What is the recommended dose of amoxicillin (amoxicillin-clavulanate) for children?

Amoxicillin-Clavulanate Dosing for Children

The recommended dose of amoxicillin-clavulanate for children is 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours for standard infections, with higher dosing of 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in two divided doses for more severe infections. 1

Age-Based Dosing Recommendations

Neonates and Young Infants

• Under 12 weeks (<3 months): 30 mg/kg/day divided every 12 hours, based on the amoxicillin component 1
• Use 125 mg/5 mL oral suspension for this age group

Children 12 weeks (3 months) and Older

For standard infections:

• Every 12 hours regimen: 45 mg/kg/day (preferred due to less diarrhea) 1
• Every 8 hours regimen: 40 mg/kg/day 1

For otitis media, sinusitis, lower respiratory tract infections, and more severe infections:

• Every 12 hours regimen: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate 2, 3
• Every 8 hours regimen: 40 mg/kg/day 1

Children Weighing 40 kg or More

• Should follow adult dosing recommendations 1
• The 250 mg/125 mg tablets should not be used until the child weighs at least 40 kg

Formulation Considerations

The pediatric formulation provides a 14:1 ratio of amoxicillin to clavulanate in an oral suspension 2, 4. This higher ratio was developed to provide greater amounts of amoxicillin while maintaining the same daily dose of clavulanate as regular strength formulations, helping to reduce gastrointestinal side effects.

Different formulations include:

• 200 mg/5 mL or 400 mg/5 mL oral suspension
• 125 mg/5 mL or 250 mg/5 mL oral suspension
• Chewable tablets for older children

Administration Guidelines

• Administer at the start of a meal to minimize gastrointestinal intolerance 1
• The every 12-hour regimen is associated with significantly less diarrhea than three times daily dosing 1, 5
• Duration of therapy for acute otitis media is typically 10 days 1

Special Considerations

High-Dose Regimen Indications

High-dose amoxicillin-clavulanate (90 mg/kg/day) is recommended for:

• Children with otitis media, sinusitis, and lower respiratory tract infections 2, 3
• Children younger than 2 years
• Those attending childcare
• Children recently treated with antibiotics
• Areas with high prevalence of resistant organisms, particularly penicillin-nonsusceptible Streptococcus pneumoniae 2

Twice Daily vs. Three Times Daily Dosing

Research shows that twice daily dosing of amoxicillin-clavulanate is as effective as three times daily dosing, which may improve medication compliance 5. The twice-daily regimen is now preferred due to comparable efficacy and better adherence.

Potential Pitfalls and Caveats

1. Formulation confusion: Different formulations have different ratios of amoxicillin to clavulanate. The 250 mg/125 mg tablet and 250 mg/62.5 mg chewable tablet are not interchangeable 1

2. Underdosing risk: Standard dosing may be inadequate for areas with high prevalence of resistant organisms. In these cases, high-dose regimens should be used 2

3. Weight-based vs. age-based dosing: Weight-based dosing is more accurate than age-based dosing 6

4. Augmented clearance: Critically ill children, particularly after cardiac surgery, may have increased clearance of amoxicillin-clavulanate and may require more frequent dosing 7

5. Renal impairment: Dose adjustment is generally not required unless impairment is severe 1

By following these evidence-based dosing recommendations, clinicians can optimize the effectiveness of amoxicillin-clavulanate therapy while minimizing adverse effects in pediatric patients.