What is the risk of not treating acute otitis media (AOM) in a 3-year-old with antibiotics?

From the Guidelines

Not treating acute otitis media (AOM) in a 3-year-old with antibiotics carries a significant risk of persistent or worsening infection, with a number needed to treat (NNT) of 3-4 to prevent treatment failure, as seen in studies such as 1 and 1. The main concern is that the infection may persist or worsen, potentially leading to complications such as mastoiditis (infection of the mastoid bone), hearing loss, tympanic membrane perforation, or spread of infection to surrounding structures. Children under 2 years old are at higher risk for complications, but 3-year-olds can still develop these issues. Without antibiotics, the child may experience prolonged pain, fever, and discomfort, which can affect sleep, eating, and overall well-being. However, many cases of AOM resolve spontaneously within 2-3 days, so watchful waiting is sometimes appropriate for mild cases in children over 2 years with no high fever or severe symptoms. Some key points to consider include:

• The American Academy of Pediatrics recommends antibiotic therapy for children with AOM, especially those under 2 years old or with severe symptoms, as outlined in 1.
• A study by Hoberman et al 1 found that antimicrobial treatment of AOM was more beneficial than in previous studies that used less stringent diagnostic criteria, with an NNT of 2.9.
• Another study by Tähtinen et al 1 found that amoxicillin-clavulanate treatment resulted in a lower treatment failure rate compared to placebo, with an NNT of 3.8. If watchful waiting is chosen, parents should monitor the child closely for worsening symptoms and seek medical attention if the child's condition deteriorates or doesn't improve within 48-72 hours. Pain management with acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours) is essential during this period to keep the child comfortable, as recommended in 1. It's also important to note that the decision not to give initial antibiotic treatment and observe should be part of a larger management strategy that includes analgesics, parent information, and provisions for a rescue antibiotic, as outlined in 1.

From the Research

Risk of Not Treating Acute Otitis Media (AOM) in a 3-Year-Old with Antibiotics

The risk of not treating AOM in a 3-year-old with antibiotics includes:

• Potential for prolonged course of AOM, as viral infection is also associated with eustachian tube (ET) dysfunction in young children 2
• Increased risk of complications, such as tympanic membrane perforation and contralateral otitis episodes, although the evidence suggests that these complications are rare 3, 4
• Potential for AOM to progress to chronic suppurative otitis media (CSOM), although the evidence on this is limited 5
• Risk of recurrent AOM, with some studies suggesting that antibiotics may reduce the risk of recurrence, particularly in children under two years of age 3, 4

Factors to Consider

When considering the risk of not treating AOM in a 3-year-old with antibiotics, the following factors should be taken into account:

• The child's age and individual risk factors, such as history of recurrent AOM or underlying medical conditions 2, 4
• The severity of symptoms and the potential for spontaneous resolution of AOM 3, 4
• The potential benefits and harms of antibiotic treatment, including the risk of adverse events and the development of antibiotic resistance 3, 6, 4
• The availability of alternative treatments, such as watchful waiting or the use of analgesics to manage symptoms 3, 4

Evidence-Based Recommendations

The evidence suggests that:

• Antibiotics may be beneficial in reducing the risk of complications and recurrence in children under two years of age with AOM, particularly those with bilateral AOM or otorrhoea 3, 4
• For children over two years of age with mild AOM, an expectant observational approach may be justified, with antibiotics reserved for those who do not improve with watchful waiting 3, 4
• Long-term antibiotics may be effective in preventing AOM in children at high risk of recurrence, although the evidence on this is limited 5