What is the management for a 3-year-old girl with ear pain and vomiting for 24 hours without signs of dehydration?

Management of Ear Pain and Vomiting in a 3-Year-Old Child

For a 3-year-old girl with ear pain and vomiting for 24 hours without signs of dehydration, provide pain relief with appropriate analgesics and consider antibiotics if acute otitis media is confirmed on examination.

Initial Assessment

Ear Examination

• Perform pneumatic otoscopy to assess for:
  • Bulging tympanic membrane
  • Limited or absent mobility
  • Erythema of the tympanic membrane
  • Opacification of the tympanic membrane
  • Middle ear effusion 1

Hydration Assessment

• Confirm absence of dehydration signs:
  • Normal skin turgor
  • Moist mucous membranes
  • Normal capillary refill time
  • Normal urine output
  • Normal mental status 1

Management Plan

Pain Management (First Priority)

• Provide immediate pain relief regardless of antibiotic decision 1
• Options include:
  • Acetaminophen (10-15 mg/kg/dose every 4-6 hours)
  • Ibuprofen (5-10 mg/kg/dose every 6-8 hours) for children over 6 months

Vomiting Management

• Small, frequent volumes of clear fluids (5 mL every minute initially)
• Gradually increase volume as tolerated 1
• Consider ondansetron (0.2 mg/kg oral; maximum 4 mg) if vomiting persists and interferes with oral intake 2

Antibiotic Decision

For confirmed acute otitis media (AOM):

1. First-line treatment: High-dose amoxicillin (80-90 mg/kg/day divided into two doses) 3

2. Alternative if penicillin allergic:

   • Non-Type I allergy: Cephalosporin
   • Type I allergy: Azithromycin or clarithromycin 3, 4

3. Duration of therapy:

   • 10-day course for children under 2 years
   • 7-day course for children 2-5 years with mild/moderate AOM 3

Observation Option

If diagnosis is uncertain or symptoms are mild:

• Defer antibiotics for 48-72 hours
• Focus on symptomatic relief
• Ensure follow-up mechanism is in place 1, 3

Home Care Instructions

1. Pain and fever management:

   • Continue analgesics as needed for pain
   • Do not use aspirin in children under 16 years 1

2. Hydration:

   • Offer small, frequent sips of clear fluids
   • Replace ongoing fluid losses (10 mL/kg for each episode of vomiting) 1
   • Continue normal diet as tolerated

3. Warning signs - Return for care if:

   • Worsening ear pain
   • Persistent vomiting
   • Fever lasting more than 48 hours
   • Decreased activity or responsiveness
   • Signs of dehydration develop 1

Follow-up

• Reassess within 48-72 hours if symptoms persist or worsen
• If antibiotics are prescribed, complete the full course even if symptoms improve 1

Important Considerations

• Vomiting may be a symptom of AOM or a separate condition like viral gastroenteritis
• Ear pain with normal tympanic membrane may indicate referred pain from pharyngitis, dental disease, or TMJ 5
• Bilious vomiting, severe abdominal pain, or altered mental status would require immediate evaluation for more serious conditions 2

Remember that pain management is essential regardless of antibiotic decision, and hydration status should be continuously monitored despite current absence of dehydration signs.