Antibiotics as the Main Treatment for Children

Topic: Antibiotic Words: 4460 Pages: 17

Table of Contents

Abstract
Clinical Problem
Purpose Statement
PICOT Question
Summary of PICOT Search Results
Implications for Nursing Practice
Contribution to the Field
References

Abstract

Acute otitis media (AOM) is a common disease that is usually observed among patients in early infancy and childhood. Several methods of treatment can be offered. Antibiotic use is one of the most frequent options in such countries as the USA and Australia. Watchful waiting is an alternative that cannot be neglected by medical workers and family members. This paper will investigate sources to find help in answering the chosen PICOT question.

Three databases, including NICE (National Institute for Health and Care Excellence), PubMed (US National Library of Medicine—National Institutes of Health), and Medscape (a global web resource), are used for the PICOT search. Specific search terms and inclusion criteria are identified to answer the research question. Fifteen articles with a strong level of evidence and various research methods and findings are analyzed in this paper.

Certain implications for nursing practices are given to explain the importance of knowledge about otitis media diagnosis and treatment among medical workers, the level of confidence, and the urgency of each step taken to assist a young patient with a specific medical problem. The results of the investigation are significant because they help in comprehending the importance of knowledge and practice in the chosen field, provide new information about the problem, and identify the value of antibiotic use regarding such methods as antibiotic therapy and watchful waiting, also known as an expectant observation. The use of antibiotics may have different outcomes for children, and this paper evaluates the peculiarities of two treatment types.

Clinical Problem

When children get sick, their parents and health-care providers face many challenges and worries because, in some cases, it can be hard to recognize the true source of pain, understand the causes of disease, and clarify the best treatment methods. However, grownups cannot neglect their responsibilities and do everything possible to help a child and remove the source of pain or, at least, reduce the level of pain. Acute otitis media (AOM) is a disease usually diagnosed in children. It is an inflammation of the middle ear characterized by abrupt pain. Children are hardly prepared for such pain, and for them, the imperative is to resolve it in a short period. Therefore, pediatric patients with acute otitis media must be provided with the best and most effective treatment.

AOM is one of the most common infections many American children suffer from, and antibiotics remain to be the main method of treatment for such a problem. However, antibiotic use is not the only option available to children. Watchful waiting is another method for consideration. Both of these methods have their positive and negative outcomes for pediatric patients. Some caregivers support the idea of watchful waiting, and many researchers admit the positive effects of antibiotic therapy. This debate occurs, and no common solution can be given on how to make the right choice and be confident in its effectiveness.

Today, 60-80% of children experience their first episodes of AOM by the first year of age. The parents of approximately 80-90% of children aged 2-3 years address physicians with the same problem for the first time. The comparison between antibiotic therapy and watchful waiting has to be developed to comprehend if the latter method can be less harmful to children during the first 72 hours of symptom onset than the former treatment.

Purpose Statement

This paper aims at discussing the peculiarities of antibiotics as the main treatment that can be offered to children aged from 6 months to 12 years and watchful waiting as one of the possible alternatives for such patients. Besides, it is necessary to clarify if the choice of watchful waiting can replace antibiotics during the first 72 hours after the problem is identified. Parents, healthcare providers, medical workers, and other caregivers have to participate in such kind of discussion to understand the effects of watchful waiting and antibiotics on pediatric patients who need appropriate and in time care.

PICOT Question

In pediatric patients aged 6 months to 12 years who are diagnosed with acute otitis media (P), how does watchful waiting (I) compared to antibiotic therapy (C) affect the reduction in antibiotic use (O) within 72 hours of symptom onset (T)?

Summary of PICOT Search Results

Taking into consideration the background of the clinical problem, the identification of the main concern, and the clarification of the goals and the question that has to be answered, certain attention has to be paid to a searching process, including the choice of engines and databases, the identification of search terms and inclusion criteria, and the evaluation of the articles that meet all requirements. In addition to such search engines as Google Scholar, several medical databases have been discovered. For example, in Google Scholar, two phrases, “acute otitis media” and “pediatric patients” were included, and time frames “from 2012 to present” were chosen to observe what kind of information was generally available.

To complete this particular evidence-based practice assignment and answer the offered PICOT question, three databases were chosen for searching for articles.

The next step that should be taken to succeed in finding information is the identification of search terms. There are five terms to be considered:

acute otitis media,
pediatric patients (or children),
antibiotic therapy,
watchful waiting,
antibiotic use reduction.

