32سورة البقرة اآلية

Upper RespiratoryInfections

Khaled Saad ZaghloulMD Pediatrics

UPPER RESPIRATORY TRACT IFECTIONS

Common cold

Pharyngitis

Sinusitis

Ear infections

Common cold Common cold

Young children have 6-8 colds per year, but Young children have 6-8 colds per year, but 10-15% of children have at least 12 10-15% of children have at least 12 infections per year. The incidence of illness infections per year. The incidence of illness decreases with age, with 2-3 illnesses per decreases with age, with 2-3 illnesses per year by adulthood. year by adulthood.

Children in out-of-home daycare centers Children in out-of-home daycare centers during the 1st year of life have 50% more during the 1st year of life have 50% more colds than children cared for only at home.colds than children cared for only at home.

Pathogens Associated with the Pathogens Associated with the Common ColdCommon Cold

Conditions That Can Mimic the Conditions That Can Mimic the Common ColdCommon Cold

Clinical features of common coldClinical features of common cold

Rhinorrhea, sore throat, cough, fever and Rhinorrhea, sore throat, cough, fever and malaise lasting up to 7 days.malaise lasting up to 7 days.

In infants cold may manifest as irritability, In infants cold may manifest as irritability, snuffles and difficulty with feeding.snuffles and difficulty with feeding.

Infants under 3 months of a age are Infants under 3 months of a age are susceptible to LRTI.susceptible to LRTI.

TREATMENTTREATMENT

The management of the The management of the common cold consists common cold consists primarily of supportive care as primarily of supportive care as recommended by American recommended by American Academy of Pediatrics.Academy of Pediatrics.

Antiviral TreatmentAntiviral Treatment

Specific antiviral therapy is not available for Specific antiviral therapy is not available for rhinovirus infections.rhinovirus infections.

Ribavirin, which is approved for treatment of Ribavirin, which is approved for treatment of severe RSV infections, has no role in the severe RSV infections, has no role in the treatment of the common cold. treatment of the common cold.

Oseltamivir and zanamivir have a modest effect Oseltamivir and zanamivir have a modest effect on the duration of symptoms associated with on the duration of symptoms associated with influenza viral infections in children.influenza viral infections in children.

The use of oral nonprescription therapies The use of oral nonprescription therapies (often containing antihistamines, antitussives, (often containing antihistamines, antitussives, and decongestants) for cold symptoms in and decongestants) for cold symptoms in children is controversial. Although some of children is controversial. Although some of these medications are effective in adults, no these medications are effective in adults, no study demonstrates a significant effect in study demonstrates a significant effect in children, and there may be serious side children, and there may be serious side effects.effects.

The American Academy of The American Academy of Pediatrics recommends that Pediatrics recommends that nonprescription cough and nonprescription cough and cold products not be used for cold products not be used for infants and children younger infants and children younger than 6 year of age.than 6 year of age.

Zinc, given as oral lozenges reduces the Zinc, given as oral lozenges reduces the duration of symptoms of a common cold if duration of symptoms of a common cold if begun within 24 hr of symptoms. The begun within 24 hr of symptoms. The function of the rhinovirus 3C protease, an function of the rhinovirus 3C protease, an essential enzyme for rhinovirus essential enzyme for rhinovirus replication, is inhibited by zinc, but there replication, is inhibited by zinc, but there has been no evidence of an antiviral effect has been no evidence of an antiviral effect of zinc in vivo.of zinc in vivo.

RhinorrheaRhinorrhea

The first-generation antihistamines may reduce The first-generation antihistamines may reduce rhinorrhea by 25-30%. The anticholinergic rather rhinorrhea by 25-30%. The anticholinergic rather than the antihistaminic properties of these drugs, and than the antihistaminic properties of these drugs, and therefore the second-generation or “nonsedating” therefore the second-generation or “nonsedating” antihistamines have no effect on common cold antihistamines have no effect on common cold symptoms. symptoms.

The major adverse effects are sedation or paradoxical The major adverse effects are sedation or paradoxical hyperactivity. Overdose may be associated with hyperactivity. Overdose may be associated with respiratory depression or hallucinations.respiratory depression or hallucinations.

CoughCough

Cough suppression is generally not necessary Cough suppression is generally not necessary in patients with colds.in patients with colds.

