This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow View responses
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Related Collections
Right arrow Infectious Disease & Immunity
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Facebook   Add to Reddit   Add to Technorati   Add to Twitter  
What's this?
PEDIATRICS Vol. 113 No. 5 May 2004, pp. 1451-1465

CLINICAL PRACTICE GUIDELINE

Diagnosis and Management of Acute Otitis Media

Subcommittee on Management of Acute Otitis Media


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 
This evidence-based clinical practice guideline provides recommendations to primary care clinicians for the management of children from 2 months through 12 years of age with uncomplicated acute otitis media (AOM).

The American Academy of Pediatrics and American Academy of Family Physicians convened a committee composed of primary care physicians and experts in the fields of otolaryngology, epidemiology, and infectious disease. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to AOM. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM.

The guideline provides a specific definition of AOM. It addresses pain management, initial observation versus antibacterial treatment, appropriate choices of antibacterials, and preventive measures. Decisions were made based on a systematic grading of the quality of evidence and strength of recommendations, as well as expert consensus when definitive data were not available. The practice guideline underwent comprehensive peer review before formal approval by the partnering organizations.

This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

Abbreviations: AOM, acute otitis media • OME, otitis media with effusion • AAP, American Academy of Pediatrics • AAFP, American Academy of Family Physicians • AHRQ, Agency for Healthcare Research and Quality • MEE, middle-ear effusion • CAM, complementary and alternative medicine

Acute otitis media (AOM) is the most common infection for which antibacterial agents are prescribed for children in the United States. As such, the diagnosis and management of AOM has a significant impact on the health of children, cost of providing care, and overall use of antibacterial agents. The illness also generates a significant social burden and indirect cost due to time lost from school and work. The estimated direct cost of AOM was $1.96 billion in 1995. In addition, the indirect cost was estimated to be $1.02 billion.1 During 1990 there were almost 25 million visits made to office-based physicians in the United States for otitis media, with 809 antibacterial prescriptions per 1000 visits, for a total of more than 20 million prescriptions for otitis media-related antibacterials. Although the total number of office visits for otitis media decreased to 16 million in 2000, the rate of antibacterial prescribing was approximately the same (802 antibacterial prescriptions per 1000 visits for a total of more than 13 million prescriptions).2–4 An individual course of antibacterial therapy can range in cost from $10 to more than $100.

There has been much discussion recently as to the necessity for the use of antibacterial agents at the time of diagnosis in children with uncomplicated AOM. Although in the United States the use of antibacterial agents in the management of AOM has been routine, in some countries in Europe it is common practice to treat the symptoms of AOM initially and only institute antibacterial therapy if clinical improvement does not occur. For the clinician, the choice of a specific antibacterial agent has become a key aspect of management. Concerns about the rising rates of antibacterial resistance and the growing costs of antibacterial prescriptions have focused the attention of the medical community and the general public on the need for judicious use of antibacterial agents. Greater resistance among many of the pathogens that cause AOM has fueled an increase in the use of broader-spectrum and generally more expensive antibacterial agents.

It is the intent of this guideline to evaluate the published evidence on the natural history and management of uncomplicated AOM and to make recommendations based on that evidence to primary care clinicians including pediatricians, family physicians, physician assistants, nurse practitioners, and emergency department physicians as well as otolaryngologists. The scope of the guideline is the diagnosis and management of uncomplicated AOM in children from 2 months through 12 years of age without signs or symptoms of systemic illness unrelated to the middle ear. It applies only to the otherwise healthy child without underlying conditions that may alter the natural course of AOM. These conditions include, but are not limited to, anatomic abnormalities such as cleft palate, genetic conditions such as Down syndrome, immunodeficiencies, and the presence of cochlear implants. Also excluded are children with a clinical recurrence of AOM within 30 days or AOM with underlying chronic otitis media with effusion (OME).


   METHODS
TOP
 ABSTRACT
 METHODS
RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 
To develop the clinical practice guideline on the management of AOM, the American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP) convened the Subcommittee on Management of Acute Otitis Media, a working panel composed of primary care and subspecialty physicians. The subcommittee was cochaired by a primary care pediatrician and a family physician and included experts in the fields of general pediatrics, family medicine, otolaryngology, epidemiology, infectious disease, and medical informatics. All panel members reviewed the AAP policy on conflict of interest and voluntary disclosure and were given an opportunity to present any potential conflicts with the subcommittee's work.

The AAP and AAFP partnered with the Agency for Healthcare Research and Quality (AHRQ) and the Southern California Evidence-Based Practice Center to develop the evidence report, which served as a major source of data for these practice guideline recommendations.1 Specific clinical issues addressed in the AHRQ evidence report were the 1) definition of AOM, 2) natural history of AOM without antibacterial treatment, 3) effectiveness of antibacterial agents in preventing clinical failure, and 4) relative effectiveness of specific antibacterial regimens. The AHRQ report focused on children between 4 weeks and 18 years of age with uncomplicated AOM seeking initial treatment. Outcomes included the presence or absence of signs and symptoms within 48 hours, at 3 to 7 days, 8 to 14 days, 15 days to 3 months, and more than 3 months and the presence of adverse effects from antibacterial treatment. Southern California Evidence-Based Practice Center project staff searched Medline (1966 through March 1999), the Cochrane Library (through March 1999), HealthSTAR (1975 through March 1999), International Pharmaceutical Abstracts (1970 through March 1999), CINAHL (1982 through March 1999), BIOSIS (1970 through March 1999), and Embase (1980 through March 1999). Additional articles were identified by review of reference lists in proceedings, published articles, reports, and guidelines. Studies relevant to treatment questions were limited to randomized, controlled trials. For natural history, prospective and retrospective comparative cohort studies were included also. A total of 3461 titles were identified initially for additional review. Of these, 2701 were excluded, and 760 required article review. Finally, 72 English-language and 2 foreign-language articles were reviewed fully. Results of the literature review were presented in evidence tables and published in the final evidence report.

New literature about otitis media is being published constantly. Although the systematic review done by the AHRQ could not be replicated with new literature, members of the Subcommittee on Management of Acute Otitis Media reviewed additional articles published through September 2003. Articles were nonsystematically evaluated for quality of methodology and importance of results. Articles used in the AHRQ review also were reevaluated for their quality. Conclusions were based on the consensus of the subcommittee after the review of newer literature and reevaluation of the AHRQ evidence. Of significance is that the literature includes relatively few cases of uncomplicated AOM in children older than 12 years. The subcommittee therefore limited this guideline to children from 2 months through 12 years of age.

The evidence-based approach to guideline development requires that the evidence in support of a policy be identified, appraised, and summarized and that an explicit link between evidence and recommendations be defined. Evidence-based recommendations reflect the quality of evidence and the balance of benefit and harm that is anticipated when the recommendation is followed. The AAP definitions of evidence-based recommendations are shown in Table 1.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Guideline Definitions for Evidence-Based Statements

 
A draft version of this practice guideline underwent extensive peer review by committees and sections within the AAP, reviewers appointed by the AAFP, outside organizations, and other individuals identified by the subcommittee as experts in the field. Members of the subcommittee were invited to distribute the draft to other representatives and committees within their specialty organizations. The resulting comments were reviewed by the subcommittee and, when appropriate, incorporated into the guideline.


   RECOMMENDATION 1
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 
To diagnose AOM the clinician should confirm a history of acute onset, identify signs of middle-ear effusion (MEE), and evaluate for the presence of signs and symptoms of middle-ear inflammation. (This recommendation is based on observational studies and a preponderance of benefit over risk; see Table 2.)


View this table:
[in this window]
[in a new window]
  		TABLE 2. Definition of AOM

 
Children with AOM usually present with a history of rapid onset of signs and symptoms such as otalgia (or pulling of the ear in an infant), irritability in an infant or toddler, otorrhea, and/or fever. These findings, other than otorrhea, are nonspecific and frequently overlap those of an uncomplicated viral upper respiratory infection.5,6 In a prospective survey among 354 children who visited a physician for acute respiratory illness, fever, earache, and excessive crying were present frequently (90%) in those with AOM. However, these symptoms also were prominent among children without AOM (72%). Other symptoms of a viral upper respiratory infection, such as cough and nasal discharge or stuffiness, often precede or accompany AOM and are nonspecific also. Accordingly, clinical history alone is poorly predictive of the presence of AOM, especially in younger children.5

The presence of MEE is commonly confirmed with the use of pneumatic otoscopy7 but can be supplemented by tympanometry8 and/or acoustic reflectometry.9–12 MEE also can be demonstrated directly by tympanocentesis or the presence of fluid in the external auditory canal as a result of tympanic membrane perforation.

Visualization of the tympanic membrane with identification of an MEE and inflammatory changes is necessary to establish the diagnosis with certainty. To visualize the tympanic membrane adequately it is essential that cerumen obscuring the tympanic membrane be removed and that lighting is adequate. For pneumatic otoscopy, a speculum of proper shape and diameter must be selected to permit a seal in the external auditory canal. Appropriate restraint of the child to permit adequate examination may be necessary also.

The findings on otoscopy indicating the presence of MEE and inflammation associated with AOM have been well defined. Fullness or bulging of the tympanic membrane is often present and has the highest predictive value for the presence of MEE. When combined with color and mobility, bulging is also the best predictor of AOM.7,13,14 Reduced or absent mobility of the tympanic membrane during performance of pneumatic otoscopy is additional evidence of fluid in the middle ear. Opacification or cloudiness, other than that caused by scarring, is also a consistent finding and is caused by edema of the tympanic membrane. Redness of the tympanic membrane caused by inflammation may be present and must be distinguished from the pink erythematous flush evoked by crying or high fever, which is usually less intense and remits as the child quiets down. In bullous myringitis, blisters may be seen on the tympanic membrane.15 When the presence of middle-ear fluid is difficult to determine, the use of tympanometry or acoustic reflectometry16 can be helpful in establishing a diagnosis.

A major challenge for the practitioner is to discriminate between OME and AOM.17,18 OME is more common than AOM. OME may accompany viral upper respiratory infections, be a prelude to AOM, or be a sequela of AOM.19 When OME is identified mistakenly as AOM, antibacterial agents may be prescribed unnecessarily.20,21 Clinicians should strive to avoid a false-positive diagnosis in children with middle-ear discomfort caused by eustachian tube dysfunction and retraction of the tympanic membrane or when acute viral respiratory infection is superimposed on chronic preexisting MEE.

The diagnosis of AOM, particularly in infants and young children, is often made with a degree of uncertainty. Common factors that may increase uncertainty include the inability to sufficiently clear the external auditory canal of cerumen, a narrow ear canal, or inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometry. An uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE.22 Acoustic reflectometry can be helpful, because it requires no seal of the canal and can determine the presence of middle-ear fluid through only a small opening in the cerumen.10,11 When the presence of middle-ear fluid is questionable or uncertain, a diagnosis of AOM may be considered but cannot be confirmed. Although every effort should be made by the clinician to differentiate AOM from OME or a normal ear, it must be acknowledged that, using all available tools, uncertainty will remain in some cases. Efforts to improve clinician education must be increased to improve diagnostic skills and thereby decrease the frequency of an uncertain diagnosis. Ideally, instruction in the proper examination of the child's ear should begin with the first pediatric rotation in medical school and continue throughout postgraduate training.18 Continuing medical education should reinforce the importance of and retrain the clinician in the use of pneumatic otoscopy. By including the degree of certainty into the formation of a management plan, the everyday challenge of pediatric examinations is incorporated into decision-making.

A certain diagnosis of AOM meets all 3 of the criteria: rapid onset, presence of MEE, and signs and symptoms of middle-ear inflammation. The clinician should maximize diagnostic strategies, particularly to establish the presence of MEE, and should consider the certainty of diagnosis in determining management. Clinicians may wish to discuss the degree of diagnostic certainty with parents/caregivers at the time of initial AOM management.


   RECOMMENDATION 2
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 
The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain. (This is a strong recommendation based on randomized, clinical trials with limitations and a preponderance of benefit over risk.)

