PATIENT COUNSELING IWatchful Waiting' for Middle Ear Fluid in Children Otitis media with effusion, an ear problem that accounts for more than 8 million physicians' visits by children per year, will usually get better without treatment. According to new guidelines from a panel convened by the Agency for Health Care Policy and Research (AHCPR), "watchful waiting" may be "preferable" to the use of antibiotics, the treatment most often used today. The panel said that otitis media with effusion, which is essentially fluid in the middle ear, often disappears on its own within three to six months.
"I think one of the biggest issues this recommendation addresses is that we overprescribe antibiotics for kids," said Leslie Hendeles, professor of pharmacy and pediatrics at the University of Florida. "In the absence of pain and fever, it makes sense to wait. Fifty to sixty percent or more of these cases will resolve themselves, so why subject kids needlessly to the possibility of allergic reactions or other side effects of antibiotics?" The guidelines are not aimed at acute otitis media, a painful infection of the inner ear that is often accompanied by fever. The fluid behind the eardrum that characterizes otitis media with effusion is often found after a child has been treated with antibiotics for an acute
Tympanic membrane (ear drum)
infection and has returned to the doctor for a follow-up visit. Other cases are detected during routine pediatric visits or when a child seems to have impaired hearing or balance problems. "I remember one child who was just learning to sit up, all of a sudden he started to fall over because the fluid in his ear threw off his balance," said Rosalie Sagraves, a professor at the University of Oklahoma College of Pharmacy, who specializes in pediatrics. According to Sagraves, pharmacists must realize that otitis media with effusion is just one of many types of otitis media. "It's not that antibiotics are never appropriate, but with this condition, it's OK to wait a few months before turning to them," she emphasized. The guidelines released by the AHCPR panel of 19 pediatricians and other health experts cover generally healthy children aged one to three years. Key points include: • Observation is effective for most children because otitis media with effusion usually resolves itself in three to six months without any treatment. • Antibiotics appear to clear up the condition in a small number of children, but they also cause reactions such as diarrhea and rashes. • If the condition lasts for three months and the child is experiencing mild-tomoderate hearing loss in both ears, the options are either use of antibiotics or November 1994
Vol. NS34, No. 11
myringotomy (lancing the ear to draw out fluid), along with placing tympanostomy tubes to drain the fluid. • Steroid therapy for otitis media with effusion is not recommended for children of any age. • Antihistamines and decongestants should not be used to treat the condition. • In children under age four, the adenoids or tonsils should not be removed to treat otitis media with effusion unless those organs are diseased. In spring 1994, a report in JAMA (1994;271:1250-5)
argued that more than a quarter of surgeries to insert tympanostomy tubes in children's ears-the most common operation for children-may be inappropriate. These tubes are inserted not only to drain persistent middle-ear fluid but also to treat recurrent episodes of acute
otitis media. Besides being a costly approach, compared with other options, use of tubes can cause infection, perforation or scarring of the eardrum, and low-grade hearing loss, the report said. Single copies of the new guidelines are available free from AH CPR by calling (800) 358-9295.
Health Dates NOVEMBER
Child Safety and Protection Month. National PTA, 700 N. Rush St., Chicago, IL 60611. (312) 787-0977. Diabetic Eye Disease Awareness Month. National Society to Prevent Blindness, 500 E. Remington Rd., Schaumburg, IL 60173. (800) 331-2020 or (708) 843-2020. National Alzheimer's Awareness Month.
Tvvo Common Ear Problems in Children Can Be Confused Following the recent release of federal guidelines advising "watchful waiting" for treating otitis media with effusion in children, some health experts voiced concern that parents would misunderstand and fail to take their children for treatment even when they have painful ear infections. To help parents and other care providers understand, phatmacists can explain the differences between the two most common ear problems in children.
In otitis media with effusion: • No signs or symptoms of infection are seen. The physician will fmd watery, mucuslike fluid behind the eardrum during a checkup. • No pain or fever notmally is present. • Both ears are usually affected. In acute otitis media: • Infection is present. • Symptoms usually include pain, fever, or both. Vol. NS34, No. 11
Alzheimer's Disease and Related Disorders Association, 919 N. Michigan Ave., Ste. 1000, Chicago, IL 606111676. (800) 272-3900 or (312) 335-8700. National Diabetes Month. American Diabetes Association, 1660 Duke St., Alexandria, VA 22314. (800) 232-3472 or (703) 549-1500. National Epilepsy Month. Epilepsy Foundation of America, 4351 Garden City Dr., Ste. 406, Landover, MD 20785. (800) EFA-1000 or (301) 459-3700. 6-12, Patient Education Week. International Patient Education Council, PO Box 1438, Rockville, MD 20849. (301) 948-1863. 18, Great American Smokeout. American Cancer Society, National Headquarters, 1599 Clifton Rd., NE, Atlanta, GA 303294251. (800) AC5-2345 or (404) 320-3333. 28--Dec. 4, National Home Care Week. National Association for Home Care, 519 CSt., NE, Washington, DC 20002. (202) 547-7424.
National Drunk and Drugged Driving Awareness Month. National Safety Council, 1019 19th St., NW, Ste. 401, Washington, DC 20036-5105. (202) 293-2270. 1, World AIDS Day. American Association for World Health, 1129 20th St., NW, Ste. 400, Washington, DC 20036. (202) 466-5883. 1-7, National Aplastic Anemia Awareness Week, Aplastic Anemia Foundation of America, PO Box 22689, Baltimore, MD 21203. (800) 747-2820 or (410) 955-2803. JANUARY
National Volunteer Blood Donor Month. American Association of Blood Banks, 8101 Glenbrook Rd., Bethesda, MD 20814. (301) 907-6977. 23-29, National Glaucoma Awareness Week. Prevent Blindness America, 500 E. Remington Rd., Schaumburg, IL 60173. (800) 331-2020 or (708) 843-2020.
NEW DRUGS & DEVICES Fluticasone Propionate for Allergic Rhinitis Fluticasone propionate (Flonase Nasal SprayGlaxo) has received approval from the Food and Drug Administration for treatment of seasonal and perennial allergic rhinitis. The corticosteroid antiinflammatory was found
effective and well-tolerated at recommended doses in drug trials involving more than 2,400 patients. Product labeling notes that the medication "should not be used for the treatment of nonallergic rhinitis." Adverse Reactions: Side effects were similar to other widely used prescription nasal sprays and were primarily associated with irritation of AMERICAN PHARMACY