Three inclusion criteria are publication years (from 2012 till present), patient age (children from 6 months to 12 years), and methods of treatment (antibiotic therapy and watchful waiting). Among the 15 articles chosen, there are eight reviews of the qualitative and quantitative literature, two retrospective studies, two mixed methods, and one trial.

The following table provides a summary of all 15 sources chosen to answer the PICOT question:

*Author(s) (year) and country*	*Purpose*	*Study Design*	*Sample Size and Site*	*Treatment*	*Results*	*Implications for Nursing*
Boatright, Holcomb, & Replogle (2015), USA	To discuss the peculiarities of antibiotic treatment offered to children with AOM.	A retrospective descriptive study based on electronic medical records.	Out of 288 patients, 100 children under 12 years of age meet the inclusion criteria. The approval to use EMRs is obtained from the Institutional Review Board.	Decreased antibiotic therapy and increased watchful waiting.	The Overprescribing of antibiotics for children is costly and unnecessary. Education, monitoring, and training for nurses are offered. A decrease in public demand for antibiotics is promoted. The attention to watchful waiting is paid.	Nurses learn and understand why watchful waiting is beneficial in treating children with AOM.
Broides, Bereza, Lavi-Givon, Fruchtman, Gazala, & Leibovitz (2016), Israel	To identify parental knowledge of AOM and investigate the effects of antibiotic therapy and watchful waiting on children in primary care.	A quantitative study (a questionnaire).	Twenty questions are given to 600 parents of children younger than 6 years of age who are treated in three primary care clinics and ERs of Soroka University Medical Center.	Antibiotics and watchful waiting.	Approximately 69% of parents state that their children have already had AOM problems, with 56% saying that antibiotic therapy is the only treatment offered. Parental knowledge makes them accept antibiotics as the main treatment method. Still, some parents are ready to test the effects of the watchful waiting approach.	Medical workers should pay more attention to the level of knowledge that parents of children with AOM have. Their choices and trust may influence patients’ treatment considerably.
Célind, Södermark, & Hjalmarson (2014) Sweden & USA	To evaluate the degree of adherence to AOM guidelines defined by the Swedish National Consensus in pediatric EDs and identify whether the results can be changed in the case where the protocols are neglected or misunderstood.	A retrospective analysis of patient records.	The records from the Queen Silvia Children’s Hospital in Gothenburg, Sweden between January 1, 2009–June 30, 2009, and March 1, 2010–June 30, 2010. Information for 91 patients is chosen out of 1,041 offered (first part) and 80 out of 652 cases (second part).	Antibiotics and watchful waiting.	Adherence to guidelines is about 70%. No significant change is observed after a campaign is offered. The use of antibiotics is proven.	Nurses should pay attention to the information provided by patients and their families when children should be diagnosed and treated for AOM. There are certain barriers, and follow-up implementations are required to achieve the necessary results.
Coticchia, Chen, Sachdeva, & Mutchnick (2013), USA	To identify new paradigms in the pathogenesis of AOM in children.	A systematic review of the literature.	No, clearly identified sample is given in the article. The main subjects are children between 6 and 12 months of age who are diagnosed with AOM.	Antibiotic therapy.	Antibiotic treatment helps to increase bacterial resistance. It can be offered to different patients, including children. Bacterial biofilm formation is discussed as the main contributor to the development of AOM.	This study helps in understanding that AOM is a disease characterized by several factors, including socio-economic challenges. The evaluation of the pathogenesis of AOM is a step that must be explained to all medical workers.
Cunningham, Guardiani, Kim, & Brook (2012), USA	To discuss the peculiarities of AOM diagnosis and medical management and evaluate recent changes in the field and the value of surgical treatment.	A systematic review of the literature during the last ten years.	Children who live in the United States and are sick with AOM during the first three years of their lives.	Antibacterial therapy for children of different age groups, antibiotics, observations, and surgical therapy.	Treatment of AOM among children remains a challenging task because of the impossibility of controlling infections in the early stages of development.	Clinicians must be educated to know how and when to use antimicrobials to avoid failure. Treatment for children is a complicated issue, and medical workers must be ready for it.
Forrest et al. (2013), USA	To explain what CDS (clinical decision support) is, identify the effects of electronic health record-based CDS, and obtain feedback on the chosen strategies.	A factorial-design cluster-randomized trial (Forrest et al., 2013).	Twenty-four primary care practices are investigated in terms of 139,305 cases, with 55,779 children aged 3 months–12 years who have AOM. The period is between December 2007 and September 2010.	Clinical decision support and performance feedback.	Antibiotics and watchful waiting can be improved using new strategies such as HER, CDS, and performance feedback.	Nurses must discover new opportunities to support children, provide their families with hope and trust, and choose interventions that do not have negative outcomes on children’s well-being.
