Otitis media

Abstract

Authors' reply Sir—We agree with Roger Damoiseaux that in primary care there is no need to treat all children with AOM younger than 2 years of age with antibiotics. However, we disagree with his statement that “a placebo-controlled randomised trial in [primary care] dealing with AOM in children less than 2 years has shown only a slight effect of antibiotics”. In fact, the results showed that symptom relief at 4 days was 41% for children who received initial antibiotic therapy compared with 28% for placebo.1Damoiseaux RAMJ van Balen FAM Hoes AW Verheij TJM de Melker RA Primary care based randomised double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years.BMJ. 2000; 320: 350-354Crossref PubMed Scopus (201) Google Scholar Conversely, for older children symptom relief at 7 days was 98% versus 86%.2Burke P Bain J Robinson D Dunleavey J Acute red ear in children: controlled trial of nonantibiotic treatment in general practice.BMJ. 1991; 303: 558-562Crossref PubMed Scopus (148) Google Scholar Additionally, the mean duration of fever days in the young children treated with antibiotics was 2 days versus 3 days in the placebo group (p=0·004).1Damoiseaux RAMJ van Balen FAM Hoes AW Verheij TJM de Melker RA Primary care based randomised double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years.BMJ. 2000; 320: 350-354Crossref PubMed Scopus (201) Google Scholar Maturation of the immune system takes place during the first 2 years of life. This fact accounts for suppurative complications of AOM—including mastoiditis—that occur most often in infants and young children; and why greater caution should be taken in children younger than 2 years.3Marcy M, Takata G, Shekelle P, et al. Management of acute otitis media. Evidence report/technology assessment no. 15 (prepared by the southern California Evidence-based Practice Center under contract no. 290-97-0001). AHRQ publication no. 01-E010. Rockville, MD: Agency for Healthcare Research and Quality, 2001Google Scholar A placebo-controlled trial restricted to this age-group reported meningitis on day 3 in one child of 123 (0·8%) randomised to initial placebo,1Damoiseaux RAMJ van Balen FAM Hoes AW Verheij TJM de Melker RA Primary care based randomised double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years.BMJ. 2000; 320: 350-354Crossref PubMed Scopus (201) Google Scholar compared with no episodes in trials2Burke P Bain J Robinson D Dunleavey J Acute red ear in children: controlled trial of nonantibiotic treatment in general practice.BMJ. 1991; 303: 558-562Crossref PubMed Scopus (148) Google Scholar, 4van Buchem FL Dunk JHM van't Hof MA Therapy of acute otitis media: myringotomy, antibiotics, or neither—a double-blind study in children.Lancet. 1981; 2: 883-887Summary PubMed Scopus (243) Google Scholar with children older than 2 years. In the Netherlands, initial observation for AOM has been practised since the early 1990s for children aged 2 years and older. In 1999, the guideline was adapted and now recommends initial observation in children older than 6 months presenting with AOM. Antibiotics are only indicated in children with heightened risk of complications, in those younger than 6 months, in those with recurrent episodes of AOM within 12 months, and in those with Down's syndrome, craniofacial malformation, or immuno deficiency. However, this adapted guideline has not yet been assessed with respect to occurrence of suppurative complications, which is necessary before final conclusions about safety and cost-effectiveness can be drawn. Although international consensus is being reached that AOM can be managed with initial observation in children 2 years and older, this is not the case for children younger than 2 years. Therefore, until we can distinguish the young children who will benefit from treatment with antibiotics from those who do well without antibiotics, we believe that advice to treat children younger than 2 years, with a certain diagnosis of AOM, with antibiotics is in agreement with practice-based international consensus. Otitis mediaThe recommendation by Maroeska Rovers and co-workers (Feb 7, p 465)1 to treat children younger than 2 years, with a certain diagnosis of acute otitis media (AOM), with antibiotics is not evidence-based. The advice is a consensus of opinion between specialists and epidemiologists. Full-Text PDF Otitis mediaIn a Seminar,1 Maroeska Rovers and colleagues suggest that the ideal preventive intervention for otitis media does not yet exist, but that it should be non-toxic and have sustained efficacy for at least several months. However, we would like to point out that a valuable preventive intervention already exists: prolonged exclusive breast-feeding has been shown to decrease the risk of otitis media in several studies and meta-analyses.2,3 The effect of breastfeeding in reducing the risk of otitis media is probably due to a combination of factors. Full-Text PDF