• Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of childhood otitis media in primary care. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2003 Feb. 18 p. (SIGN publication; no. 66). [77 references]

Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.

The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.

Clinical Assessment

Diagnosis

B - Healthcare professionals should have an increased awareness of the possibility of the presence of otitis media with effusion in asymptomatic children. The following groups of children are at particular risk:

• Those in day care
• Those with older siblings
• Those with parents who smoke
• Those who present with hearing or behavioural problems

Medical Treatment

Acute Otitis Media

B - Children diagnosed with acute otitis media should not routinely be prescribed antibiotics as the initial treatment.

B - Delayed antibiotic treatment (antibiotic to be collected at parents' discretion after 72 hours if the child has not improved) is an alternative approach which can be applied in general practice.

B - If an antibiotic is to be prescribed, the conventional five day course is recommended at dosage levels indicated in the British National Formulary.

A - Children with acute otitis media should not be prescribed decongestants or antihistamines.

D - Parents should give paracetamol for analgesia but should be advised of the potential danger of overuse.

B - Insertion of oils should not be prescribed for reducing pain in children with acute otitis media.

Otitis Media with Effusion

D - Children with otitis media with effusion should not be treated with antibiotics.

B - Decongestants, antihistamines or mucolytics should not be used in the management of otitis media with effusion.

B - The use of either topical or systemic steroid therapy is not recommended in the management of children with otitis media with effusion.

D - Autoinflation may be of benefit in the management of some children with otitis media with effusion.

Follow up and Referral

Referral

D - Children with frequent episodes (more than four in six months) of acute otitis media, or complications, should be referred to an otolaryngologist.

A - Children under three years of age with persistent bilateral otitis media with effusion and hearing loss of <25 dB, but no speech and language, development or behavioural problems, can be safely managed with watchful waiting. If watchful waiting is being considered, the child should undergo audiometry to exclude a more serious degree of hearing loss.

B - Children with persistent bilateral otitis media with effusion who are over three years of age or who have speech language, developmental or behavioural problems should be referred to an otolaryngologist.

Patient Issues

Information for Parents, Teachers, and Carers

B - Parents of children with otitis media with effusion should be advised to refrain from smoking.

C - Parents should be advised that breastfeeding may reduce the risk of their child developing otitis media with effusion.

C - Grommet insertion is not a contraindication to swimming.

Definitions

Grades of Recommendations

A - At least one meta-analysis, systematic review of randomised controlled trials (RCTs), or randomised controlled trial rated as 1++ and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B - A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C - A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rate as 2++

D - Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Levels of Evidence

1++ - High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+ - Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1- - Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ - High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ - Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2- - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 - Non-analytic studies, e.g. case reports, case series

4 - Expert opinion

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of childhood otitis media in primary care. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2003 Feb. 18 p. (SIGN publication; no. 66). [77 references]

Not applicable: The guideline was not adapted from another source.

2003 Feb

Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.]

Scottish Executive Health Department

Not stated

Guideline Development Group: Professor John Bain (Chairman); Dr Patricia Townsley (Secretary); Miss Karen Boyle; Mr John Dempster; Dr Ali El-Ghorr; Dr Peter Ewing; Mr Neil Geddes; Dr Ann MacKinnon; Dr Adrian Margerison; Mr William McKerrow; Dr Neil Sabiston; Dr Gavin Stark

All members of the Scottish Intercollegiate Guidelines Network (SIGN) guideline development groups are required to complete a declaration of interests, both personal and non-personal. A personal interest involves payment to the individual concerned, e.g., consultancies or other fee-paid work commissioned by or shareholdings in the pharmaceutical industry; a non-personal interest involves payment which benefits any group, unit or department for which the individual is responsible, e.g., endowed fellowships or other pharmaceutical industry support. SIGN guideline group members should be able to act as independently of external commercial influences as possible, therefore, individuals who declare considerable personal interests may be asked to withdraw from the group. Details of the declarations of interest of any guideline development group member(s) are available from the SIGN executive.

This summary was prepared by ECRI on November 20, 2003. The information was verified by the guideline developer on January 16, 2004.