Letters Section Editor: Robert M. Golub, MD, Senior Editor.
In Reply: Dr Johnson makes a good point, and it would be interesting for Dr Spiro and colleagues to confirm whether prior duration of prolonged and severe symptoms was in effect an exclusion criterion for their study. If such children were included, the study is perhaps unlikely to have the power to assess adverse outcomes in such groups because few children are likely to have severe prior symptoms for more than 3 days. When presenting the study protocol to physicians interested in participating in a study of delayed prescribing,1 my colleagues and I made it clear that the approach to delaying had to be pragmatic and modified by prior duration of severe illness. In a large Dutch cohort, the only child to develop mastoiditis waited significantly longer than 3 days before getting antibiotics.2 Thus, given the nature of the existing evidence, it would perhaps be unwise to allow children with severe symptoms for more than 3 days to wait a further 3 days.
Little P. Wait-and-See Prescription for Acute Otitis Media—Reply. JAMA. 2007;297(2):152–153. doi:10.1001/jama.297.2.152-b