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 has provided minimal relief. This
morning, the child refused breakfast and appeared to be “getting worse.”
Vital signs at the clinic reveal
HR 110 bpm, 28 respiratory rate, and tympanic temperature of 103.2 degrees F.
The mother reports no known allergies. The child has not been on antibiotics
for the last year. The child does not have history of OM. The child is
otherwise healthy without any other known health problems.
After your questioning and
examination, you diagnose this child with bilateral Acute Otitis Media.
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.
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)
this a revision of a previous guideline or an original? What is the date of
Original guideline written November
2003 and endorsed by APA in July 2013
the concept of “systematic review of current best evidence.”
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.
was conflict of interest managed in the development of these guidelines?
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.
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).
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.
are “key Action statements?”
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.
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