Paracetamol Suppositories and Diarrhea in Infants with AOM
Paracetamol suppositories do not cause or worsen diarrhea in children with acute otitis media. The diarrhea your 10-month-old is experiencing is almost certainly from the amoxicillin, not from paracetamol given rectally.
Understanding the Source of Diarrhea
- Amoxicillin is the primary culprit for diarrhea in this clinical scenario, occurring in approximately 25% of treated children compared to 15% in placebo groups—a 10% absolute increase directly attributable to the antibiotic 1
- The American Academy of Pediatrics acknowledges that amoxicillin causes adverse gastrointestinal events (primarily diarrhea and rash) in approximately 5% more patients than placebo, though these are generally mild 1, 2
- Paracetamol (acetaminophen) itself—whether given orally or rectally—is not associated with diarrhea as an adverse effect 3
Why Rectal Paracetamol is Safe to Continue
- The route of administration (rectal suppository versus oral) does not change the gastrointestinal side effect profile of paracetamol, as the drug's systemic effects are the same once absorbed 3
- Paracetamol and ibuprofen are the recommended first-line agents for pain control in AOM and should be continued throughout the acute phase regardless of antibiotic choice 1, 4
- Pain management is mandatory in every child with AOM, as antibiotics provide no symptomatic relief in the first 24 hours, and even after 3-7 days of treatment, 30% of children younger than 2 years may have persistent pain or fever 4
Managing the Amoxicillin-Related Diarrhea
- Do not discontinue amoxicillin prematurely for mild diarrhea, as this increases treatment failure risk (21% with inadequate treatment versus 5% with complete treatment) 1
- Monitor for diaper dermatitis, which occurred in 51% of amoxicillin-treated children versus 35% in placebo groups, and apply barrier creams prophylactically 1
- Ensure the full 10-day course of amoxicillin is completed for a 10-month-old infant, as this age group requires the longer duration 4
When to Reassess and Consider Changing Antibiotics
- Reassess at 48-72 hours to evaluate both AOM response and antibiotic tolerability 1, 4
- If AOM symptoms worsen or fail to improve by 48-72 hours AND the diarrhea becomes severe or intolerable, consider switching to intramuscular ceftriaxone rather than amoxicillin-clavulanate 1, 4
- Do not switch to amoxicillin-clavulanate if diarrhea is already problematic, as the clavulanate component significantly increases gastrointestinal adverse effects beyond amoxicillin alone 1