Autistic spectrum disorder

I have absolutely no interest in dealing with behavioural problems in kids, unfortunately, it is part of the job as a GP. There is a strong push from parents and schools to label these children with a diagnosis. Once they have a diagnosis, they can receive extra fundings and extra help at school. Having said that, it is also important to diagnose children with ASD early so that there is a better chance for them to function independently in the future.

What is Autism?

• Lifelong neurodevelopment disability that affects how an individual communicates and interacts with people and their environment. There are difficulties in 2 primary areas. 
• social interaction 
• repetitie behaviours and interests

How common is autism ?

• Australia 1/160 - 1/100
• USA & Europe 6-7/1000

What cause autistic spectrum disorder?

• exact cause is unknown 
• multifactorial is the keyword in exam 
• some genetic factors in play
• monozygotic twins 60%
• dizygotic 3 %
• More common in males than females 4:1
• More common in certain chromosomal disorders e.g. Fragile X syndrome 
• Increased in neurogenetic disorders e.g. tuberous sclerosis 

• NOT CAUSED BY VACCINATION

How do children with Autistic spectrum disorder present?

• Parents usually aware before 18 months 
• Most common parental concerns include delayed speech and behaviour problems

What is the Role of GP?

• Identify problem early and refer 
• Need to conduct a full history and physical exam
• Appropriate referrals e.g. hearing/vision, intervention services+/-therapy, paediatrician
• ongoing multidisciplinary management and review

What are some absolute indications for immediate refer?

• No Babbling, pointing or other gestures by 12 months
• No sharing of interests in objects with another person
• No single words by 16 months
• No 2 word spontaneous phrases by 24 months
• Any loss of language or social skills at any age

Any screening tools available ?

• M-Chat (16-30 months) Free to download online. Just type M-Chat on google.

What are some key elements in intervention?

• The earlier the better, the more the better
• early intervention between 15-25 hours a week
• Multidisciplinary supportive individualized
• In collaboration with family 
• Strategies to be able to generalise skills
• Develop functional, spontaneous communication 
• Reduction of maladaptive behaviours
• Teach functional adaptive skills
• Opportunity for neurotypical peer interaction 
• Clear Goal setting, predictability and routine 
• Continual review 

Does medication help?

• In general, medication does not help. 
• It is mainly used to treat other co-morbidities e.g. ADHD, insomnia, anxiety etc

What is the prognosis?

• 10 % adults with ASD live independently 

References: 

• Austism spectrum disorder by Dr. Gillian Brooks from diploma of child health webcast 2016

Henoch-Schonlein purpura

Condition

• Commonest vasculitis of children 

Classic triad 

• non thrombocytopenic purpura 
• large joint arthritis
• abdominal pain 

History 

• upper respiratory tract infection including a group A streptococcal tonsillopharyngitis
• mainly in children
• rash, mainly on buttocks and legs
• arthritis: mainly ankles and knees
• abdominal pain - colicky 
• haematuria
• associations
• kidney involvement - deposition of IgA immune complex
• Malaena
• intussusception 
• Scrotal involvement

Investigaions

• FBE
• UEC
• Urine: protein and blood: spun specimen, micro for casts

Management

• Analgesics 
• Check UEC 
• Beware of renal failure 

Faecal incontinence

Key points:

• most likely caused by constipation 
• RCH website has good summary on laxatives
• don't forget psychological cause 
• refer early if not winning, as this can be problematic for the child and the family 

What causes faecal incontinence?

• Functional 
• constipation associated faecal incontinence, involuntary
• non retentive faecal incontinence (encopresis)
• may have a psychosocial basis 
• Organic 
• anorectal malformation, spinal disorders, hirschsprung's disease, CP, mental retardation etc

Assessment ?

• General history
• Bowel habit details
• frequency of defecation 
• consistency of stool 
• intestinal hurry - soiling 
• toilet posture, school practices re: toilet 
• Fluid intake 
• Diet/fibre intake/cow's milk history
• Bristol stool chart. Normal is type 3 and 4.

