• September 11, 2007, Rocephin (ceftriaxone sodium): Roche informed healthcare professionals about revisions made to the prescribing information for Rocephin to clarify the potential risk associated with concomitant use of Rocephin with calcium or calcium-containing solutions or products.

• General. Do complete pediatric exam at every visit, according to standard clinical guidelines (e.g., American Academy of Pediatrics guidelines: www.aap.org/policy/paramtoc.html) and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services required for children on Medicaid (See: Early and Periodic Screening, Chapter 05, State Medicaid Manual: www.cms.hhs.gov/manuals/pub45/pub_45.asp). Whatever the chief complaint, use visit as an opportunity to identify and address all problems. Remember that this may be your only contact with the family. Homeless families may not see a medical provider unless their child is sick.
• Otologic examination. Good evaluation of appearance of tympanic membranes is vital for prompt diagnosis. If cerumen is present, enough must be removed to allow inspection of eardrum. Irrigation should be avoided unless there is no suspicion of underlying perforation of tympanic membrane. Because follow-up may not be possible, use of a curette and otoscope is preferable for homeless children; use of hydrogen peroxide drops may help dissolve wax, but requires one or more return visits, which may be more difficult to arrange with homeless families. Clear distinction should be made between a well aerated middle ear, one that is filled with sterile effusion (retracted appearance, dull, with loss of light reflex), and one with acute otitis media filled with purulent effusion (bulging with a white or yellow creamy appearance). Redness alone (in absence of fluid) does not indicate a middle ear infection.

Diagnostic Tests

• Pneumatic otoscopy, tympanometry. These tests help to confirm presence of fluid behind the tympanic membrane, and thus support the diagnosis of acute otitis media or middle ear effusion. While not necessary to make the diagnosis, they can be helpful if examiner is unsure of middle ear status by routine otoscopy alone.
• Hearing screening. Do a routine audiometric screening at every visit, especially if child has a history of otitis media. Suspicion of hearing loss should trigger referral to an audiologist to conduct a formal diagnostic test. Emphasize importance of Early and Periodic Screening (including hearing), Diagnosis, and Treatment (EPSDT) as part of primary care–covered services under Medicaid, for which most homeless children qualify.

Plan and Management

Education, Self-Management

• Common occurrence. Explain to parent that otitis media is very common and may recur often, to prevent loss of confidence in medical providers. Main message is that treatment must not be delayed.
• Signs and symptoms. Educate parent about signs and symptoms of otitis media. Pulling or rubbing ear, fluid coming from ear, hearing/balance problems, and fever are indications of immediate need to see a medical provider (but ear touching alone does not necessarily mean an ear infection).
• Breast feeding, bottle propping. Educate parent about advantages of breast feeding (if no contraindications) and risks of bottle propping in preventing otitis media. Provide lactation guide at shelters, drop-in centers, and meal sites used by homeless families. Refer to Women, Infants, and Children (WIC) program, if available in community.
• Prevention. Explain what parent can do to reduce child's susceptibility to future infections: smoke-free environment, smoking cessation program for parent, frequent hand washing to prevent spread of viral infections in shelter, etc. Some clinicians recommend a harm reduction approach to parental smoking. For example, suggest that parent smoke outdoors, wear a poncho while smoking, and remove it before holding child to reduce child’s exposure to second-hand smoke.
• Risks of delayed/ interrupted treatment. Explain risks to hearing, speech, emotional development, and school performance from chronic untreated ear infections.
• Antibiotics. Emphasize that all antibiotics prescribed must be completed. (Don’t stop when symptoms cease or use for next infection.) Urge parent to use standard measurements for antibiotics (not just "a swig"). Provide measuring device. Educate parent about possible side effects of antibiotics, especially diarrhea.
• After hours. Tell parent what to do and number to call if problems arise outside clinic hours.

Medications

• Antibiotics should be used in cases of acute otitis media only. Although there is some evidence that antibiotics can be deferred while awaiting spontaneous resolution of infection, this approach is not appropriate in homeless populations, as close follow-up is not assured. Antibiotics should not be used for chronic sterile effusion, but hearing evaluation is important and an ear, nose and throat (ENT) referral may be necessary.
• Simpler regimen. In general, shorter courses of antibiotics given once daily (such as five-day course of azithromycin) are preferred over more complicated regimens. Consideration should be given to intramuscular routes, such as single dose of ceftriaxone, in which medication delivery is assured. Medications that require refrigeration should be avoided if client does not have access to refrigeration. For a child over five years of age, consider use of capsules as an alternative to liquid preparations, which often require measuring and refrigeration. Capsules are relatively easy to swallow, even for a young child, or can be opened and sprinkled in food, if necessary.
• Prescriptions. Find out if patient has health insurance coverage; if not, refer to social worker or case manager for assistance in applying for Medicaid or the State Children's Health Insurance Program (SCHIP), which cover prescription drugs recommended to treat otitis media. Most homeless children are eligible for Medicaid or SCHIP. If patient is uninsured or if co-payments required by patient's health plan present a financial barrier to treatment, consider giving patient medication samples on site, if available, recognizing possible difficulty in obtaining continued medication. Investigate other options for reduced-cost drugs (e.g., pharmaceutical companies' Patient Assistance Programs for low-income individuals and/or US Department of Health and Human Services' 340B Pharmaceutical Discount program, if eligible [http://bphc.hrsa.gov/opa/howto.htm]).

  Assist family in getting prescriptions filled, especially if required to use an approved pharmacy within a managed care network. Know what medications are on your state’s Medicaid/SCHIP drug formularies and which ones require pre-authorization by a managed care plan. If possible, prescribe medications that do not require prior authorization, which delays treatment and may discourage homeless families from getting prescriptions filled.