Cough appears to be from postnasal drip, and Cough appears to be from postnasal drip, and treatment with a first-generation antihistamine treatment with a first-generation antihistamine may be helpful. may be helpful.

Honey (5-10 mL in children ≥1 year old) has a Honey (5-10 mL in children ≥1 year old) has a modest effect on relieving nocturnal coughmodest effect on relieving nocturnal cough

In some patients, cough may be a result of virus-In some patients, cough may be a result of virus-induced reactive airways disease. These patients induced reactive airways disease. These patients can have cough that persists for days to weeks can have cough that persists for days to weeks after the acute illness and might benefit from after the acute illness and might benefit from bronchodilator. bronchodilator.

Codeine or dextromethorphan has no effect on Codeine or dextromethorphan has no effect on cough from colds and has potential enhanced cough from colds and has potential enhanced toxicity. toxicity.

Expectorants such as guaifenesin are not effective Expectorants such as guaifenesin are not effective antitussive agents. antitussive agents.

Ineffective TreatmentsIneffective Treatments

Vitamin C, guaifenesin, and inhalation of Vitamin C, guaifenesin, and inhalation of warm, humidified air are not effective.warm, humidified air are not effective.

Echinacea extracts is not effective as a Echinacea extracts is not effective as a common cold treatment. common cold treatment.

There is no evidence that the common cold or There is no evidence that the common cold or persistent acute purulent rhinitis of less than persistent acute purulent rhinitis of less than 10 days in duration benefits from antibiotics.10 days in duration benefits from antibiotics.

Acute Acute PharyngitisPharyngitis

PharyngotonsillitisPharyngotonsillitis

TonsillophayngitisTonsillophayngitis

Inflammation of the Pharynx and Inflammation of the Pharynx and TonsilsTonsils

One of the most common pediatric infections.One of the most common pediatric infections.

Pathogens:Pathogens:

Viral: Viral: Rhino/Adeno/Corona/EBV/CMV/ HSVRhino/Adeno/Corona/EBV/CMV/ HSV

Bacterial: Bacterial: Streptococcus pyogenes – most serious typeStreptococcus pyogenes – most serious type-Scarlet fever-Scarlet fever-Rheumatic fever-Rheumatic fever-Glomerulonephritis-Glomerulonephritis

Infectious Agents That Cause PharyngitisInfectious Agents That Cause Pharyngitis

Pathogens:Pathogens:

> 0-2 years Viral ++++ GAS+0-2 years Viral ++++ GAS+

> 5-above Viral +++ GAS++5-above Viral +++ GAS++

(15-20%)(15-20%)

Streptococcus infection causing inflammation of the throat and tonsils.

TreatmentTreatment

Specific therapy is unavailable for most viral Specific therapy is unavailable for most viral pharyngitis. However, symptomatic therapy can be an pharyngitis. However, symptomatic therapy can be an important part of the overall treatment plan. important part of the overall treatment plan.

An oral antipyretic/analgesic agent can relieve fever An oral antipyretic/analgesic agent can relieve fever and sore throat pain. and sore throat pain.

Anesthetic sprays and lozenges (often containing Anesthetic sprays and lozenges (often containing benzocaine, phenol, or menthol) can provide local benzocaine, phenol, or menthol) can provide local relief in children.relief in children.

TreatmentTreatment

Most untreated episodes of GAS pharyngitis resolve Most untreated episodes of GAS pharyngitis resolve uneventfully within 5 days, but early antibiotic therapy uneventfully within 5 days, but early antibiotic therapy hastens clinical recovery by 12-24 hr. hastens clinical recovery by 12-24 hr.

The primary benefit and intent of antibiotic treatment The primary benefit and intent of antibiotic treatment is the prevention of acute rheumatic fever (ARF); it is is the prevention of acute rheumatic fever (ARF); it is highly effective when started within 9 days of onset of highly effective when started within 9 days of onset of illness. Antibiotic therapy does not prevent APSGN.illness. Antibiotic therapy does not prevent APSGN.