Examination?

• Developmental 
• nutritional 
• abdominal 
• neurological 
• spine/reflexes
• anorectal exam ? PR (not necessary)
• anal tone/sensation 

What are the investigations?

• bowel chart/diary
• abdominal x-rays (esp if no faecal retention found on rectal exam)
• abdominal ultrasound (rectal diameter for rectal distention > 2.9 cm). Not every centre knows how to do it, check with radiology first, otherwise, it will just be wasting of time
• anorectal manometry 
• blood tests limited value (TFTs, Ca)

What is the management ?

• Good flow chart from DCH lecture 

• Education 
• Laxatives 
• disimpact if significant retention 
• maintenance therapy, 6 months at least 
• Toileting program: bowel opening post meals 
• Treat anal fissures
• Toilet diary (behaviour modification) 

Toileting program 

• Ensure adequate fluid intake (50ml/kg/day)
• Ensure adequate fibre intake
• Toilet posture
• support feet with a stool, it helps relaxing pelvic floor muscle
• toilet sit after meals (gastrocolic reflex)

References

• Diploma of child health: encopresis and enuresis lecture 

Approach to constipation

• Constipation is common, occurring in 30 % of children

• Red flags
• constipation presents early in life < 6 weeks
• functional constipation is the most common cause of constipation in childhood 

• Some other less common causes 
• Medical: cow milk allergy, coeliac disease, hypercalcaemia, hypothyroidism 
• Surgical: hirschsprung disease, meconium ileus, anatomic malformations of anus and spinal cord abnormalities

• History
• Timing of meconium passage
• Painful/frightening precipitant
• Straining 
• Toilet refusal, hiding while defecting, crossing legs or other withholding behaviour 
• Faecal or urinary incontinence, day or night 
• Weight loss, vomiting or PR blood loss - suggests possible organic disease
• Stool description 

• Examination 
• Height and weight -- failure to thrive
• Abdomen - palpable faeces
• Spine - deep sacral cleft or tuft of hair 
• Neurology - assessment of lower limbs 
• Anal area - visually examine for fissures, internal examination not required

• Management 

• Behaviour modifications
• Toilet sits - 5 minutes 3 times a day, preferably after meals 
• use chart or diary 
• Diet 
• Medication
• Titrate medicaion aiming for one soft, easy to pass bowel action per day 
• children: stool softener or iso-osmotic laxative 
• infants 6-12 months: colocyl drops or lactulose 
• infants < 6 months: coloxyl drops 

References: 

• RCH 
• John Murtagh

Approach to enuresis

• Enuresis can be defined as daytime wetting (diurnal enuresis) after age 4 years or night-time wetting (nocturnal enuresis) after 6 years. Usually no treatment is required before that. 

• Red flags
• Referral > 6 years old or any age with continual dripping to paediatric nephrologist
• Any child with a febrile urinary tract infection with abnormal renal US
• Any child with a congenital anatomic genitourinary concern  (posterior urethral valves, vesicoureteral reflux, hydronephrosis, ureteropelvic junction obstruction, bladder or urethral abnormalities or genital malformation)

• It is very common. About 50% of children aged 3 years wet the bed, as do 20% of children aged 4 years and 15% of children aged 5. 

• Usually there is no underlying cause found but we tend to blame:
• parents: there is a genetic tendency
• small bladder
• deep sleeper
• kidneys like to produce urine at night 
• Constipation (make sure the child is not constipated)

• Some disorders that we like to exclude:
• urinary tract infection 
• diabetes mellitus
• diabetes insipidus
• neurogenic bladder
• urinary tract abnormality

