What is the recommended treatment for otitis media in children?

Treatment Recommendations for Acute Otitis Media in Children

Amoxicillin is the recommended first-line treatment for acute otitis media in children, with the decision to treat based on age, symptom severity, and diagnostic certainty. 1, 2

Diagnosis of Acute Otitis Media

The diagnosis of acute otitis media (AOM) requires:

• A history of acute onset of signs and symptoms 1
• The presence of middle-ear effusion 1
• Signs and symptoms of middle ear inflammation 1
• Specific diagnostic findings include:
  • Moderate to severe bulging of the tympanic membrane or new onset of otorrhea not due to acute otitis externa 1
  • Mild bulging of the tympanic membrane with recent (<48 hours) onset of ear pain or intense erythema of the tympanic membrane 1

Treatment Algorithm Based on Age and Severity

Children Under 6 Months

• Immediate antibiotic therapy is recommended 1, 2

Children 6-23 Months

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

Children 24 Months and Older

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

Antibiotic Selection

First-Line Therapy

• Amoxicillin at a dose of 80-90 mg/kg/day divided into 2-3 doses 1, 2
  • Duration: 10 days for children under 2 years; 5-7 days for children 2 years and older 1, 2
  • This high dose is recommended to overcome potential resistance from Streptococcus pneumoniae 1, 3

Second-Line Therapy

• Amoxicillin-clavulanate should be used when: 1
  • The child has received amoxicillin in the past 30 days 1
  • The child has concurrent purulent conjunctivitis 1
  • The child has a history of recurrent AOM unresponsive to amoxicillin 1
  • Treatment failure with amoxicillin occurs 1

For Penicillin Allergy

• Non-type I hypersensitivity: Cefdinir, cefpodoxime, or cefuroxime 2
• Type I hypersensitivity: Macrolides (though efficacy may be limited due to resistance) 1

Observation Option ("Watchful Waiting")

• Appropriate for select children based on age, diagnostic certainty, and illness severity 1
• Involves deferring antibiotics for 48-72 hours and focusing on symptomatic relief 1
• Suitable for:
  • Otherwise healthy children 6 months to 2 years with non-severe illness and uncertain diagnosis 1
  • Children 2 years and older without severe symptoms or with uncertain diagnosis 1
• Requires assurance of follow-up within 48-72 hours 1

Pain Management

• Pain assessment and management is essential regardless of whether antibiotics are prescribed 1, 2
• Appropriate analgesics should be recommended, especially during the first 24 hours 1, 2

Treatment Failure Management

• Reassess if symptoms worsen or fail to respond within 48-72 hours of starting treatment 1, 2
• Consider switching to amoxicillin-clavulanate if initial treatment with amoxicillin fails 1, 2
• Consider tympanocentesis/myringotomy for persistent symptoms despite appropriate antibiotic therapy 4

Common Pitfalls and Caveats

• Distinguishing between AOM and otitis media with effusion (OME) can be difficult; OME is often misdiagnosed as AOM, leading to unnecessary antibiotic use 1
• Isolated redness of the tympanic membrane with normal landmarks is not an indication for antibiotic therapy 1
• Despite the increasing prevalence of beta-lactamase-producing bacteria, recent evidence shows that amoxicillin remains effective as first-line therapy for most cases of AOM 3
• Completing the full course of antibiotics is essential, even if symptoms improve before completion 2