Blog: Announcement: Evidence-Based Treatments for Acute Otitis Media

April 27, 2015 – This week's post is also available from the Cochrane Child Health blog.

Acute otitis media (AOM), or middle ear infection, is one of the most common diseases of childhood. AOM presents most frequently in children under the age of two, with 75% of children having at least one episode before one year of age [1,2]. Although AOM is very common, it can be challenging to accurately diagnose – symptoms of AOM often overlap with acute respiratory illness, visualization of the tympanic membrane can be obscured by cerumen, and slight changes in the tympanic membrane can be hard to detect [1]. 

The Canadian Paediatric Society recommends antibiotics for treatment in all children under the age of six months, and for children who are six months to two years when the diagnosis of AOM is certain [2]. For children older than six months with mild symptoms, the Canadian Paediatric Society recommends a ‘watchful waiting’ approach supported by a topical or oral analgesic [2]. Given the prevalence of AOM in these age groups, antibiotics are being prescribed very frequently. With increasing concern about antibiotic resistance, guidelines need to be created to prevent inappropriate prescription for children who have been misdiagnosed with AOM, and treatments need to be supported by strong evidence to justify their use.

Including six systematic reviews, covering 92 randomized controlled trials with 19,695 participants, a Cochrane overview investigated the available evidence on treatments for AOM in children. Below is the key evidence you need to know when treating a child with AOM.  

Effectiveness of Antibiotics

• Compared to placebo,children treated with antibiotics reported less pain 2-7 days after treatment initiation.
• Children taking antibiotics were more likely to have vomiting, diarrhea, and rash. 

Short-Course Antibiotics

• There is no evidence to support one length of antibiotic treatment over another.

Immediate versus Delayed Antibiotics

• Children who immediately received antibiotics had no difference in pain 3-7 days after treatment initiation compared to children who had a delay in antibiotic receipt.
• Because the quality of the evidence was poor, no firm conclusions were made in the review about the risks and benefits of delayed start of antibiotic treatment. 

Decongestants and Antihistamines

• There was no evidence in support of the use of decongestants or antihistamines to treat AOM.
• The authors discouraged the use of decongestants and antihistamines in young children because of their potentially harmful side effect profile caused by unintentional overdose [3]. 

Topical Analgesia

• There was some low quality evidence suggesting that topical analgesia may reduce pain after ten minutes of administration in children over five years. However, no adverse events were recorded.
• Because the quality of the evidence was poor, no firm conclusions were made in the review about the risks and benefits of topical analgesia for AOM.

The authors of the overview concluded:

“The literature to date suggests that antibiotic use in young children with stringently diagnosed AOM appears to be justified, although benefits must be balanced with risk, particularly adverse events and bacterial resistance, and with a role for parental preferences. Improving the accuracy of diagnosis (e.g. training programs for otoscopy and cerumen removal), is thus an important mechanism for reducing inappropriate antibiotic use.”

In 2009, the Canadian Paediatric Society released a position statement with information on treatment and recommendations to guide proper diagnosis of AOM [2].

Resources:

Translating Emergency Knowledge for Kids (TREKK):

Acute otitis media Bottom Line Recommendations (French & English)
Acute otitis media Evidence Repository
Acute otitis Media Cochrane Pediatric Emergency Medicine Reviews

References:

1. Oleszczuk, M., Fernandes, R. M., Thomson, D., & Shaikh, N. (2012). The Cochrane Library and acute otitis media in children: an overview of reviews. Evidence‐Based Child Health: A Cochrane Review Journal, 7(2), 393-402.
2. Forgie, S., Zhanel, G., & Robinson, J. (2009). Management of acute otitis media. Paediatrics & Child Health, 14(7), 457-460.
3. Goldman, R. D., & Hazardous Substances Committee. (2011). Treating cough and cold: guidance for caregivers of children and youth. Paediatrics & Child Health, 16(9), 564.