• Gastrointestinal (GI) upsets. Prescribe medications with minimal gastrointestinal side effects. Diarrhea is more difficult for homeless families to manage because of limited access to diapers and facilities for cleansing child. Maintaining adequate hydration can also be a problem if fluids are not readily available.
• Pain medication. Provide treatment for pain. Clinicians often under-treat pain associated with acute otitis media. Homeless families may delay pain management while moving from place to place. A crying child in pain increases the stress experienced by homeless families.
• Aids to adherence. Give parent a cross-off chart to keep track of medication administered to child. Use medication boxes for pills. Make sure parent can read prescription labels and all written instructions/educational materials.

Associated Problems/Complications

• Congregate living in shelters or doubled up with other families increases homeless children’s risk of exposure to viral infection, which may increase the incidence of otitis media.
• Parental smoking. High prevalence of tobacco smoking among homeless people increases risk of otitis media in their children. Refer parent to smoking cessation program; counsel to explore readiness to change. Consider child's exposure to other smoke from marijuana, crack cocaine, etc.
• Hearing problems. Multiple/chronic ear infections can result in hearing loss that may affect child’s attachment to parent, emotional and social development, and how parent interacts with child.
• Speech delays. Homeless children have more problems with speech delays unrelated to otitis media than poor housed children. These problems are exacerbated by ear infections. Many homeless children have delayed social and verbal skills, which make it difficult to assess for speech delays.
• Lack of transportation. Homeless families often have difficulty obtaining transportation to specialty appointments. Help client with transportation to needed health services.
• Financial barriers. Lack of health insurance or required co-payments for pharmaceuticals may make it difficult for homeless families to obtain prescribed medications. Help family obtain all entitlements for which child is eligible (including Medicaid/SCHIP) and/or reduced-cost drugs available through public or private patient assistance programs.
• Poor adherence. Assess parent's ability to understand directions and follow through with treatment. Help parent seek assistance, if needed (e.g., substance abuse counseling, help from childcare center’s staff). Use nonjudgmental language. Acknowledge how complicated homeless peoples’ lives are, and the fact that there are conflicting priorities. Be sure parent understands importance of this treatment for the child. Explain things to patient/parent on a level they can understand. Articulate expectations that are realistic but high.
• Familial stress. A child with acute or chronic illness presents another source of stress for a family already dealing with the highly stressful experience of homelessness. Help to alleviate stress by facilitating access to stable housing, supportive services, and other resources (e.g., through childcare centers and schools).

Follow-Up

• Frequency. Re-check child in 5 to 7 days after initial treatment is initiated to ensure that an acute infection is resolving (fluid may take months to go away). If infection has not improved, a change in medical therapy may be necessary. Patients who have purulent drainage from ear (otorrhea) should be seen by an ENT doctor if drainage persists for more than a week or two. Children with sterile middle ear fluid should be followed up in about 2 to 3 months and referred to an ENT doctor if fluid persists.
• Primary care provider (PCP). Share information with patient's primary care provider (if any); refer immediately; facilitate transportation. Make sure provider understands family's living situation and special needs.
• Specialists. More aggressive referrals are needed for homeless children, who require access to professionals in multiple clinical disciplines. Access to specialists is limited in many places, especially rural areas. Work toward establishing relationships with specialists in your community. Develop referral relationships with specialists willing to accept Medicaid patients or provide pro bono care for children who do not qualify for public health insurance. (Recognize that most homeless children are eligible for Medicaid or SCHIP.)
• Referral to audiologist/speech pathologist. Primary care providers should have a low threshold for referral of homeless children for hearing and speech screening. Homeless people have special problems with delayed treatment when continuity of care is lacking. If referral is delayed, there may not be another opportunity for assessment and intervention to arrest damaging results of otitis media. Any hearing loss, balance problem, speech delay, or sleep disorder with effusion or chronic ear infection should trigger referral to an audiologist and/or a speech pathologist. If speech/hearing loss milestones are unclear, refer. Educate clinicians to whom you refer patients about family’s living conditions.
• Myringotomy/tympanostomy. Consider referral if chronic otitis media is suspected. Typical thresholds for surgery are fluid with hearing loss for three months, or 5 to 6 episodes of otitis media in a six-month period. However, early referral may be necessary, since it may be difficult to document these criteria in homeless children.
• Case management. Whenever possible, involve a social worker or case manager to facilitate return visits. Give appointment slips to parent/family member, social worker, and shelter staff.
• Outreach. Coordinate medical care with an outreach worker.

References open in a new window

• American Academy of Pediatrics. Managing otitis media with effusion in young children. Practice guidelines. Pediatrics. 1994 Nov. 94(5). www.aap.org/policy/otitis.htm.
• American Academy of Family Practitioners. Otitis Media with Effusion in Young Children, Clinical Recommendations, 1994, 2002: http://www.aafp.org/x1596.xml.
• Uphold & Graham. Acute otitis media. Clinical Guidelines in Family Practice. Gainesville, FL: Barmarrae, 1998: 338–346.

• American Academy of Pediatrics. Managing otitis media with effusion in young children. Practice guidelines. Pediatrics. 1994 Nov. 94(5). www.aap.org/policy/otitis.htm.
• American Academy of Family Practitioners. Otitis Media with Effusion in Young Children, Clinical Recommendations, 1994, 2002: http://www.aafp.org/x1596.xml.
• Uphold & Graham. Acute otitis media. Clinical Guidelines in Family Practice. Gainesville, FL: Barmarrae, 1998: 338–346.

Electronic copies: Available in Portable Document Format (PDF) from the National Health Care for the Homeless Council, Inc. Web site.

Print copies: Available from the National Health Care for the Homeless Council, Inc., P. O. Box 60427, Nashville, TN 37206-0427; Phone: (615) 226-2292

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.