use.
• Delayed prescribing changes patient and family beliefs about antibiotics.
• Delayed prescribing achieves acceptable symptom control.

Dr. Little concluded in his editorial that delayed prescribing of antibiotics is a reasonable approach when a child is not systemically ill and the physician has no major concerns about sicker or at-risk patients, including those with systemic symptoms, comorbidity, or those younger than six months. This school of thought is echoed in the American Academy of Pediatrics and American Academy of Family Physicians Clinical Practice Guidelines for Diagnosis and Management of Acute Otitis Media.