Dr. Scott vs. the New England Journal of Medicine: Who Do You Trust?

by Scott Iwashyna

(just kidding NEJM – please don’t beat me up)     

So one of the down-sides of evidence-based medicine is that the data seldom seems to stand for itself.  The papers always need a conclusion/discussion of the results to help you understand what just happened.  Conveniently this here doctor-person happens to have an even smarter super doctor-person older brother (also see link — He’s REALLY smart) who helps me decode the data and come to my own conclusions. [Mind you if I misinterpreted what he said, he is not responsible.]

On January 13th, NEJM published an article about the treatment of acute otitis media (read: inner ear infection) in children under age 2.  According to the Editorial attached to the article:

“The results of each study showed a significant benefit among children who received the drug with respect to the duration of acute signs of illness…more young children with a certain diagnosis of acute otitis media recover more quickly when they are treated with an appropriate antimicrobial agent.” 

So clearly, all truly diagnosed cases of Otitis Media should be treated?  Not so fast.

Looking at the data, there are a couple of take home points for kids age 6 to 24 months:

  • In cases that are diagnosed by stringent criteria including acute onset, otoscopic exam and parental point of view about their child’s symptoms, slightly more than 1 in 10 kids treated with antibiotics are likely to still feel pretty badly 10 days out.
  • If a parent wants their child treated with antibiotics it will likely have their children feel better about 12-24 hours before a child who didn’t receive antibiotics.  (Which is good to know, because I wasn’t entirely sure my antibiotics were doing anything at all!)
  • The flip-side being: If you are a parent who would prefer not to use antibiotics, your child will likely only feel sick for 12-24 hours more than they would have with antibiotics.
  • Although the long-term follow up in this study isn’t great, it doesn’t look like long-term outcomes are not at all different for the placebo vs antibiotic groups.
  • If you follow a “watchful waiting” approach (my interpretation of their clinical failure at day 4 arm of the study), we will give out 50% less antibiotics and 50% of kids will get better without treatment at all.
  • 25% of kids on antibiotics got diarrhea

In the end – antibiotics or not for acute otitis media for this age range still seems to be a discussion between a parent and their doctor with no definitive evidence to support one side or the other.  The decision has more to do with how important it is to get better quicker (a VERY valid choice) and how you feel about giving antibiotics to your child (a VERY personal choice).

A note about the case of mastoiditis in the study (which is really rare):  I don’t love giving antibiotics, but I feel fairly comfortable that I would have given an 11 month old with a 14 out of 14 score on the AOM-SOM on day 1 of symptoms antibiotics if he/she had come into clinic -  regardless, this child had a penicillin-resistant bug, so he/she still wouldn’t have gotten better.  By day 2-3, I would have seen the child in my clinic and admitted them to the hospital or changed antibiotics.  Hooray for practicing pediatrics with parents who are able to come in for follow up reliably and often!

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{ 3 comments… read them below or add one }

(Wendy Sue) Seattle Mama Doc

Great post. We agree about the study and the recommendations, and yes, you’re super-duper lucky to have good reliable follow-up.

Best part of this post for me was to learn about your brother and your admiration and respect. Delightful.
Here’s my take on the same studies…
http://seattlemamadoc.seattlechildrens.org/treating-ear-infections-with-antibiotics/
So glad to find your blog!

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Brianna

hello – I realize this post may be old but I have a question about a child less than 6 months old – and I can’t find any answers! I took my soon who is 9 weeks old to the doctor because his lung sounds were junky (crackles and wheezes), he had a cough and was not drinking his bottles very well. the doctor diagnosed him with an ear infection and prescribed amoxicillin. I did not argue at the time, although I now wish I would have probed with more questions, and did fill the prescription but haven’t given it (this was 2 days ago). my son did not have a fever when we went in, and still doesn’t. he really isn’t all that fussy; still smiling and cooing with me, sleeping well at naps and through the night (has been sleeping through the night for a couple weeks now) and really his only problem is that he does not want to eat very much (was eating 6 oz at each feeding and now only wants 3-4. I do not want to give the antibiotics because if it’s a viral infection then it will be a waste to do and also potentially harmful (referring to the study from Yale that showed that babies under 6 months old that were given antibiotics were 70% more likely to develop asthma – and this exact thing happened to my brother, who had antibiotics at 6 weeks old for a strep infection, and then developed asthma at age 3 and has had to use inhalers and nebulizers his whole life and is now 23 years old). another reason I believe it is viral is because my daughter is now in preschool and i’m sure that’s where we got it from; I am slightly sick too with a runny/stuffy nose and sneezing. it’s been a few days since baby’s symptoms began and he isn’t getting any worse (still no fever and no other new symptoms) but I couldn’t say he is getting better either (still has a junky cough and lung sounds). I don’t know what to do! any thoughts?

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Brianna

also, he is bottle fed, unfortunately breastfeeding went awry for us – but we always feed him as upright as possible and try to keep him upright after eating for awhile. also, the doctor who diagnosed him only looked in his ears very briefly (which I understand – it is difficult to look in babies or children’s ears thoroughly); she also said his lung sounds were clear which is not true. I am no doctor and would never claim to know it all, but I am a registered nurse and I do know how to use a stethoscope, and have one at home, and my son’s lung sounds are far from clear. so I don’t really trust this doctor, I sort of feel like she just prescribed antibiotics to get me out of there quickly (it was a Saturday morning walk-in clinic, not my child’s regular doctor), even though I did not pressure for meds in any way, I just wanted to find out if he had bronchiolitis or if it was something worse like pneumonia. I don’t want to give the antibiotics unless I know it’s bacterial and medically necessary…. but I also don’t want to wait it out and then have something worse happen to my sweet little man. I need some solid advice!

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