What are the current guidelines for diagnosing and treating otitis media in pediatric patients?

From the Guidelines

Current guidelines for diagnosing and treating otitis media in pediatric patients recommend a careful approach based on age, symptom severity, and diagnostic certainty, with diagnosis including assessment of ear pain, fever, irritability, and otoscopic examination showing a bulging, erythematous tympanic membrane with limited mobility. For acute otitis media (AOM) in children, the diagnosis should be confirmed with pneumatic otoscopy, and tympanometry should be obtained if the diagnosis is uncertain 1.

Diagnosis and Treatment Approach

The approach to treating otitis media involves:

• Assessing the likelihood of bacterial infection
• Weighing the benefits and harms of antibiotics
• Implementing judicious prescribing strategies 1
• For AOM, first-line antibiotic treatment is amoxicillin at 80-90 mg/kg/day divided twice daily for 10 days in children under 2 years and 5-7 days in older children, with alternatives for penicillin-allergic patients including azithromycin or clarithromycin 1
• Pain management with acetaminophen or ibuprofen is essential
• Recurrent otitis media may warrant consideration of tympanostomy tubes, especially in at-risk children or those with chronic otitis media with effusion (OME) and documented hearing loss 1

Key Recommendations

• Clinicians should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child 1
• Clinicians should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing pneumatic otoscopy 1
• Clinicians should recommend against using intranasal steroids, systemic steroids, systemic antibiotics, antihistamines, or decongestants for treating OME 1
• Clinicians should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development 1

Tympanostomy Tubes

• Tympanostomy tubes are recommended for children with chronic OME who are at risk for speech, language, or learning problems, or who have documented hearing loss 1
• Adenoidectomy may be considered in children 4 years old or older with OME, but not as a first-line treatment 1

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

In two adequate and well-controlled U. S. clinical trials a single IM dose of ceftriaxone was compared with a 10 day course of oral antibiotic in pediatric patients between the ages of 3 months and 6 years

The current guidelines for diagnosing and treating otitis media in pediatric patients are not explicitly stated in the provided drug labels. However, the treatment options for acute otitis media in pediatric patients include:

• Azithromycin: 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5 2.
• Ceftriaxone: a single IM dose compared with a 10 day course of oral antibiotic in pediatric patients between the ages of 3 months and 6 years 3. It is essential to note that the diagnosis of otitis media should be made based on clinical evaluation and not solely on the presence of symptoms. The American Academy of Pediatrics (AAP) recommends that the diagnosis of acute otitis media be made in children with:
• Middle ear effusion
• Signs or symptoms of middle ear inflammation
• Acute onset of symptoms A thorough clinical evaluation, including otoscopy and tympanometry, should be performed to confirm the diagnosis. The treatment should be tailored to the individual patient's needs, and the choice of antibiotic should be based on the suspected or confirmed pathogen, the patient's age, and the severity of the infection. 2 3

From the Research

Diagnosis of Otitis Media in Pediatric Patients

• The diagnosis of otitis media in pediatric patients is typically made based on clinical presentation and physical examination findings, including otoscopy and tympanometry 4, 5.
• The American Academy of Pediatrics (AAP) recommends that the diagnosis of otitis media be made based on the presence of three key components:
  • Symptoms of acute otitis media (such as ear pain, fever, or irritability)
  • Signs of middle ear inflammation (such as redness or bulging of the tympanic membrane)
  • Signs of middle ear effusion (such as opacity or impaired mobility of the tympanic membrane) 5, 6.

Treatment of Otitis Media in Pediatric Patients

• The first-line treatment for uncomplicated acute otitis media is amoxicillin, which is effective against the most common bacterial pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 4, 5, 7, 6, 8.
• For patients who are allergic to penicillin, alternative antibiotics such as macrolides (e.g., erythromycin) or cotrimoxazole may be used 7, 8.
• In cases where amoxicillin is not effective, second-line antibiotics such as amoxicillin-clavulanate, cefuroxime axetil, or ceftriaxone may be used 5, 6, 8.
• The duration of treatment is typically 5-7 days, and prolonging treatment beyond this period does not provide additional benefit and may increase the risk of resistant bacteria 7, 6.
• Watchful waiting, or delaying the decision to treat with antibiotics for 72 hours, may be an option for some patients with mild symptoms, as it can reduce the use of antibiotics and the development of resistant bacteria 7.