Many episodes of AOM are associated with pain.23 Although pain is an integral part of the illness, clinicians often see otalgia as a peripheral concern not requiring direct attention.24 The AAP published the policy statement "The Assessment and Management of Acute Pain in Infants, Children, and Adolescents"25 to assist the clinician in addressing pain in the context of illness. The management of pain, especially during the first 24 hours of an episode of AOM, should be addressed regardless of the use of antibacterial agents.

Various treatments of otalgia have been used, but none has been well studied. The clinician should select a treatment based on a consideration of benefits and risks and, wherever possible, incorporate parent/caregiver and patient preference (Table 3).


View this table:
[in this window]
[in a new window]
  		TABLE 3. Treatments for Otalgia in AOM

 

   RECOMMENDATION 3A
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 
Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up. (This option is based on randomized, controlled trials with limitations and a relative balance of benefit and risk.)

The "observation option" for AOM refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief. The decision to observe or treat is based on the child's age, diagnostic certainty, and illness severity. To observe a child without initial antibacterial therapy, it is important that the parent/caregiver has a ready means of communicating with the clinician. There also must be a system in place that permits reevaluation of the child. If necessary, the parent/caregiver also must be able to obtain medication conveniently.

This option should be limited to otherwise healthy children 6 months to 2 years of age with nonsevere illness at presentation and an uncertain diagnosis and to children 2 years of age and older without severe symptoms at presentation or with an uncertain diagnosis. In these situations, observation provides an opportunity for the patient to improve without antibacterial treatment. The association of age younger than 2 years with increased risk of failure of watchful waiting and the concern for serious infection among children younger than 6 months influence the decision for immediate antibacterial therapy. Consequently, the panel recommends an age-stratified approach that incorporates these clinical considerations along with the certainty of diagnosis (Table 4).


View this table:
[in this window]
[in a new window]
  		TABLE 4. Criteria for Initial Antibacterial-Agent Treatment or Observation in Children With AOM

 
Placebo-controlled trials of AOM over the past 30 years have shown consistently that most children do well, without adverse sequelae, even without antibacterial therapy. Between 7 and 20 children must be treated with antibacterial agents for 1 child to derive benefit.34–36 By 24 hours, 61% of children have decreased symptoms whether they receive placebo or antibacterial agents. By 7 days, approximately 75% of children have resolution of symptoms.37 The AHRQ evidence-report meta-analysis showed a 12.3% reduction in the clinical failure rate within 2 to 7 days of diagnosis when ampicillin or amoxicillin was prescribed, compared with initial use of placebo or observation (number needed to treat: 8).1

In 1990 the Dutch College of General Practitioners adopted a guideline for the management of AOM that recommended treating symptoms without antibacterial agents for 24 hours (for those 6–24 months old) or 72 hours (for those more than 24 months) and adding antibacterial agents if no improvement is evident at reassessment. A 1999 revision to this early guideline does not distinguish the younger age group for special consideration.38 Although this guideline has been widely adopted in The Netherlands, its use in other countries requires consideration of the availability of access to care for follow-up and the presence of an adult who can adequately monitor the child's course. Although there are no controlled studies that address the question of whether the Dutch guideline has resulted in more complications after AOM, van Buchem et al39,136 found that only 2.7% of 4860 Dutch children older than 2 years given only symptomatic treatment developed severe illness, defined by persistent fever, pain, or discharge after 3 to 4 days. Only 2 children developed mastoiditis. One case of mastoiditis was present at initial assessment, and the other developed within the first week and resolved promptly with oral antibacterial agents.

Randomized trials of observation with symptomatic treatment have been few. A recent randomized trial in general practice in the United Kingdom compared providing immediate antibacterial therapy with delaying antibacterial agents for 72 hours in children aged 6 months to 10 years.40 Seventy-six percent of children in the delayed-treatment group never required antibacterial agents. Seventy percent of the delayed-antibacterial group were symptomatically better at 3 days, whereas 86% of the immediate-treatment group were better. Immediate use of antibacterial agents was associated with approximately 1-day-shorter illness and one-half teaspoon a day less acetaminophen consumption but no difference in school absence, pain, or distress scores. Among children with fever or vomiting on day 1, those receiving immediate antibacterial agents were 21% less likely to have distress on day 3. In children without fever or vomiting, immediate antibacterial agents decreased distress on day 3 by only 4%.41 This study, however, was limited because of the use of imprecise criteria for the diagnosis of AOM and the use of low doses of amoxicillin (125 mg, 3 times a day, for 7 days for all patients regardless of weight) in the treatment group.

The likelihood of recovery without antibacterial therapy differs depending on the severity of signs and symptoms at initial examination. Kaleida et al42 divided patients into severe and nonsevere groups based on degree of fever, a scoring system based on duration and severity of pain or apparent discomfort, and estimated parental anxiety. In the nonsevere group, initial treatment failure occurred in 3.8% more children who received placebo rather than amoxicillin. In the severe group of children, the initial failure rate on placebo plus myringotomy was 23.5% versus an initial failure rate of 9.6% on amoxicillin alone (a difference of 13.9%).

Several investigators report poorer outcomes in younger children. A greater number of penicillin-resistant strains of pneumococci are isolated in those younger than 18 months, compared with older children,43 and are associated with an increased bacteriologic failure rate in children younger than 2 years.44–47 The study by Kaleida et al42 also shows a greater initial clinical failure rate (9.8%) in children younger than 2 years than in those older than 2 years (5.5%) who were in the placebo group.

Routine antibacterial therapy for AOM is often cited as the main reason for the decrease in the incidence of mastoiditis in the antibacterial era.48,49 By the 1950s, mastoiditis (frequent in the pre-antibacterial-agent era48) had decreased dramatically. Although some have expressed concern about a possible resurgence,50,51 such concern is not supported by published data.

The AHRQ evidence report on AOM concluded that mastoiditis is not increased with initial observation, provided that children are followed closely and antibacterial therapy is initiated in those who do not improve. Pooled data from 6 randomized trials and 2 cohort studies showed comparable rates of mastoiditis in children (0.59%) who received initial antibacterial therapy and children (0.17%) who received placebo or observation (P = .212). External validity might be limited, however, because some trials excluded very young children or those with severe illness.1

Recently published case series of pediatric mastoiditis show that acute mastoiditis is most common in infants and young children and can be the presenting sign of AOM in a patient with no prior middle-ear disease.50–60 Routine antibacterial therapy of AOM is not an absolute safeguard against mastoiditis and other complications, because most cases (36%–87%) have received prior antibacterial-agent therapy.50,53,57–59,61–63

Van Zuijlen et al64 compared national differences in acute mastoiditis rates from 1991 to 1998 for children 14 years of age or younger. Incidence rates were higher in The Netherlands, Norway, and Denmark (in which antibacterial agents are not necessarily given on initial diagnosis of AOM) than in the United Kingdom, Canada, Australia, and the United States (in which antibacterial agents are prescribed in more than 96% of cases). However, despite initial use of antibacterial agents more than twice as often in Norway and Denmark than in The Netherlands, mastoiditis rates in all 3 countries were comparable.

Thus current evidence does not suggest a clinically important increased risk of mastoiditis in children when AOM is managed only with initial symptomatic treatment without antibacterial agents. Clinicians should remain aware that antibacterial-agent treatment might mask mastoiditis signs and symptoms, producing a subtle presentation that can delay diagnosis.56,59,61

Although bacteremia may accompany AOM, particularly in children with a temperature higher than 39°C,65 there is little evidence that routine antibacterial treatment for otitis media prevents bacterial meningitis. In a study of 4860 children with AOM who did not receive antibacterial therapy, no cases of bacterial meningitis were observed.39 However, in a study involving 240 children between 6 and 24 months of age, 1 child in the placebo group was subsequently diagnosed as having meningitis.66 In another report, positive blood cultures were equally common in children with bacterial meningitis regardless of whether they received preadmission treatment with antibacterials for AOM (77% and 78%).67 Thus, as with mastoiditis, the incidence of meningitis in those with AOM is unlikely to be influenced by initial treatment of AOM with antibacterial agents.

The incidence of invasive pneumococcal disease has decreased since the introduction of the protein-polysaccharide conjugate vaccine (PPV7). There has been a 69% decline in children younger than 2 years between 1998–1999 and 2001. The decline in this age group for invasive disease caused by vaccine serotypes during that period was 78%.68 How this will affect the risk of AOM-associated invasive pneumococcal disease is not known yet.

As noted by Dagan and McCracken,69 studies comparing efficacy of different antibacterial agents or placebo compared with antibacterial therapy often have significant design flaws that may influence the outcome of the studies. Methodologic considerations include enrollment criteria, sample size, diagnostic criteria, dosing regimens, definition and timing of outcome criteria, age, severity of symptoms, race, immune system, compliance, virulence and resistance of the infecting organism, duration of antibacterial therapy, and the presence of an underlying respiratory infection. One of the most important issues among the design characteristics of the studies of otitis media is the definition of AOM used in the individual investigations. If studies that evaluate the impact of antibacterial therapy on the clinical course of children with AOM have weak definitions of AOM (that allow the inclusion of children who are more likely to have OME than AOM), recipients of placebo will not respond significantly differently from those who receive antibacterial therapy.

Given the sum of the available evidence, clinicians may consider observation with symptomatic treatment as an option for initial management of selected children with AOM. If the "observation option" is used, the clinician should share with parents/caregivers the degree of diagnostic certainty and consider their preference. The potential of antibacterial therapy at the initial visit to shorten symptoms by 1 day in 5% to 14% of children can be compared with the avoidance of common antibacterial side effects in 5% to 10% of children, infrequent serious side effects, and the adverse effects of antibacterial resistance. When considering this option, the clinician should verify the presence of an adult who will reliably observe the child, recognize signs of serious illness, and be able to provide prompt access to medical care if improvement does not occur. If there is worsening of illness or if there is no improvement in 48 to 72 hours while a child is under observation, institution of antibacterial therapy should be considered. Reexamination may be warranted if discussion with the parents raises concern as to the degree of illness.

Strategies for following children being managed with initial observation include a parent-initiated visit and/or phone contact for worsening condition or no improvement at 48 to 72 hours, a scheduled follow-up appointment in 48 to 72 hours, routine follow-up phone contact, or use of a safety-net antibiotic prescription to be filled if illness does not improve in 48 to 72 hours.70,71 Clinicians should determine the most appropriate strategy for their practice setting, taking into account the availability and reliability of the reporting parent/caregiver, available office resources, cost to the health care system and the family, and the convenience of the family. An assessment of the potential risk of inappropriate use of an antibacterial agent in a patient who may be worsening or may have a condition other than AOM must also be made. Table 5 summarizes the data on initial observation versus initial antibacterial-agent treatment of AOM.


View this table:
[in this window]
[in a new window]
  		TABLE 5. Comparative AOM Outcomes for Initial Observation Versus Antibacterial Agent*

 

   RECOMMENDATION 3B
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 
If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. (This recommendation is based on randomized, clinical trials with limitations and a preponderance of benefit over risk.)

When amoxicillin is used, the dose should be 80 to 90 mg/kg per day. (This option is based on extrapolation from microbiologic studies and expert opinion, with a preponderance of benefit over risk.)

If a decision is made to treat with antibacterial agents, there are numerous medications that are clinically effective. The choice of first-line treatment should be based on the anticipated clinical response as well as the microbiologic flora likely to be present. The justification to use amoxicillin as first-line therapy in most patients with AOM relates to its general effectiveness when used in sufficient doses against susceptible and intermediate resistant pneumococci as well as its safety, low cost, acceptable taste, and narrow microbiologic spectrum.75

In patients who have severe illness (moderate to severe otalgia or fever of 39°C or higher42) and in those for whom additional coverage for ß-lactamase-positive Haemophilus influenzae and Moraxella catarrhalis is desired, therapy should be initiated with high-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin component, with 6.4 mg/kg per day of clavulanate in 2 divided doses).76 This dose has sufficient potassium clavulanate to inhibit all ß-lactamase-producing H influenzae and M catarrhalis.

