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The Diagnosis and Management of Acute Otitis Media Abstract Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children CLINICAL PRACTICE GUIDELINE The Diagnosis and Management of Acute Otitis Media Allan S. Lieberthal, MD, FAAP, Aaron E. Carroll, MD, MS, abstract FAAP, Tasnee Chonmaitree, MD, FAAP, Theodore G. Ganiats, This evidence-based clinical practice guideline is a revision of the 2004 MD, Alejandro Hoberman, MD, FAAP, Mary Anne Jackson, MD, FAAP, Mark D. Joffe, MD, FAAP, Donald T. Miller, MD, acute otitis media (AOM) guideline from the American Academy of Pe- MPH, FAAP, Richard M. Rosenfeld, MD, MPH, FAAP, Xavier D. diatrics (AAP) and American Academy of Family Physicians. It provides Sevilla, MD, FAAP, Richard H. Schwartz, MD, FAAP, Pauline A. recommendations to primary care clinicians for the management of Thomas, MD, FAAP, and David E. Tunkel, MD, FAAP, FACS children from 6 months through 12 years of age with uncomplicated KEY WORDS AOM. acute otitis media, otitis media, otoscopy, otitis media with effusion, watchful waiting, antibiotics, antibiotic prophylaxis, In 2009, the AAP convened a committee composed of primary care tympanostomy tube insertion, immunization, breastfeeding fi physicians and experts in the elds of pediatrics, family practice, oto- ABBREVIATIONS laryngology, epidemiology, infectious disease, emergency medicine, AAFP—American Academy of Family Physicians and guideline methodology. The subcommittee partnered with the AAP—American Academy of Pediatrics AHRQ—Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality and the Southern Califor- AOM—acute otitis media nia Evidence-Based Practice Center to develop a comprehensive review CI—confidence interval of the new literature related to AOM since the initial evidence report of FDA—US Food and Drug Administration — fl 2000. The resulting evidence report and other sources of data were LAIV live-attenuated intranasal in uenza vaccine MEE—middle ear effusion used to formulate the practice guideline recommendations. MIC—minimum inhibitory concentration The focus of this practice guideline is the appropriate diagnosis and NNT—number needed to treat OM—otitis media initial treatment of a child presenting with AOM. The guideline provides OME—otitis media with effusion a specific, stringent definition of AOM. It addresses pain management, OR—odds ratio initial observation versus antibiotic treatment, appropriate choices of PCV7—heptavalent pneumococcal conjugate vaccine PCV13—13-valent pneumococcal conjugate vaccine antibiotic agents, and preventive measures. It also addresses recur- RD—rate difference rent AOM, which was not included in the 2004 guideline. Decisions were SNAP—safety-net antibiotic prescription made on the basis of a systematic grading of the quality of evidence TIV—trivalent inactivated influenza vaccine — and benefit-harm relationships. TM tympanic membrane WASP—wait-and-see prescription The practice guideline underwent comprehensive peer review before This document is copyrighted and is property of the American formal approval by the AAP. Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American This clinical practice guideline is not intended as a sole source of guid- Academy of Pediatrics. Any conflicts have been resolved through ance in the management of children with AOM. Rather, it is intended to a process approved by the Board of Directors. The American assist primary care clinicians by providing a framework for clinical Academy of Pediatrics has neither solicited nor accepted any decision-making. It is not intended to replace clinical judgment or es- commercial involvement in the development of the content of this publication. tablish a protocol for all children with this condition. These recommend- The recommendations in this report do not indicate an exclusive ations may not provide the only appropriate approach to the course of treatment or serve as a standard of medical care. management of this problem. Pediatrics 2013;131:e964–e999 Variations, taking into account individual circumstances, may be appropriate. (Continued on last page) e964 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 25, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS Key Action Statement 1A: Clinicians temperature less than 39°C [102.2°F]). to penicillin. Evidence Quality: Grade should diagnose acute otitis media Evidence Quality: Grade B. Strength: B. Strength: Recommendation. (AOM)inchildrenwhopresentwith Recommendation. Key Action Statement 4B: Clinicians moderate to severe bulging of the Key Action Statement 3C: Non- should prescribe an antibiotic with tympanic membrane (TM) or new severe unilateral AOM in young additional β-lactamase coverage onset of otorrhea not