Antibiotic therapy should not be delayed for children Antibiotic therapy should not be delayed for children with symptomatic pharyngitiswith symptomatic pharyngitis

TonsillectomyTonsillectomy

Recurrent tonsillitisRecurrent tonsillitis

Peritonsillar Abscess (Quinsy)Peritonsillar Abscess (Quinsy)

Obstructive Sleep Apnea (Kissing Obstructive Sleep Apnea (Kissing Tonsils)Tonsils)

AdenoidectomyAdenoidectomy

Chronic Secretory Otitis MediaChronic Secretory Otitis Media

Upper Airway Obstruction Upper Airway Obstruction (Snoring)(Snoring)

SinusitisSinusitis

Suppurative infection of the sinusesSuppurative infection of the sinuses

PredispositionPredisposition

Common cold, Allergic rhinitis: Approximately 0.5-Common cold, Allergic rhinitis: Approximately 0.5-2% of viral upper respiratory tract infections in 2% of viral upper respiratory tract infections in children and adolescents are complicated by acute children and adolescents are complicated by acute symptomatic bacterial sinusitis.symptomatic bacterial sinusitis.

Nasotracheal /nasogastric intubationsNasotracheal /nasogastric intubations

Cyanotic heart diseaseCyanotic heart disease

C.F, Ig disorders, immotile cilia syndromeC.F, Ig disorders, immotile cilia syndrome

HIV, immune compromised patientsHIV, immune compromised patients

Sinus FormationSinus Formation

At birth: Maxillary , Ethmoid and At birth: Maxillary , Ethmoid and Sphenoid are present.Sphenoid are present.

At one year: Frontal sinusAt one year: Frontal sinus

Pneumotization comes laterPneumotization comes later

ETIOLOGYETIOLOGY

The bacterial pathogens causing acute bacterial The bacterial pathogens causing acute bacterial sinusitis in children include Streptococcus sinusitis in children include Streptococcus pneumoniae (~30%), Haemophilus influenzae pneumoniae (~30%), Haemophilus influenzae (~20%), and Moraxella catarrhalis (~20%). (~20%), and Moraxella catarrhalis (~20%).

Approximately 50% of H. influenzae and 100% of Approximately 50% of H. influenzae and 100% of M. catarrhalis are β-lactamase positive.M. catarrhalis are β-lactamase positive.

Approximately 25% of S. pneumoniae penicillin Approximately 25% of S. pneumoniae penicillin resistant.resistant.

PresentationPresentation

Mucopurulent rhinorrhea.Mucopurulent rhinorrhea.

Night cough.Night cough.

Nasal speech.Nasal speech.

Facial swelling (pain, headache, Facial swelling (pain, headache, tenderness).tenderness).

X-Ray/CT shows clouding/air fluid X-Ray/CT shows clouding/air fluid level.level.

TherapyTherapy

Amox- clavulenic acidAmox- clavulenic acid

Cephalosporin: cefdinir, cefuroxime axetil, Cephalosporin: cefdinir, cefuroxime axetil, cefpodoxime, or cefixime. cefpodoxime, or cefixime.

In older children, levofloxacin is an alternativeIn older children, levofloxacin is an alternative

antibiotic. antibiotic.

Azithromycin and trimethoprim-sulfamethoxazole Azithromycin and trimethoprim-sulfamethoxazole are no longer indicated because of a high prevalence are no longer indicated because of a high prevalence of antibiotic resistance.of antibiotic resistance.

TherapyTherapy

In severe sinusitis, treatment In severe sinusitis, treatment with high-dose amoxicillin-with high-dose amoxicillin-clavulanate (80-90 mg/kg/day of clavulanate (80-90 mg/kg/day of amoxicillin) should be initiated. amoxicillin) should be initiated. Ceftriaxone (50 mg/kg, IV or Ceftriaxone (50 mg/kg, IV or IM).IM).

ComplicationsComplications

orbital cellulitis (read it VIP)orbital cellulitis (read it VIP)

epidural/ subdural empyemaepidural/ subdural empyema

brain abscessbrain abscess

dural sinus thrombosisdural sinus thrombosis

MeningitisMeningitis

osteomyelitis of the frontal osteomyelitis of the frontal

bone (Pott puffy tumor)bone (Pott puffy tumor)

TTT of complicationsTTT of complications

DrainageDrainage

Broad spectrum antibiotics.Broad spectrum antibiotics.

