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Guidelines add important specifics.

The guidelines address five important areas and provide update, clarification, and greater granularity than the original guidelines did.

They emphasize the diagnostic criteria, and strengthen the significance of bulging as a diagnostic requirement for AOM as well as the requirement for the presence of middle-ear effusion. This will be challenging as many clinicians are not well trained in the use of pneumatic otoscopy. The guidelines were not written to apply to infants younger than 6 months, and in the youngest infants, tympanometry and acoustic reflectometry may be less accurate.

The initial approach remains assessment of the need for antibiotic treatment based on age and severity, as well as assessment of pain and appropriate management of pain. The choice between antibiotic management and observation is further clarified in these guidelines based on current evidence. The new guidelines discuss but do not highlight the results of two recent randomized clinical trials that showed that half of the children in the placebo group did not have a satisfactory resolution. Presumably, this information should be included in any discussion with parents about the role for antibiotics in treating young children with AOM. The criteria recommended for the routine use of antibiotics in children less than 2 years old-bilateral disease, acute otorrhea, or high fever-all are supported by evidence.

The choice of amoxicillin or amoxicillin-clavulanate as the first-line antibiotics is appropriate. The lack of any recommendation for azithromycin will hopefully help educate clinicians about its limited activity against Haemophilus in children with culture-positive AOM and the significant prevalence of macrolide-resistant pneumococci in the community.

The pneumococcal conjugate vaccine has proven beneficial, both for preventing AOM and recurrent AOM, and for obviating tympanostomy tube insertion. It is important that the vaccine be administered early in life, before recurrent AOM can develop. Influenza vaccine also is valuable during influenza seasons for preventing flu and its AOM complication.

Although the guidelines take an absolute approach against antibiotic prophylaxis, there may be some specific children where it may still have value despite concerns about promoting resistance through selective pressure.

Dr. Stephen L Pelton is chief of pediatric infectious disease and also is the coordinator of the maternal-child HW program at Boston Medical Center. He was not involved in development of the AAP guidelines and responded to a request to comment on the guidelines.


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Title Annotation:VIEW ON THE NEWS
Publication:Pediatric News
Geographic Code:1USA
Date:Mar 1, 2013
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