Many clinical studies comparing the effectiveness of various antibacterial agents in the treatment of AOM do not carefully define standard criteria for diagnosis of AOM at entry or for improvement or cure at follow-up.69 Another way to measure the outcome of treatment of AOM with various antibacterial agents is to assess bacteriologic efficacy. Although this does not provide a one-to-one correlation with clinical effectiveness, there is a definite concordance between the two.77–79 Children who experience a bacteriologic cure improve more rapidly and more often than children who experience bacteriologic failure. Carlin et al79 showed an 86% agreement between clinical and bacteriologic response. Dagan et al77 showed that 91% of clinical failures at or before day 10 were culture-positive at days 4 to 5. If we use bacteriologic cure as a surrogate for clinical efficacy, there is strong evidence that drugs that achieve antibacterial concentrations that are able to eradicate pathogens from the middle-ear fluid are the preferred selection.80,81

Numerous studies have shown that the common pathogens in AOM are Streptococcus pneumoniae, nontypeable H influenzae, and M catarrhalis.82,83 S pneumoniae has been recovered from the middle-ear fluid of approximately 25% to 50% of children with AOM, H influenzae from 15% to 30%, and M catarrhalis from approximately 3% to 20%.83 There is some evidence that the microbiology of AOM may be changing as a result of routine use of the heptavalent pneumococcal vaccine. Block et al84 showed an increase in H Influenzae from 39% to 52% of isolates in children 7 to 24 months of age with AOM and a decrease in S pneumoniae from 49% to 34% between 1992–1998 and 2000–2003. Viruses, including respiratory syncytial virus, rhinovirus, coronavirus, parainfluenza, adenovirus, and enterovirus, have been found in respiratory secretions and/or MEE in 40% to 75% of AOM cases and in MEE without bacteria in 5% to 22% of cases and may be responsible for many cases of apparent antibacterial agent "failure." In approximately 16% to 25% of cases of AOM, no bacterial or viral pathogen can be detected in MEE.19,85,86

Currently approximately 50% of isolates of H influenzae and 100% of M catarrhalis derived from the upper respiratory tract are likely to be ß-lactamase-positive nationwide.87 Between 15% and 50% (average: 30%) of upper respiratory tract isolates of S pneumoniae are also not susceptible to penicillin; approximately 50% of these are highly resistant to penicillin (minimum inhibitory concentration: 2.0 µg/mL or higher), and the remaining 50% are intermediate in resistance (minimum inhibitory concentration: between 0.1 and 1.0 µg/mL).88–91 The mechanism of penicillin resistance among isolates of S pneumoniae is not associated with ß-lactamase production but rather an alteration of penicillin-binding proteins. This phenomenon, which varies considerably according to geographic location, results in resistance to penicillins and cephalosporins.

Data from early studies of patients with AOM show that 19% of children with S pneumoniae and 48% with H influenzae cultured on initial tympanocentesis who were not treated with antibacterial agents cleared the bacteria at the time of a second tympanocentesis 2 to 7 days later.92 Estimates are that approximately 75% of children infected with M catarrhalis also experience bacteriologic cure, based on resolution after treatment with an antibacterial agent to which it is not susceptible (amoxicillin).93,94 Only S pneumoniae that are highly resistant to penicillin will not respond to conventional doses of amoxicillin.95 Accordingly, approximately 80% of children with AOM will respond to treatment with high-dose amoxicillin, including many caused by resistant pneumococci. The higher dose will yield middle-ear fluid levels that exceed the minimum inhibitory concentration of all S pneumoniae that are intermediate in resistance to penicillin and many, but not all, highly resistant S pneumoniae.76 Risk factors for the presence of bacterial species likely to be resistant to amoxicillin include attendance at child care, recent receipt (less than 30 days) of antibacterial treatment, and age younger than 2 years.96,97

If the patient is allergic to amoxicillin and the allergic reaction was not a type I hypersensitivity reaction (urticaria or anaphylaxis), cefdinir (14 mg/kg per day in 1 or 2 doses), cefpodoxime (10 mg/kg per day, once daily), or cefuroxime (30 mg/kg per day in 2 divided doses) can be used. In cases of type I reactions, azithromycin (10 mg/kg per day on day 1 followed by 5 mg/kg per day for 4 days as a single daily dose) or clarithromycin (15 mg/kg per day in 2 divided doses) can be used in an effort to select an antibacterial agent of an entirely different class. Other possibilities include erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or sulfamethoxazole-trimethoprim (6–10 mg/kg per day of trimethoprim). Alternative therapy in the penicillin-allergic patient who is being treated for infection that is known or presumed to be caused by penicillin-resistant S pneumoniae is clindamycin at 30 to 40 mg/kg per day in 3 divided doses. In the patient who is vomiting or cannot otherwise tolerate oral medication, a single dose of parenteral ceftriaxone (50 mg/kg) has been shown to be effective for the initial treatment of AOM.98,99

The optimal duration of therapy for patients with AOM is uncertain. Studies comparing standard duration of treatment (10 days) to short-duration treatment (1–7 days) were often characterized by limitations including inadequate sample size (therefore having low or limited statistical power), few or no children younger than 2 years, exclusion of otitis-prone children, lack of standardized or stringent criteria for the diagnosis of AOM or for improvement or cure, use of an antibacterial medication that had less than optimal efficacy against common middle-ear pathogens, use of lower than recommended dosage of a medication, and lack of analysis of outcome by age.100 Not surprisingly, the results of these studies were variable. Several more recent studies have been reported that addressed the issue of duration of therapy.101–105 The results favoring standard 10-day therapy have been most significant in children younger than 2 years and suggestive of increased efficacy in those 2 to 5 years of age. Thus, for younger children and for children with severe disease, a standard 10-day course is recommended.106 For children 6 years of age and older with mild to moderate disease, a 5- to 7-day course is appropriate.


   RECOMMENDATION 4
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 
If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent, the clinician should change the antibacterial agent. (This recommendation is based on observational studies and a preponderance of benefit over risk.)

When antibacterial agents are prescribed for AOM, the time course of clinical response should be 48 to 72 hours. With few exceptions, the first 24 hours of therapy are characterized by a stabilization of the clinical condition. Early during this period the patient may actually worsen slightly. In the second 24 hours, the patient should begin to improve. If initially febrile, the patient is expected to defervesce within 48 to 72 hours. Irritability should improve, and sleeping and eating patterns should begin to normalize.37 If the patient is not improved by 48 to 72 hours, either another disease is present or the therapy that has been chosen was not adequate. When observation has been the chosen management and spontaneous improvement has not been noted by 48 to 72 hours, antibacterial therapy is indicated to limit the duration of further illness.

The patient should be given clear instructions at the initial visit as to when and how to communicate continuation or worsening of signs and symptoms to the clinician to expedite a change in treatment.

Antibacterial-agent choice after initial failure of observation or first-line antibacterial therapy should be based on the likely pathogen(s) present and on clinical experience. If the patient was treated with initial observation, amoxicillin should be started at a dose of 80 to 90 mg/kg per day. For patients who have severe illness (moderate to severe otalgia or temperature of 39°C or higher42), in those for whom additional coverage for ß-lactamase-positive H influenzae and M catarrhalis is desired, and for those who had been treated initially with amoxicillin and did not improve, high-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin component, with 6.4 mg/kg per day of clavulanate in 2 divided doses)76 should be used. Alternatives in patients with a history of a non-type I allergic reaction to penicillins are cefdinir, cefpodoxime, or cefuroxime.88 In cases of type I reactions, alternatives are azithromycin, clarithromycin, erythromycin-sulfisoxazole, or sulfamethoxazole-trimethoprim. Ceftriaxone (50 mg/kg per day), given for 3 consecutive days either intravenously or intramuscularly, can be used in children with vomiting or in other situations that preclude administration of oral antibacterial agents. In the treatment of AOM unresponsive to initial antibacterial therapy, a 3-day course of ceftriaxone has been shown to be better than a 1-day regimen.99 Although trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole have traditionally been useful as first- and second-line therapy for patients with AOM, recent pneumococcal surveillance studies indicate that resistance to these 2 combination agents is substantial.90,95 Therefore, when patients fail to improve while receiving amoxicillin, neither trimethoprim-sulfamethoxazole107 nor erythromycin-sulfisoxazole is optimal for antibacterial therapy.

A patient who fails amoxicillin-potassium clavulanate should be treated with a 3-day course of parenteral ceftriaxone because of its superior efficacy against S pneumoniae, compared with alternative oral antibacterials.91,99 If AOM persists, tympanocentesis should be recommended to make a bacteriologic diagnosis. If tympanocentesis is not available, a course of clindamycin may be considered for the rare case of penicillin-resistant pneumococcal infection not responding to the previous regimens. If the patient still does not improve, tympanocentesis with Gram-stain, culture, and antibacterial-agent sensitivity studies of the fluid is essential to guide additional therapy. Table 6 summarizes antibacterial options.


View this table:
[in this window]
[in a new window]
  		TABLE 6. Recommended Antibacterial Agents for Patients Who Are Being Treated Initially With Antibacterial Agents or Have Failed 48 to 72 Hours of Observation or Initial Management With Antibacterial Agents

 
Once the patient has shown clinical improvement, follow-up is based on the usual clinical course of AOM. Persistent MEE after resolution of acute symptoms is common and should not be viewed as a need for active therapy. Two weeks after an episode of AOM, 60% to 70% of children have MEE, decreasing to 40% at 1 month and 10% to 25% after 3 months.37(161–162) OME must be differentiated clinically from AOM and requires additional monitoring but not antibacterial therapy. Assurance that OME resolves is particularly important for children with cognitive or developmental delays that may be impacted adversely by transient hearing loss associated with MEE.


   RECOMMENDATION 5
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 
Clinicians should encourage the prevention of AOM through reduction of risk factors. (This recommendation is based on strong observational studies and a preponderance of benefits over risks.)

A number of factors associated with early or recurrent AOM are not amenable to change, for example, genetic predisposition, premature birth, male gender, Native American/Inuit ethnicity, family history of recurrent otitis media, presence of siblings in the household, and low socioeconomic status.108–113

During infancy and early childhood, reducing the incidence of respiratory tract infections by altering child care center attendance patterns can reduce the incidence of recurrent AOM significantly.108,114 The implementation of breastfeeding for at least the first 6 months also seems to be helpful against the development of early episodes of AOM.108,109 Avoiding supine bottle feeding ("bottle propping"),115 reducing or eliminating pacifier use in the second 6 months of life,116 and eliminating exposure to passive tobacco smoke117,118 have been postulated to reduce the incidence of AOM in infancy; however, the utility of these interventions is unclear.108,109,114,119,120

Immunoprophylaxis with killed121 and live-attenuated intranasal122 influenza vaccines has demonstrated more than 30% efficacy in prevention of AOM during the respiratory illness season. Most of the children in these studies were older than 2 years. A controlled study among infants and toddlers 6 to 23 months of age failed to demonstrate any efficacy of killed vaccine in preventing AOM.123 Pneumococcal conjugate vaccines have proven effective in preventing vaccine-serotype pneumococcal otitis media, but their overall benefit is small, with only a 6% reduction in the incidence of AOM.124–126 Medical office visits for otitis were reduced by 7.8% and antibiotic prescriptions by 5.7% in a large clinical practice after introduction of the pneumococcal conjugate vaccine.127 Respiratory syncytial virus, parainfluenza virus, and adenovirus vaccines currently under development hold additional promise for prevention of ear infections.


   RECOMMENDATION 6
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 
No recommendations for complementary and alternative medicine (CAM) for treatment of AOM are made based on limited and controversial data.

Increasing numbers of parents/caregivers are using various forms of nonconventional treatment for their children.128,129 The types of treatments used can differ depending on the ethnic background and belief system of the family and the availability of alternative medicine in a particular community. Treatments that have been used for AOM include homeopathy, acupuncture, herbal remedies, chiropractic treatments, and nutritional supplements.130 Many physicians ask parents, caregivers, or older children if they are using medicines, supplements, or other means to maintain health or treat specific conditions;131 however, parents/caregivers are often reluctant to tell their physicians that they are using complementary or alternative treatments.132 Although most treatments are harmless, some are not. Some treatments can have a direct and dangerous effect, whereas others may interfere with the effects of conventional treatments.30 Clinicians should become more informed about CAM, ask whether they are being used, and be ready to discuss potential benefits or risks.133

To date there are no studies that conclusively show a beneficial effect of alternative therapies used for AOM. Recent interest in the use of CAM has led to research efforts to investigate its efficacy.134 It is difficult to design and conduct studies on certain forms of CAM because of the unique nature of the treatment.135 Any study conducted will need to show proof of effectiveness of a specific therapy when compared with the natural history of AOM. Conclusions regarding CAM cannot be made until research evidence is available.


