S: A 5-year-old male is brought to the primary care clinic by his
mother with a chief complaint of bilateral ear pain for the last three days.
The mother states that the child has been crying frequently due to the pain.
Ibuprofen administered at home with minimal relief. Today, refused breakfast
and appeared to be “getting worse.”
O: Vital signs – HR 110 bpm, 28 respiratory rate, and tympanic
temperature of 103.2 degrees F. No known allergies. No antibiotics for the last
year. No history of OM. No past medical history or surgeries.
A: After your questioning and examination, you diagnose this child
with bilateral Acute Otitis Media.
Acute Otitis Media – middle
ear effusion, physical evidence of middle ear inflammation, and symptoms such
as pain, irritability, or fever.
explain your search strategy.
Utilization of various internet,
textbook and journals searches. Esurance of only access and refer to peer
reviewed, reputable sources and none greater than 5 years in circulation.
developed the guideline?
The guideline, The Diagnosis and Management of Otitis
Media, was developed by the American Academy of Pediatrics and endorsed by
the American Academy of Family Physicians (APA, 2013). (It applies to otherwise
healthy children 6 months through 12 years of age)
this a revision of a previous guideline or an original? What is the date of
Original guideline written November
2003 and endorsed by APA in July 2013
the concept of “systematic review of current best evidence.”
review is a summary of the medical literature that uses explicit
and reproducible methods to systematically search, critically appraise, and
synthesize on a specific issue. Researchers conducting systematic reviews use explicit
methods aimed at minimizing bias, in order to produce more reliable findings
that can be used to inform decision making (Neinstein, et. Al.,
2016). Systematic reviews are also a type of journal article,
published alongside primary research articles in scholarly journals.
was conflict of interest managed in the development of these guidelines?
Professional expectations dictate that clinical practice
guidelines are based on credible scientific evidence, critical computation of said
evidence, and un-biased clinical judgment that relates the evidence to the
needs of practitioners and patients (IOM, 2009). Arguably, the most compelling issue
in the development of clinical practice guidelines is the lack of research that
can be used to guide the evolution of comprehensive recommendations applied to
clinical practice. Through professional collaboration and respect for one
another’s idealism and expertise, any conflict of interest issue can be
is quality of evidence defined?
In 2014 the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) Working Group presented its initial proposal
for patient management. GRADE provides a
specific definition for
the quality of evidence in
the context of making recommendations. The quality of evidence reflects the extent to which confidence
in an estimate of the effect is adequate to support a particular recommendation
(Atkins, et. al., 2014).
differences among strong recommendation, recommendation, and option.
The strength of a recommendation indicates the
extent to which one can be confident that adherence to the recommendation will
do more good than harm. The steps in ascertaining strength of evidence and ability to make
judgment to use recommendations include:
The quality of evidence being tested compared with prior
comparable studies or evidence.
The quality of evidence effect on critical outcomes
The balance between benefits and harms
The strength of recommendations versus option
Once the validity of the evidence is
ascertained, the user can decide whether to strongly recommend vs only present
as option. The recommendation also depends on intended use and application to
situations; thus, use is at discretion of user.
are “key Action statements?”
Key action statements are fundamental aspect of the
development process, which allows moving from conception to completion in a
designated timeframe, emphasizes a logical sequence of indispensable actions supported by an augment
documentation, profiles evidence, and makes recommendation grades that
link action to
evidence (IOM, 2009). Key action statements should be clear and precise to
avoid inconsistent interpretation and prevent inappropriate practice variation.
Having drafted a list of key statements, the user should review the list for
ambiguous or vague actions.
this particular child, what are the specific treatment recommendations
including any diagnostics, medications (include exact dosage, frequency, length
of treatment), follow-up, referral, prevention, and pain control.
ü Amoxicillin 80-90 mg/kg/day PO (maximum 3
g/24h) divided BID for 5-7d; 10d may be required if illness is severe (Amoxicillin-clavulanate has a broader spectrum than
amoxicillin and may be a better initial antibiotic. However, because of cost
and adverse effects, the APA has deemed amoxicillin as first-line AOM
treatment) (APA, 2013 and Burns, et. al., 2017).
ü Acetaminophen 15mg/kg every 6 hours
as needed for pain/fever (alternate with ibuprofen) (APA, 2013).
ü Ibuprofen 10mg/kg every 6 hours as
needed for pain/fever (alternate with acetaminophen) (APA, 2013).
ü No referral required at this, will
consider ENT if AOM develops reoccurring pattern
ü Follow up in 2 weeks; sooner of