• Creaven BK, Brodie L, Joseph SP, O'Dea K, Schultz B, Post P. Adapting your practice: treatment and recommendations for homeless children with otitis media. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2008. 29 p. [60 references]

This is the current release of the guideline.

This guideline updates a previous version: Bonin E, Brammer S, Brehove T, Hale A, Hines L, Kline S, Kopydlowski MA, Misgen M, Obias ME, Olivet J, O'Sullivan A, Post P, Rabiner M, Reller C, Schulz B, Sherman P, Strehlow AJ, Yungman J. Adapting your practice: treatment and recommendations for homeless children with otitis media. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2003. 24 p.

Diagnosis & Evaluation

History

• Housing & medical home – At every visit, document patient's housing status and living conditions, list barriers to treatment, and inquire about regular source of primary care.
• Exposure to viral illness – Inquire about congregate living situations (shelters, daycare) and recent exposure to people with upper respiratory infections (colds, flu).
• Exposure to smoke – Ask if anyone in regular contact with the child smokes, whether mother smoked during pregnancy. Ask about passive exposure to marijuana, cocaine.
• Breast vs. bottle feeding – Ask if infant is being breastfed or bottle fed; if the latter, does infant drink from bottle while lying on back? Explore stresses in parent's life that may interfere with adequate attention to infant.
• Sleep disturbance – Ask if ear discomfort interrupts child's sleep (and that of others in the shelter/household).
• Hearing difficulties, delayed speech – Ask when child's hearing was last screened; elicit information about possible hearing difficulties (trouble listening?) and speech delays (speak as well as peers?). Consider other causes of developmental delay (premature birth, weak parenting skills).
• Social development/behavior – Inquire about child's interaction with family members and behavior at daycare/school. Explore possible causes of behavior problems besides hearing loss (stress, feeling ostracized, family violence).
• Missed school – Ask about missed school days due to ear discomfort or other illness.
• Prior ear infections/treatment – Ask about number and treatment of past ear infections, symptoms and duration of current complaint, and whether child has received full course of any antibiotic treatments.
• History of allergies – Ask about allergic reactions (asthma, rhinitis, sinusitis); recognize that homeless children are 3-6 times more likely than other children to have asthma.
• Other medical history – Ask about medical conditions common to homeless people that may directly or indirectly affect the child's health (anemia, obesity, lead toxicity, tuberculosis [TB], sexually transmitted diseases [STDs], behavioral health problems, human immunodeficiency virus [HIV]). Review immunization record. Ask about medications/complementary and alternative medicine therapies (CAM) the child has received for ear infections or other reasons.

Physical Examination

• General – Perform a complete pediatric exam at every visit. Whatever the chief complaint, use each visit as opportunity to identify and address all problems, recognizing that homeless families may not see a medical provider unless their child is sick.
• Otologic examination – Thoroughly examine tympanic membranes; evaluate for acute otitis medica (AOM), otitis media with effusion (OME). To remove cerumen, consider use of curette instead of hydrogen peroxide drops, which require multiple return visits. In evaluating ear pain, consider possibility of a foreign body in the ear.
• Dental examination – Evaluate for dental caries and other oral health problems that may cause ear pain. (Homeless families often have unmet dental health needs.)

Diagnostic Tests

• Pneumatic otoscopy/tympanometry/acoustic reflectometry – Consider cost-effectiveness, accuracy, availability, and ease of use on outreach in selecting a device to confirm diagnosis of AOM/OME. Pneumatic otoscopy is recommended if other diagnostic technologies are unavailable to the provider.
• Hearing screening – Perform routine audiometric screening at every visit. If hearing loss is suspected, refer to audiologist. Be aware that hearing screening is among the services to which children on Medicaid are entitled (most homeless children qualify for Medicaid).

Plan & Management

Education, Self-Management

• Incidence – Inform parent/caregiver that children 6-24 mos. old have highest risk of ear infections. Explain relationship of AOM in infants to previous upper respiratory infections (URIs); stress importance of vaccinations (Haemophilus influenzae type B [HIB], 7-valent pneumococcal conjugate vaccine [PCV-7]) to prevent URIs.
• Signs & symptoms – Specify signs and symptoms of otitis media (OM) requiring immediate visit to a medical provider: ear pain, irritability, ear drainage, fever, pulling/rubbing ear. Instruct parent/caregiver to follow up with a primary care provider (PCP) if symptoms worsen within first 24-72 hrs after treatment. Work with case manager/shelter-based nurse to expedite follow-up care.
• Management – Urge families to discuss potential follow-up barriers with PCP (financial, transportation, geographical, limited time off from work, behavioral health problems, family stressors). Assist in resolution of identified barriers and weigh these factors in deciding whether to "wait and observe" or prescribe antibiotics for AOM in a homeless child. Assess parent/caregiver's ability and resources to participate in the plan of care.
• Risks of delayed/interrupted treatment – Explain risks to hearing, speech, emotional development, school performance from chronic, serious ear infections.
• Prevention – Explain what parent/caregiver can do to reduce child's susceptibility to future ear infections:

  Breastfeeding: Prevents/reduces severity of OM (if no contraindications). Provide lactation guide at shelters, drop-in centers, meal sites used by homeless families.

