Management of Unilateral Acute Otitis Media in an Infant
For this infant with unilateral purulent effusion and decreased tympanic membrane mobility but no severe symptoms, observation with follow-up in 48 hours (Option C) is the best next step in management.
Age-Based Treatment Algorithm
The critical decision point here depends on the child's exact age within the infant range:
If the child is under 6 months old:
- Immediate antibiotic therapy with amoxicillin is mandatory regardless of whether the AOM is unilateral or bilateral 1
- All infants <6 months with confirmed AOM require antibiotics for 10 days 1
- High-dose amoxicillin (80-90 mg/kg/day divided into 2 doses) is the first-line choice 1, 2
If the child is 6-23 months old:
- Observation is appropriate for unilateral, non-severe AOM 1
- The American Academy of Pediatrics permits watchful waiting for nonsevere unilateral AOM in this age group 1
- Immediate antibiotics would be required only if: bilateral AOM, severe symptoms (moderate-to-severe otalgia, otalgia ≥48 hours, or temperature ≥39°C), or otorrhea 1
Why Observation is Preferred (for 6-23 month olds)
The clinical presentation lacks severe features:
- No fever present 1
- Breastfeeding well (indicating no significant systemic illness) 1
- No other symptoms suggesting severity 1
- Unilateral disease only 1
The observation strategy should include providing a safety-net antibiotic prescription with clear instructions to fill only if symptoms worsen or fail to improve, ensuring parents have reliable access to follow-up care 1.
Why Not Amoxicillin-Clavulanate Initially
Amoxicillin-clavulanate is reserved for specific circumstances 1:
- Recent amoxicillin use within 30 days
- Concurrent purulent conjunctivitis
- Treatment failure after initial amoxicillin
None of these conditions are present in this case 1. The child has no recent history of infections, making prior antibiotic exposure unlikely 1.
Why Not ENT Referral for Tympanostomy Tubes
Tympanostomy tubes are considered for 1:
- Recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months with one in the preceding 6 months)
- Persistent otitis media with effusion lasting ≥3 months with hearing loss
This is a single episode without recurrence history, making tube placement premature 1.
Implementation of Observation Strategy
During the 48-hour observation period 1:
- Provide pain management regardless of antibiotic decision (acetaminophen or ibuprofen) 1
- Instruct parents to monitor for worsening symptoms
- Reassess if symptoms worsen or fail to improve within 48-72 hours 1
- If antibiotics become necessary, start high-dose amoxicillin 80-90 mg/kg/day 1, 2
Critical Caveat
If this infant is actually under 6 months of age, the answer changes to Option A (amoxicillin) because immediate antibiotics are non-negotiable in this youngest age group 1. The question states "[AGE]-month-old," so the specific age determines whether observation or immediate treatment is appropriate.