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Focus on all 7 recommendations to manage AOM.

SAN FRANCISCO -- Don't let controversy over one aspect of the recent guidelines for management of acute otitis media divert attention from other key recommendations, S. Michael Marcy, M.D., said.

Much of the reaction to the guidelines published in May 2004 has focused on an option to observe selected children with AOM rather than start antibiotics (FAMILY PRACTICE NEWS, April 1, 2004, p. 1). Some critics of this option are overreacting, he said at the annual meeting of the American Academy of Pediatrics.

Keep in mind all of the main recommendations, said Dr. Marcy of Kaiser Foundation Hospital, Panorama City, Calif., and a consultant to the AAP and American Academy of Family Physicians Joint Subcommittee on Management of Acute Otitis Media, which developed the document:

* Complete the diagnostic steps. Confirm that the child's ear problem came on acutely, identity signs of middle ear effusion, and evaluate the child for signs and symptoms of middle ear inflammation. All three must be present to call it AOM.

* Manage pain. 'It's our primary job to relieve pain," Dr. Marcy said. In small in rants, ear pain may manifest as irritability and disturbed sleep.

Use acetaminophen or NSAIDs for moderate pain. Cautiously consider codeine or its analogs for greater pain. Don't prescribe codeine if the child is younger than 18 months or you don't know and trust the parent. Codeine will suppress cough and make the child sleepy. Don't use it if the child is lethargic, coughing, or wheezing.

Benzocaine drops help in perhaps half of cases, and effects last about half an hour at best. Myringotomy can relieve severe pain instantly in some children with bulging tympanic membranes.

* Opt for observation instead of antibiotic therapy in selected patients. "It is not a mandate," he stressed. "I totally reject the objections that are being made by a lot of people that say the guidelines are going to have children screaming through the night." Observation is an option only for nonsevere illness in some children.

The document recommends antibacterial therapy for a certain diagnosis of AOM in children up to 2 years of age, for certain and severe AOM in older children, for an uncertain diagnosis of AOM in infants younger than 6 months, and for uncertain but severe AOM in children aged 6 months to 2 years.

Observation is an option--provided that follow-up is assured--for nonsevere illness and an uncertain diagnosis of AOM in ages 6 months to 2 years or a certain diagnosis in ages 2 years or older. Nonsevere illness is defined as mild otalgia and a temperature less than 39[degrees]C. Observation only is recommended for an uncertain diagnosis of AOM in those aged 2 years or older. "All of these will be otitis media with effusion," Dr. Marcy said.

* Choose amoxicillin as first-line antibacterial therapy for most children. The guidelines call for higher-than-usual doses: 80-90 mg/kg per day in two divided doses, which produces higher drug levels in blood and middle ear fluid, overcomes resistance in pneumococci, and covers a broader spectrum of organisms, he said. Treat for 10 days in children younger than 6 years; use shorter courses for older children.

If you suspect or know that the child has non-type I allergy to [beta]-lactam medications, choose a second-generation cephalosporin. Cefdinir seems to taste the best, he said. For a child with severe allergy, choose from other medications listed in the guidelines.

* Reassess if the child's condition does not improve within 48-72 hours. Schedule a follow-up contact or appointment when you first see the patient. For patients initially managed by observation, if you confirm the diagnosis of AOM, start antibacterial therapy. For patients initially managed with an antibiotic, change the medication. The guidelines spell out preferred second- and third-line therapies.

* Encourage prevention. Promote breast-feeding over bottles. Modify group day care activities if necessary. Immunize the child against pneumococcal disease and influenza.

* Make the call for use of complementary or alternative medicine. The subcommittee said it has no recommendations on this topic, citing limited and controversial data on it for AOM.
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Title Annotation:Infectious Diseases
Author:Boschert, Sherry
Publication:Family Practice News
Geographic Code:1USA
Date:Dec 1, 2004
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