What is the recommended dosing of amoxicillin (amoxicillin/clavulanic acid) for pediatric patients?

Amoxicillin/Clavulanate Pediatric Dosing

For most pediatric infections, use high-dose amoxicillin/clavulanate at 90 mg/kg/day of the amoxicillin component divided into 2 doses (maximum 4000 mg/day), which provides optimal coverage against resistant Streptococcus pneumoniae and β-lactamase-producing organisms. 1

Standard Dosing Regimens by Indication

Respiratory Tract Infections (Pneumonia, Sinusitis)

For children under 5 years with community-acquired pneumonia:

• 90 mg/kg/day of amoxicillin component in 2 divided doses 1, 2
• This high-dose regimen is specifically indicated for presumed bacterial pneumonia 3

For children 5 years and older with pneumonia:

• 90 mg/kg/day of amoxicillin component in 2 divided doses (maximum 4000 mg/day) 1, 2

For β-lactamase producing H. influenzae:

• Either 45 mg/kg/day in 3 doses OR 90 mg/kg/day in 2 doses of the amoxicillin component 1, 3

Acute Otitis Media

High-dose regimen (90 mg/kg/day with 6.4 mg/kg/day clavulanate in 2 divided doses) is indicated for: 3

• Children who received antibiotics within the past 4-6 weeks 1
• Age less than 2 years 3
• Daycare attendance 3
• Incomplete H. influenzae type b vaccination 3
• Moderate to severe illness 3

Age-Based Oral Suspension Dosing (Standard Formulations)

For children less than 1 year (1-12 months):

• 2.5 mL of 125/31 suspension three times daily 3

For children 1-6 years:

• 5 mL of 125/31 suspension three times daily 3

For children 7-12 years:

• 5 mL of 250/62 suspension three times daily 3

For children 12-18 years:

• 1 tablet (250/125) three times daily 3

Critical Dosing Principles

The high-dose formulation (90/6.4 mg/kg/day) provides a 14:1 ratio of amoxicillin to clavulanate, which causes less diarrhea than other preparations while maintaining efficacy. 3

Maximum single dose is 2 grams per dose regardless of weight. 3

For infants less than 3 months, the maximum recommended dose is 30 mg/kg/day divided every 12 hours due to incompletely developed renal function. 4

Treatment Duration and Monitoring

Standard treatment duration is 10 days for most respiratory infections, particularly pneumonia. 1, 3, 2

Children should demonstrate clinical improvement within 48-72 hours of starting therapy. 1, 2

If no improvement occurs within 48-72 hours, reevaluation and further investigation are necessary, including consideration of atypical pathogens or complications. 1, 2

Formulation Selection

The high-dose formulation (600 mg amoxicillin per 5 mL) is preferred for:

• Community-acquired pneumonia 1, 2
• Areas with high pneumococcal resistance (>10%) 3
• Recent antibiotic exposure 1
• Risk factors for resistant organisms 3

Standard formulations (125/31 or 250/62) may be used for:

• Mild infections without risk factors 3
• Urinary tract infections 5
• Skin and soft tissue infections 4

Common Pitfalls to Avoid

Always verify the suspension concentration (125/31 vs 250/62 vs 600/42.9) before calculating volume to avoid dosing errors. 3

Using standard doses when high-dose therapy is indicated leads to treatment failure with resistant organisms. 3

Subtherapeutic doses fail to achieve adequate tissue concentrations and promote antimicrobial resistance. 3

Do not use the 875 mg tablet formulation in patients with severe renal impairment (GFR <30 mL/min). 4

Renal Impairment Dosing (for children >40 kg)

For GFR 10-30 mL/min:

• 500 mg or 250 mg every 12 hours, depending on infection severity 4

For GFR <10 mL/min:

• 500 mg or 250 mg every 24 hours, depending on infection severity 4

For hemodialysis patients:

• 500 mg or 250 mg every 24 hours, with an additional dose during and at the end of dialysis 4

Administration Instructions

Administer at the start of a meal to minimize gastrointestinal intolerance. 4

Shake oral suspension well before each use. 4

After reconstitution, discard any unused suspension after 14 days; refrigeration is preferable but not required. 4