What is the recommended liquid concentration and total amount of amoxicillin (amoxicillin) for a child with acute otitis media?

Amoxicillin Liquid Concentration and Total Amount for Pediatric Acute Otitis Media

For a child with acute otitis media, prescribe amoxicillin oral suspension at 80-90 mg/kg/day divided into two doses daily, using either the 400 mg/5 mL concentration (for twice-daily dosing) or the 250 mg/5 mL concentration (for three-times-daily dosing), with a total supply sufficient for 10 days of treatment. 1, 2

Specific Dosing Instructions to Call Into Pharmacy

For Children Under 2 Years:

• Dose: 80-90 mg/kg/day divided into 2 doses (every 12 hours) 1, 2
• Preferred concentration: 400 mg/5 mL suspension 3
• Duration: 10 days 1, 3
• Example calculation for 10 kg child:
  • Total daily dose = 800-900 mg/day
  • Per dose = 400-450 mg twice daily
  • Volume per dose = 5-5.6 mL of 400 mg/5 mL suspension
  • Total amount to dispense: 100-112 mL 2, 3

For Children 2 Years and Older:

• Dose: 80-90 mg/kg/day divided into 2 doses 1, 2
• Alternative concentration: 250 mg/5 mL suspension (if dosing three times daily at 40 mg/kg/day) 3
• Duration: 5-7 days may be sufficient for older children, though 10 days is standard 1

Alternative Concentration Options:

• 200 mg/5 mL suspension: Can be used with twice-daily dosing at 45 mg/kg/dose 3
• 125 mg/5 mL suspension: Can be used with three-times-daily dosing at 20-40 mg/kg/day 3

Rationale for High-Dose Therapy

• High-dose amoxicillin (80-90 mg/kg/day) is specifically recommended by the American Academy of Pediatrics and American Academy of Family Physicians as first-line treatment for AOM to achieve adequate middle ear fluid concentrations against drug-resistant Streptococcus pneumoniae 1, 4, 2
• The twice-daily dosing regimen is preferred over three-times-daily dosing because it is associated with significantly less diarrhea and improved compliance 3, 5
• Approximately 87% of S. pneumoniae isolates are susceptible to high-dose amoxicillin versus only 83% for standard-dose therapy 4

When to Use Amoxicillin-Clavulanate Instead

Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate) if: 1, 2

• Child received amoxicillin in the past 30 days 1
• Concurrent purulent conjunctivitis is present (suggests H. influenzae) 1, 2
• History of recurrent AOM unresponsive to amoxicillin 1
• No clinical improvement after 48-72 hours of amoxicillin therapy 1, 2

Common Pitfalls to Avoid

• Do not use standard-dose amoxicillin (40-45 mg/kg/day) for initial treatment of AOM in the current era of antibiotic resistance 1, 4, 2
• Do not substitute two 250 mg/125 mg amoxicillin-clavulanate tablets for one 500 mg/125 mg tablet as they contain different amounts of clavulanic acid 3
• Do not forget pain management regardless of antibiotic choice—this is an essential component of AOM treatment 4, 2
• Reassess at 48-72 hours if symptoms persist or worsen, as treatment failure requires switching to alternative therapy 1, 2
• For children under 2 years, treatment duration should be 8-10 days, not the shorter 5-7 day courses sometimes used in older children 2, 3

Practical Pharmacy Call Script

"I need amoxicillin oral suspension, 400 mg/5 mL concentration. The dose is [X] mL twice daily for 10 days. Please dispense [total volume needed] mL."

Calculate total volume as: (dose per administration in mL) × 2 doses/day × 10 days 2, 3