• Investigations
• Urine MCS
• Renal ultrasound 

• Management for nocturnal diuresis
• it is mainly behavioural
• the most effective way is using a bed alarm 
• it takes 6-8 weeks for it to work 
• takes some effort and parents will need to be happy to get involved
• first step: get a bed alarm. it sounds obvious but some parents do not want to because financial reasons
• second step: practice using it with the child. Pour salting water on to it and listen to the alarm
• Practice routine when the alarm goes off. The child needs to get up, turn the alarm off, go to the toilet and empty bladder completely, come back and change the sheet/material on top of the alarm and turn the alarm back, go back to sleep
• The child is better only to wear underpants to go to sleep rather with trousers 
• for parents handout: go to http://www.rch.org.au/kidsinfo/fact_sheets/bedwetting/

• Medication if alarm fails:
• DDAVP 200-400 mcg tablets 
• if that fails, use that with an alarm 

References:

• General practice 5th edition by John Murtagh
• RCH 

Approach to common paediatric problems

Crying and fussing in infants

Blocked nasolacrimal duct

Failure to thrive (FTT)

Short stature

Enuresis

Encopresis

Constipation

Approach to delayed puberty

Definition

• Absence of pubertal development in 
• girls > 14 years 
• boys > 15 years

Causes

• Constitutional delay (commonest, usually familial)
• Chronic illness (coeliac etc)
• Poor nutrition and exercise
• anorexia nervosa 
• Turner syndrome and gonadal failure

Investigations

• FBE and ESR
• Kidney function 
• Thyroid function tests
• chromosomal analysis (usually in girls to exclude turner's syndrome 
• serum FSH, LH, Prolactin, testosterone (exclude kallman syndrome) 
• x-ray of the wrist to determine bone age 
• pelvic ultrasound in girls 

Management 

• Refer to endocrinologist 

References:

1. http://www.apeg.org.au/Portals/0/Resources/Hormones_and_Me_6_Delayed_Puberty.pdf

2. John Murtagh

Approach to short stature

The three major growth factors are genetic, nutritional and hormonal. The hormones that are essential for a normal growth process are growth hormone and insulin-like growth factor I (the key), thyroxine, cortisol and sex steroids.

Ten essential questions from murtagh

1. Is the child actually short ?
2. Is the child short compared with other children?
3. Is the child unexpectedly short from a genetic viewpoint?
4. Is the child's growth slowing ?
5. If the growth is slow, what is the reason?
6. How dose the child feel about the short stature?
7. How does the height percentile match against a growth velocity chart?
8. Has puberty commenced?
9. Is there any specific investigation warranted?
10. Is there any specific therapy warranted?

The causes of short stature can be grouped into the following categories:
1. Organic causes
2. Constitutional delay
3. Familial short stature

Examination
1. General inspections includes dysmorphic features and nutritional status. Measure all anthropometry (height, weight, GV, upper/lower segment ratio) and compare with percentile charts
2. Measure skeletal proportions
3. Assess pubertal status

Investigations
If GV is < 25th percentile for bone age, consider

• TSH
• FBE and ESR
• Coeliac disease
• Chromosomes in all girls. Karyotype to exclude Turnes 45 XO 
• Growth hormone studies: IGF - 1 
• Kidney function 
• Bone age x-ray (left wrist) 

Management:

- May require growth hormone 

References:;

John Murtagh 

http://www.rch.org.au/uploadedFiles/Main/Content/MedEd/fracp/short%20stature%20NEJM.pdf

Failure to thrive / poor growth

Don't forget that there are two patients during the consultation. (Mum and baby)

Most common cause > 90 %. Normal variant and nutritional deprivation

History and examination is the key. No use ordering a lot investigations

Measure weight, height and head circumference and plot them on growth chart

** Feeding history is the key **

General observation is the key to this examination. Mother baby interaction, signs  of abuse and neglect, loss of muscle bulk and subcutaneous fat sores.