  Prop baby, not bottle: Hold baby's head at 45-degree angle to prevent fluid from flowing into eustachian tubes. (Refer to the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC], where available, if formula feeding.)

  Smoke-free environment: Passive smoking increases frequency of ear infections. Recommend smoking cessation program for parent or harm reduction—(i.e., reduce child's exposure to second-hand smoke [by smoking outdoors, wearing removable apparel, washing hands before holding child]).

  Prevent URIs: Frequent hand washing to prevent spread of viral infections in congregate settings. Have child fully immunized against pneumococcal disease.

• Antibiotics – Urge completion of all antibiotics as prescribed (don't stop when symptoms cease or use for next infection). Provide measuring device. Explain why use of leftover/borrowed medication is never recommended and why meds should not be placed in a baby bottle. Address safe storage and how to manage refrigeration if required.
• After hours – Instruct parent/caregiver what to do and number to call if problems arise when clinic is closed.

Medications

• Antibiotics – Prescribe only for AOM; if close follow-up is not assured, treat immediately instead of waiting for spontaneous resolution of infection. (For chronic OME with suspected hearing loss, refer to ear, nose, and throat specialist [ENT].)
• Simple regimen – Prefer shorter courses of inexpensive antibiotics with once daily dosing (if clinically indicated) that do not require refrigeration and are easily tolerated. Use intramuscular delivery as a last resort. Consider use of capsules for children over age 5 (can be opened and sprinkled in food if necessary).
• Prescriptions – If patient does not have health insurance, provide assistance in applying for Medicaid/State Children's Health Insurance Program (SCHIP), charity care, patient assistance programs, or 340B Pharmaceutical Discount program.
• Gastrointestinal (GI) upsets – Prescribe medications with minimal GI side effects, recognizing difficulties homeless families have in managing diarrhea and maintaining hydration (limited access to diapers, clean water, bathing facilities).
• Pain management – Recognize that pain management during the first 24 hours of an acute ear infection is important, whether antibacterial treatment is used or not. Mobility of homeless families often delays pain management; a crying child increases stress for families struggling to cope with the inordinate stresses of homelessness.
• Aids to adherence – Be sure instructions for administrating medication and dosing intervals are understood and that parent/caregiver can read prescription labels and educational materials. Provide aids to assure accurate dosing (chart, measuring device).
• Immunization – Immunize infants and young children against pneumococcal disease (PCV7) to reduce risk for OM.

Associated Problems, Complications

• Congregate living – increases risk of exposure to viral infections and incidence of OM. Educate families about preventive measures.
• Parental smoking – increases risk of OM in children exposed to secondhand smoke. Refer parent to smoking cessation program; assess readiness to change.
• Hearing problems – secondary to multiple/chronic ear infections may affect child's attachment to parent and emotional and social development. Screen hearing routinely; refer to audiologist/ENT specialist as needed.
• Speech delays – exacerbated by ear infections in homeless children (who may have delayed social and verbal skills unrelated to OM). Refer to speech pathologist as needed.
• Lack of transportation – can impede access to specialty care. Help with transportation to needed health services.
• Financial barriers – lack of health insurance or resources to make co-payments impeding access to prescription medications. Help family apply for entitlements (Medicaid/SCHIP) and reduced-cost drugs through patient assistance programs.
• Poor adherence – due to misunderstanding of instructions, difficulty administering meds while patient is in childcare or school, parental problem that interferes with treatment (mental illness, addiction). Assess parent's capacity to understand instructions and follow through with treatment; help parent obtain assistance if needed.
• Familial stress – homelessness exacerbated by acute/chronic illness. Facilitate access to stable housing, supportive services, and other resources (through childcare centers, schools).

Follow-up

• Primary care – Help family find regular source of primary care, apply for medical assistance, and identify housing alternatives. Provide care until they find stable housing and a PCP that meets their needs. If child already has a PCP, refer immediately; facilitate transportation and share information about family's living situation and special needs. Obtain family's consent for release of information.
• Frequency – Follow-up care from a PCP in 5–7 days or less after initial treatment for AOM, depending on severity; if infection has not improved in 48–72 hours, consider change in medication. PCP follow-up for otorrhea >2 weeks duration. Follow-up for OM with sterile effusion in 2–3 months; referral to ENT if fluid persists.
• Specialty referrals – Develop referral arrangements with specialists willing to accept Medicaid patients or provide pro bono care, recognizing that homeless children require access to professionals in multiple clinical disciplines.

  Refer to audiologist/speech pathologist if there is hearing loss, balance problem, speech delay, sleep disorder with effusion, chronic infection, or if speech/hearing milestones are unclear

  Refer to ENT specialist if chronic OM is suspected, to evaluate need for myringotomy and pressure equalizing tube placement (thresholds for surgery: fluid with hearing loss for 3 mos. or 5-6 episodes OM within 6 mos.)