Acute Otitis MediaAcute Otitis Media

Acute Otitis Media - DefinitionsAcute Otitis Media - Definitions

The term The term otitis media (OM) otitis media (OM) has 2 main has 2 main categories: acute infection, which is categories: acute infection, which is termed suppurative or termed suppurative or acute otitis media acute otitis media (AOM), (AOM), and inflammation accompanied and inflammation accompanied by by middle-ear effusion (MEE), middle-ear effusion (MEE), termed termed nonsuppurative or nonsuppurative or secretory OM, secretory OM, or or otitis otitis media with effusion (OME). media with effusion (OME).

These 2 main types of OM are These 2 main types of OM are interrelated: acute infection usually is interrelated: acute infection usually is succeeded by residual inflammation and succeeded by residual inflammation and effusion that, in turn, predispose effusion that, in turn, predispose children to recurrent infection. MEE is a children to recurrent infection. MEE is a feature of both AOM and of OME and is feature of both AOM and of OME and is an expression of the underlying middle-an expression of the underlying middle-ear mucosal inflammation.ear mucosal inflammation.

Acute Otitis Media - DefinitionsAcute Otitis Media - Definitions

Recurrent otitis Recurrent otitis >3 episodes of AOM within 6 months that middle ear is >3 episodes of AOM within 6 months that middle ear is normal, without effusions, between episodesnormal, without effusions, between episodesMost children with recurrent acute otitis media are otherwise Most children with recurrent acute otitis media are otherwise healthyhealthy

Otitis proneOtitis proneSix or more acute otitis media episodes in the first 6 years of Six or more acute otitis media episodes in the first 6 years of lifelife12% of children in the general population 12% of children in the general population

Persistent Middle-Ear EffusionPersistent Middle-Ear EffusionWhen an episode of otitis media results in persistence of When an episode of otitis media results in persistence of middle-ear fluid for 3 months, & TM remains immobilemiddle-ear fluid for 3 months, & TM remains immobileMore common in white children & < 2 yMore common in white children & < 2 y

AOM vs. COMAOM vs. COM

Chronic otitis mediaChronic otitis mediaCalled chronic serous otitis in the past, this pattern is usually defined as Called chronic serous otitis in the past, this pattern is usually defined as a middle-ear effusion that has been present for at least 3 months.a middle-ear effusion that has been present for at least 3 months.

Some sort of Eustachian tube dysfunction is the principal predisposing Some sort of Eustachian tube dysfunction is the principal predisposing factor.factor.

Persistent structural changes, such as a persistent eardrum perforation, Persistent structural changes, such as a persistent eardrum perforation, imply past otitis but not necessarily chronic infection. imply past otitis but not necessarily chronic infection.

Acute otitis media is commonly defined as…Acute otitis media is commonly defined as…1. Presence of a middle ear effusion (MEE) 1. Presence of a middle ear effusion (MEE) 2. TM inflammation 2. TM inflammation 3. Presenting with a rapid onset of symptoms such as fever, irritability, or 3. Presenting with a rapid onset of symptoms such as fever, irritability, or

earache earache

Definition of acute otitis media Definition of acute otitis media

Definition of AOMDefinition of AOM

A diagnosis of AOM requires …A diagnosis of AOM requires …

1) History of acute onset of signs and 1) History of acute onset of signs and symptomssymptoms

2) Presence of MEE2) Presence of MEE

3) Signs and symptoms of middle-ear 3) Signs and symptoms of middle-ear inflammationinflammation

Acute Otitis MediaAcute Otitis Media

The most common infection for which antibacterial The most common infection for which antibacterial

agents are prescribed for children in the USA.agents are prescribed for children in the USA.

1/3 1/3 of office visits to pediatricians.of office visits to pediatricians.

The peak incidence and prevalence of OM is during The peak incidence and prevalence of OM is during

the 1st 2 y of life. More than 80% of children will have the 1st 2 y of life. More than 80% of children will have

experienced at least 1 episode of OM by the age of 3 y.experienced at least 1 episode of OM by the age of 3 y.

Normal TMNormal TM

Gray Gray Pink Pink

Clinical diagnosis Clinical diagnosis 

A diagnosis of AOM can be established if acute purulent A diagnosis of AOM can be established if acute purulent otorrhea is present and otitis externa has been excluded.otorrhea is present and otitis externa has been excluded.

