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SNAPPERS and WASPERS vs. the sting of AOM
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In last month’s issue, there was an interesting question posed as a point/counter to Robert Siegel, MD, and Ellen Wald, MD, regarding the use of watchful waiting as a way to reduce antibiotic use for acute otitis media, and the issue surfaced again in this month’s issue of Pediatrics (see related story here).
One can certainly appreciate the optimistic approach of Siegel and others regarding the use of this approach for AOM.
Still, the use of any of the several different “alternative” approaches to antibiotic prescribing for AOM in young children must be disclosed with full caveats to parents and to practitioners alike.
As opposed to “do nothing,” these approaches have been euphemistically labeled as “watchful waiting exercise,” or WWE (not the wrestlers, please), “safety net antibiotic prescription,” or SNAP, or “wait and see prescription,” or WASP. Each is a variation on a common theme: diagnose AOM and temporize.
For the practitioners who are asking, “why bother,” the theory is that many cases of AOM will spontaneously resolve without therapy, as has been shown in some placebo-controlled trials, thus avoiding antibiotic overuse. For the problems with placebo (non-treatment) data, I refer the reader to Dr. Pichichero’s excellent article in the Pediatric Infectious Diseases Journal (2009) regarding all the pitfalls of placebo- controlled AOM trials.
For WASPERS, SNAPPERs and therapeutic nihilists, the data from each of these trials had their own pitfalls. These major caveats have included: unblinded investigators/parents; lack of details on diagnostic criteria for AOM; what percentage of patients had true reddened, bulging or pus-filled TMs, not just serous otitis media (OME) with pain or ear tugging (a horribly inaccurate symptom for AOM in young children). Also, most children in these trials were older than 2 years (In the Damoiseaux trial, 70% of untreated children younger than 2 years had persistent symptoms at day 11). More worrisome, assessment of successful outcome was done by a follow-up telephone call? As I always say: AT&T is a wonderful phone company but a horrible diagnostician, particularly in clinical trials with a significant lost-to-follow-up rate. Cases of mastoiditis and meningitis (very rare occurrences otherwise these days) have been documented in these nontreatment groups as well.
The real issue to me is how well we do in making the diagnosis of AOM, especially in young children (who account for most cases of real AOM) and especially among less experienced and mid-level practitioners.
This is often the most challenging part of my day: commonly restraining a toddler, infant, or even a young preschooler, to examine the TMs. Up to 80% of those younger than 1 year need cerumen removed, which is often a real battle, requiring much strength, trust and fortitude on the part of the doctor and the parent. Or does one just cop out at this time, with the diagnosis of uncertainty? (SNAP/WASP are fair choices here then)? Ear Curette and Water-Pik are truly pediatric practice essentials if we are doing our job.
Then how good is the equipment one uses? For those still using disposable speculums with their Welch-Allyn otoscopes for children younger than 2 years, shame on you. Those things are too narrow and stubby to get into the canals of most of them. It’s similar to “exploring Mammoth Cave with a penlight.” (Block, Pediatrics. 2001)
Next, we should accept that bona fide diagnosis of AOM is culture positive for true otopathogens in more than 90% of AOM cultures done by tympanocentesis (de lBaccaro. J Pediatrics. 1992; Schwartz. PIDJ. 1999, Block. PIDJ. 1995). Bona fide AOM is painful and very discomforting in nearly all children. (This year, watching my two otitis-prone grandsons younger than 1 year old reminded me poignantly of this.) Granted, some children may have lower-grade symptoms with true AOM. But I would rather give a well-tested, nearly always safe from serious AEs (especially in children) antibiotic than recommend multiple doses of narcotics for the pain (especially in children), which has absolutely no effect on AOM. And, do we want to take a chance on long-term persistence of AOM/OME/hearing loss and rare bad sequela from untreated AOM? Are we at medicolegal risk here as well, with the lack of substantial data (Block, Pediatric Annals. 2002 )? Or the parent question, “Now doctor, why in the heck did I bring in my child for XX symptoms and pay you XX dollars just to hear that?”
In affluent practices, SNAPPERS and WASPERS may be common, but nearly all of my parents in our practice want (or even demand) their child to get better almost immediately: 1) for the child’s sake, and 2) so they can get them back to day care and/or themselves back to work. They prefer to rely on my three years of intense pediatric training, plus my years of education and experience managing countless cases of AOM. They can never really be fully self-informed, and most practitioners do not really have the massive amounts of time to fully inform them about all the nuances of AOM treatment or not (Hmmm, yet, I could offer them to purchase a copy of my book — Diagnosis and Management of AOM, 2005).
Thus, similar to all other diagnoses in my practice, my judgment as to what is the “best” approach to AOM will have to be relied upon. They will also assume that I have made the diagnosis with certainty and accuracy, which is really the biggest hurdle. By contrast, temporizing antibiotics when an “uncertain diagnosis” looms may be prudent for many. I also know that most of my parents with a SNAP/WASP have filled the prescription within a few hours. If one chooses to use these approaches, they should not be offered to those patients younger than 2 years (AAP policy statement, Damoiseaux article), to those with any real symptoms or otalgia or otitis prone condition, and to any family who is not totally reliable.
On the other hand, a phone variation on SNAP/WASP may be great for the child with purulent upper respiratory infection for several days. Our practice — as a unified front — is able to ask parents to wait for “magical” eight or nine days of bad rhinorrhea before they can call back for an antibiotic prescription for sinusitis (Wald et al, Pediatrics, 2009, nicely showed the benefits of antibiotics here). This has been another of our practice’s optimistic compromises with the realities of the working family, childhood bacterial illness and the need to avoid antibiotic overuse.
Stan L. Block, MD, FAAP, is professor of clinical pediatrics at the University of Kentucky College of Medicine in Lexington, KY. and the University of Louisville Medical School in Louisville, KY., and a full-time pediatrician in practice in Bardstown, KY. He is also an Infectious Diseases in Children editorial board member.