What is the management approach for acute otitis media (AOM) in pediatrics?

Management of Acute Otitis Media in Pediatrics

The management of acute otitis media (AOM) in pediatric patients should follow a structured approach based on age, symptom severity, and diagnostic certainty, with amoxicillin as first-line antibiotic therapy when antibiotics are indicated and appropriate pain management for all cases. 1

Diagnosis

• AOM should be diagnosed in children with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa 1
• AOM can also be diagnosed with mild bulging of the TM and recent (less than 48 hours) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) or intense erythema of the TM 1

Pain Management

• Pain control is paramount and should be addressed regardless of whether antibiotics are prescribed 2
• Analgesics should be continued as long as needed to control pain, especially during the first 24 hours 2
• Both paracetamol (acetaminophen) and ibuprofen may be more effective than placebo in relieving ear pain in children with AOM 3

Treatment Algorithm Based on Age and Severity

Children < 6 months

• Not covered in the guidelines (recommendations apply to children 6 months through 12 years) 1

Children 6-23 months

• Severe AOM (moderate to severe otalgia, otalgia for ≥48 hours, or temperature ≥39°C): Prescribe antibiotics immediately 1
• Non-severe bilateral AOM: Prescribe antibiotics 1
• Non-severe unilateral AOM: Either prescribe antibiotics or offer observation with close follow-up based on joint decision-making with parents/caregivers 1

Children ≥24 months

• Severe AOM: Prescribe antibiotics immediately 1
• Non-severe AOM (bilateral or unilateral): Either prescribe antibiotics or offer observation with close follow-up based on joint decision-making with parents/caregivers 1

Antibiotic Selection

• First-line therapy: Amoxicillin (80-90 mg/kg/day in 2 divided doses) when the child has not received amoxicillin in the past 30 days, does not have concurrent purulent conjunctivitis, and is not allergic to penicillin 1, 2
• Second-line therapy (use when child has received amoxicillin in last 30 days, has concurrent purulent conjunctivitis, or has history of recurrent AOM unresponsive to amoxicillin): Antibiotic with additional β-lactamase coverage such as amoxicillin-clavulanate 1
• For penicillin allergy: Alternative options include cefdinir, cefpodoxime, or cefuroxime 2
• For acute otitis media in children: Azithromycin can be dosed as 30 mg/kg as a single dose, or 10 mg/kg once daily for 3 days, or 10 mg/kg on day 1 followed by 5 mg/kg/day on days 2-5 4

Follow-up and Treatment Failure

• Reassess the patient if symptoms worsen or fail to respond to initial antibiotic treatment within 48-72 hours 1, 5
• If initially managed with observation, begin antibiotics if symptoms worsen or don't improve within 48-72 hours 5, 2
• If initially treated with antibiotics, change to a second-line agent if symptoms persist 5, 2
• Complete resolution of symptoms may take up to 2 weeks even with appropriate treatment 5

Special Considerations

• Persistent middle ear effusion (MEE) is common after AOM resolution and does not require antibiotics 5
• After successful antibiotic treatment, 60-70% of children have MEE at 2 weeks, 40% at 1 month, and 10-25% at 3 months 5
• Routine follow-up visits are not scientifically supported for all children with AOM once clinical improvement occurs 5

Prevention Strategies

• Reduce risk factors where possible:
  • Modify daycare attendance patterns
  • Encourage breastfeeding for at least six months
  • Avoid supine bottle feeding
  • Reduce or eliminate pacifier use after six months of age 2
• Immunization with pneumococcal conjugate vaccines and influenza vaccine is recommended 2

Common Pitfalls to Avoid

• Failing to reassess patients who don't improve within 48-72 hours 5
• Assuming persistent MEE requires antibiotics 5
• Missing alternative causes of persistent symptoms, such as fungal infections, dermatologic disorders, unrecognized foreign body, or perforated tympanic membrane 5
• Overuse of antibiotics in cases where observation would be appropriate 6, 7