   FUTURE RESEARCH
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
SUMMARY
 CONCLUSIONS
 REFERENCES
 
Despite the voluminous literature about AOM, there still are many opportunities for future research to continue to clarify the accurate diagnosis and most effective management of this common condition. Most important is that future studies address concerns regarding the quality and applicability of many studies in AOM.21,69,78,100 Future studies should use standardized criteria for diagnosis, outcome, and severity of illness; increase sample size, which in general has been too limited to identify small but significant differences in clinical outcome; include children younger than 2 years and older than 12 years; use doses of medication shown to achieve adequate levels in the middle ear to treat the target organisms successfully; and stratify outcomes by age and severity of illness. In addition, studies done in limited geographic areas must be replicated in other areas to ensure generalizability.

Some of the studies that should be considered include:

  • Additional validation of standard definitions of AOM
  • New or improved technologies for objective diagnosis of MEE
  • Efficacy of education programs to improve clinician diagnostic skills
  • Additional studies on pain management including topical agents, CAM, and role of tympanocentesis/myringotomy in pain management
  • Large population-based studies on the benefits and risks of the "observation option" looking at antibacterial use; bacterial resistance; incidence of adverse events; long-term effects on hearing; persistence of MEE; and parent, patient, and clinician satisfaction
  • Continued development of new antibacterial agents to address potential changes in resistance patterns of organisms responsible for AOM (studies on new agents must be appropriately designed and have adequate sample size to show clinical efficacy equal to or better than current agents)
  • Randomized, controlled trials on duration of treatment in all age groups
  • Vaccine research directed at more of the causative organisms of AOM
  • Additional studies on potential measures to prevent AOM


   SUMMARY
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
CONCLUSIONS
 REFERENCES
 
This clinical practice guideline provides evidence-based recommendations for the definition and management of AOM in children from 2 months through 12 years of age without signs or symptoms of systemic illness unrelated to the middle ear. It emphasizes accurate diagnosis and adherence to a consistent definition of AOM. Management of the pain associated with AOM is identified as an essential aspect of care. An option to observe a select group of children with AOM with symptomatic therapy for 48 to 72 hours is supported by evidence and may potentially lead to decreased use of antibacterial agents. If a decision is made to treat with an antibacterial agent, amoxicillin at a dose of 80 to 90 mg/kg per day is recommended as the initial antibacterial agent of choice for most children. Additional guidance is given for choosing an antibacterial agent when an alternative to amoxicillin is indicated. Also addressed is evidence related to the prevention of AOM and the role of CAM in the treatment of AOM. The recommendations are summarized in Fig. 1.


Figure 1
Figure 1
View larger version (69K):
[in this window]
[in a new window]
  		Fig 1. Management of AOM.

 

   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
REFERENCES
 
1. Recommendation: To diagnose AOM the clinician should confirm a history of acute onset, identify signs of MEE, and evaluate for the presence of signs and symptoms of middle-ear inflammation.
2. Strong recommendation: The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain.
3A. Option: Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up.
3B. Recommendation: If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children.

Option: When amoxicillin is used, the dose should be 80 to 90 mg/kg per day.

4. Recommendation: If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent, the clinician should change the antibacterial agent.
5. Recommendation: Clinicians should encourage the prevention of AOM through reduction of risk factors.
6. No recommendation: There is insufficient evidence to make a recommendation regarding the use of CAM for AOM.

Subcommittee on Management of Acute Otitis Media
Allan S. Lieberthal, MD, Cochairperson

Theodore G. Ganiats, MD, Cochairperson

Edward O. Cox, MD

Larry Culpepper, MD, MPH

Martin Mahoney, MD, PhD

Donald Miller, MD, MPH

Desmond K. Runyan, MD, DrPH

Nina Lisbeth Shapiro, MD

Ellen Wald, MD*

Liaisons
Richard Besser, MD

Centers for Disease Control and Prevention

Ellen Friedman, MD

American Academy of Otolaryngology-Head and Neck Surgery

Norman Wendell Todd, MD

American Academy of Otolaryngology-Head and Neck Surgery

Consultants
S. Michael Marcy, MD

Richard M. Rosenfeld, MD, MPH

Richard Shiffman, MD

Staff
Maureen Hannley, PhD

Carla Herrerias, MPH

Bellinda Schoof, MHA, CPHQ


   FOOTNOTES
 
The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

* Dr Ellen Wald withdrew from the Subcommittee on Management of Acute Otitis Media before publication of this guideline. Back


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RECOMMENDATION 1
 RECOMMENDATION 2
 RECOMMENDATION 3A
 RECOMMENDATION 3B
 RECOMMENDATION 4
 RECOMMENDATION 5
 RECOMMENDATION 6
 FUTURE RESEARCH
 SUMMARY
 CONCLUSIONS
 REFERENCES
 

