What is the recommended treatment for acute otitis media in children?

Treatment of Acute Otitis Media in Children

The first-line treatment for acute otitis media (AOM) in children is high-dose amoxicillin (80-90 mg/kg/day), with pain management as an essential component of care. 1

Diagnosis Criteria

Accurate diagnosis is crucial before initiating treatment. AOM requires:

• Moderate to severe bulging of the tympanic membrane OR new-onset otorrhea
• OR mild bulging with recent-onset ear pain or intense erythema 1
• History of acute onset of signs and symptoms
• Presence of middle-ear effusion
• Signs/symptoms of middle ear inflammation 2

Treatment Algorithm

Step 1: Pain Assessment and Management

• Assess pain in all children with AOM
• If pain is present, provide appropriate analgesia:
  • Acetaminophen or ibuprofen for systemic relief
  • Topical analgesics for faster relief (10-30 minutes) 1

Step 2: Antibiotic Decision

Age-based approach:

• Children <6 months: Always provide immediate antibiotic therapy 1
• Children 6 months to 2 years:
  • With severe symptoms OR bilateral AOM: Immediate antibiotics
  • With mild symptoms AND unilateral AOM: Observation option possible with follow-up in 48-72 hours 2, 1
• Children ≥2 years:
  • With severe symptoms: Immediate antibiotics
  • With mild symptoms: Observation option (48-72 hours) with symptomatic relief 2

Step 3: Antibiotic Selection

• First-line: High-dose amoxicillin (80-90 mg/kg/day) 1, 3

  • Duration: 10 days for children <2 years and those with severe symptoms
  • 7-day course for children 2-5 years with mild/moderate AOM
  • 10-day course for children ≥6 years with mild/moderate AOM 2

• For treatment failures after 48-72 hours:

  • Amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) 1, 3

• For penicillin allergy:

  • Non-Type I allergy: Cefdinir, cefpodoxime, or cefuroxime 2, 1
  • Type I/severe allergy: Clindamycin (when S. pneumoniae suspected) 1
  • Alternative: Intramuscular ceftriaxone (50 mg/kg/day for 5 days) for treatment failures 1

Special Considerations

Children with Tympanostomy Tubes

• Use topical antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) instead of oral antibiotics 1
• Clean ear canal before administering drops
• Limit topical therapy to a single course of no more than 10 days 1

Follow-up

• Evaluate response to treatment in 48-72 hours, especially for children under observation 1
• Persistent middle ear effusion (MEE) after AOM treatment is common and does not require additional antibiotics if the child is asymptomatic 1

Common Pitfalls to Avoid

1. Misdiagnosis: Distinguishing AOM from otitis media with effusion (OME) is crucial. OME does not require antibiotics 2

2. Inappropriate antibiotic selection: Avoid trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole due to high resistance rates 1

3. Overuse of broad-spectrum antibiotics: Use amoxicillin as first-line when appropriate rather than starting with broader coverage 1

4. Inadequate pain management: Pain control is essential regardless of antibiotic decision 2

5. Aminoglycoside-containing eardrops: Avoid with tympanostomy tubes due to ototoxicity risk 1

6. Prolonged topical antibiotics: Can lead to fungal infections 1

The most recent evidence strongly supports high-dose amoxicillin as first-line therapy for uncomplicated AOM in children, with appropriate adjustments based on age, symptom severity, and risk factors for resistant organisms.