S: A 5-year-old male is brought to the primary care clinic by his mother with a chief complaint of bilateral ear pain for the last three days. The mother states that the child has been crying frequently due to the pain. Ibuprofen administered at home with minimal relief. Today, refused breakfast and appeared to be “getting worse.”
O: Vital signs – HR 110 bpm, 28 respiratory rate, and tympanic temperature of 103.2 degrees F. No known allergies. No antibiotics for the last year. No history of OM. No past medical history or surgeries.
A: After your questioning and examination, you diagnose this child with bilateral Acute Otitis Media.
P: See below
DDX: Acute Otitis Media
· Briefly explain your search strategy.
Utilized various internet, textbook and journals searches. I ensured to only access and refer to peer reviewed, reputable sources and none greater than 5 years in circulation.
· Who developed the guideline?
The guideline, The Diagnosis and Management of Otitis Media, was developed by the American Academy of Pediatrics and endorsed by the American Academy of Family Physicians (APA, 2013). (It applies to otherwise healthy children 6 months through 12 years of age)
· Is this a revision of a previous guideline or an original? What is the date of publication?
Original guideline written November 2003 and endorsed by APA in July 2013
· Explain the concept of “systematic review of current best evidence.”
A systematic review is a summary of the medical literature that uses explicit and reproducible methods to systematically search, critically appraise, and synthesize on a specific issue. Researchers conducting systematic reviews use explicit methods aimed at minimizing bias, in order to produce more reliable findings that can be used to inform decision making (Neinstein, et. Al., 2016). Systematic reviews are also a type of journal article, published alongside primary research articles in scholarly journals.
· How was conflict of interest managed in the development of these guidelines?
Professional expectations dictate that clinical practice guidelines are based on credible scientific evidence, critical computation of said evidence, and un-biased clinical judgment that relates the evidence to the needs of practitioners and patients (IOM, 2009). Arguably, the most compelling issue in the development of clinical practice guidelines is the lack of research that can be used to guide the evolution of comprehensive recommendations applied to clinical practice. Through professional collaboration and respect for one another’s idealism and expertise, any conflict of interest issue can be resolved.
· How is quality of evidence defined?
In 2014 the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group presented its initial proposal for patient management. GRADE provides a specific definition for the quality of evidence in the context of making recommendations. The quality of evidence reflects the extent to which confidence in an estimate of the effect is adequate to support a particular recommendation (Atkins, et. al., 2014).
· Explain differences among strong recommendation, recommendation, and option.
The strength of a recommendation indicates the extent to which one can be confident that adherence to the recommendation will do more good than harm. The steps in our approach, which follow these judgments, are to make sequential judgments about:
· The quality of evidence across studies for each important outcome
· Which outcomes are critical to a decision
· The overall quality of evidence across these critical outcomes
· The balance between benefits and harms
· The strength of recommendations
Once the validity of the evidence is ascertained, the user can decide whether to strongly recommend vs only present as option. The recommendation also depends on intended use and application to situations; thus, use is at discretion of user.
· What are “key Action statements?”
Key action statements are fundamental aspect of the development process, which allows moving from conception to completion in a designated timeframe, emphasizes a logical sequence of indispensable actions supported by an augment documentation, profiles evidence, and makes recommendation grades that link action to evidence (IOM, 2009). Key action statements should be clear and precise to avoid inconsistent interpretation and prevent inappropriate practice variation. Having drafted a list of key statements, the user should review the list for ambiguous or vague actions.
· For this particular child, what are the specific treatment recommendations including any diagnostics, medications (include exact dosage, frequency, length of treatment), follow-up, referral, prevention, and pain control.
ü Amoxicillin 80-90 mg/kg/day PO (maximum 3 g/24h) divided BID for 5-7d; 10d may be required if illness is severe (Amoxicillin-clavulanate has a broader spectrum than amoxicillin and may be a better initial antibiotic. However, because of cost and adverse effects, the APA has deemed amoxicillin as first-line AOM treatment) (APA, 2013 and Burns, et. al., 2017).
ü Acetaminophen 15mg/kg every 6 hours as needed for pain/fever (alternate with ibuprofen) (APA, 2013).
ü Ibuprofen 10mg/kg every 6 hours as needed for pain/fever (alternate with acetaminophen) (APA, 2013).
ü No referral required at this, will consider ENT if AOM develops reoccurring pattern
ü Follow up in 2 weeks; sooner of needed