What is the treatment for acute otitis media (AOM) in children?

Treatment of Acute Otitis Media in Children

For children with acute otitis media (AOM), high-dose amoxicillin (80-90 mg/kg/day) is the first-line antibiotic treatment, with duration based on age: 10 days for children under 2 years and 5-7 days for older children. 1, 2

Diagnosis Criteria

• AOM requires a history of acute onset of signs and symptoms, presence of middle ear effusion, signs of middle ear inflammation, and symptoms such as otalgia, irritability, or fever 1, 2

Treatment Algorithm

Initial Management Decision

• Pain management is essential regardless of antibiotic decision 1, 2
• Children <6 months of age with confirmed AOM: Prescribe antibiotics immediately 1
• Children 6-23 months with bilateral AOM, severe symptoms, or otorrhea: Prescribe antibiotics immediately 1
• Children 6-23 months with unilateral AOM without severe symptoms OR children ≥24 months with non-severe illness: May observe without antibiotics for 48-72 hours with appropriate pain management 1, 2

Antibiotic Selection

• First-line therapy: Amoxicillin at 80-90 mg/kg/day divided into 2 doses 1, 3, 2
• Duration of therapy:
  • Children <2 years: 10 days 1, 4
  • Children 2-5 years with mild/moderate symptoms: 7 days 4
  • Children ≥6 years with mild/moderate symptoms: 10 days 4

Alternative Antibiotics

• For penicillin allergy (non-type I hypersensitivity): Cefdinir, cefpodoxime, or cefuroxime 3, 2
• For recent amoxicillin use, concurrent purulent conjunctivitis, or need for β-lactamase coverage: Amoxicillin-clavulanate 1

Treatment Failure Management

• Reassess if symptoms worsen or fail to improve within 48-72 hours 1, 2
• If initially treated with amoxicillin: Switch to amoxicillin-clavulanate 1, 2
• If initially treated with amoxicillin-clavulanate: Consider intramuscular ceftriaxone (50 mg/kg) 4
• For multiple treatment failures: Consider tympanocentesis for culture and susceptibility testing 4
• When tympanocentesis is not available: Consider clindamycin (for S. pneumoniae) with or without cefdinir, cefixime, or cefuroxime (for H. influenzae and M. catarrhalis) 4

Special Considerations

Persistent Middle Ear Effusion

• Middle ear effusion without symptoms (otitis media with effusion or OME) is common after AOM resolution 4
• 60-70% of children have middle ear effusion 2 weeks after treatment, decreasing to 10-25% at 3 months 4
• OME requires monitoring but not antibiotics 4

Recurrent AOM Management

• For children with recurrent episodes, systemic antibiotics are still needed to treat acute episodes 5
• Preventive measures have small to moderate effects in reducing AOM burden 5

Common Pitfalls and Caveats

• Avoid macrolides as first-line therapy due to high rates of pneumococcal resistance 2
• Complete the full antibiotic course even if symptoms improve before completion 2
• The current standard high-dose amoxicillin recommendation (80-90 mg/kg/day) is based on increasing resistance patterns of S. pneumoniae 6
• Viral co-infection may reduce antibiotic effectiveness and requires consideration of higher dosing 6
• For children with repeated treatment failures, consultation with specialists (otolaryngologist, infectious disease) may be necessary before using unconventional antibiotics like levofloxacin or linezolid 4

Follow-up Recommendations

• Routine follow-up visits are not necessary for all children with AOM 4
• Consider reassessment for young children with severe symptoms, recurrent AOM, or when requested by parents 4
• Special attention to resolution of middle ear effusion is important for children with cognitive or developmental delays who may be adversely affected by transient hearing loss 4