  1. Marcy M, Takata G, Chan LS, et al. Management of Acute Otitis Media. Evidence Report/Technology Assessment No. 15. AHRQ Publication No. 01-E010 Rockville, MD: Agency for Healthcare Research and Quality; 2001
  2. Schappert SM. Office visits for otitis media: United States, 1975–90. Adv Data. 1992;214 :1 –18[Medline]
  3. Cherry DK, Woodwell DA. National ambulatory medical care survey: 2000 summary. Adv Data. 2002;328 :1 –32[Medline]
  4. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA. 2002;287 :3096 –3102[Abstract/Free Full Text]
  5. Niemela M, Uhari M, Jounio-Ervasti K, Luotonen J, Alho OP, Vierimaa E. Lack of specific symptomatology in children with acute otitis media. Pediatr Infect Dis J. 1994;13 :765 –768[Web of Science][Medline]
  6. Kontiokari T, Koivunen P, Niemela M, Pokka T, Uhari M. Symptoms of acute otitis media. Pediatr Infect Dis J. 1998;17 :676 –679[CrossRef][Web of Science][Medline]
  7. Pelton SI. Otoscopy for the diagnosis of otitis media. Pediatr Infect Dis J. 1998;17 :540 –543[CrossRef][Web of Science][Medline]
  8. Brookhouser PE. Use of tympanometry in office practice for diagnosis of otitis media. Pediatr Infect Dis J. 1998;17 :544 –551[CrossRef][Web of Science][Medline]
  9. Kimball S. Acoustic reflectometry: spectral gradient analysis for improved detection of middle ear effusion in children. Pediatr Infect Dis J. 1998;17 :552 –555[CrossRef][Web of Science][Medline]
  10. Barnett ED, Klein JO, Hawkins KA, Cabral HJ, Kenna M, Healy G. Comparison of spectral gradient acoustic reflectometry and other diagnostic techniques for detection of middle ear effusion in children with middle ear disease. Pediatr Infect Dis J. 1998;17 :556 –559[CrossRef][Web of Science][Medline]
  11. Block SL, Mandel E, McLinn S, et al. Spectral gradient acoustic reflectometry for detection of middle ear effusion by pediatricians and parents. Pediatr Infect Dis J. 1998;17 :560 –564[CrossRef][Web of Science][Medline]
  12. Block SL, Pichichero ME, McLinn S, Aronovitz G, Kimball S. Spectral gradient acoustic reflectometry: detection of middle ear effusion in suppurative acute otitis media. Pediatr Infect Dis J. 1999;18 :741 –744[CrossRef][Web of Science][Medline]
  13. Karma PH, Penttila MA, Sipila MM, Kataja MJ. Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media. I. The value of different otoscopic findings. Int J Pediatr Otorhinolaryngol. 1989;17 :37 –49[CrossRef][Web of Science][Medline]
  14. Karma PH, Sipila MM, Kataja MJ, Penttila MA. Pneumatic otoscopy and otitis media. II. Value of different tympanic membrane findings and their combinations. In: Lim DJ, Bluestone CD, Klein JO, Nelson JD, Ogra PL, eds. Recent Advances in Otitis Media: Proceedings of the Fifth International Symposium. Burlington, ON, Canada: Decker Periodicals; 1993:41–45
  15. Merifield DO, Miller GS. The etiology and clinical course of bullous myringitis. Arch Otolaryngol. 1966;84 :487 –489[Abstract/Free Full Text]
  16. Klein JO, McCracken GH Jr. Introduction: current assessments of diagnosis and management of otitis media. Pediatr Infect Dis J. 1998;17 :539[CrossRef]
  17. Pichichero ME, Poole MD. Assessing diagnostic accuracy and tympanocentesis skills in the management of otitis media. Arch Pediatr Adolesc Med. 2001;155 :1137 –1142[Abstract/Free Full Text]
  18. Pichichero ME. Diagnostic accuracy, tympanocentesis training performance, and antibiotic selection by pediatric residents in management of otitis media. Pediatrics. 2002;110 :1064 –1070[Abstract/Free Full Text]
  19. Chonmaitree T. Viral and bacterial interaction in acute otitis media. Pediatr Infect Dis J. 2000;19(suppl) :S24 –S30[CrossRef][Web of Science][Medline]
  20. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis media—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101 :165 –171[Abstract/Free Full Text]
  21. Wald ER. Acute otitis media: more trouble with the evidence. Pediatr Infect Dis J. 2003;22 :103 –104[CrossRef][Web of Science][Medline]
  22. Rosenfeld RM. Diagnostic certainty for acute otitis media. Int J Pediatr Otorhinolaryngol. 2002;64 :89 –95[CrossRef][Web of Science][Medline]
  23. Hayden GF, Schwartz RH. Characteristics of earache among children with acute otitis media. Am J Dis Child. 1985;139 :721 –723[Abstract/Free Full Text]
  24. Schechter NL. Management of pain associated with acute medical illness. In: Schechter NL, Berde CB, Yaster M, eds. Pain in Infants, Children, and Adolescents. Baltimore, MD: Williams & Wilkins; 1993:537–538
  25. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108 :793 –797[Abstract/Free Full Text]
  26. Bertin L, Pons G, d'Athis P, et al. A randomized, double-blind, multicentre controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children. Fundam Clin Pharmacol. 1996;10 :387 –392[Web of Science][Medline]
  27. Hoberman A, Paradise JL, Reynolds EA, Urkin J. Efficacy of Auralgan for treating ear pain in children with acute otitis media. Arch Pediatr Adolesc Med. 1997;151 :675 –678[Abstract/Free Full Text]
  28. Sarrell EM, Mandelberg A, Cohen HA. Efficacy of naturopathic extracts in the management of ear pain associated with acute otitis media. Arch Pediatr Adolesc Med. 2001;155 :796 –799[Abstract/Free Full Text]
  29. Barnett ED, Levatin JL, Chapman EH, et al. Challenges of evaluating homeopathic treatment of acute otitis media. Pediatr Infect Dis J. 2000;19 :273 –275[CrossRef][Web of Science][Medline]
  30. Jacobs J, Springer DA, Crothers D. Homeopathic treatment of acute otitis media in children: a preliminary randomized placebo-controlled trial. Pediatr Infect Dis J. 2001;20 :177 –183[Web of Science][Medline]
  31. Rosenfeld RM, Bluestone CD. Clinical efficacy of surgical therapy. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis Media. 2nd ed. Hamilton, ON, Canada: BC Decker Inc; 2003:227–240
  32. New York Region Otitis Project. Observation Option Toolkit for Acute Otitis Media. Publication No. 4894. New York, NY: State of New York, Department of Health; 2002
  33. Rosenfeld RM. Observation option toolkit for acute otitis media. Int J Pediatr Otorhinolaryngol. 2001;58 :1 –8[CrossRef][Web of Science][Medline]
  34. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr. 1994;124 :355 –367[CrossRef][Web of Science][Medline]
  35. Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ. 1997;314 :1526 –1529[Abstract/Free Full Text]
  36. Glasziou PP, Del Mar CB, Hayem M, Sanders SL. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2000;4 :CD000219
  37. Rosenfeld RM, Kay D. Natural history of untreated otitis media. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis Media. 2nd ed. Hamilton, ON, Canada: BC Decker Inc; 2003:180–198
  38. Appelman CL, Van Balen FA, Van de Lisdonk EH, Van Weert HC, Eizenga WH. Otitis media acuta. NHG-standaard (eerste herziening) [in Dutch]. Huisarts Wet. 1999;42 :362 –366
  39. van Buchem FL, Peeters MF, van't Hof MA. Acute otitis media: a new treatment strategy. Br Med J (Clin Res Ed). 1985;290 :1033 –1037[Medline]
  40. Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ. 2001;322 :336 –342[Abstract/Free Full Text]
  41. Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ. 2002;325 :22[Abstract/Free Full Text]
  42. Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics. 1991;87 :466 –474[Abstract/Free Full Text]
  43. Barry B, Gehanno P, Blumen M, Boucot I. Clinical outcome of acute otitis media caused by pneumococci with decreased susceptibility to penicillin. Scand J Infect Dis. 1994;26 :446 –452[Web of Science][Medline]
  44. Appelman CL, Claessen JQ, Touw-Otten FW, Hordijk GJ, de Melker RA. Co-amoxiclav in recurrent acute otitis media: placebo controlled study. BMJ. 1991;303 :1450 –1452[Abstract/Free Full Text]
  45. Froom J, Culpepper L, Grob P, et al. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network. BMJ. 1990;300 :582 –586[Abstract/Free Full Text]
  46. Froom J, Culpepper L, Bridges-Webb C, et al. Effect of patient characteristics and disease manifestations on the outcome of acute otitis media at 2 months. Arch Fam Med. 1993;2 :841 –846[Abstract/Free Full Text]
  47. Shurin PA, Rehmus JM, Johnson CE, et al. Bacterial polysaccharide immune globulin for prophylaxis of acute otitis media in high-risk children. J Pediatr. 1993;123 :801 –810[CrossRef][Web of Science][Medline]
  48. Rudberg RD. Acute otitis media: comparative therapeutic results of sulfonamide and penicillin administered in various forms. Acta Otolaryngol Suppl. 1954;113 :1 –79[Medline]
  49. Palva T, Pulkkinen K. Mastoiditis. J Laryngol Otol. 1959;73 :573 –588[Medline]
  50. Hoppe JE, Koster S, Bootz F, Niethammer D. Acute mastoiditis—relevant once again. Infection. 1994;22 :178 –182[CrossRef][Web of Science][Medline]
  51. Bahadori RS, Schwartz RH, Ziai M. Acute mastoiditis in children: an increase in frequency in Northern Virginia. Pediatr Infect Dis J. 2000;19 :212 –215[CrossRef][Web of Science][Medline]
  52. Faye-Lund H. Acute and latent mastoiditis. J Laryngol Otol. 1989;103 :1158 –1160[Web of Science][Medline]
  53. Ghaffar FA, Wordemann M, McCracken GH Jr. Acute mastoiditis in children: a seventeen-year experience in Dallas, Texas. Pediatr Infect Dis J. 2001;20 :376 –380[CrossRef][Web of Science][Medline]
  54. Harley EH, Sdralis T, Berkowitz RG. Acute mastoiditis in children: a 12-year retrospective study. Otolaryngol Head Neck Surg. 1997;116 :26 –30[CrossRef][Web of Science][Medline]
  55. Kaplan SL, Mason EO Jr, Wald ER, et al. Pneumococcal mastoiditis in children. Pediatrics. 2000;106 :695 –699[Abstract/Free Full Text]
  56. Kvestad E, Kvaerner KJ, Mair IW. Acute mastoiditis: predictors for surgery. Int J Pediatr Otorhinolaryngol. 2000;52 :149 –155[CrossRef][Web of Science][Medline]
  57. Linder TE, Briner HR, Bischoff T. Prevention of acute mastoiditis: fact or fiction? Int J Pediatr Otorhinolaryngol. 2000;56 :129 –134[CrossRef][Web of Science][Medline]
  58. Nadal D, Herrmann P, Baumann A, Fanconi A. Acute mastoiditis: clinical, microbiological, and therapeutic aspects. Eur J Pediatr. 1990;149 :560 –564[CrossRef][Web of Science][Medline]
  59. Petersen CG, Ovesen T, Pedersen CB. Acute mastoidectomy in a Danish county from 1977 to 1996 with focus on the bacteriology. Int J Pediatr Otorhinolaryngol. 1998;45 :21 –29[CrossRef][Web of Science][Medline]
  60. Scott TA, Jackler RK. Acute mastoiditis in infancy: a sequela of unrecognized acute otitis media. Otolaryngol Head Neck Surg. 1989;101 :683 –687[Web of Science][Medline]
  61. Dhooge IJ, Albers FW, Van Cauwenberge PB. Intratemporal and intracranial complications of acute suppurative otitis media in children: renewed interest. Int J Pediatr Otorhinolaryngol. 1999;49 :S109 –S114[CrossRef][Web of Science][Medline]
  62. Gliklich RE, Eavey RD, Iannuzzi RA, Camacho AE. A contemporary analysis of acute mastoiditis. Arch Otolaryngol Head Neck Surg. 1996;122 :135 –139[Abstract/Free Full Text]
  63. Luntz M, Brodsky A, Nusem S, et al. Acute mastoiditis—the antibacterial agent era: a multicenter study. Int J Pediatr Otorhinolaryngol. 2001;57 :1 –9[CrossRef][Web of Science][Medline]
  64. Van Zuijlen DA, Schilder AG, Van Balen FA, Hoes AW. National differences in acute mastoiditis: relationship to prescribing patterns of antibiotics for acute otitis media? Pediatr Infect Dis J. 2001;20 :140 –144[Web of Science][Medline]
  65. Schutzman SA, Petrycki S, Fleisher GR. Bacteremia with otitis media. Pediatrics. 1991;87 :48 –53[Abstract/Free Full Text]
  66. Damoiseaux RA, van Balen FA, Hoes AW, Vaerheij TJ, 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 –354[Abstract/Free Full Text]
  67. Kilpi T, Anttila M, Kallio MJ, Peltola H. Severity of childhood bacterial meningitis: duration of illness before diagnosis. Lancet. 1991;338 :406 –409[CrossRef][Web of Science][Medline]
  68. Whitney CG, Farley MM, Hadler J, et al. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med. 2003;348 :1737 –1746[Abstract/Free Full Text]
  69. Dagan R, McCracken GH Jr. Flaws in design and conduct of clinical trials in acute otitis media. Pediatr Infect Dis J. 2002;21 :894 –902[CrossRef][Web of Science][Medline]
  70. Cates C. An evidence based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study. BMJ. 1999;318 :715 –716[Free Full Text]
  71. Siegel RM, Kiely M, Bien JP, et al. Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics. 2003;112 :527 –531[Abstract/Free Full Text]
  72. Rosenfeld RM. Clinical efficacy of medical therapy. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis Media. 2nd ed. Hamilton, ON, Canada: BC Decker Inc; 2003:199–226
  73. Burke P, Bain J, Robinson D, Dunleavey J. Acute red ear in children: controlled trial of non-antibiotic treatment in general practice. BMJ. 1991;303 :558 –562[Abstract/Free Full Text]
  74. Ruben RJ. Sequelae of antibiotic therapy. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis Media. Hamilton, ON, Canada: BC Decker Inc; 1999:303–314
  75. Piglansky L, Leibovitz E, Raiz S, et al. Bacteriologic and clinical efficacy of high dose amoxicillin for therapy of acute otitis media in children. Pediatr Infect Dis J. 2003;22 :405 –413[CrossRef][Web of Science][Medline]
  76. Dagan R, Hoberman A, Johnson C, et al. Bacteriologic and clinical efficacy of high dose amoxicillin/clavulanate in children with acute otitis media. Pediatr Infect Dis J. 2001;20 :829 –837[CrossRef][Web of Science][Medline]
  77. Dagan R, Leibovitz E, Greenberg D, Yagupsky P, Fliss DM, Leiberman A. Early eradication of pathogens from middle ear fluid during antibiotic treatment of acute otitis media is associated with improved clinical outcome. Pediatr Infect Dis J. 1998;17 :776 –782[CrossRef][Web of Science][Medline]
  78. Marchant CD, Carlin SA, Johnson CE, Shurin PA. Measuring the comparative efficacy of antibacterial agents for acute otitis media: the "Pollyanna phenomenon." J Pediatr. 1992;120 :72 –77[CrossRef][Web of Science][Medline]
  79. Carlin SA, Marchant CD, Shurin PA, Johnson CE, Super DM, Rehmus JM. Host factors and early therapeutic response in acute otitis media. J Pediatr. 1991;118 :178 –183[CrossRef][Web of Science][Medline]
  80. Vogelman B, Gudmundsson S, Leggett J, Turnidge J, Ebert S, Craig WA. Correlation of antimicrobial pharmacokinetic parameters with therapeutic efficacy in an animal model. J Infect Dis. 1988;158 :831 –847[Web of Science][Medline]
  81. Craig W. Pharmacokinetic/pharmacodynamic parameters: rationale for antibacterial dosing of mice and men. Clin Infect Dis. 1998;26 :1 –10[Web of Science][Medline]
  82. Berman S. Otitis media in children. N Engl J Med. 1995;332 :1560 –1565[Free Full Text]
  83. Klein JO. Otitis media. Clin Infect Dis. 1994;19 :823 –833[Web of Science][Medline]
  84. Block SL, Hedrick JA, Harrison CJ. Routine use of Prevnar in a pediatric practice profoundly alters the microbiology of acute otitis media. Paper presented at: Pediatric Academic Societies Annual Meeting; May 3–6, 2003; Seattle, WA
  85. Pitkaranta A, Virolainen A, Jero J, Arruda E, Hayden FG. Detection of rhinovirus, respiratory syncytial virus, and coronavirus infections in acute otitis media by reverse transcriptase polymerase chain reaction. Pediatrics. 1998;102 :291 –295[Abstract/Free Full Text]
  86. Heikkinen T, Thint M, Chonmaitree T. Prevalence of various respiratory viruses in the middle ear during acute otitis media. N Engl J Med. 1999;340 :260 –264[Abstract/Free Full Text]
  87. Doern GV, Jones RN, Pfaller MA, Kugler K. Haemophilus influenzae and Moraxella catarrhalis from patients with community-acquired respiratory tract infections: antimicrobial susceptibility patterns from the SENTRY Antimicrobial Surveillance Program (United States and Canada, 1997). Antimicrob Agents Chemother. 1999;43 :385 –389[Abstract/Free Full Text]
  88. Sinus and Allergy Health Partnership. Antibacterial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 2000;123 :S5 –S31[CrossRef]
  89. Doern GV, Brueggemann AB, Pierce G, Holley HP Jr, Rauch A. Antibiotic resistance among clinical isolates of Haemophilus influenzae in the United States in 1994 and 1995 and detection of beta-lactamase-positive strains resistant to amoxicillin-clavulanate: results of a national multicenter surveillance study. Antimicrob Agents Chemother. 1997;41 :292 –297[Abstract]
  90. Doern GV, Pfaller MA, Kugler K, Freeman J, Jones RN. Prevalence of antimicrobial resistance among respiratory tract isolates of Streptococcus pneumoniae in North America: 1997 results from the SENTRY Antimicrobial Surveillance Program. Clin Infect Dis. 1998;27 :764 –770[Web of Science][Medline]
  91. Jacobs MR, Felmingham D, Appelbaum PC, Guneberg RN, Alexander Project Group. The Alexander Project 1998–2000: susceptibility of pathogens isolated from community-acquired respiratory tract infection to commonly used antimicrobial agents. J Antimicrob Chemother. 2003;52 :229 –246[Abstract/Free Full Text]
  92. Howie VM, Ploussard JH. Efficacy of fixed combination antibiotics versus separate components in otitis media. Effectiveness of erythromycin estolate, triple sulfonamide, ampicillin, erythromycin estolate-triple sulfonamide, and placebo in 280 patients with acute otitis media under two and one-half years of age. Clin Pediatr (Phila). 1972;11 :205 –214[Abstract/Free Full Text]
  93. Klein JO. Microbiologic efficacy of antibacterial drugs for acute otitis media. Pediatr Infect Dis J. 1993;12 :973 –975[Web of Science][Medline]
  94. Barnett ED, Klein JO. The problem of resistant bacteria for the management of acute otitis media. Pediatr Clin North Am. 1995;42 :509 –517[Web of Science][Medline]
  95. Jacobs MR, Bajaksouzian S, Zilles A, Lin G, Pankuch GA, Appelbaum PC. Susceptibilities of Streptococcus pneumoniae and Haemophilus influenzae to 10 oral antimicrobial agents, based on pharmacodynamic parameters: 1997 U.S. Surveillance study. Antimicrob Agents Chemother. 1999;43 :1901 –1908[Abstract/Free Full Text]
  96. Wald ER, Mason EO Jr, Bradley JS, Barson WJ, Kaplan SL, US Pediatric Multicenter Pneumococcal Surveillance Group. Acute otitis media caused by Streptococcus pneumoniae in children's hospitals between 1994 and 1997. Pediatr Infect Dis J. 2001;20 :34 –39[CrossRef][Web of Science][Medline]
  97. Kellner JD, Ford-Jones EL. Streptococcus pneumoniae carriage in children attending 59 Canadian child care centers. Toronto Child Care Centre Study Group. Arch Pediatr Adolesc Med. 1999;153 :495 –502[Abstract/Free Full Text]
  98. Green SM, Rothrock SG. Single-dose intramuscular ceftriaxone for acute otitis media in children. Pediatrics. 1993;91 :23 –30[Abstract/Free Full Text]
  99. Leibovitz E, Piglansky L, Raiz S, Press J, Leiberman A, Dagan R. Bacteriologic and clinical efficacy of one day vs. three day intramuscular ceftriaxone for treatment of nonresponsive acute otitis media in children. Pediatr Infect Dis J. 2000;19 :1040 –1045[Web of Science][Medline]
  100. Paradise JL. Short-course antibacterial treatment for acute otitis media: not best for infants and young children. JAMA. 1997;278 :1640 –1642[Abstract/Free Full Text]
  101. Hoberman A, Paradise JL, Burch DJ, et al. Equivalent efficacy and reduced occurrence of diarrhea from a new formulation of amoxicillin/clavulanate potassium (Augmentin) for treatment of acute otitis media in children. Pediatr Infect Dis J. 1997;16 :463 –470[CrossRef][Web of Science][Medline]
  102. Cohen R, Levy C, Boucherat M, Langue J, de la Rocque F. A multicenter, randomized, double-blind trial of 5 versus 10 days of antibacterial agent therapy for acute otitis media in young children. J Pediatr. 1998;133 :634 –639[CrossRef][Web of Science][Medline]
  103. Cohen R, Levy C, Boucherat M, et al. Five vs. ten days of antibiotic therapy for acute otitis media in young children. Pediatr Infect Dis J. 2000;19 :458 –463[CrossRef][Web of Science][Medline]
  104. Pessey JJ, Gehanno P, Thoroddsen E, et al. Short course therapy with cefuroxime axetil for acute otitis media: results of a randomized multicenter comparison with amoxicillin/clavulanate. Pediatr Infect Dis J. 1999;18 :854 –859[CrossRef][Web of Science][Medline]
  105. Pichichero ME, Marsocci SM, Murphy ML, Hoeger W, Francis AB, Green JL. A prospective observational study of 5-, 7-, and 10-day antibiotic treatment for acute otitis media. Otolaryngol Head Neck Surg. 2001;124 :381 –387[CrossRef][Web of Science][Medline]
  106. Dowell SF, Butler JC, Giebink SG, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance—a report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J. 1999;18 :1 –9[CrossRef][Web of Science][Medline]
  107. Leiberman A, Leibovitz E, Piglansky L, et al. Bacteriologic and clinical efficacy of trimethoprim-sulfamethoxazole for the treatment of acute otitis media. Pediatr Infect Dis J. 2001;20 :260 –264[CrossRef][Web of Science][Medline]
  108. Daly KA, Giebink GS. Clinical epidemiology of otitis media. Pediatr Infect Dis J. 2000;19(suppl 5) :S31 –S36
  109. Paradise JL, Rockette HE, Colborn DK, et al. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics. 1997;99 :318 –333[Abstract/Free Full Text]
  110. Kero P, Piekkala P. Factors affecting the occurrence of acute otitis media during the first year of life. Acta Paediatr Scand. 1987;76 :618 –623[Web of Science][Medline]
  111. Curns AT, Holman RC, Shay DK, et al. Outpatient and hospital visits associated with otitis media among American Indian and Alaska Native children younger than 5 years. Pediatrics. 2002;109(3) . Available at: www.pediatrics.org/cgi/content/full/109/3/e41
  112. Casselbrant ML, Mandel EM, Fall PA, et al. The hereditability of otitis media: a twin and triplet study. JAMA. 1999;282 :2125 –2130[Abstract/Free Full Text]
  113. Uhari M, Mantysaari K, Niemela M. A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis. 1996;22 :1079 –1083[Web of Science][Medline]
  114. Adderson EE. Preventing otitis media: medical approaches. Pediatr Ann. 1998;27 :101 –107[Web of Science][Medline]
  115. Brown CE, Magnuson B. On the physics of the infant feeding bottle and middle ear sequela: ear disease in infants can be associated with bottle feeding. Int J Pediatr Otorhinolaryngol. 2000;54 :13 –20[CrossRef][Web of Science][Medline]
  116. Niemela M, Pihakari O, Pokka T, Uhari M. Pacifier as a risk factor for acute otitis media: a randomized, controlled trial of parental counseling. Pediatrics. 2000;106 :483 –488[Abstract/Free Full Text]
  117. Etzel RA, Pattishall EN, Haley NJ, Fletcher RH, Henderson FW. Passive smoking and middle ear effusion among children in day care. Pediatrics. 1992;90 :228 –232[Abstract/Free Full Text]
  118. Ilicali OC, Keles N, Deger K, Savas I. Relationship of passive cigarette smoking to otitis media. Arch Otolaryngol Head Neck Surg. 1999;125 :758 –762[Abstract/Free Full Text]
  119. Wellington M, Hall CB. Pacifier as a risk factor for acute otitis media [letter]. Pediatrics. 2002;109 :351[Free Full Text]
  120. Paradise JL, Ah-Tye C. Positional otitis media and otorrhea after tympanostomy-tube placement [letter]. Pediatrics. 2002;109 :349 –350[Free Full Text]
  121. Clements DA, Langdon L, Bland C, Walter E. Influenza A vaccine decreases the incidence of otitis media in 6- to 30-month-old children in day care. Arch Pediatr Adolesc Med. 1995;149 :1113 –1117[Abstract/Free Full Text]
  122. Belshe RB, Gruber WC. Prevention of otitis media in children with live attenuated influenza vaccine given intranasally. Pediatr Infect Dis J. 2000;19(suppl 5) :S66 –S71
  123. Hoberman A, Greenberg DP, Paradise JL, et al. Effectiveness of inactivated influenza vaccine in preventing acute otitis media in young children: a randomized controlled trial. JAMA. 2003;290 :1608 –1616[Abstract/Free Full Text]
  124. Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute otitis media. N Engl J Med. 2001;344 :403 –409[Abstract/Free Full Text]
  125. Black S, Shinefield H, Fireman B, et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Pediatr Infect Dis J. 2000;19 :187 –195[CrossRef][Web of Science][Medline]
  126. Jacobs MR. Prevention of otitis media: role of pneumococcal conjugate vaccines in reducing incidence and antibiotic resistance. J Pediatr. 2002;141 :287 –293[CrossRef][Web of Science][Medline]
  127. Fireman B, Black SB, Shinefield HR, Lee J, Lewis E, Ray P. Impact of the pneumococcal conjugate vaccine on otitis media. Pediatr Infect Dis J. 2003;22 :10 –16[CrossRef][Web of Science][Medline]
  128. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Del-banco TL. Unconventional medicine in the United States. N Engl J Med. 1993;328 :246 –252[Abstract/Free Full Text]
  129. Eisenberg DM, Davis R, Ettner S, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 1998;280 :1569 –1575[Abstract/Free Full Text]
  130. Spigelblatt L, Laine-Ammara G, Pless IB, Guyver A. The use of alternative medicine by children. Pediatrics. 1994;94 :811 –814[Abstract/Free Full Text]
  131. Angell M, Kassirer JP. Alternative medicine—the risks of untested and unregulated remedies. N Engl J Med. 1998;339 :839 –841[Free Full Text]
  132. Kemper KJ. The Holistic Pediatrician: A Parent's Comprehensive Guide to Safe and Effective Therapies for the 25 Most Common Childhood Ailments. New York, NY: Harper Perennial; 1996
  133. American Academy of Pediatrics, Committee on Children With Disabilities. Counseling families who choose complementary and alternative medicine for their child with chronic illness or disability. Pediatrics. 2001;107 :598 –601[Abstract/Free Full Text]
  134. Grimm W, Muller HH. A randomized controlled trial of the effect of fluid extract of Echinacea purpurea on the incidence and severity of colds and respiratory infections. Am J Med. 1999;106 :138 –143[CrossRef][Web of Science][Medline]
  135. Barret B, Vohmann M, Calabrese C. Echinacea for upper respiratory infection. J Fam Pract. 1999;48 :628 –635[Web of Science][Medline]
  136. van Buchem FL, Dunk JH, van't Hof MA. Therapy of acute otitis media: myringotomy, antibiotics, or neither? A double-blind study in children. Lancet. 1981;2(8252) :883 –887
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Facebook Facebook   Add to Reddit Reddit   Add to Technorati Technorati   Add to Twitter Twitter    What's this?