due to acute children: The clinician should ei- for AOM when a decision to treat otitis externa. Evidence Quality: ther prescribe antibiotic therapy with antibiotics has been made, Grade B. Strength: Recommendation. or offer observation with close and the child has received amoxi- Key Action Statement 1B: Clinicians follow-up based on joint decision- cillin in the last 30 days or has should diagnose AOM in children making with the parent(s)/caregiver concurrent purulent conjunctivitis, who present with mild bulging of the for unilateral AOM in children 6 or has a history of recurrent AOM TM and recent (less than 48 hours) months to 23 months of age without unresponsive to amoxicillin. Evi- onset of ear pain (holding, tugging, severe signs or symptoms (ie, mild dence Quality: Grade C. Strength: rubbing of the ear in a nonverbal otalgia for less than 48 hours Recommendation. and temperature less than 39°C child) or intense erythema of Key Action Statement 4C: Clinicians [102.2°F]). When observation is the TM. Evidence Quality: Grade C. should reassess the patient if the used, a mechanism must be in place Strength: Recommendation. caregiver reports that the child’s to ensure follow-up and begin anti- Key Action Statement 1C: Clinicians symptoms have worsened or failed biotic therapy if the child worsens should not diagnose AOM in chil- to respond to the initial antibiotic or fails to improve within 48 to dren who do not have middle ear treatment within 48 to 72 hours 72 hours of onset of symptoms. effusion (MEE) (based on pneu- and determine whether a change Evidence Quality: Grade B. Strength: matic otoscopy and/or tympanometry). in therapy is needed. Evidence Recommendation. Evidence Quality: Grade B. Strength: Quality: Grade B. Strength: Recom- Recommendation. Key Action Statement 3D: Nonsevere mendation. AOM in older children: The clinician Key Action Statement 2: The man- Key Action Statement 5A: Clinicians should either prescribe antibiotic agement of AOM should include an therapy or offer observation with should not prescribe prophylactic assessment of pain. If pain is close follow-up based on joint antibiotics to reduce the frequency present, the clinician should rec- decision-making with the parent(s)/ of episodes of AOM in children with ommend treatment to reduce pain. caregiver for AOM (bilateral or uni- recurrent AOM. Evidence Quality: Evidence Quality: Grade B. Strength: lateral) in children 24 months or Grade B. Strength: Recommendation. Strong Recommendation. older without severe signs or Key Action Statement 5B: Clinicians Key Action Statement 3A: Severe symptoms (ie, mild otalgia for less may offer tympanostomy tubes for AOM: The clinician should prescribe than 48 hours and temperature less recurrent AOM (3 episodes in 6 antibiotic therapy for AOM (bilateral than 39°C [102.2°F]). When obser- months or 4 episodes in 1 year or unilateral) in children 6 months vation is used, a mechanism must with 1 episode in the preceding and older with severe signs or be in place to ensure follow-up and 6 months). Evidence Quality: Grade symptoms (ie, moderate or severe begin antibiotic therapy if the child B. Strength: Option. otalgia or otalgia for at least 48 worsens or fails to improve within Key Action Statement 6A: Clinicians hours or temperature 39°C [102.2°F] 48 to 72 hours of onset of symptoms. should recommend pneumococcal or higher). Evidence Quality: Grade B. Evidence Quality: Grade B. Strength: conjugate vaccine to all children Strength: Strong Recommendation. Recommendation. according to the schedule of the Key Action Statement 3B: Non- Key Action Statement 4A: Clinicians Advisory Committee on Immuniza- severe bilateral AOM in young should prescribe amoxicillin for tion Practices of the Centers for children: The clinician should pre- AOM when a decision to treat with Disease Control and Prevention, scribe antibiotic therapy for bi- antibiotics has been made and the American Academy of Pediatrics lateral AOM in children 6 months child has not received amoxicillin in (AAP), and American Academy of through 23 months of age without thepast30daysor the child does Family Physicians (AAFP). Evidence severe signs or symptoms (ie, mild not have concurrent purulent con- Quality: Grade B. Strength: Strong otalgia for less than 48 hours and junctivitis or the child is not allergic Recommendation. PEDIATRICS Volume 131, Number 3, March 2013 e965 Downloaded from www.aappublications.org/news by guest on September 25, 2021 Key Action Statement 6B: Clinicians resulting in antibiotic prescriptions for primary care clinicians including should recommend annual influenza remained relatively stable (80% in 1995– pediatricians and family physicians, vaccine to all
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