Grossman, Silverman, & Miron (2013), Israel	To recognize physician and visit characteristics that may influence the development of antibiotic therapy among children with AOM.	A systematic review of records and statistical analysis.	The records of Maccabi Healthcare Services. The population includes patients who, between 2002 and 2009, were between 1 and 15 years of age, who were members of an HMO, and who had AOM. There were 976,233 visits from children.	Delayed treatment of otitis media.	A high rate of immediate antibiotic treatment causes numerous concerns. Therefore, it is suggested to delay treatment if possible to address all factors that may influence the development of the disease among children.	Clinicians should learn the impact of geographical location, antibiotic prescribing, and other interventions that can influence a child’s well-being.
Grossman et al. (2016), Israel	To evaluate the relationships between delayed antibiotic treatment and severity of subsequent acute mastoiditis admission (Grossman et al., 2016).	A prospective observational study and statistical analysis.	In Israel, 512 children aged 0–14 with acute mastoiditis admitted to hospitals between 2007 and 2012.	Delayed antibiotic treatment.	Antecedent AOM by itself cannot be associated with the development of complications caused by acute mastoiditis. However, a fast spread of the infection can be explained by the effects of mastoiditis on the work of the body.	Nurses learn the protective characteristics of antibiotics that can be offered to children with AOM.
Marom, Nokso-Koivisto, & Chonmaitree (2012), USA	To present the current knowledge of viral–bacterial infection that influences the development of AOM.	A systematic review of the literature.	No clarifications are given because of the goal of the study.	Early antibiotic treatment.	AOM is a common disease that affects millions of children. It is characterized by certain economic and individual burdens. Viral–bacterial infections are crucial for AOM pathogenesis. Parents should learn how to use probiotics and antibiotics to protect their children.	Nurses learn how to cooperate with parents and apply knowledge about pathogenic bacteria in treatment for infants.
McGrath, Becker-Dreps, Pate, & Brookhart (2013), USA	To examine trends in antibiotic treatment offered to children, as well as failures.	Analytical review of data taken from a database.	The study covered 4,629,460 children aged 3 months to 12 years with AOM who were given antibiotics and untreated.	Antibiotic treatment.	Four million children under 13 years have AOM. The use of antibiotics as the main treatment method has been decreased. Watchful waiting can be offered as a supportive means but not an independent treatment option.	Clinicians learn more about antibiotic dispensing. Non-penicillin therapies must be developed as an opportunity to resist antibiotic infections.
Rettig, & Tunkel (2014), USA	To review management concepts and changes that have been observed during the last two decades.	A systematic review of the literature.	No information is given.	Antibiotic therapy and analgesia.	It is necessary to distinguish AOM from chronic otitis due to the existing factors and complications in treatment. The bacteriology of AOM undergoes certain changes due to offered pneumococcal vaccines. Though complications of AOM are not frequent, they must be investigated to avoid morbidity.	Children with AOM may be observed without antibiotic treatment. Knowledge of infections that can influence the development of AOM is obligatory.
Schilder et al. (2016), United Kingdom	To investigate different aspects of AOM management.	A review of the literature during the last two decades.	The study design does not presuppose these issues.	Antibiotic approach.	The generic impact must be mentioned in AOM management. Parents and children must be consulted systematically in order not to miss the period when treatment is required.	Clinicians and researchers must agree on the same epidemiology, prevention, and treatment of AOM to avoid further complications and lack of time for help.
Sun, McCarthy, & Liberman (2017), USA	To evaluate the cost-effectiveness of watchful waiting.	A retrospective review of randomly selected patients.	In this study, 250 patients younger than 18 years and diagnosed with AOM are chosen randomly according to concepts from the International Classification of Diseases.	Watchful waiting.	The implementation of watchful waiting in AOM management may be cost-effective from a societal point of view. This method can reduce patients’ visits although additional education and follow-ups may be required.	Parents and care providers must learn the specifics of watchful waiting when it is offered as the main treatment method for children. It has its own pros and cons.
Tamir, Shemesh, Oron, & Marom (2016), Israel	To identify differences and similarities of protocols for AOM management in developed and developing countries.	A comparative study.	This study drew upon 99 sources from 62 countries (22 developed and 40 developing).	Antibiotics and watchful waiting.	Watchful waiting is usually supported in hospitals in developing countries. Antibiotics are used in developed countries.	Global perspectives help to clarify if social and economic factors may influence the choice of treatment method offered to a child.
Thomas, Berner, Zahnert, & Dazert (2014), Germany	To explain how to diagnose AOM, define the level of complications, and initiate appropriate treatments.	A selective literature review of sources with evidence-based recommendations.	From the year 2000 and older peer-reviewed articles based on American guidelines.	Immediate antibiotic therapy and symptomatic treatment.	A purulent tympanic effusion may be defined as indicative of AOM. Only some children may need immediate antibiotic treatment. In many cases, symptomatic treatment is appropriate.	Certain important factors that may influence the development of AOM are identified. Follow-ups, prevention, and communication are discussed to assist medical workers with treatment.