This article has been cited by other articles:


Home page
 ANN INTERN MEDHome page
A. Mehrotra, H. Liu, J. L. Adams, M. C. Wang, J. R. Lave, N. M. Thygeson, L. I. Solberg, and E. A. McGlynn
Comparing Costs and Quality of Care at Retail Clinics With That of Other Medical Settings for 3 Common Illnesses
Ann Intern Med, September 1, 2009; 151(5): 321 - 328.
[Abstract] [Full Text] [PDF]

Home page
 JAMAHome page
C. G. Grijalva, J. P. Nuorti, and M. R. Griffin
Antibiotic Prescription Rates for Acute Respiratory Tract Infections in US Ambulatory Settings
JAMA, August 19, 2009; 302(7): 758 - 766.
[Abstract] [Full Text] [PDF]

Home page
 J Antimicrob ChemotherHome page
E. K. Vouloumanou, D. E. Karageorgopoulos, M. S. Kazantzi, A. M. Kapaskelis, and M. E. Falagas
Antibiotics versus placebo or watchful waiting for acute otitis media: a meta-analysis of randomized controlled trials
J. Antimicrob. Chemother., July 1, 2009; 64(1): 16 - 24.
[Abstract] [Full Text] [PDF]

Home page
 Arch Otolaryngol Head Neck SurgHome page
M. C. Thorne, L. Chewaproug, and L. M. Elden
Suppurative Complications of Acute Otitis Media: Changes in Frequency Over Time
Arch Otolaryngol Head Neck Surg, July 1, 2009; 135(7): 638 - 641.
[Abstract] [Full Text] [PDF]

Home page
 BMJHome page
N. Bezakova, R. A M J Damoiseaux, A. W Hoes, A. G M Schilder, and M. M Rovers
Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: survey of trial participants
BMJ, June 30, 2009; 338(jun30_1): b2525 - b2525.
[Abstract] [Full Text] [PDF]

Home page
 Pediatr. Rev.Home page
S. J. Alter
Pneumococcal Infections
Pediatr. Rev., May 1, 2009; 30(5): 155 - 164.
[Full Text] [PDF]

