What is the recommended management for ear pain in children?

Management of Ear Pain in Children

Immediately administer analgesics (ibuprofen or acetaminophen) to any child presenting with ear pain, as this is the cornerstone of management and provides pain relief within 24 hours, while antibiotics offer no symptomatic benefit in the first 24 hours. 1, 2

Immediate Pain Management (First Priority)

• Analgesics should be started immediately regardless of whether antibiotics are prescribed or withheld, as pain management is the primary therapeutic goal and antibiotics provide zero pain relief in the first 24 hours 1, 2

• Both ibuprofen and acetaminophen are effective, with low-quality evidence suggesting both are superior to placebo (ibuprofen: 7% vs 25% with pain at 48 hours, NNT=6; acetaminophen: 10% vs 25% with pain at 48 hours, NNT=7) 3

• Ibuprofen may have advantages over acetaminophen including less frequent dosing (every 6-8 hours vs every 4 hours), longer duration of action, and superior antipyretic effects, though evidence of difference in pain relief is insufficient 4

• Administer analgesics on a fixed schedule around-the-clock for the first few days, not "as needed," including waking the child at night for medication administration 1

• Alternating ibuprofen and acetaminophen can be considered, though evidence supporting this approach is limited 1, 2

• Topical 1% lidocaine ear drops added to oral analgesics provide rapid additional pain relief within 10 minutes (25-50% greater pain reduction compared to oral analgesics alone), though this is not standard first-line therapy 5

Diagnostic Assessment Before Antibiotic Decision

• Confirm the diagnosis of acute otitis media (AOM) using pneumatic otoscopy before deciding on antibiotics, requiring three elements: acute onset of symptoms, middle ear effusion (decreased tympanic membrane mobility), and signs of middle ear inflammation (bulging, erythema) 1, 2

• Isolated tympanic membrane redness without bulging or effusion does NOT warrant antibiotics, as this is often viral or from crying 2

• Use validated age-appropriate pain scales to assess severity: Wong-Baker FACES scale for children ≥3 years, FLACC scale for children 2 months to 7 years 1

Antibiotic Decision Algorithm

Immediate Antibiotics Indicated For:

• Severe symptoms: moderate-to-severe otalgia >48 hours OR temperature ≥39°C (102.2°F) 2
• Bilateral AOM in children <2 years of age 2
• AOM with otorrhea (perforated tympanic membrane) 2
• Toxic appearance or signs of another bacterial infection 2

Observation Without Immediate Antibiotics Appropriate For:

• Non-severe unilateral AOM in children 6-23 months: mild otalgia <48 hours AND temperature <39°C 1, 2
• Non-severe AOM in children ≥2 years: mild otalgia <48 hours AND temperature <39°C 2
• Critical requirement: A reliable mechanism MUST be in place for follow-up within 48-72 hours and ability to initiate antibiotics if symptoms worsen or fail to improve 1, 2

Antibiotic Selection When Indicated

• First-line: High-dose amoxicillin 80-90 mg/kg/day divided every 12 hours (maximum 500 mg/dose), as this provides adequate coverage against resistant Streptococcus pneumoniae 2, 6

• Duration: 10 days for children <2 years; 5-7 days for children ≥2 years 2

• Penicillin allergy (non-type I hypersensitivity): cefdinir, cefpodoxime, or cefuroxime 2

• Take amoxicillin at the start of a meal to minimize gastrointestinal intolerance 6

Reassessment and Follow-Up

• Reassess within 48-72 hours if no improvement in pain or fever, or immediately if symptoms worsen 2

• If initially observed without antibiotics, start amoxicillin if symptoms persist or worsen 2

• If already on antibiotics without improvement at 48-72 hours, switch to alternative agent (e.g., amoxicillin-clavulanate for beta-lactamase producing organisms) 2

• Expect that 30% of children <2 years will have persistent pain or fever at 3-7 days even with appropriate antibiotic therapy, so continue analgesics as needed 1, 2

Non-Pharmacologic Adjuncts

• Supplement (not replace) pharmacologic pain management with: distraction techniques, favorite toys/video games, cold or hot packs to neck/ears, reading, playing, ensuring adequate hydration, and encouraging eating/chewing 1

• Maintaining hydration is associated with less pain, so offer frequent small amounts of fluids 1

Critical Pitfalls to Avoid

• Never withhold analgesics while "waiting for antibiotics to work", as antibiotics provide zero pain relief in the first 24 hours and pain may persist for 7-10 days 1, 2

• Do not prescribe antibiotics for isolated tympanic membrane redness without bulging and effusion 2

• Do not use observation approach without ensuring reliable follow-up mechanism for reassessment within 48-72 hours 1, 2

• Do not underdose amoxicillin—the 80-90 mg/kg/day dosing is essential for resistant pneumococcal coverage, not the older 40-45 mg/kg/day dosing 2

• Do not assume antibiotics will control pain—continue analgesics for the full duration of symptoms, typically 7-10 days 1