Analysis of 15 articles written by authors from different parts of the world proves that many hospitals and caregivers support the idea that antibiotic treatment must be offered to patients with AOM aged 6 months to 12 years. The reasons for this choice have clear social, economic, and personal backgrounds (Grossman et al., 2012; Grossman et al., 2016; McGrath et al., 2013; Schilder et al., 2016). For example, the investigations of Schilder et al. (2016) show that the prevalence and incidence of AOM have a direct relation to the economic status of the country.

The economic burden is the challenge may African countries cannot solve, and citizens have to use personal knowledge and abilities to protect their children against infections. Still, the results obtained by et al. (2013) prove that many US populations suffer from the same health problem despite the presence or absence of the economic burden. Therefore, it is necessary to focus on social problems and personal challenges, including the level of knowledge physicians, use to treat their pediatric patients (Grossman et al., 2012) and the access to a broad spectrum of antibiotics that can be given to children in case of emergency (McGarth et al., 2013).

However, there are also studies where watchful waiting is proved an appropriate treatment method that makes it possible to reduce the negative impact of antibiotics and protect children against the development of complications caused by AOM (Boatright et al., 2015; Célind et al., 2014; Coticchia et al., 2013; Sun et al., 2017; Tamir et al., 2016; Thomas et al., 2014). Grossman et al. (2016) support the idea of delayed treatment with the help of antibiotics and the use of watchful waiting for 48-72 hours for children older than 6 months. They prove that delayed antibiotics therapy and the presence of watchful waiting as the method of treatment can be chosen due to no observed mastoiditis complications. In comparison to Grossman et al. (2016), Célind et al. (2014) suggest such treatment for children older two years with no toxic appearance.

The clarifications given by Célind et al. (2014) can also be supported by the study developed by Cunningham et al. (2012) who underline the importance of specific antibiotics for children older two years, meaning that watchful waiting can be implemented safely and successfully. Still, the support of antibiotics like amoxicillin is also obligatory because it is not as harmful as many other antibiotics.

The findings by Sun et al. (2017) differ from other studies introduced in the articles because these authors support the idea of delayed antibiotic treatment and watchful waiting as an option. At the same time, they introduce new requirements that have to be considered when the decision to wait is made. Watchful waiting during the first 72 hours cannot be appropriate for patients who meet such criteria as otalgia ≥ 48 hours and a higher temperature (≥39^oC). Watchful waiting cannot also be offered to children aged 6-23 months. In general, almost all authors explain that pediatric patients diagnosed with AOM can have different symptoms and the level of pain. It is wrong to make some general conclusions about the appropriateness or avoidance of watchful waiting as an option for treating such patients.

Therefore, though watchful waiting can affect the reduction in antibiotic use, the outcomes of such treatment are hard to predict, and each situation has to be evaluated separately. Additional sources with different approaches and outcomes prove that AOM is an urgent problem, a disease that may influence the lives of many children (Broides et al., 2016; Cunningham et al., 2012; Forrest et al., 2013; Marom et al., 2013; Rettig & Tunkel, 2014).

Implications for Nursing Practice

In clinical practice, these findings can be used in a variety of ways. For example, it is possible to use this material for educational and training purposes. Nurses, medical workers, physicians, and other clinicians can investigate the experience of their colleagues and make improvements in their own practice. On the one hand, different countries are characterized by different economic statuses and social opportunities for people.

