What are the treatment options for pediatric ear infections?

Treatment Options for Pediatric Ear Infections

For pediatric ear infections, first-line treatment is high-dose amoxicillin (80-90 mg/kg/day), with topical antibiotic drops preferred over oral antibiotics for children with tympanostomy tubes and drainage. 1, 2

Diagnosis and Assessment

• Acute Otitis Media (AOM) requires:
  • Moderate to severe bulging of tympanic membrane OR new-onset otorrhea
  • OR mild bulging with recent ear pain or intense erythema 3
• Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1

Treatment Algorithm

1. Pain Management (First Priority)

• Acetaminophen or ibuprofen for systemic pain relief 3
• Topical analgesics may provide faster relief (within 10-30 minutes) 3

2. Antibiotic Decision-Making

Children < 2 years:

• Immediate antibiotic therapy for bilateral otitis media 3
• Always treat with antibiotics if under 6 months 3

Children ≥ 2 years with mild symptoms:

• Watchful waiting is appropriate if:
  • Non-severe illness
  • No high fever (< 39°C)
  • No toxic appearance
  • Unilateral infection
  • Otalgia < 48 hours 4
• Ensure follow-up in 48-72 hours 3

3. Antibiotic Selection

First-line therapy:

• Amoxicillin 80-90 mg/kg/day (maximum 3g/day) divided twice daily for 5-10 days 1, 5
  • Overcomes resistant pneumococci
  • Take at start of meals to minimize GI intolerance 5

For treatment failures after 48-72 hours:

• Amoxicillin-clavulanate 90 mg/6.4 mg per kg per day 3, 1
  • Better coverage against both S. pneumoniae and H. influenzae

For penicillin allergy:

• Non-Type I allergy: Cefuroxime axetil or cefpodoxime proxetil 3
• Type I/severe allergy: Clindamycin (when S. pneumoniae suspected) 3
• Alternative: Azithromycin 30 mg/kg as single dose or 10 mg/kg once daily for 3 days 6

4. Special Situations

Children with tympanostomy tubes:

• Topical antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) are preferred over oral antibiotics 2
  • Higher drug concentration at infection site
  • Better coverage of likely pathogens, especially P. aeruginosa
  • Fewer systemic side effects 2
• Clinical cure rates: 77-96% with topical therapy vs. 30-67% with systemic antibiotics 2

Application of ear drops:

• Clean ear canal of debris before administering drops
• Use tissue spears or gentle suction with infant nasal aspirator 2
• "Pump" the tragus after placing drops to help them enter the ear tube 2
• Limit topical therapy to a single course of no more than 10 days 2

Follow-up and Monitoring

• Improvement should be seen within 48-72 hours of starting antibiotics 3
• Persistent middle ear effusion (MEE) is common after AOM treatment and does not require additional antibiotics if the child is asymptomatic 3
• Children with tympanostomy tubes should have routine follow-up every 4-6 months 2

Prevention Strategies

• Pneumococcal and influenza vaccination can reduce AOM risk 3
• Reduce risk factors: limit daycare attendance and tobacco smoke exposure 3

Common Pitfalls to Avoid

1. Overuse of broad-spectrum antibiotics when amoxicillin is sufficient for initial therapy
2. Using aminoglycoside-containing eardrops with tympanostomy tubes (risk of ototoxicity) 2
3. Treating isolated redness of tympanic membrane with normal landmarks 3
4. Using trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole due to high resistance rates 3
5. Prolonged use of antibiotic eardrops (>10 days) which may lead to yeast infections 2
6. Failing to distinguish between new infection versus persistent middle ear effusion 3

By following this evidence-based approach, most pediatric ear infections can be effectively managed with appropriate pain control and judicious use of antibiotics.