Red flags:

• Signs of abuse or neglect
• Poor carer understanding 
• Signs of family vulnerability e.g. drug and etoh abuse, domestic violence, social isolation, no family support 
• signs of poor attachment 
• parental mental health issues
• already/previously case managed by child protection services
• did not attend or cancelled previous appointments
• signs of dehydration 
• signs of malnutrition or significant illness

Investigation (if required):

• FBE, ESR
• UEC, LFT
• Iron studies
• Calcium, phosphate
• Thyroid function 
• Blood glucose
• Urine MCS
• Coeliac screen
• Stool MCS
• Stool for fat globules and fatty acid crystals 

Management depends on the cause. Most of the time can be managed in the community. Admission may be required if the child is dehydrated and unstable social situation. 

References:

RCH

John murtagh

unsettled or crying babies

Background

- It is normal for babies to cry
- The mneumonic is PURPLE crying

• P for peak of crying. Peaking at about 2 months
• U for unexpected crying. 
• R for resists soothing. 
• P for pain like face
• L for long lasting. Crying can last for several hours a day
• E for evening. Cry more in the late afternoon and evening

- Common non pathological causes of crying 

• Excessive tiredness
• Hunger 

- Differential diagnoses to consider include:

• Cow milk/soy protein allergy 
• GORD
• Lactose overload/malabsorption 

Red flags:

- Sudden onset of irritability and crying should not be diagnosed as colic, a specific cause is usually present
- The maternal and family psychosocial state must be taken into account. Maternal post-natal depression may be a factor in presentation. Note that excessive crying is the most proximal risk factor for shaken baby syndrome

- Suspect cow milk/soy protein allergy if

• vomiting/blood or mucus in diarrhoea/poor weight gain/family history in first degree relative/signs of atopy (eczema/wheezing)/significant feeding problems (especially worsening with time) 
• gastro-esophageal reflux is diagnosed
• lactose malabsorption is diagnosed in formula fed babies

Investigation

• really depends on the history 
• for acute cry
• Urine MCS (if acute crying and vomiting)
• Fluoroscein staining of eyes (if history suggestive)

Management

• Exclude medical cause (including mum--> ? depression) 
• Explanation and reassurance

1. Engage in a partnership with the parents

2. Explain normal crying and sleep patterns

3. Assist parents to help their baby deal with discomfort and distress

• Give mother permission to rest once per day 

4. Assess maternal and emotional state and mother baby relationship

5. Sometimes when you are really frustrated, it is ok to put your baby down few minutes and calm yourself down

Written information

Conclusion

• Most of the time it is normal and no medical cause is found 
• The most important thing is to gain the parents trust
• Give them clear explanation 
• Minimal intervention from us is the best intervention

References:

John Murtagh 

RCH website

Approach to sore throat

Sore throat: diagnostic strategy model

Probability diagnosis

• Viral pharyngitis
• Streptococcal tonsillitis
• Chronic sinusitis with postnasal drip
• Oropharyngeal candidiasis

Serious disorders not to be missed

• Cardiovascular 
• angina
• myocardial infarction 
• Neoplasia
• cancer of oropharynx, tongue
• Blood dycrasias (e.g. agranulocytosis, acute leukaemia)
• Severe infections:
• acute epiglottitis 
• peritonsillar abscess
• pharyngeal abscess
• diphtheria 
• HIV/AIDS

Pitfalls (often missed)

• Foreign body 
• Epstein-Barr mononucleosis
• Candida
• common in infants
• steroid inhalers
• STIs:
• gonococcal pharyngitis
• herpes simples (type II)
• syphilis
• Irritants (e.g. cigarette smoke, chemicals)
• Reflux oesophagitis --> pharyngolaryngitis
• Tonsilloliths
• Cricopharyngeal spasm
• Kawasaki disease
• Chronic mouth breathing 
• aphthous ulceration 
• Thyroiditis
• Rarities
• scleroderma
• behcet disease
• sarcoidosis 
• malignant granuloma 
• tuberculosis

Paediatric sleep disorder

Paediatric sleep disorder is very common. Most of the time it is behavioural and does not require  medication. Recently, there is a huge surge in melatonin prescription and most of the scripts come from paediatricians. I also have parents coming in asking for melatonin to help their kids going to sleep. The following is a structured approach I use in a consultation:

History taking. I use this mneumonic called BEARS.