The findings of these articles show that such countries as Israel, the USA, Germany, and Australia may offer different approaches to treating children with AOM. Their choices have clear grounds and explanations. On the other hand, each country has its own religious beliefs, cultural preferences, and traditions that cannot be neglected even in the field of nursing, medicine, and healthcare. These articles can be used in nursing practice as the possibility to clarify if there is a connection between religion/culture and those first 72 hours in the life of a child who is diagnosed with AOM.

Another important implication is connected with the personal attitudes of people to the profession of a nurse. Seventy-two hours in the life of a child who has AOM problems are crucial. A nurse must understand the importance of diagnosis and treatment. To afford the possibility of choice, it is required to have enough evidence and facts to make the right decision. It is not enough to identify a problem, ask questions to gather enough information, and acquire evidence to make a diagnosis. It is necessary to comprehend why watchful waiting can be more effective for patients under 12 years of age in comparison to immediate antibiotic therapy.

Besides, with the help of the offered articles, nurses can investigate their skills and understand what kind of help they can offer to their pediatric patients and their families. Sometimes, it is not easy to work with children and support their families. Nurses have to learn all the time. Even if they believe that they know a lot, there is always some space for improvement. Reading these articles and the investigation of different researchers’ thoughts is a significant contribution to nursing practice.

Finally, it is necessary to admit that the chosen sources reinforce the idea that the decision to use watchful waiting instead of immediate antibiotics must be made in conjunction with caregivers and the plan of care offered. There are many mechanisms in this procedure, and the authors of the sources admit that waiting can lead to certain positive and negative results at the same time. There are no clearly identified solutions and facts.

Therefore, clinicians and all caregivers must understand the level of their responsibility. In addition to these sources, it is possible to underline the importance of additional evidence regarding the attitudes of caregivers to the necessity to reach independent conclusions and influence the lives of children and their families. Pediatric patients’ care is characterized by a high level of responsibility. Sometimes, nurses are ready for it, and sometimes, they need additional help and explanations. These articles demonstrate different approaches to treating patients aged from 6 months to 12 years. Besides, there are several good recommendations on how to make a decision and avoid negative outcomes that can be observed in case watchful waiting is used instead of antibiotics during the first 72 hours after being diagnosed.

Contribution to the Field

The results of the analysis of 15 sources offer a significant contribution to the field of study. First, these sources underline the importance of continuing education and training even if caregivers have extensive experience. When sources contain interesting information and are defined as peer-reviewed, there are no doubts that all facts, recommendations, and solutions make a point. Antibiotic therapy and watchful waiting are two effective treatment methods that can influence a pediatric patient’s conditions in several ways. For example, a patient may feel relief without any antibiotics, and watchful waiting may become an appropriate solution to be made. There are also situations when patients cannot wait a lot and require antibiotic treatment as soon as possible. Nurses have to know how to identify such situations, and the offered article can be used as educative material to rely on.

Second, it is clear that no specific conclusion can be drawn from the material gathered at the moment because watchful waiting is characterized by certain positive and negative outcomes at the same time. Almost the same situation can be observed with the use of antibiotics. The situation of each patient is unique. There is no opportunity to create a certain system and work in accordance with specific guidelines. Each patient has their own age, symptoms, and peculiar medical restrictions.

In some cases, a ten-year-old boy with AOM can wait 72 hours and avoid using antibiotics even if the temperature is high. The boy can inform parents or caregivers about possible changes or the level of pain. The same cannot be observed in a patient whose age is about 2 years. With the help of these articles, it becomes clear that it is normal for a nurse not to have a clear answer to the offered PICOT question regarding the existing variety of situations and patients.

Finally, the articles can be used to improve nurses’ knowledge about antibiotics and their effects on patients of different ages. In many countries, antibiotics comprise a therapy that cannot be rejected by millions of families because they find it effective to use antibiotics and deal with an infection in a short period, neglecting any other possible negative outcomes that can be observed in the body. Sometimes, the economic status of the country has to be recognized because some people can afford to use antibiotics any time they find it necessary, and some people are still challenged by the conditions that social insurance programs may have.

