NUR 7070 Module 5 Pediatric Primary Care Paper: Acute Otitis Media in an 18-Month-Old Example

A Bulging Drum at Eighteen Months: Diagnosis, a Weight-Based Amoxicillin Dose and a Plan for Parents in Acute Otitis Media

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7070: Primary Care Diagnosis, Management and Health Promotion

Mentor Name

Month Day, Year

A Bulging Drum at Eighteen Months: Diagnosis, a Weight-Based Amoxicillin Dose and a Plan for Parents in Acute Otitis Media

Introduction

Lucia is an invented patient, an 18-month-old girl who attends a day care center five days a week while her parents work. Her mother brings her in after two bad nights. Four days of cold symptoms came first; the fever arrived yesterday and read 39.2 this morning, and since then she has pulled at her right ear, cried whenever she is laid flat and left most of her meals. She has had no vomiting, rash, stiff neck or lethargy. She has had one ear infection, at 11 months, treated with amoxicillin. She has no drug allergies, her vaccines are up to date and she weighs 11 kilograms. On examination she is irritable but consolable and well hydrated. On the right the drum is red and pushed outward so that its bony landmarks disappear, and a puff of air through the otoscope barely moves it. The left drum is slightly pink but not bulging.

Making the Diagnosis

Acute otitis media is often overdiagnosed, because a red eardrum alone can come from crying or fever. Under the AAP guideline (Lieberthal et al., 2013), the eardrum itself must show the infection: a clearly bulging drum, fresh discharge through it that is not from an outer ear infection, or a slightly bulging drum together with new ear pain or a very red drum. A middle ear effusion must be present. Lucia's right drum shows marked bulging and poor mobility, which together meet the diagnostic standard. Her left ear does not, so this is unilateral disease.

Deciding Whether to Treat

Many children with acute otitis media recover without antibiotics, and the guideline allows observation in some cases. Severe illness, in the guideline's terms, means real ear pain, pain that has lasted two days or more, or a fever reaching 39, and any of these in a child past six months calls for an antibiotic. For children 6 to 23 months it also recommends antibiotics for bilateral disease even without severe signs, while unilateral disease without severe signs may be treated or observed after discussion with the family (Lieberthal et al., 2013). Lucia's fever of 39.2 places her in the severe category, so antibiotics are recommended.

The evidence behind this recommendation is strongest in young children. Hoberman et al. (2011) randomized children 6 to 23 months with carefully diagnosed acute otitis media to amoxicillin-clavulanate or placebo. Treatment failure was much less common with the antibiotic, and symptoms resolved faster. Rovers et al. (2006) pooled the raw records of children from several trials and showed that antibiotics helped most when a child under two had both ears infected or had fluid draining from the ear, and helped little in milder cases.

Choosing the Drug and Dose

High-dose amoxicillin is the first-line antibiotic because it reaches middle ear concentrations high enough to overcome the intermediate penicillin resistance of many pneumococci (Lieberthal et al., 2013). The clavulanate combination becomes the first choice if amoxicillin was given within the last month, if pus is also coming from the eyes, or if earlier ear infections failed amoxicillin. Lucia's last course was seven months ago and she has no conjunctivitis, so amoxicillin is appropriate.

The guideline dose is 90 milligrams for each kilogram she weighs, spread over a day in two equal doses. For 11 kilograms, that is 990 milligrams a day, or 495 milligrams per dose. Using the 400 milligrams per 5 milliliter suspension, each dose is 6.2 milliliters. For a child under two, the guideline recommends a full ten-day course.

Pain Relief

Ear pain is the symptom that troubles Lucia and her parents most, and antibiotics do not relieve it in the first day. The guideline recommends treating pain whether or not antibiotics are given (Lieberthal et al., 2013). Acetaminophen at 15 milligrams per kilogram, 165 milligrams or 5.1 milliliters of the 160 milligram per 5 milliliter suspension, every six hours as needed, or ibuprofen at 10 milligrams per kilogram, 110 milligrams or 5.5 milliliters of the 100 milligram per 5 milliliter suspension, every six to eight hours, may be used. Ibuprofen is preferred at night because it lasts longer. Parents are told not to give both at the same time without guidance and to use the syringe that comes with each bottle.

Teaching the Family

Her mother is taught in plain language: Lucia has an infection behind her eardrum; she needs the pink medicine twice a day for ten days even after she feels better; pain medicine will help her sleep; most children improve within 48 to 72 hours. She should call if Lucia is not better in 48 to 72 hours, if the fever climbs, if she develops a stiff neck, swelling behind the ear, unusual sleepiness or vomiting that stops her taking medicine, or if a rash appears. Day care exposure and bottle feeding while lying down raise the risk of future infections, and avoiding secondhand smoke and keeping vaccines up to date reduce it. Diarrhea is a common side effect of amoxicillin and usually mild. The mother's preferred language is Spanish, so written instructions are given in Spanish and the dosing is demonstrated with the syringe.

Follow-Up

A routine ear recheck is not needed if Lucia improves. If symptoms persist after 48 to 72 hours, she is reexamined, and if treatment has failed, amoxicillin-clavulanate is started. An effusion may persist for weeks after the infection clears and does not need antibiotics; it is checked at her next well visit, and her hearing and speech are monitored if it lasts three months or more.

Conclusion

Lucia meets the guideline criteria for acute otitis media, and her fever places her in the severe category, so antibiotics are recommended, consistent with the stronger benefit seen in children under two. High-dose amoxicillin is calculated from her weight, pain is treated with weight-based doses, and her mother leaves with a clear plan in her own language.

References

Hoberman, A., Paradise, J. L., Rockette, H. E., Shaikh, N., Wald, E. R., Kearney, D. H., Colborn, D. K., Kurs-Lasky, M., Bhatnagar, S., Haralam, M. A., Zoffel, L. M., Jenkins, C., Pope, M. A., Balentine, T. L., & Barbadora, K. A. (2011). Treatment of acute otitis media in children under 2 years of age. New England Journal of Medicine, 364(2), 105-115. https://doi.org/10.1056/NEJMoa0912254

Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., Joffe, M. D., Miller, D. T., Rosenfeld, R. M., Sevilla, X. D., Schwartz, R. H., Thomas, P. A., & Tunkel, D. E. (2013). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964-e999. https://doi.org/10.1542/peds.2012-3488

Rovers, M. M., Glasziou, P., Appelman, C. L., Burke, P., McCormick, D. P., Damoiseaux, R. A., Gaboury, I., Little, P., & Hoes, A. W. (2006). Antibiotics for acute otitis media: A meta-analysis with individual patient data. The Lancet, 368(9545), 1429-1435. https://doi.org/10.1016/S0140-6736(06)69606-2