Antibiotics or watchful waiting for acute otitis media in urban Aboriginal and Torres Strait Islander children?

Acute otitis media, one of the most common infectious disorders during childhood, can be caused by viruses, but usually has a bacterial origin.1 It is among the most frequent reasons for prescribing antibiotics for children.2 Episodes of acute otitis media are often self‐limiting and resolve without treatment, but antibiotics are regularly prescribed because, if persistent, it can develop into chronic ear disease that may lead to perforation of the tympanic membrane, hearing loss,3 and, less frequently, serious and even life‐threatening complications.4 In Australia, an estimated 80% of general practice presentations by children under 15 years of age with acute otitis media result in the prescribing of antibiotics.1 The risks of complications are greater for Aboriginal and Torres Strait Islander children living in remote communities, and the prescribing of antibiotics consequently more appropriate.5

In this issue of the MJA, Reath and colleagues6 highlight the importance of involving the parents and carers of Aboriginal and Torres Strait Islander children in decisions about treating acute otitis media, particularly given the limited benefit of antibiotics for this disease and the risks for the community that result from their overuse. The authors used a qualitative approach to provide a voice to families who participated in the WATCH randomised clinical trial, which compared the benefits of watchful waiting and antibiotic therapy for urban Aboriginal and Torres Strait Islander children with acute otitis media. Reath and colleagues found a diversity of opinion among parents and in the community regarding the use of antibiotics. For many, watchful waiting alone was an acceptable or preferred approach to managing acute otitis media; other preferred that a prescription be provided alongside watchful waiting so that they could readily access antibiotics should they feel they were required.6

The management of acute otitis media prior to seeking medical assistance is important and may influence whether antibiotics are recommended to treat the disease. Some families told Reath and colleagues that they identified the disease and maintained a period of watchful waiting before seeking medical care; in other cases, watchful waiting may not be undertaken because children are taken to medical practitioners as soon as the initial signs of acute otitis media appear, or the condition is detected during routine screening. The different approaches reflect individual families’ choices, often based on multigenerational experience with ear disease.6

Recent guidelines for the treatment of acute otitis media in Aboriginal and Torres Strait Islander children5 recommend watchful waiting and treatment with oral analgesics if the child is not at risk of chronic suppurative otitis media (ie, persistent discharge following tympanic membrane perforation). Certain factors may indicate a higher risk of complications, and children may be considered to be at higher risk if they live in a remote community or regional area where the prevalence of chronic suppurative otitis media is greater than 4%.5 Despite these recommendations, antibiotic therapy is regularly prescribed for Aboriginal and Torres Strait Islander children living in urban areas, where they are at relatively low risk of chronic suppurative otitis media.3 The study by Reath and colleagues shows that many families living in towns would be willing to accept a period of watchful waiting as an alternative to immediate antibiotic therapy.

The authors noted the critical role played by Aboriginal research officers in their study. Involving Aboriginal staff in developing partnerships and relationships of respect and trust is paramount when undertaking health research, and translating research findings into practice is crucial when working with Aboriginal families in relation to ear health care. As Aboriginal staff appreciate how health fits into the priorities of everyday life for families, they typically work in a strongly supportive manner, ensuring that time is taken to confirm that carers understand the ear health needs of their children. The study by Reath and colleagues highlights the importance of listening to family members and recognising their knowledge of their child and experience with ear health. This level of engagement and respect can be difficult in busy mainstream health services, and greater recruitment, development, and involvement of Aboriginal and Torres Strait Islander clinicians in primary health care are needed. Aboriginal Community Controlled Health Services can be especially valuable in this respect.7,8

Aboriginal staff are often members of the community in which they work, enabling them to assist non‐Aboriginal colleagues with communicating effectively and providing culturally safe advice to Aboriginal families. Involving Aboriginal staff in the clinical care and leadership of mainstream urban primary care organisations will enhance the involvement of families in the care of their children with ear health problems.

The report by Reath and colleagues illustrates the importance of clinicians in primary care engaging in respectful partnerships with families to develop an approach to acute otitis media that reflects the needs of the child and is informed by the experience of the family. General practitioners and other primary care clinicians are central to increased engagement and partnership with families in shared decision making. Increasing the involvement of Aboriginal and Torres Strait Islander staff in primary care services will facilitate increased trust and enable a partnership between families and clinicians for improving ear health care for Aboriginal children.