Home page
 Evid. Based Nurs.Home page
C. J Cates
Delayed antibiotics for children with acute otitis media: is practice change sustainable?
Evid. Based Nurs., April 1, 2009; 12(2): 39 - 40.
[Full Text] [PDF]

Home page
 EDUCATION AND PRACTICEHome page
S Majumdar, K Wu, N D Bateman, and J Ray
Diagnosis and management of otalgia in children
Arch. Dis. Child. Ed. Pract., April 1, 2009; 94(2): 33 - 36.
[Full Text] [PDF]

Home page
 J Antimicrob ChemotherHome page
C. J. Harrison, C. Woods, G. Stout, B. Martin, and R. Selvarangan
Susceptibilities of Haemophilus influenzae, Streptococcus pneumoniae, including serotype 19A, and Moraxella catarrhalis paediatric isolates from 2005 to 2007 to commonly used antibiotics
J. Antimicrob. Chemother., March 1, 2009; 63(3): 511 - 519.
[Abstract] [Full Text] [PDF]

Home page
 Evid. Based Med.Home page
C. J Cates
Delayed antibiotics for children with acute otitis media: is practice change sustainable?
Evid. Based Med., February 1, 2009; 14(1): 2 - 3.
[Full Text] [PDF]

Home page
 Red BookHome page
Haemophilus influenzae Infections
Red Book, January 1, 2009; 2009(1): 314 - 321.
[Full Text]

Home page
 Red BookHome page
Pneumococcal Infections
Red Book, January 1, 2009; 2009(1): 524 - 535.
[Full Text]

Home page
 Red BookHome page
Principles of Appropriate Use for Upper Respiratory Tract Infections
Red Book, January 1, 2009; 2009(1): 740a - 742a.
[Full Text]

Home page
 Red BookHome page
Tables of Antibacterial Drug Dosages
Red Book, January 1, 2009; 2009(1): 744a - 757a.
[Full Text]

Home page
 J. Am. Podiatr. Med. Assoc.Home page
R. G. Smith
Penicillin and Cephalosporin Drug Allergies: A Paradigm Shift
J Am Podiatr Med Assoc, November 1, 2008; 98(6): 479 - 488.
[Abstract] [Full Text] [PDF]

Home page
 CLIN PEDIATRHome page
M. E. Pichichero, J. R. Casey, A. Hoberman, and R. Schwartz
Pathogens Causing Recurrent and Difficult-to-Treat Acute Otitis Media, 2003-2006
Clinical Pediatrics, November 1, 2008; 47(9): 901 - 906.
[Abstract] [PDF]

Home page
 BMJHome page
S. Keyhani, L. C Kleinman, M. Rothschild, J. M Bernstein, R. Anderson, and M. Chassin
Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort
BMJ, October 3, 2008; 337(oct03_1): a1607 - a1607.
[Abstract] [Full Text] [PDF]

Home page
 Evid. Based Nurs.Home page
S. Wright
Topical aqueous 2% lignocaine eardrops reduced ear pain in children with acute otitis media
Evid. Based Nurs., October 1, 2008; 11(4): 107 - 107.
[Full Text] [PDF]

Home page
 Arch. Dis. Child.Home page
Y Berkun, R Nir-Paz, A B. Ami, A Klar, E Deutsch, and H Hurvitz
Acute otitis media in the first two months of life: characteristics and diagnostic difficulties
Arch. Dis. Child., August 1, 2008; 93(8): 690 - 694.
[Abstract] [Full Text] [PDF]

Home page
 AAP Grand RoundsHome page
M. Aldous
Reducing After-Hours Visits for Ear Pain
AAP Grand Rounds, July 1, 2008; 20(1): 1 - 2.
[Full Text] [PDF]

Home page
 CLIN PEDIATRHome page
M. L. Holland and M. Fagnano
Appropriate Antibiotic Use for Acute Otitis Media: What Consumers Find Using Web Searches
Clinical Pediatrics, June 1, 2008; 47(5): 452 - 456.
[Abstract] [PDF]

Home page
 The Annals of PharmacotherapyHome page
E. R Arkins and J. M Koehler
Use of the Observation Option and Compliance with Guidelines in Treatment of Acute Otitis Media
Ann. Pharmacother., May 1, 2008; 42(5): 726 - 727.
[Full Text] [PDF]

Home page
 PediatricsHome page
J. H. Chao, S. Kunkov, L. B. Reyes, S. Lichten, and E. F. Crain
Comparison of Two Approaches to Observation Therapy for Acute Otitis Media in the Emergency Department
Pediatrics, May 1, 2008; 121(5): e1352 - e1356.
[Abstract] [Full Text] [PDF]

Home page
 Infect. Immun.Home page
E. A. Ruckdeschel, C. Kirkham, A. J. Lesse, Z. Hu, and T. F. Murphy
Mining the Moraxella catarrhalis Genome: Identification of Potential Vaccine Antigens Expressed during Human Infection
Infect. Immun., April 1, 2008; 76(4): 1599 - 1607.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
S. B. Meropol, H. A. Glick, and D. A. Asch
Age Inconsistency in the American Academy of Pediatrics Guidelines for Acute Otitis Media
Pediatrics, April 1, 2008; 121(4): 657 - 668.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
S. B. Meropol
Valuing Reduced Antibiotic Use for Pediatric Acute Otitis Media
Pediatrics, April 1, 2008; 121(4): 669 - 673.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
C. M. Sox, J. A. Finkelstein, R. Yin, K. Kleinman, and T. A. Lieu
Trends in Otitis Media Treatment Failure and Relapse
Pediatrics, April 1, 2008; 121(4): 674 - 679.
[Abstract] [Full Text] [PDF]

Home page
 Arch Otolaryngol Head Neck SurgHome page
L. Koopman, A. W. Hoes, P. P. Glasziou, C. L. Appelman, P. Burke, D. P. McCormick, R. A. Damoiseaux, N. Le Saux, and M. M. Rovers
Antibiotic Therapy to Prevent the Development of Asymptomatic Middle Ear Effusion in Children With Acute Otitis Media: A Meta-analysis of Individual Patient Data
Arch Otolaryngol Head Neck Surg, February 1, 2008; 134(2): 128 - 132.
[Abstract] [Full Text] [PDF]

Home page
 Arch Pediatr Adolesc MedHome page
D. B. McWilliams, R. M. Jacobson, H. K. Van Houten, J. M. Naessens, and K. L. Ytterberg
A Program of Anticipatory Guidance for the Prevention of Emergency Department Visits for Ear Pain
Arch Pediatr Adolesc Med, February 1, 2008; 162(2): 151 - 156.
[Abstract] [Full Text] [PDF]

Home page
 Arch Pediatr Adolesc MedHome page
S. Berman
Otitis Media, Shared Decision Making, and Enhancing Value in Pediatric Practice
Arch Pediatr Adolesc Med, February 1, 2008; 162(2): 186 - 188.
[Full Text] [PDF]

Home page
 PediatricsHome page
F. Zhou, A. Shefer, Y. Kong, and J. P. Nuorti
Trends in Acute Otitis Media-Related Health Care Utilization by Privately Insured Young Children in the United States, 1997-2004
Pediatrics, February 1, 2008; 121(2): 253 - 260.
[Abstract] [Full Text] [PDF]

Home page
 AAP Grand RoundsHome page
D. Schiff
Multiresistant Pneumococci in Otitis Media
AAP Grand Rounds, January 1, 2008; 19(1): 4 - 4.
[Full Text] [PDF]

Home page
 Arch Otolaryngol Head Neck SurgHome page
D. Ho, B. W. Rotenberg, and R. G. Berkowitz
The Relationship Between Acute Mastoiditis and Antibiotic Use for Acute Otitis Media in Children
Arch Otolaryngol Head Neck Surg, January 1, 2008; 134(1): 45 - 48.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
J. A. Finkelstein, S. S. Huang, K. Kleinman, S. L. Rifas-Shiman, C. J. Stille, J. Daniel, N. Schiff, R. Steingard, S. B. Soumerai, D. Ross-Degnan, et al.
Impact of a 16-Community Trial to Promote Judicious Antibiotic Use in Massachusetts
Pediatrics, January 1, 2008; 121(1): e15 - e23.
[Abstract] [Full Text] [PDF]

Home page
 JAMAHome page
M. E. Pichichero and J. R. Casey
Emergence of a Multiresistant Serotype 19A Pneumococcal Strain Not Included in the 7-Valent Conjugate Vaccine as an Otopathogen in Children
JAMA, October 17, 2007; 298(15): 1772 - 1778.
[Abstract] [Full Text] [PDF]

Home page
 Arch Pediatr Adolesc MedHome page
J. Chianese, A. Hoberman, J. L. Paradise, D. K. Colborn, D. Kearney, H. E. Rockette, and M. Kurs-Lasky
Spectral Gradient Acoustic Reflectometry Compared With Tympanometry in Diagnosing Middle Ear Effusion in Children Aged 6 to 24 Months
Arch Pediatr Adolesc Med, September 1, 2007; 161(9): 884 - 888.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
Committee on Infectious Diseases
Infection Prevention and Control in Pediatric Ambulatory Settings
Pediatrics, September 1, 2007; 120(3): 650 - 665.
[Abstract] [Full Text] [PDF]

Home page
 Journal of Health Politics, Policy and LawHome page
J. B. Wolf
Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign
Journal of Health Politics Policy and Law, August 1, 2007; 32(4): 595 - 636.
[Abstract] [PDF]

Home page
 PediatricsHome page
L. Vernacchio, R. M. Vezina, and A. A. Mitchell
Management of Acute Otitis Media by Primary Care Physicians: Trends Since the Release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline
Pediatrics, August 1, 2007; 120(2): 281 - 287.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
K. Revai, L. A. Dobbs, S. Nair, J. A. Patel, J. J. Grady, and T. Chonmaitree
Incidence of Acute Otitis Media and Sinusitis Complicating Upper Respiratory Tract Infection: The Effect of Age
Pediatrics, June 1, 2007; 119(6): e1408 - e1412.
[Abstract] [Full Text] [PDF]

Home page
 Clin. Microbiol. Rev.Home page
S. Tristram, M. R. Jacobs, and P. C. Appelbaum
Antimicrobial Resistance in Haemophilus influenzae
Clin. Microbiol. Rev., April 1, 2007; 20(2): 368 - 389.
[Abstract] [Full Text] [PDF]

Home page
 CLIN PEDIATRHome page
S. M. Chandler, S. M. S. Garcia, and D. P. McCormick
Consistency of Diagnostic Criteria for Acute Otitis Media: A Review of the Recent Literature
Clinical Pediatrics, March 1, 2007; 46(2): 99 - 108.
[Abstract] [PDF]

Home page
 Ann Fam MedHome page
A. S. Coco
Cost-Effectiveness Analysis of Treatment Options for Acute Otitis Media
Ann. Fam. Med, January 1, 2007; 5(1): 29 - 38.
[Abstract] [Full Text] [PDF]

Home page
 Arch. Dis. Child.Home page
S L Block
Searching for the Holy Grail of acute otitis media.
Arch. Dis. Child., December 1, 2006; 91(12): 959 - 961.
[Full Text] [PDF]

Home page
 Pediatr. Rev.Home page
Z. A. Malik, N. Litman, and H. M. Adam
Ampicillin and amoxicillin.
Pediatr. Rev., November 1, 2006; 27(11): 434 - 436.
[Full Text] [PDF]

Home page
 PediatricsHome page
D. A. Varrasso
Otitis Media: The Need for a New Paradigm in Medical Education
Pediatrics, October 1, 2006; 118(4): 1731 - 1733.
[Full Text] [PDF]

Home page
 PediatricsHome page
Subcommittee on Diagnosis and Management of Bronch
Diagnosis and Management of Bronchiolitis
Pediatrics, October 1, 2006; 118(4): 1774 - 1793.
[Abstract] [Full Text] [PDF]

Home page
 JAMAHome page
D. M. Spiro, K.-Y. Tay, D. H. Arnold, J. D. Dziura, M. D. Baker, and E. D. Shapiro
Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial.
JAMA, September 13, 2006; 296(10): 1235 - 1241.
[Abstract] [Full Text] [PDF]

