PEDIATRICS Vol. 114 No. 3 September 2004, pp. 898-899 (doi:10.1542/10.1542/peds.2004-0963)
Socioeconomics and Otitis Media
Stephen L. Liston, MDENT Specialty Care of Minnesota,
St Paul, MN 55102
To the Editor.—
The clinical practice guideline of the American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media1 recognizes a subset of children with uncomplicated acute otitis media who can be observed without the use of antibiotics. I have recommended this course of action to a number of parents who have insisted on antibiotic treatment, not because of any medical concerns about their child not receiving the antibiotic, but because of a socioeconomic fact. In the United States today there are many families in which both parents must work to make enough income to pay their bills. Unfortunately, most day care providers will not care for a sick, febrile child. This means that 1 parent, usually the mother, would have to miss work to stay at home to care for the sick child. This is a real financial burden on such families, and so they request that their child be treated with antibiotics to get the child back to day care sooner.
REFERENCE
- American Academy of Pediatrics, Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media.
Pediatrics. 2004;113
:1451
–1465
[Abstract/Free Full Text]
Richard M. Rosenfeld, MD, MPH
Pediatric Otolaryngology,
State University of New York Downstate Medical Center and Long Island College Hospital,
Brooklyn, NY 11201
In Reply.—
Dr Liston raises an important issue: can immediate antibiotic therapy for acute otitis media (AOM) return a child to school or day care more promptly than initial observation? The answer requires careful consideration of the published evidence plus the harm/benefit ratio of antibiotic therapy.
Only 2 randomized trials have addressed the issue of school absence: 1 found no significant difference between immediate versus delayed antibiotic therapy,1 and the other reported a significant decrease of 
1.5 days for children who received antibiotic versus placebo.2 In both studies the mean duration of pain or crying was also reduced by 0.5 to 1.0 day. Another trial of antibiotic versus placebo showed similar results for children <2 years old, but the AOM guideline does not recommend initial observation for certain diagnosis in this age category.3
Unfortunately for parents seeking a prompt recovery, the benefits of antibiotics are not manifest for at least 24 hours, by which time 60% of children 
2 years old already have symptom relief.4 Consequently, only 3% of parents report missed days of work when a child with nonsevere AOM is initially observed.5 Beyond 24 hours, antibiotics provide an absolute increase in clinical resolution over placebo of only 4% at 2 to 3 days (number needed to treat = 25) and at 9% at 4 to 7 days (number needed to treat = 11).4 Analgesics, not antibiotics, are the key to prompt initial relief of AOM, which is why pain treatment is highlighted as an essential aspect of management in the guideline.3
As Dr Liston notes, most day care providers will not care for a sick, febrile child, but they also will not care for one with diarrhea. When antibiotics are prescribed immediately for AOM, the incidence of diarrhea more than doubles, compared with initial observation (19% vs 9%).1 Additional risks of antibiotics include allergic reactions, gastrointestinal upset, accelerated bacterial resistance, and unfavorable changes in nasopharyngeal bacterial flora.6–9 Antibiotics may not only fail to eradicate the organism causing AOM but also can induce middle-ear effusion superinfection with resistant pneumococci from the nasopharynx.10 Antibiotic prescribing also increases revisit rates and the likelihood of seeking medical care for future illness.11 Many of the above-mentioned adverse events result in missed work for parents, which is precisely what they sought to avoid by using antibiotics immediately.
The data shown above suggest that the harm/benefit ratio for immediate antibiotic therapy of AOM favors a trial of initial observation for selected children with AOM, particularly those 2 years old with nonsevere illness or an uncertain diagnosis. Adequate analgesia is essential, especially during the first 24 hours after diagnosis. Nonetheless, observation is simply an option in the new guideline, not a recommendation, which leaves substantial room for clinician and parent preference.3 There is nothing wrong with immediate antibiotic therapy for any case of properly diagnosed AOM if that is what the family prefers. Most symptom relief with AOM, however, results from natural history, not antibiotics, and the modest therapeutic benefits seen after 24 hours may be offset by undesirable side effects.
REFERENCES
- Little P, Gould C, Williamson, Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media.
BMJ. 2001;322
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[Abstract/Free Full Text] - Burke P, Bain J, Robinson D, Dunleavey J. Acute red ear in children: controlled trial of nonantibiotic treatment in general practice. BMJ. 1991;303 :558 –562
- American Academy of Pediatrics, Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113 :1451 –1465
- Rosenfeld RM. Clinical efficacy of medical therapy. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis Media. 2nd ed. Hamilton, ON, Canada: BC Decker; 2003:199–226
- Siegel RM, Kiely M, Bien JP, et al. Treatment of otitis media with a safety-net prescription.
Pediatrics. 2003;112
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[Abstract/Free Full Text] - Ghaffar F, Muniz LS, Katz K. Effects of amoxicillin/clavulanate or azithromycin on nasopharyngeal carriage of Streptococcus pneumoniae and Haemophilus influenzae in children with acute otitis media. Clin Infect Dis. 2000;31 :875 –880[CrossRef][Web of Science][Medline]
- Gonzales R, Malone DC, Maselli JH, Sande MA. Excessive antibiotic use for respiratory infections in the United States. Clin Infect Dis. 2001;33 :757 –762[CrossRef][Web of Science][Medline]
- Ghaffar F, Muniz LS, Katz K, et al. Effects of large dosages of amoxicillin/clavulanate or azithromycin on nasopharyngeal carriage of Streptococcus pneumoniae, Haemophilus influenzae, nonpneumococcal alpha-hemolytic streptococci, and Staphylococcus aureus in children with acute otitis media. Clin Infect Dis. 2002;34 :1301 –1309[CrossRef][Web of Science][Medline]
- Erickson PR, Herzberg MC. Emergence of antibiotic resistant Streptococcus sanguis in dental plaque of children after frequent antibiotic therapy. Pediatr Dent. 1999;21 :181 –185[Medline]
- Dagan R, Leibovitz E, Cheletz G, Leiberman A, Porat N. Antibiotic treatment in acute otitis media promotes superinfection with resistant Streptococcus pneumoniae carried before initiation of treatment. J Infect Dis. 2001;183 :880 –886[CrossRef][Web of Science][Medline]
- Little P, Williamson I, Warner G, Gantley M, Kinmonth AI. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics.
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[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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