What is the first-line treatment for a 1.5-year-old child with an ear infection?

First-Line Treatment for Acute Otitis Media in an 18-Month-Old Child

For a 1.5-year-old child with acute otitis media (AOM), immediate antibiotic therapy with high-dose amoxicillin (80-90 mg/kg/day divided into 2-3 doses) for 10 days is the first-line treatment. 1, 2

Why Immediate Antibiotics Are Required

• Children under 2 years of age require immediate antibiotic therapy regardless of symptom severity or whether the infection is unilateral or bilateral 1, 2
• The observation option (watchful waiting) is not appropriate for children younger than 24 months with confirmed AOM 1
• Young infants have higher risk of complications and difficulty in reliable clinical monitoring, making immediate treatment essential 2

Specific Antibiotic Regimen

First-Line Therapy

• High-dose amoxicillin at 80-90 mg/kg/day divided into 2 or 3 equal doses 1, 2, 3, 4
• Duration: 10 days for all children under 2 years of age 1, 2
• High-dose formulation is critical for eradicating penicillin-resistant Streptococcus pneumoniae, the most common pathogen 2, 5

Alternative Antibiotics (If Penicillin Allergy)

• For non-type I hypersensitivity: cefdinir, cefpodoxime, or cefuroxime 2, 4
• For type I hypersensitivity (anaphylaxis risk): azithromycin, though cephalosporin cross-reactivity risk should be assessed 4

Second-Line Therapy (Treatment Failure)

• Amoxicillin-clavulanate if no improvement within 48-72 hours 2, 5
• Also use amoxicillin-clavulanate if the child took amoxicillin in the previous 30 days or has concomitant purulent conjunctivitis 4

Essential Concurrent Management

Pain Control

• Pain assessment and management are mandatory regardless of antibiotic use 2
• Appropriate analgesics (acetaminophen or ibuprofen) should be provided, especially during the first 24 hours 2

Follow-Up Protocol

• Reassess if symptoms persist or worsen after 48-72 hours of antibiotic therapy 2, 5
• Treatment failure signs include: worsening condition, persistence of symptoms beyond 48 hours, or recurrence within 4 days of completing treatment 2
• Complete the full 10-day course even if symptoms improve earlier 2

Common Pitfalls to Avoid

• Do not use observation/watchful waiting in children under 24 months—this is only appropriate for children ≥24 months with nonsevere, unilateral AOM 1
• Do not prescribe standard-dose amoxicillin (40-45 mg/kg/day)—high-dose formulation is required for resistant organisms 2, 5
• Do not shorten the antibiotic course to 5-7 days in children under 2 years—10 days is required 1, 2
• Ensure proper diagnosis with visualization of the tympanic membrane showing moderate-to-severe bulging, new-onset otorrhea, or mild bulging with recent ear pain (<48 hours) or intense erythema 1, 4

Key Diagnostic Criteria

AOM diagnosis requires all three components 1, 5:

• Acute onset of signs and symptoms
• Middle ear effusion (detected by pneumatic otoscopy or tympanometry)
• Signs of middle ear inflammation (bulging tympanic membrane, erythema, or otorrhea)