B: Bedtime problems.

E: Excessive daytime sleepiness

A: Awakenings during the night

R: Regularity and duration of sleep

S: Sleep disorder breathing

After history, you can usually able to categorise the child into one of the sleep disorder categories.
1. Not enough sleep (difficulty initiating or maintaining sleep)--> behavioural intervention
2. Increased need for sleep (excessive sleepiness or hyper somnolence) --> refer
3. Fragmented sleep  (episodic disturbances e.g. sleep related breathing disorders or movement disorder)--> refer

At GP setting, the most common sleeping disorder we encounter is not enough sleep. This often happens with infants or young children. Parents come in complaining that they are not getting enough sleep and demand something to be done straight away. They cannot handle this anymore. There is always a sense of urgency and as a GP, you always feel pressure to do something to relieve their distress.

There are some resources out there which I use as a guideline when I am under the pump from the parents or when I need some guidance:

Behavioural sleep problems in school aged children

Sleep health foundation has plenty of information about sleeping and children


The reality is that most parents want quick fix and when you tell them that there is no quick fix or you don't prescribe what they want. They get upset pretty quickly so parental rapport is very important at the beginning of the consultation.

Limp in Children : diagnostic strategy

Probability diagnosis

• post trauma/intense exercise causing strain syndromes
• ill fitting shoes
• Hip disorders, esp. transient synovitis
• Heel disorders (12-14 years)

Serious disorders not to be missed

• A. Toddlers
• DDH
• Child abuse
• Septic arthritis
• Foreign body (e.g. needle in foot)
• 4-8 years
• Perth's disorder
• Transient synovitis
• Adolescents
• SCFE
• Avulsion injuries (e.g. ischial tuberosity)
• Osteochondritis dissecans of knee
• Duchenne muscular dystrophy
• All groups
• Septic infections
• septic arthritis
• osteomyelitis
• tuberculosis
• Tumour
• Juvenile chronic arthritis
• Spinal disorders
• discitis
• fracture
• Pitfalls
• Foreign body 
• Osteochonndritis (aseptic necrosis)
• femoral head - Perthes' disorder
• knee - osgood-schlatter disorder
• calcaneum - sever disorder
• navicular - kohler disorder
• Myalgia 
• growing pains
• Overuse syndrome 
• patellar tendonopathy 
• Stress fracture
• Paget's disease 

Paget's disease

Paget's disease

• a chronic disorder of the adult skeleton in which new soft bone replaces localised areas of normal bone
• cause unknown 

Clinical features

• M:F ratio 2:1
• 95% asymptomatic 
• symptoms include joint pain and stiffness (e.g. hips, knees), bone pain (usually spine), deformity. headache and deafness
• Bone pain is typically deep and aching; it occurs at rest, particularly at night
• signs may include deformity, enlarged skull, bowing of tibia, waddling gait and hyper dynamic circulation 

Diagnosis

• Page's disease is diagnosed radiologically 
• early: lytic lesions or flame shaped, advancing lytic wedges in long bones
• late: mixed lytic and sclerotic areas, thickened trabecular, bone expansion, cortical thickening and deformity
• isotope bone scanning is more sensitive

Investigation (2)

• Plasma alkaline phosphatase
• Liver function tests
• Vitamin D levels
• Isotope bone scan
• Radiography of affected bones

Treatment 

• Asymptomatic disease dose not require treatment
• indications for treatment 
• pain 
• neurological complications 
• significant osteolytic lesions 
• involvement of long bones, vertebrae or base of skull 
• before surgery involving pagetic bones
• significant joint involvement 
• Recommended drugs
• zoledronic acid 5 mg single dose, given IV over 15 mins
• alendronate 40 mg daily, given orally for 3-6 months
• risedronate 30 mg daily, given orally for 2 months