In general, the problem of AOM among children between 6 months and 12 years of age has been properly explained and described with the help of the chosen sources. Many trials and retrospective studies aim at comparing results in different hospitals and medical centers. The main subject of the investigation is the outcome of watchful waiting in the treatment of patients aged 6 months to 12 years during the first 72 hours of symptom onset. At times, it can be normal and effective to wait and observe the changes in the patient. However, in many cases, children cannot deal with pain, and they need antibiotics to reduce pain and avoid the development of complications. Supporters of both immediate as well as delayed antibiotic therapy can be found.

Watchful waiting is a method that has enough grounds to be supported, especially within 72 hours of symptom onset. Still, the sources help to understand that neither of the therapies identified can promote positive outcomes only. Each patient has different symptoms, and various complications can be developed even under the control of experienced medical workers. Pediatric patients introduce a unique group of people who need high-quality help, support, and understanding. Some patients cannot speak, express their concerns, and inform about all possible symptoms and complaints. Parents are not always able to recognize a problem. Therefore, watchful waiting and antibiotic treatment are the options that can be made by different nurses for different patients, and it is hard to predict the standards that should be followed unquestioningly.

References

Boatright, C., Holcomb, L., & Replogle, W. (2015). Treatment patterns for pediatric acute otitis media: A gap in evidence-based theory and clinical practice. Pediatric Nursing, 41(6), 271-276. Web.

Broides, A., Bereza, O., Lavi-Givon, N., Fruchtman, Y., Gazala, E., & Leibovitz, E. (2016). Parental acceptability of the watchful waiting approach in pediatric acute otitis media. World Journal of Clinical Pediatrics, 5(2), 198-205. Web.

Célind, J., Södermark, L., & Hjalmarson, O. (2014). Adherence to treatment guidelines for acute otitis media in children: The necessity of an effective strategy of guideline implementation. International Journal of Pediatric Otorhinolaryngology, 78(7), 1128-1132. Web.

Coticchia, J. M., Chen, M., Sachdeva, L., & Mutchnick, S. (2013). New paradigms in the pathogenesis of otitis media in children. Frontiers in Pediatrics, 1(52). Web.

Cunningham, M., Guardiani, E., Kim, H. J., & Brook, I. (2012). Otitis media. Future Microbiology, 7(6), 733-753. Web.

Forrest, C. B., Fiks, A. G., Bailey, L. C., Localio, R., Grundmeier, R. W., Richards, T.,… Alessandrini, E. A. (2013). Improving adherence to otitis media guidelines with clinical decision support and physician feedback. Pediatrics, 131(4), 1071-1081. Web.

Grossman, Z., Silverman, B. G., & Miron, D. (2013). Physician specialty is associated with adherence to treatment guidelines for acute otitis media in children. Acta Paediatrica, 102(1), 29-33. Web.

Grossman, Z., Zehavi, Y., Leibovitz, E., Grisaru-Soen, G., Meyouhas, Y. S., Kassis, I.,… Abozaid, S. (2016). Severe acute mastoiditis admission is not related to delayed antibiotic treatment for antecedent acute otitis media. The Pediatric Infectious Disease Journal, 35(2), 162-165. Web.

Marom, T., Nokso-Koivisto, J., & Chonmaitree, T. (2012). Viral–bacterial interactions in acute otitis media. Current Allergy and Asthma Reports, 12, 551-558. Web.

McGrath, L. J., Becker-Dreps, S., Pate, V., & Brookhart, M. A. (2013). Trends in antibiotic treatment of acute otitis media and treatment failure in children, 2000–2011. PLoS One, 8(12). Web.

Rettig, E., & Tunkel, D. E. (2014). Contemporary concepts in management of acute otitis media in children. Otolaryngologic Clinics of North America, 47(5), 651-672. Web.

Schilder, A. G., Chonmaitree, T., Cripps, A. W., Rosenfeld, R. M., Casselbrant, M. L., Haggard, M. P., & Venekamp, R. P. (2016). Otitis media. Nature Reviews Disease Primers, 2, 1-18. Web.

Sun, D., McCarthy, T. J., & Liberman, D. B. (2017). Cost-effectiveness of watchful waiting in acute otitis media. Pediatrics, 139(4). Web.

Tamir, S. O., Shemesh, S., Oron, Y., & Marom, T. (2016). Acute otitis media guidelines in selected developed and developing countries: Uniformity and diversity. Archives of Disease in Childhood, 0, 1-8. Web.

Thomas, J. P., Berner, R., Zahnert, T., & Dazert, S. (2014). Acute otitis media – A structured approach. Deutsches Ärzteblatt International, 111(9), 151-162. Web.