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Comparison of two otitis media guidelines
  1. J Harry Baumer
  1. Correspondence to:
    Dr J H Baumer
    Derriford Hospital, Plymouth, Devon PL6 8DH, UK;

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Acute otitis media is common in children, with approximately 1 in 4 having an episode in the first 10 years of life. It is particularly common in young children. In the USA infants average 1.2 and 1.1 episodes of acute otitis media in the first and second year of life, respectively, and it is the most common infection for which antibiotics are prescribed. Antibiotic use is currently less common in the UK.

Two clinical guidelines have recently been published, one from the Scottish Intercollegiate Guidelines Network (SIGN),1 and the other from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians.2 Both were developed largely using current best practice, in the context of different health care systems. This review compares and contrasts their recommendations (tables 1 and 2). Both cover the diagnosis and treatment in primary care of uncomplicated acute otitis media in otherwise healthy children without facial or genetic abnormalities.


There is strong agreement between the two guidelines where both provide recommendations, despite the different health care systems. They largely agree on the antibiotics to be used, the option of delayed antibiotic treatment, and on the diagnostic features of acute otitis media.

The grading systems differ (appendices 1 and 2), which makes direct comparisons of the perceived strength of evidence difficult. The supporting discussion includes details of the research evidence, although individual studies are not assigned an explicit level of evidence in the AAP guideline.

The SIGN guideline makes a stronger statement against the use of antibiotics; it does not qualify its recommendation in children under 2 years of age despite acknowledging the lack of good evidence in these children. The AAP guideline qualifies its statement on whether to use antibiotics (table 3).

The AAP guideline recommends a 10 day course of antibiotics except in older children with mild to moderate illness (in whom observation is the recommended option); it does not refer to the relevant Cochrane review,3 which recommends a five day course in uncomplicated ear infections. The SIGN guideline acknowledges that the optimum duration of antibiotics in young children or those with severe illness has yet to be established.

In summary, both guidelines recommend against routine antibiotic use in healthy children presenting with acute otitis media in primary care. However, in the USA, children with otitis media are more likely to receive antibiotics, as a 10 day course, based on the recommendations in their guidelines. There are many aspects of this common condition that still need further research, particularly in younger children.

Appendix 1 US guideline

Appendix 2 Recommendation grades and levels of evidence in Scottish guidelines

Table 1

 Key points of the two guidelines: diagnosis

Table 2

 Key points of the two guidelines: management

Table 3

 AAP guideline on use of antibiotics