Norwegian consensus is that only children with recurrent episodes of otitis media need antibiotics

EDITOR—O'Neill's review of the management of acute otitis media from Clinical Evidence was interesting.1 Straand et al showed that 64% of children aged 0-12 years with acute otitis media in a Norwegian county received antibiotic treatment,2 but in a study from an accident and emergency department in Tromsø 91% of the children with acute otitis media received antibiotics.3 This shows the conflict between day to day practice and clinical guidelines that recommend no standard antibiotic treatment for acute otitis media.

O'Neill also addresses the question whether children with recurrent otitis media benefit from antibiotic treatment. The latest Norwegian consensus recommends identifying children who should have antibiotic treatment every time they have otitis media.4 These children have had three or more episodes of acute otitis media during the previous six months or four or more episodes during the previous year. Before the age of 2 years 40% of all children will have an episode of acute otitis media, and 4% will have recurrent episodes. Several studies have been performed to explain why these children are prone to ear infections. Risk factors include a genetic disposition, the age of the first ear infection, and male sex.4 Concentrations of antibody against pneumococcus capsule antigens 6A, 14, and 19F are low, and children with recurrent infections are hypothesised to have delayed production of specific immunoglobulins, being unable to increase their own production until the age of 6.4

These factors are reasons for giving children with recurrent episodes antibiotic prophylaxis as an alternative to surgical treatment. In a meta-analysis of 958 children one in nine showed improvement after antibiotic treatment.1 In a small Swedish study intermittent antibiotic treatment with penicillin V for 10 days was given every time the child had an upper respiratory infection.5 This resulted …