'Watchful Waiting' Best for Ear Infections, Pediatricians Say

Feb. 25, 2013— -- In an effort to rein in antibiotic use, the American Academy of Pediatrics has issued stricter guidelines on diagnosing and treating ear infections in kids.

The updated guidelines, published in the March issue of the journal Pediatrics, also added a recommendation against prophylactic antibiotic use in kids with recurrent ear infections.

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The 2013 guidelines are specifically for uncomplicated acute otitis media at ages 6 months to 12 years in otherwise healthy children without tympanostomy tubes, anatomic abnormalities such as cleft palate or Down syndrome, immune deficiencies or cochlear implants.

"We've been waiting for these guidelines for some time," said Dr. Andrew Hertz, medical director of the University Hospitals Rainbow Care Network in Cleveland.

"There's been a movement for a number of years for pediatricians to provide less antibiotics for ear infections and simply observe those children with mild findings on physical examination," he explained in an interview.

"Hopefully, now that there is a practice guideline ... that you don't have to prescribe an antibiotic for every ear infection, this will decrease the use of antibiotics and thereby make antibiotics more successful and more useful when they are prescribed."

The pediatrics organization also cited overdiagnosis, "often without adequate visualization of the tympanic membrane," as a problem.

The 2004 guidelines used a three-part definition for acute otitis media: Acute onset of symptoms; acute middle ear inflammation; and middle ear effusion. The 2013 update also requires middle ear effusion for diagnosis, but it now has to be based on tympanometry or pneumatic otoscopy.

Although early acute otitis media can occur without effusion, the guidelines committee acknowledged, "the risk of overdiagnosis supersedes that concern."

They suggested that clinicians should be aware as they use these criteria that recent onset of ear pain and intense erythema of the ear drum can be the only otoscopic finding.

Other diagnostic criteria are: Moderate to severe bulging of the tympanic membrane or new onset of discharge not due to an infected ear canal; and mild bulging of the ear drum and onset of ear pain within 48 hours, which could be indicated by holding, tugging, rubbing of the ear for nonverbal children, or intense redness of the tympanic membrane.

Antibiotics should be given for severe cases of bilateral or unilateral acute otitis media for children 6 months or older based on ear pain that is moderate or severe, lasts for at least 48 hours, or is accompanied by a temperature of 102.2 degrees or higher.

For less severe cases, watchful waiting could be offered instead of antibiotics in joint decision-making with parents or caregivers. However, kids ages 6 to 23 months with both ears affected should be given antibiotics.

"When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms," the guidelines noted.

Another change in the 2004 guidelines addressed recurrent acute otitis media, defined as three episodes in 6 months or four in the prior year with one in the past 6 months.

Prophylactic antibiotics shouldn't be prescribed to reduce recurrences, according to the AAP. However, these children may be offered the option of tympanostomy tubes.

These practice patterns should decrease use of antibiotics with the benefit of fewer adverse effects, such as diarrhea and allergic reactions, and decreased potential for bacterial resistance, the guidelines noted.

When antibiotics are given, amoxicillin remains the first-line agent, with drugs with additional beta-lactamase coverage selected for kids who have already had it in the prior month or are allergic to penicillin.

Physicians should recommend the pneumococcal conjugate vaccine and annual flu shot for all children, which can help reduce acute otitis media associated with those infections, the guidelines noted.