BALTIMORE — One-third of 31 young children with colds met the American Academy of Pediatrics criteria for acute otitis media in a prospective study.
Children with preexisting middle ear effusion at baseline were even more likely to meet AAP criteria for acute otitis media (AOM) when they developed a cold, suggesting that “much of what qualifies as AOM in children is in actuality part of the natural history of a cold and resolves quickly without any specific treatment,” Dr. Carlos E. Armengol said in an interview after his presentation at the annual meeting of the Pediatric Academic Societies.
“I believe the AAP guidelines are good, but we need to focus more research on what requires treatment with antibiotics and what doesn't,” added Dr. Armengol, who practices pediatrics in Charlottesville and is affiliated with the University of Virginia, Charlottesville.
The AOM criteria, which also were endorsed by the American Academy of Family Physicians, include recent, abrupt onset of signs and symptoms; the presence of middle ear effusion; and signs or symptoms of middle ear inflammation, including either distinct erythema of the tympanic membrane or otalgia, which presents in young nonverbal children as irritability, ear pulling, fever, vomiting, and/or poor sleep (Pediatrics 2004;113:1451–65).
The children in the study were aged 6 months to 3 years. They were all healthy and without tympanostomy tubes. All were from Dr. Armengol's private pediatric practice, but they were not his patients. The children continued to see their own primary care physicians at the family's discretion, and none of the study findings were shared with those physicians during the study.
Patients were enrolled while asymptomatic and seen every 2–3 weeks until the onset of a cold. Each family kept a daily symptom diary during the upper respiratory infection, and the child was seen 6–10 times for study visits during the course of the upper respiratory infection.
A study nurse verified that parents had recorded symptoms daily during the illness, performed tympanometry at each visit, suctioned nasal secretions for viral polymerase chain reaction testing, and scheduled follow-up study visits. No discussion of findings or advice by the study physician was allowed.
The study physician's only role was to perform pneumatic otoscopy and photography of the tympanic membrane at each study visit. The children visited their primary physician for acute care visits at the discretion of the family.
A total of 11 of the 31 (35%) patients met AAP criteria for AOM during the colds, with 10 of them meeting the criteria in the first week of the upper respiratory infection. In all, the AAP criteria were met during 14% of 200 study visits.
Of the 12 colds in children who had middle ear effusion (MEE) at baseline, 7 (58%) met the AAP acute otitis media criteria, compared with just 4 (21%) of the 19 colds in children who had no ear fluid at baseline. Of the 81 study visits made by the 12 children who had MEE at baseline, 26% met the AAP acute otitis media criteria, versus just 6% of the 119 visits made by the 19 children without baseline MEE, a highly significant difference.
Of the 10 patients who met AAP criteria for AOM during the first week of cold symptoms, acute otitis media resolved in 8 patients without intervention.
Dr. Armengol presented several cases. A 3-year-old girl without effusion at baseline developed MEE by day 4 of the upper respiratory infection and met the criteria for acute otitis media, but AOM resolved within days without treatment. Another patient, an 11-month-old boy who had asymptomatic MEE at baseline, developed symptoms that met AAP criteria as his ear was improving, suggesting that even “some with a bulging, pus-filled tympanic membrane can resolve spontaneously,” he said.
During the interview, Dr. Armengol said, “Unfortunately, many researchers and pediatricians are advocating the use of antibiotics until more information is available. I take the opposite view. I think we should use less antibiotics and better follow-up until more information is available.” He also said, “Pharmaceutical companies need to move away from comparative studies for antibiotic treatment of ear infections. If 80% of children with AOM are going to improve anyway, then of course any antibiotic will appear to work well against another antibiotic. They need to use more stringent criteria for ear infections, such as symptoms and a bulging ear drum, and they need to use a placebo control.”
This study was funded by the Pendleton Pediatric Infectious Disease Laboratory at the university. Dr. Armengol said he had no financial conflicts.
FULL TEXT
