What is the appropriate management for an 11-month-old male presenting with nausea, vomiting, diarrhea, fever, loss of appetite, and ear infection symptoms, including bulging tympanic membranes, who has not urinated for 6 hours and has mild abdominal distention?

Management of 11-Month-Old with Dehydration and Acute Otitis Media

This child requires immediate intravenous rehydration for severe dehydration (no urine for 6 hours), followed by high-dose oral amoxicillin for acute otitis media once adequately hydrated. 1

Immediate Priority: Address Dehydration

Assess Severity of Dehydration

• No urination for 6 hours in an 11-month-old indicates at least moderate dehydration (6-9% fluid deficit), possibly severe 1
• Additional concerning signs to evaluate: sunken fontanelle, dry mucous membranes, decreased skin turgor, tachycardia, altered mental status, poor perfusion 1
• The mild abdominal distention should be assessed for ileus, which would mandate IV therapy 1

Rehydration Strategy

For moderate dehydration (6-9% deficit):

• Administer oral rehydration solution (ORS) containing 50-90 mEq/L sodium at 100 mL/kg over 2-4 hours 1
• Use small volumes initially (one teaspoon) with gradual increases as tolerated 1
• Replace ongoing stool losses with 10 mL/kg ORS for each watery stool 1

For severe dehydration (≥10% deficit) or if oral rehydration fails:

• Initiate IV rehydration immediately with lactated Ringer's or normal saline, 20 mL/kg boluses until pulse, perfusion, and mental status normalize 1
• Continue IV fluids until the child can tolerate oral intake without risk of aspiration and has no ileus 1
• Transition to ORS for remaining deficit replacement once stabilized 1

Common pitfall: The 6-hour anuria strongly suggests this child needs IV rehydration rather than oral therapy alone, especially given the concurrent infection and decreased oral intake 1

Concurrent Management: Acute Otitis Media

Diagnosis Confirmation

• Bilateral erythematous and bulging tympanic membranes confirm acute otitis media (AOM) 1, 2
• The fever, irritability, and loss of appetite are consistent with AOM 3, 4

Antibiotic Therapy

High-dose amoxicillin is first-line treatment:

• Dose: 80-90 mg/kg/day divided every 12 hours (or 40 mg/kg/day divided every 8 hours for severe infection) 1, 5, 2
• This higher dosing is critical for coverage of resistant Streptococcus pneumoniae, particularly given the recent viral illness which reduces antibiotic efficacy 6, 2
• Treatment duration: minimum 10 days for children under 2 years with bilateral AOM 1, 5

Rationale for immediate antibiotics (not observation):

• Child is under 2 years of age 1, 3
• Bilateral AOM present 1, 3
• Severe symptoms (fever, dehydration, loss of appetite) 1, 3

Pain Management

• Provide analgesics (acetaminophen or ibuprofen) regardless of antibiotic use 1, 7
• Continue as long as needed for comfort 1

Nutritional Management

Resume age-appropriate feeding immediately upon rehydration:

• Continue or resume full-strength formula or breast milk without delay 1
• Do not dilute formula or restrict diet 1
• Lactose-containing formulas are acceptable unless clinical worsening occurs (not just positive stool reducing substances) 1

Follow-Up and Monitoring

Reassess within 48-72 hours:

• Verify adequate hydration status and urine output 1
• Confirm clinical improvement of AOM symptoms 1, 7
• If persistent severe symptoms despite 48-72 hours of amoxicillin, switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) 1

Red flags requiring immediate re-evaluation:

• Continued anuria or worsening dehydration 1
• Worsening ear pain, fever, or irritability on antibiotics 1
• Increasing abdominal distention suggesting ileus 1
• Altered mental status 1

Common pitfall: Do not use topical antibiotic ear drops for AOM without tympanostomy tubes—these are only indicated for acute otitis externa or acute tympanostomy tube otorrhea 1, 7