Presence of a middle ear effusion Presence of a middle ear effusion & & acute signs of middle acute signs of middle ear inflammation ear inflammation in presence of in presence of acute onset of signs & acute onset of signs & symptomssymptoms

History History

Children with AOM usually present with …Children with AOM usually present with …History of rapid onset of otalgia (or pulling of the ear in an History of rapid onset of otalgia (or pulling of the ear in an infant), irritability, poor feeding in an infant or toddler, otorrhea, infant), irritability, poor feeding in an infant or toddler, otorrhea, and/orand/or fever fever

Except otorrhea other findings are nonspecific i.e. Except otorrhea other findings are nonspecific i.e.

Fever, earache, and excessive crying present in Fever, earache, and excessive crying present in children …children …

90% 90% with AOM with AOM

72% 72% without AOMwithout AOM

Laboratory testsLaboratory tests

Routine laboratory studies, including complete Routine laboratory studies, including complete blood count and ESR, are not useful in the blood count and ESR, are not useful in the evaluation of otitis media. evaluation of otitis media.

Otoscopy Otoscopy

The key to distinguishing AOM from OME is the The key to distinguishing AOM from OME is the performance of performance of pneumatic otoscopy pneumatic otoscopy using using appropriate tools and an adequate light sourceappropriate tools and an adequate light source

Use of visual otoscopy alone is discouragedUse of visual otoscopy alone is discouraged

Pneumatic otoscope - equipment Pneumatic otoscope - equipment

Technique Technique

Systematic assessment Systematic assessment of the TM by the use of the of the TM by the use of the COMPLETE COMPLETE Color Color

Other conditions Other conditions

Mobility Position Mobility Position

Lighting Lighting

Entire surface Entire surface

Translucency Translucency

External auditory canal and auricle External auditory canal and auricle

Normal tympanic membraneNormal tympanic membrane

Middle-Ear EffusionMiddle-Ear Effusion

MEE is commonly confirmed …MEE is commonly confirmed …

Directly by…Directly by…Tympanocentesis Tympanocentesis

Presence of fluid in the external auditory canalPresence of fluid in the external auditory canal

Indirectly by… Indirectly by… Pneumatic otoscopy Pneumatic otoscopy

Tympanometry Tympanometry

Acoustic reflectometryAcoustic reflectometry

Signs of presence of MEESigns of presence of MEE

Signs of presence of MEESigns of presence of MEE

Fluid levelFluid level BobblesBobbles

Signs of presence of MEESigns of presence of MEE

Perforation Perforation Cobble stoningCobble stoning

Normal TMNormal TM

TranslucentTranslucent

Signs of presence of MEESigns of presence of MEE

OpaqueOpaqueSemi-opaqueSemi-opaque

Normal TMNormal TM

Pink Pink Gray Gray

Signs of presence of MEESigns of presence of MEE

White White Pale yellowPale yellow

Signs of presence of MEESigns of presence of MEE

BulgingBulgingDistinct fullnessDistinct fullness

Normal TMNormal TM

Pink Pink Gray Gray

Signs of middle-ear inflammationSigns of middle-ear inflammation

Marked rednessMarked rednessInjectionInjection

Established acute otitis mediaEstablished acute otitis media

Differential diagnosis - Differential diagnosis -

Other conditions Other conditions Redness of tympanic membrane Redness of tympanic membrane

AOMAOM

CryingCrying

Upper respiratory infection with congestion and inflammation of the mucosa lining the Upper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tractentire respiratory tract

Trauma and/or cerumen removalTrauma and/or cerumen removal

Decreased or absent mobility of tympanic membrane Decreased or absent mobility of tympanic membrane AOM and OMEAOM and OME

Tympanosclerosis Tympanosclerosis

A high negative pressure within the middle ear cavityA high negative pressure within the middle ear cavity

Ear pain Ear pain Otitis externa Otitis externa

Ear traumaEar trauma

Throat infectionsThroat infections

Foreign bodyForeign body

Temporomandibular joint syndromeTemporomandibular joint syndrome

Uncertainty in diagnosis of AOMUncertainty in diagnosis of AOM

The diagnosis of AOM, particularly in infants and The diagnosis of AOM, particularly in infants and young children, is often made with a degree of young children, is often made with a degree of uncertainty. uncertainty. Common factors …Common factors …

Inability to sufficiently clear the external auditory Inability to sufficiently clear the external auditory canal of cerumencanal of cerumenNarrow ear canalNarrow ear canalInability to maintain an adequate seal for successful Inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometrypneumatic otoscopy or tympanometry

An uncertain diagnosis of AOM is caused most An uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE. often by inability to confirm the presence of MEE.

