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

(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!