References

1. John Murtagh p.747
2. http://www.racgp.org.au/afp/2012/march/paget-disease-of-bone/

Testicular Torsion

Condition

• Testicular Torsion

History

• sudden onset, severe scrotal pain
• Swollen and painful scrotum
• Vomiting and abdominal pain 
• Can occur at any age but more common in neonates and children between the age of 12 - 14

Examination 

• Red, tender, swollen scrotum
• Loss of cremasteric reflex
• High lying testes secondary to twisting of the spermatic cord
• Horizontal lie of the contralateral testes 

Investigation

• Do not order ultrasound to confirm diagnosis in paediatric cases 

Management 

• Urgent referral to hospital for operation 
• Torsion must be corrected within 4-6 hours to prevent gangrene of the testis

References

- DCH:  common surgical problems South 

Acute Otitis Media

Condition

• Acute Otitis Media 

Definition 

• Middle ear infection 
• The common organisms are viral (25%), streptococcus pneumonia, Haemophilus influenza and Moraxella catarrhalis 

Main features

• Fever, irritability, otalgia and otorrhoea 
• TM: translucency, colour, position and motility
• self-limiting (60% of children treated with placebo became pain-free in 24 hours, and spontaneous resolution AOM occurs in approximately 80% of children)
• According to eTG, diagnosis is likely if there is 
• acute onset of signs and symptoms 
• and a demonstrable middle ear effusion (MEE) characterised by any of the following:
• Bulging of the tympanic membrane
• Limited or absent movement of the tympanic membrane in response to changes in air pressure from a pneumatic otoscope
• An air-fluid level behind the tympanic membrane
• Perforation of the tympanic membrane with otorrhoea 
• Signs and symptoms of middle ear inflammation, characterised by redness of the tympanic membrane
• The incidence of mastoiditis in children with untreated AOM is 1: 1000

Management

• Avoid the routine use of antibiotic therapy for acute otitis media
• Initial antibiotic for all children with systemic features and may be required in children younger than 6 months without systemic features. The treatment recommendations apply regardless whether the tympanic membrane has perforated
• Children without systemic features
• In children aged 6 months or older --> observe, if symptoms persist more than 48 hrs, consider antibiotic treatment
• In children aged younger than 6 months --> treat with antibiotic
• Children with systemic features
• amoxycillin 15 mg/kg up to 500 mg orally, 8 hourly for 5 days
• or (for patients suspected to be non adherent) amoxycillin 30 mg/kg to 1 g orally, 12 hourly for 5 days
• Patients who have an inadequate response to amoxycillin therapy within 48 to 72 hours may have infection caused by a beta-lactamase- producing strain of H. influenza or M. catarrhalis, adding clavulanate provides increased cavity against these pathogens. Use
• Amoxycillin + clavulanate 22.5 + 3.2 mg/kg up to 500 + 125 mg orally, 8 hourly for 5 to 7 days
• For patients hypersensitive to penicillins use 
• cefuroxime (child 3 months to 2 years: 10mg/kg up to 125mg; 2 years or older: 15mg/kg up to 500 mg) orally, 12 hourly for 5 days
• trimethoprim + sulfamethoxazole (child 1 month or older) 4 + 20 mg/kg up to 160 + 800 mg orally, 12 hourly for 5 days 

References

• eTG

Paediatric skin rash

It is a very common condition, and it is probably the most difficult to diagnose and manage. Fortunately, most of the time, they are self limiting.

Dr. Adrian Bonsall tried to put an end to this confusion. He developed this algorithm which was published in the Royal Children's Handbook.

This algorithm is quite self explanatory.

Professor Robin Marks also made an attempt in tackling this issue. He covers more than paediatric skin rash. His approach was referenced in John Murtagh's general practice.

He stated that most common dermatological problems fall into one of seven categories. If the rash dose not fall into these 7 categories, the person should be seen by a consultant dermatologist.

