Evid Based Nurs 14:10 doi:10.1136/ebn1114
  • Child health
  • Cohort study

About half of children under age 3 whose parents suspected acute otitis media have the diagnosis; restless sleep, ear rubbing and fever are not predictive

  1. Diane Montgomery
  1. Texas Woman's University College of Nursing, Houston, Texas, USA
  1. Correspondence to Diane Montgomery
    6700 Fannin Street, Houston, TX 77030, USA; dmontgomery{at}

Commentary on: [Abstract/FREE Full text]

Acute otitis media (AOM) is one of the most common infectious diseases in young children affecting approximately 80% of children by the age of 2 years and accounts for more than 40% of paediatric office visits.1 Another very common illness in children which often accompanies otitis media is an upper respiratory tract infection (URI) occurring six to eight times a year making it difficult to distinguish the coexistence of an AOM. Signs and symptoms of a URI cause significant distress to parents leading parents to suspect a diagnosis of an AOM in their children often insisting on antibiotics. Current guidelines from the American Academy of Paediatrics recommend more judicial use of antibiotics to decrease antibiotic resistance.2 Therefore, if parents can recognise when AOM is not present based on the symptomatology, requests for antibiotics may decrease.

Parents suspect AOM

Laine and colleagues examined whether parental suspicion of otitis media displayed in their child, such as pulling on ears, sleeplessness and signs of upper respiratory congestion, predicted the presence of an otitis media. It has long been accepted that these symptoms as well as ear pain, fever and irritability indicate an AOM.1,,3 The researchers investigated a group of 469 children in the prime age range in which most otitis media occurs (6–36 months) whose parents suspected otitis media in their children. The children were equally divided between those with the diagnosis of otitis media (237) and those without (232). Although it was not clear how they obtained the sample except to indicate that the participants were part of a larger study investigating AOM in primary care. The researchers developed very specific criteria to determine the diagnosis and performed inter-rater reliability prior to the start of the study with 90% of the examining physicians correctly identifying otitis media confirmed by an otolaryngologist, which adds credibility to the study. Three different standardised instruments obtained from previous published studies were utilised to determine whether parents could correctly identify AOM on the basis of symptoms displayed in their children. Statistical analysis appeared to be applicable to the study results to prove statistical significance in the different groups.

Symptoms alone cannot predict AOM

The results of the study indicated that parents could not predict the presence of AOM based on symptomatology. Neither the episode, length of time, nor the severity of symptoms related to the otitis media diagnosis, was found to be statistically significant. Regarding the results, parents reported disturbed sleep, which interfered with their life, as the main reason they suspected otitis media, although it was not found to predict the diagnosis. Another common complaint from the parents who suspected AOM is ear pulling which has been long accepted as a sign of AOM in children3 was demystified in this study because the researchers found that there was no relationship and tended to be present more in children without AOM. The design of the study might have influenced this since parents in the study had to suspect otitis media to be included.

The study supported previous research which concludes that fever occurs in less than half the children with the diagnosis of AOM as well as the coexistence of URI symptoms.2 3 Although it did contradict the research that the presence of ear rubbing, a sign of ear pain, is a predictive factor.4 There was no significant relationship found in severity of ear pain reported. However, being able to identify ear pain in this young a child is difficult at best and therefore a limitation to these findings. The only finding that seemed to be similar to other research was there appeared to be a relationship between conjunctivitis and AOM.

Triage nurses beware

Because the researchers found that AOM could not be predicted by occurrence, duration or severity of non-specific symptoms and that each child displays different symptoms with an AOM, treatment should not be based on symptomatology alone. Triage nurses should use care when instructing parents over the phone differentiating between AOM and URI and need to determine if the child should be seen by other factors.


  • Competing interests None.


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