• Case management – Involve social worker/ case manager/ shelter nurse to facilitate return visits.
• Outreach – Coordinate medical care with an outreach worker; work closely with daycare staff to promote preventive measures.

None provided

The recommendations were based on a comprehensive review of published reports and consensus opinion of the group regarding their relevance to the care of homeless children.

• Creaven BK, Brodie L, Joseph SP, O'Dea K, Schultz B, Post P. Adapting your practice: treatment and recommendations for homeless children with otitis media. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2008. 29 p. [60 references]

2003 (revised 2008)

Health Care for the Homeless (HCH) Clinician's Network - Medical Specialty Society
National Health Care for the Homeless Council, Inc. - Private Nonprofit Organization

Health Resources and Services Administration

U.S. Department of Health and Human Services

Advisory Committee for the Adaptation of Clinical Guidelines for Homeless Children with Otitis Media

2008 Edition Committee Members: Bernie K. Creaven, MN, RN, Carolyn Downs Family Medical Clinic, Seattle, Washington; Lesley Brodie, MD, Wasatch Homeless Health Care, Inc., Salt Lake City, Utah; Sharon P. Joseph, MD, FAAP, New York Children's Health Project, New York, York; Kathy O'Dea, RN, CNP, Hennepin County Human Services & Public, Health Department HCH project, Minneapolis, Minnesota; Betty Schulz, CPNP, RN, Mercy Children's Health Outreach Project, Baltimore, Maryland; Patricia A. Post, MPA (Editor) National Health Care for the Homeless Council, Nashville, Tennessee

2003 Edition Committee Members: Edward Bonin, MN, FNP-C, RN, Tulane University Health Sciences Center, Adolescent Drop-In Health Services, New Orleans, Louisiana; Sharon Brammer, FNP, H.E. Savage Health Care for the Homeless, Mobile, Alabama; Theresa Brehove, MD, Venice Family Clinic, Venice, California; Abby Hale, PA-C, Homeless Healthcare Project, Community Health Center of Burlington, Burlington, Vermont; Lorna Hines, CMA, The Outreach Project, Primary Health Care, Inc., Des Moines, Iowa; Susan Kline, MN, ARNP, Public Health - Seattle and King County, Seattle, Washington; Mary Ann Kopydlowski, BSN, RN, Boston Health Care for the Homeless Program, Jamaica Plain, Massachusetts; Mike Misgen, MA, LPC, Colorado Coalition for the Homeless, Stout Street Clinic, Denver, Colorado; Maria Elisa Obias, MSN, CNS, RN, Care Alliance, Cleveland, Ohio; Jeffrey Olivet, MA, Albuquerque Health Care for the Homeless, Inc., Albuquerque, New Mexico; Adele O´Sullivan, MD, Maricopa County Dept. of Public Health, Phoenix, Arizona; Mark Rabiner, MD, Saint Vincent´s Hospital & Medical Center, New York, New York; Christine Reller, MSN, RN, Hennepin County Community Health Dept., Health Care for the Homeless Project, Minneapolis, Minnesota; Betty Schulz, CPNP, RN, Mercy Children´s Health Outreach Project, Baltimore, Maryland; Peter Sherman, MD, New York Children´s Health Project, New York, New York; Aaron Strehlow, PhD, FNP-C, RN, UCLA School of Nursing Health Center at the Union Rescue Mission, Los Angeles, California; Jeffrey Yungman, MSW, Crisis Ministries´ Health Care for the Homeless Project, Charleston, South Carolina

The Health Care for the Homeless Clinicians' Network, which oversaw development of this guideline, has a stated policy concerning conflict of interest. First, all transactions will be conducted in a manner to avoid any conflict of interest. Secondly, should situations arise where a member is involved in activities, practices or other acts which conflict with the interests of the Network and its Membership, the member is required to disclose such conflicts of interest, and excuse him or herself from particular decisions where such conflicts of interest exist.

No conflicts of interest were noted during preparation of this guideline.

This is the current release of the guideline.

This guideline updates a previous version: Bonin E, Brammer S, Brehove T, Hale A, Hines L, Kline S, Kopydlowski MA, Misgen M, Obias ME, Olivet J, O'Sullivan A, Post P, Rabiner M, Reller C, Schulz B, Sherman P, Strehlow AJ, Yungman J. Adapting your practice: treatment and recommendations for homeless children with otitis media. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2003. 24 p.

None available

This NGC summary was completed by ECRI on May 24, 2004. The information was verified by the guideline developer on June 24, 2004. This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This NGC summary was updated by ECRI Institute on April 3, 2009. The updated information was verified by the guideline developer on April 27, 2009.

All material in this document is in the public domain and may be used and reprinted without special permission. Citation as to source, however, is appreciated. Suggested citation: Creaven BK, Brodie L, Joseph SP, O'Dea K, Schulz B, Post P. Adapting Your Practice: Treatment and Recommendations for Homeless Children with Otitis Media, 29 pages. Nashville: Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc, 2008.