• Infections
• Bacterial: impetigo
• Viral 
• Warts
• Herpes simplex, herpex zoster
• Pityriasis rosea
• Exanthemata
• Fungal
• Tinea
• Candidiasis
• Pityriasis versicolor
• Acne
• Psoriasis
• Atopic dermatitis (eczema)
• Urticaria 
• Acute and chronic 
• Papular
• Pediculosis
• Scabies
• Insect bites
• Sun-related skin cancer
• Drug-related eruptions 

GORD in infants

I have seen multiple infants presented with "reflux". In fact, their symptoms are inconsolable crying. (Irritable, wake up from their sleeps.) They often presented with young worrying parents. Maternal child health nurses often come up with different diagnoses to explain crying babies e.g. UTI, reflux, cow's milk protein allergy. Their favourite ones seem to be reflux. It is very easy just to prescribe the parents a PPI and send them home. I have done it before when I cannot be bothered arguing with the parents but it is not the right thing to do and I will not do it again.

Key points on how to approach the situation:

1. Explained GOR is normal. Everyone gets reflux, including adults, we all get reflux on average 3 times per day.

2. Reflux rarely causes crying.

3. GORD is the complication of GOR which includes oesophagitis, failure to thrive and aspiration. Make sure check their weight and height.

4. The symptoms of GORD are vomiting with:

• pronounced irritability and arching
• refusal to feed
• weight loss or crossing centimes
• haematemesis 
• chronic cough, wheeze 
• apnoeas

5. Don't suggest changing of formula 

6. It is normal for babies to cry. Make sure mum is ok. Encourage symptom diary. (RCH symptom diary)

7. Try 5s to console a crying baby:

- swaddling- firm clothing, not too loose

- lie baby on side or stomach (only on awake baby with parents present)

- Shush

- Swing - sway them from side to side

- Suckling

8. If you think it is reflux, refer them to paediatrician and start them on PPI. 

References:

- Royal children's hospital guideline
- John Murtagh 8th edition

Acute Otitis Media

Acute Otitis Media 

I see so many ear pain everyday, however, I still feel that I don't have a good grasp on this topic. Parents are often anxious and pushing for antibiotics. I believe that GPs do have a standard to uphold and should only prescribe it only when it is clinically indicated. 

Key Points:

- The diagnosis of AOM is difficult to make especially in children under the age of 3. Studies have shown that the accuracy was: ENT surgeons 74%, paediatricians 51% and GPs 46%.

- Recurrent otitis media is 3 or more episodes in 6 months or 4 or more in 12 months. 

- Common organisms which cause AOM are: streptococcal pneumoniae, Haemophilus influenza-nontypeable and moraxella catarrhalis. 

- Treatment of AOM involves the following:

• Adequate analgesia: paracetamol, amethocaine, benzocaine or lidocaine.
• Antibiotic therapy recommendations:
• well, older than 2 years, no ABx for 48hrs
• Children under the age of 2 as they are more likely to develop complications
• children with severe illness with pain, or a tympanic membrane perforation 
• a child with known immunodeficiency 
• indigenous children, including aboriginal, Torres Strait islander and Maori and other Pacific Islander children
• Children with a cochlear implant
• antibiotic regime: amoxycillin 15mg/kg 3 times per day x 5days; allergic to penicillin, use cefuroxime 10mg/kg to 500 mg twice per day for 5 days or ceflacor 10mg/kg up to 250 mg 3 x per day for 5 days
• topical antibiotics (mainly ciprofloxacin) can be used with tympanic membrane perforation
• Vaccination with the polyvalent pneumococcal vaccine reduces the incidence of am BY 8 % 

- Prevention of recurrent otitis media

• avoid childcare
• avoid smoking 
• breastfeed x 6 months to 12 months
• avoid pacifiers/dummies
• polyvalent pneumococcal vaccines
• 2 weeks after an episode of AOM, 70% of children will have middle ear effusion but most perforation would have healed.
• Treating blocked nose may not help with acute otitis media. Saline to clear the nose and steroid spray to reduce the size of adenoid
• Adenoidectomy has not been shown to be effective in preventing recurrent AOM

References:

- Check program : ENT