What is the treatment for a 5-year-old with a cough for 10 days who now has an earache, suspected to be otitis media?

Treatment for a 5-Year-Old with 10-Day Cough and New Earache

Immediate Antibiotic Treatment is Recommended

For a 5-year-old child with a 10-day cough who now develops an earache suggestive of acute otitis media (AOM), prescribe high-dose amoxicillin 80-90 mg/kg/day divided into 2 doses for 5-7 days. 1, 2

Diagnostic Confirmation

Before prescribing antibiotics, confirm the diagnosis of AOM by examining the tympanic membrane for: 1, 3

• Moderate to severe bulging of the tympanic membrane, OR
• Mild bulging with recent onset ear pain (less than 48 hours), OR
• Intense erythema of the tympanic membrane with acute symptoms
• New-onset otorrhea not due to otitis externa

Critical pitfall to avoid: Do not prescribe antibiotics based solely on isolated redness of the tympanic membrane without other diagnostic findings—this is not an indication for treatment. 3

First-Line Antibiotic Selection

Standard First-Line Treatment

Amoxicillin 80-90 mg/kg/day divided into 2 doses is the antibiotic of choice for this age group. 1, 2, 3, 4

• The high dose (80-90 mg/kg/day) is critical for eradicating penicillin-resistant Streptococcus pneumoniae, the most common bacterial pathogen. 2
• Treatment duration for children ≥2 years with non-severe symptoms is 5-7 days. 1, 3

When to Use Alternative First-Line Agents

Switch to amoxicillin-clavulanate (80 mg/kg/day of the amoxicillin component) if: 1, 3

• The child received amoxicillin within the past 30 days
• Concurrent purulent conjunctivitis is present
• History of recurrent AOM unresponsive to amoxicillin

Penicillin Allergy Alternatives

For non-type I hypersensitivity reactions, use: 2

• Cefdinir, cefpodoxime, or cefuroxime

For type I hypersensitivity (anaphylaxis risk), use: 3

• Azithromycin (though efficacy is lower than amoxicillin)

Pain Management is Mandatory

Pain assessment and management is essential regardless of antibiotic use, especially during the first 24 hours. 2, 3

• Recommend appropriate analgesics (acetaminophen or ibuprofen)
• Consider topical analgesic drops for additional relief 3

Context: The Prolonged Cough

The 10-day cough history is important context but does not change AOM management: 1

• Cough lasting >10 days may represent viral upper respiratory infection, post-viral cough, or bacterial sinusitis
• The French guidelines recommend antibiotics for cough only if fever ≥38.5°C persists for >3 days, or if pneumonia/atelectasis is confirmed on chest X-ray 1
• In children >3 years with prolonged cough, consider atypical bacteria (Mycoplasma pneumoniae, Chlamydia pneumoniae) if clinical picture suggests this 1
• However, the new earache with confirmed AOM takes priority and requires immediate treatment as outlined above

Follow-Up and Treatment Failure

Reassess if symptoms worsen or fail to improve within 48-72 hours: 1, 3

• If initially treated with amoxicillin, switch to amoxicillin-clavulanate
• If initially treated with amoxicillin-clavulanate, consider ceftriaxone IM or referral to specialist 3
• Ensure proper visualization of the tympanic membrane at reassessment to confirm diagnosis 2

Special Considerations for This Age Group

• At 5 years old, this child falls into the category where observation without immediate antibiotics could be considered for non-severe unilateral AOM, but given the 10-day preceding illness, immediate antibiotic treatment is more prudent 1, 3
• The prolonged antecedent cough suggests the child has been systemically unwell, making bacterial superinfection more likely 1
• Complete the full antibiotic course even if symptoms improve before completion 2