Home page
 Dentomaxillofac RadiolHome page
K Orhan, C Delilbasi, and A. Orhan
Radiographic evaluation of pneumatized articular eminence in a group of Turkish children.
Dentomaxillofac. Radiol., September 1, 2006; 35(5): 365 - 370.
[Abstract] [Full Text] [PDF]

Home page
 CLIN PEDIATRHome page
S. L. Block
Comparative Tolerability, Safety and Efficacy of Tablet Formulations of Twice-Daily Clarithromycin 250 mg versus Once-Daily Extended-Release Clarithromycin 500 mg in Pediatric and Adolescent Patients
Clinical Pediatrics, September 1, 2006; 45(7): 641 - 648.
[Abstract] [PDF]

Home page
 PediatricsHome page
C. G. Grijalva, K. A. Poehling, J. P. Nuorti, Y. Zhu, S. W. Martin, K. M. Edwards, and M. R. Griffin
National Impact of Universal Childhood Immunization With Pneumococcal Conjugate Vaccine on Outpatient Medical Care Visits in the United States
Pediatrics, September 1, 2006; 118(3): 865 - 873.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
J. Dohar, W. Giles, P. Roland, N. Bikhazi, S. Carroll, R. Moe, B. Reese, S. Dupre, M. Wall, D. Stroman, et al.
Topical Ciprofloxacin/Dexamethasone Superior to Oral Amoxicillin/Clavulanic Acid in Acute Otitis Media With Otorrhea Through Tympanostomy Tubes
Pediatrics, September 1, 2006; 118(3): e561 - e569.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
D. A. Varrasso, D. Ashe, R. Ruben, and R. Propp
Watchful Waiting for Acute Otitis Media: Are Parents and Physicians Ready?
Pediatrics, August 1, 2006; 118(2): 849 - 850.
[Full Text] [PDF]

Home page
 CLIN PEDIATRHome page
M. E. Pichichero
Pathogen Shifts and Changing Cure Rates for Otitis Media and Tonsillopharyngitis
Clinical Pediatrics, July 1, 2006; 45(6): 493 - 502.
[Abstract] [PDF]

Home page
 PediatricsHome page
A. I.O. Plasschaert, M. M. Rovers, A. G. M. Schilder, T. J. M. Verheij, and E. Hak
Trends in doctor consultations, antibiotic prescription, and specialist referrals for otitis media in children: 1995-2003.
Pediatrics, June 1, 2006; 117(6): 1879 - 1886.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
J. Garbutt, I. Rosenbloom, J. Wu, and G. A. Storch
Empiric first-line antibiotic treatment of acute otitis in the era of the heptavalent pneumococcal conjugate vaccine.
Pediatrics, June 1, 2006; 117(6): e1087 - e1094.
[Abstract] [Full Text] [PDF]

Home page
 NEJMHome page
M. H. Kyaw, R. Lynfield, W. Schaffner, A. S. Craig, J. Hadler, A. Reingold, A. R. Thomas, L. H. Harrison, N. M. Bennett, M. M. Farley, et al.
Effect of Introduction of the Pneumococcal Conjugate Vaccine on Drug-Resistant Streptococcus pneumoniae
N. Engl. J. Med., April 6, 2006; 354(14): 1455 - 1463.
[Abstract] [Full Text] [PDF]

Home page
 Red BookHome page
Haemophilus influenzae Infections
Red Book, January 1, 2006; 2006(1): 310 - 318.
[Full Text]

Home page
 Red BookHome page
Pneumococcal Infections
Red Book, January 1, 2006; 2006(1): 525 - 537.
[Full Text]

Home page
 Red BookHome page
Principles of Appropriate Use for Upper Respiratory Tract Infections
Red Book, January 1, 2006; 2006(1): 737a - 740a.
[Full Text]

Home page
 J Law Med EthicsHome page
J. Ducharme
Clinical Guidelines and Policies: Can they Improve Emergency Department Pain Management?
J. Law Med. Ethics, December 1, 2005; 33(4): 783 - 790.
[PDF]

Home page
 PediatricsHome page
D. Merenstein, M. Diener-West, A. Krist, M. Pinneger, and L. A. Cooper
An Assessment of the Shared-Decision Model in Parents of Children With Acute Otitis Media
Pediatrics, December 1, 2005; 116(6): 1267 - 1275.
[Abstract] [Full Text] [PDF]

Home page
 The Annals of PharmacotherapyHome page
M. P. Cober and C. E Johnson
Otitis Media: Review of the 2004 Treatment Guidelines
Ann. Pharmacother., November 1, 2005; 39(11): 1879 - 1887.
[Abstract] [Full Text] [PDF]

Home page
 CLIN PEDIATRHome page
L. G. Yamamoto, R. N. Sumida, S. S. Yano, D. C. Derauf, P. E. Martin, and P. J. Eakin
Does Crying Turn Tympanic Membranes Red?
Clinical Pediatrics, October 1, 2005; 44(8): 693 - 697.
[Abstract] [PDF]

Home page
 Arch Pediatr Adolesc MedHome page
L. Hong, S. M. Levy, J. J. Warren, D. V. Dawson, G. R. Bergus, and J. S. Wefel
Association of Amoxicillin Use During Early Childhood With Developmental Tooth Enamel Defects
Arch Pediatr Adolesc Med, October 1, 2005; 159(10): 943 - 948.
[Abstract] [Full Text] [PDF]

Home page
 J. Epidemiol. Community HealthHome page
S Verd
Acute otitis media after forceps delivery
J Epidemiol Community Health, September 1, 2005; 59(9): 809 - 809.
[Full Text] [PDF]

Home page
 J Hum LactHome page

J Hum Lact, August 1, 2005; 21(3): 289 - 295.
[Abstract] [PDF]

Home page
 Antimicrob. Agents Chemother.Home page
C. Soley, A. Arguedas, W. Porras, S. Guevara, C. Loaiza, A. Perez, G. Rincon, M. Schultz, J. Arguedas, and R. Brilla
In Vitro Activities of Levofloxacin and Comparable Agents against Middle Ear Fluid, Nasopharyngeal, and Oropharyngeal Pathogens Obtained from Costa Rican Children with Recurrent Otitis Media or Failing Other Antibiotic Therapy
Antimicrob. Agents Chemother., July 1, 2005; 49(7): 3056 - 3058.
[Abstract] [Full Text] [PDF]

Home page
 Arch Pediatr Adolesc MedHome page
F. Marchetti, L. Ronfani, S. C. Nibali, G. Tamburlini, and for the Italian Study Group on Acute Otitis Media
Delayed Prescription May Reduce the Use of Antibiotics for Acute Otitis Media: A Prospective Observational Study in Primary Care
Arch Pediatr Adolesc Med, July 1, 2005; 159(7): 679 - 684.
[Abstract] [Full Text] [PDF]

Home page
 ANN INTERN MEDHome page
D. Atkins, K. Fink, and J. Slutsky
Better Information for Better Health Care: The Evidence-based Practice Center Program and the Agency for Healthcare Research and Quality
Ann Intern Med, June 21, 2005; 142(12_Part_2): 1035 - 1041.
[Abstract] [Full Text] [PDF]

Home page
 ANN INTERN MEDHome page
D. B. Matchar, E. V. Westermann-Clark, D. C. McCrory, M. Patwardhan, G. Samsa, S. Kulasingam, E. Myers, A. Sarria-Santamera, A. Lee, R. Gray, et al.
Dissemination of Evidence-based Practice Center Reports
Ann Intern Med, June 21, 2005; 142(12_Part_2): 1120 - 1125.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
D. P. McCormick, T. Chonmaitree, C. Pittman, K. Saeed, N. R. Friedman, T. Uchida, and C. D. Baldwin
Nonsevere Acute Otitis Media: A Clinical Trial Comparing Outcomes of Watchful Waiting Versus Immediate Antibiotic Treatment
Pediatrics, June 1, 2005; 115(6): 1455 - 1465.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
J. A. Finkelstein, C. J. Stille, S. L. Rifas-Shiman, and D. Goldmann
Watchful Waiting for Acute Otitis Media: Are Parents and Physicians Ready?
Pediatrics, June 1, 2005; 115(6): 1466 - 1473.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
A. S. Lieberthal and T. G. Ganiats
Thoughts on the American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline on Acute Otitis Media: A Different Perspective: In Reply
Pediatrics, May 1, 2005; 115(5): 1444 - 1445.
[Full Text] [PDF]

Home page
 PediatricsHome page
H. Pellman
Thoughts on the American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline on Acute Otitis Media: A Different Perspective
Pediatrics, May 1, 2005; 115(5): 1443 - 1444.
[Full Text] [PDF]

Home page
 PediatricsHome page
M. E. Pichichero
A Review of Evidence Supporting the American Academy of Pediatrics Recommendation for Prescribing Cephalosporin Antibiotics for Penicillin-Allergic Patients
Pediatrics, April 1, 2005; 115(4): 1048 - 1057.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
E. R. Wald
To Treat or Not to Treat
Pediatrics, April 1, 2005; 115(4): 1087 - 1089.
[Full Text] [PDF]

Home page
 CLIN PEDIATRHome page
P. C. Appelbaum
Are Cephalosporins Appropriate for the Treatment of Acute Otitis Media in This Era of Increasing Antimicrobial Resistance Among Common Respiratory Tract Pathogens?
Clinical Pediatrics, March 1, 2005; 44(2): 95 - 107.
[PDF]

Home page
 Emerg. Med. J.Home page
S Carter and C Laird
10 Assessment and care of ENT problems
Emerg. Med. J., February 1, 2005; 22(2): 128 - 139.
[Full Text] [PDF]

Home page
 PediatricsHome page
H. Hoover and O. F. Roddey
The Overlooked Importance of Tympanic Membrane Bulging
Pediatrics, February 1, 2005; 115(2): 513 - 513.
[Full Text] [PDF]

Home page
 Health Aff (Millwood)Home page
D. Atkins, J. Siegel, and J. Slutsky
Making Policy When The Evidence Is In Dispute
Health Aff., January 1, 2005; 24(1): 102 - 113.
[Abstract] [Full Text] [PDF]

Home page
 EDUCATION AND PRACTICEHome page
J H. Baumer
Comparison of two otitis media guidelines
Arch. Dis. Child. Ed. Pract., December 1, 2004; 89(3): ep76 - ep78.
[Full Text] [PDF]

Home page
 Pediatr. Rev.Home page
W. J. Durbin
Pneumococcal Infections
Pediatr. Rev., December 1, 2004; 25(12): 418 - 424.
[Full Text] [PDF]

Home page
 Evid. Based Nurs.Home page
23 Apr 2004 to 23 Jul 2004
Evid. Based Nurs., October 1, 2004; 7(4): e4 - e4.
[Full Text] [PDF]

Home page
 Evid. Based Med.Home page
Other articles noted
Evid. Based Med., September 1, 2004; 9(5): e5 - e5.
[Full Text] [PDF]

Home page
 PediatricsHome page
S. L. Liston and R. M. Rosenfeld
Socioeconomics and Otitis Media
Pediatrics, September 1, 2004; 114(3): 898 - 899.
[Full Text] [PDF]

Home page
 JWatch Emergency Med.Home page
Clinical Practice Guideline for Diagnosis and Treatment of Acute Otitis Media
Journal Watch Emergency Medicine, June 30, 2004; 2004(630): 7 - 7.
[Full Text]

Home page
 JWatch Infect. DiseasesHome page
Management of Acute Otitis Media and Otitis Media with Effusion
Journal Watch Infectious Diseases, June 4, 2004; 2004(604): 2 - 2.
[Full Text]

Home page
 JWatch GeneralHome page
Diagnosis and Management of Acute Otitis Media
Journal Watch (General), May 14, 2004; 2004(514): 7 - 7.
[Full Text]

eLetters:

Read all eLetters

This guideline could as well have suggested initial observation with analgesia for all
Atle Klovning
Pediatrics Online, 22 Jun 2004 [Full text]
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow View responses
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Related Collections
Right arrow Infectious Disease & Immunity
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Facebook   Add to Reddit   Add to Technorati   Add to Twitter  
What's this?