Management Management

Symptomatic therapy - 1Symptomatic therapy - 1

Pain remedies Pain remedies PO analgesicsPO analgesics

The efficacy of a topical agentThe efficacy of a topical agent (combination of antipyrine, benzocaine, and glycerin) (combination of antipyrine, benzocaine, and glycerin)

Remedies such as distraction, external application of heat or Remedies such as distraction, external application of heat or cold, and oil instilled into the external auditory canal have been cold, and oil instilled into the external auditory canal have been proposed, but there are no controlled trials that directly address proposed, but there are no controlled trials that directly address the effectiveness of these remediesthe effectiveness of these remedies

Symptomatic therapy - 2Symptomatic therapy - 2

Decongestants and antihistamines Decongestants and antihistamines Alone or in combination were associated with…Alone or in combination were associated with…

Increased medication side effects Increased medication side effects

Did not Did not improve healing or prevent surgery or other improve healing or prevent surgery or other complications in AOM complications in AOM

Not approved by AAP for < 2 year oldNot approved by AAP for < 2 year old

In addition, treatment with antihistamines may In addition, treatment with antihistamines may prolong the prolong the duration of middle ear effusionduration of middle ear effusion

Which antibiotic ???Which antibiotic ???

Which antibiotic ???Which antibiotic ???

Microbiology of Microbiology of AOMAOM

Bacterial Species Frequency Major Mechanism of

Resistance What we can do?

S. pneumoniae +++ penicillin-resistant (PBP2a) High Dose PCN

H. influenzae ++beta-lactamase

35-50% beta-lactamase Inhibitors (clavulanate)M. catarrhalis ++

beta-lactamase55-100%

Antibacterial therapyAntibacterial therapy

If a decision is made to treat with an antibacterial agent, If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most the clinician should prescribe amoxicillin for most children. children.

When amoxicillin is used, the dose should be When amoxicillin is used, the dose should be 80 - 90 mg/kg/day 80 - 90 mg/kg/day

Predicted treatment failure rates Predicted treatment failure rates based on PD breakpoints for for expected pathogens in low- or high-risk AOMexpected pathogens in low- or high-risk AOM

AOM high risk for amoxicillin-resistant organismAOM high risk for amoxicillin-resistant organism

In patients who have severe illness In patients who have severe illness

&&

AOM high risk for amoxicillin-resistant organismAOM high risk for amoxicillin-resistant organismChildren who were received antibiotics in the previous 30 days Children who were received antibiotics in the previous 30 days

Children with concurrent purulent conjunctivitis (otitis-conjunctivitis Children with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome) syndrome)

Children receiving amoxicillin for chemoprophylaxis of recurrent AOM Children receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection) (or urinary tract infection)

High-dose amoxicillin-clavulanate High-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )(90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )

Algorithm to distinguish AOM from OMEAlgorithm to distinguish AOM from OME

Malpractice Malpractice

Decongestants may decreased blood flow to the respiratory Decongestants may decreased blood flow to the respiratory mucosa, which may impair delivery of antibiotics mucosa, which may impair delivery of antibiotics

Antihistamines may Antihistamines may prolong the duration of middle ear prolong the duration of middle ear effusioneffusion

Prevention Prevention

Continue exclusive breastfeeding as long as Continue exclusive breastfeeding as long as possiblepossible

NO "bottle-propping" or taking a bottle to bed NO "bottle-propping" or taking a bottle to bed

Smoke-free environmentSmoke-free environment

IF high-risk for recurrent acute otitis media IF high-risk for recurrent acute otitis media Prolonged courses of antimicrobial prophylaxisProlonged courses of antimicrobial prophylaxis

Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) given once daily at bedtime for 3 to 6 months or longer given once daily at bedtime for 3 to 6 months or longer

Pneumococcal vaccine & influenza vaccine Pneumococcal vaccine & influenza vaccine marginally benefitmarginally benefit

Pneumococcal vaccine reduce all otitis media by 6%. Pneumococcal vaccine reduce all otitis media by 6%.