What are the guidelines for treating acute otitis media (AOM) in pediatric patients?

Guidelines for Treating Ear Infections in Children

Diagnosis Requirements

Proper diagnosis of acute otitis media (AOM) requires acute onset of symptoms, presence of middle ear effusion, and signs of middle ear inflammation—isolated redness of the tympanic membrane without other findings does NOT warrant antibiotics. 1, 2

• Use pneumatic otoscopy with an air-tight seal to accurately visualize the tympanic membrane and confirm middle ear effusion 3
• Look specifically for bulging tympanic membrane, decreased mobility, and acute symptoms (ear pain, fever, irritability) 2, 4

Treatment Algorithm by Age and Severity

Infants Under 6 Months

All infants under 6 months with confirmed AOM require immediate antibiotic therapy—no observation option. 1, 2

• Prescribe high-dose amoxicillin 80-90 mg/kg/day divided into 2-3 doses for 10 days 1, 2
• This age group has higher complication risk and difficulty with reliable clinical monitoring 1

Children 6-23 Months

Immediate antibiotics are mandatory for bilateral AOM or severe symptoms (moderate-to-severe ear pain, pain ≥48 hours, or fever ≥39°C/102.2°F). 1, 2

• For unilateral, non-severe AOM: watchful waiting is acceptable IF reliable follow-up within 48-72 hours can be ensured 2, 3
• Provide safety-net antibiotic prescription with clear instructions to fill only if symptoms worsen or fail to improve 2
• If antibiotics are needed: amoxicillin 80-90 mg/kg/day for 10 days 1, 2

Children 2 Years and Older

Immediate antibiotics for severe symptoms; observation acceptable for mild-to-moderate cases with reliable follow-up. 1, 3

• Severe symptoms = high fever >38.5°C persisting >3 days or moderate-to-severe pain 1
• If antibiotics prescribed: 7-day course for ages 2-5 years with mild-moderate symptoms; 5-7 days for ages ≥6 years 2, 3

First-Line Antibiotic Selection

High-dose amoxicillin (80-90 mg/kg/day divided into 2 doses) is the first-line treatment for most children with AOM. 1, 2, 3

• This dosing is critical for eradicating penicillin-resistant Streptococcus pneumoniae, the most common pathogen 1
• Amoxicillin has proven effectiveness, safety, low cost, acceptable taste, and narrow spectrum 3, 4

When to Use Amoxicillin-Clavulanate Instead

Switch to amoxicillin-clavulanate 90 mg/kg/day (based on amoxicillin component) as first-line if: 1, 2, 3

• Child received amoxicillin within previous 30 days
• Concurrent purulent conjunctivitis present
• History of recurrent AOM unresponsive to amoxicillin

Penicillin Allergy Alternatives

For non-type I hypersensitivity reactions: 1, 2

• Cefdinir 14 mg/kg/day in 1-2 doses, OR
• Cefuroxime 30 mg/kg/day in 2 doses, OR
• Cefpodoxime 10 mg/kg/day in 2 doses 3

For type I hypersensitivity (IgE-mediated): 1

• Azithromycin (though lower efficacy than amoxicillin for AOM) 1, 5
• Azithromycin dosing for AOM: 30 mg/kg as single dose, OR 10 mg/kg once daily for 3 days, OR 10 mg/kg day 1 then 5 mg/kg days 2-5 5

Pain Management—MANDATORY for All Patients

Pain control must be addressed immediately in every patient, regardless of antibiotic decision, as antibiotics provide no symptomatic relief in the first 24 hours. 1, 2, 3

• Prescribe acetaminophen or ibuprofen dosed appropriately for age and weight 2, 3
• Continue analgesics throughout acute phase—even after 3-7 days of antibiotics, 30% of children under 2 years have persistent pain 2
• Topical analgesic drops may provide additional relief within 10-30 minutes 1

Treatment Failure Management

Reassess if symptoms worsen or fail to improve within 48-72 hours. 1, 2, 3

• Confirm AOM diagnosis with proper tympanic membrane visualization 1
• If initially treated with amoxicillin: switch to amoxicillin-clavulanate 90 mg/kg/day 1, 2
• If initially treated with amoxicillin-clavulanate: switch to ceftriaxone 50 mg/kg IM/IV daily for 1-3 days (3-day course superior to 1-day) 2, 3
• For multiple treatment failures: consider tympanocentesis for culture and susceptibility testing 2, 3

Post-Treatment Follow-Up

Routine follow-up visits are NOT necessary for uncomplicated AOM, but middle ear effusion commonly persists after treatment. 2, 3

• 60-70% have effusion at 2 weeks, 40% at 1 month, 10-25% at 3 months 2, 3
• This post-AOM effusion (otitis media with effusion) requires monitoring but NOT antibiotics unless persisting >3 months with hearing loss 3
• Consider follow-up for infants <6 months, recurrent AOM, or children with developmental delays who may be affected by transient hearing loss 2

Recurrent AOM Management

Recurrent AOM is defined as ≥3 episodes in 6 months or ≥4 episodes in 12 months with one in preceding 6 months. 2

Prevention Strategies

• Administer pneumococcal conjugate vaccine (PCV-13) and annual influenza vaccination 1, 3
• Encourage breastfeeding for at least 6 months 3
• Reduce/eliminate pacifier use after 6 months 3
• Eliminate tobacco smoke exposure 3
• Minimize daycare attendance when possible 3

Surgical Intervention

Long-term prophylactic antibiotics are discouraged—consider tympanostomy tubes instead. 1, 3

• Tubes reduce recurrence with failure rates of 21% for tubes alone, 16% for tubes with adenoidectomy 3
• Consider tubes for persistent otitis media with effusion ≥3 months with hearing loss or significant effect on child's well-being 3

Critical Pitfalls to Avoid

• Never prescribe antibiotics for isolated tympanic membrane redness without middle ear effusion and acute symptoms 1, 2
• Never use antibiotics for otitis media with effusion (fluid without acute symptoms) 2, 3
• Never use topical antibiotics for AOM—these are contraindicated and only indicated for otitis externa or tube otorrhea 3
• Never skip pain management—it's the most critical immediate intervention 2, 3
• Never use corticosteroids routinely for AOM—current evidence does not support their effectiveness 3