The observation option states that, because more than 80% of AOM cases resolve on their own, antibiotics can safely be withheld for up to 72 hours in selected children, during which time the child is observed and treatment is restricted to antipyretics and analgesics.

Antibiotics are started if the child fails to improve at the end of the initial observation period or worsens at any time during the observation period. The breakdown of which patients are appropriate for initial observation is shown in the accompanying table.¹³

As illustrated in the table, the target population for initial observation is the otherwise healthy child 2 years of age or older who has good follow-up and is not judged to be severely ill, as would be suggested by high fever or severe otalgia not easily ameliorated with analgesics. Children with any associated conditions that might reflect a relatively immunocompromised state would also be excluded from initial observation. Such conditions might include diabetes, Down syndrome, or any craniofacial abnormalities.

In the otherwise healthy child 6 months to 2 years, initial observation is an option if the diagnosis is uncertain, as would be suggested by clinical signs or symptoms of acute middle ear inflammation in the absence of high probability of concurrent middle ear effusion.

The observation option has been incorporated into the clinical practice guidelines of the American Academy of Pediatrics and the American Academy of Family Physicians. To date, the American College of Emergency Physicians has not made an endorsement.

The question should be asked: Is the observation option a workable treatment strategy in the unique environment of the emergency department?

There are two studies that have addressed this very question. Spiro et al. and Fischer et al. conducted two similar studies in which the parents of children who were diagnosed with AOM and were deemed appropriate candidates for initial observation were sent home with prescriptions for antibiotics. However, the parents were asked not to fill the prescription unless their child's condition worsened or failed to improve at the end of the observation period. Spiro et al. and Fischer et al. demonstrated that in 62% and 73% of cases, respectively, complete resolution of the symptoms of AOM took place without requiring antibiotics. In addition, both studies revealed a high degree of parental satisfaction with the treatment strategy, and no untoward effects occurred.