From the Guidelines
For a child with recurrent otitis media being discharged to parental care, I recommend watchful waiting and completing the full course of prescribed antibiotics, typically amoxicillin (40-90 mg/kg/day divided twice daily for 10 days) or amoxicillin-clavulanate if resistant bacteria are suspected, as the natural history of recurrent AOM without MEE is quite favorable and benefits of tympanostomy tubes for this clinical indication are uncertain 1. Pain management with acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) is important for comfort. Some key points to consider include:
- Keeping the child's ears dry during bathing and swimming
- Following up with your pediatrician in 2-3 weeks to ensure complete resolution
- Watching for warning signs requiring immediate attention: fever above 102.2°F (39°C), increasing ear pain, drainage from the ear, or changes in hearing
- Preventive measures include avoiding secondhand smoke, breastfeeding infants when possible, practicing good hand hygiene, keeping vaccinations current (particularly pneumococcal and influenza vaccines), and limiting pacifier use in older infants
- Recurrent otitis media occurs because children have shorter, more horizontal eustachian tubes that don't drain as effectively as adults', making them more susceptible to fluid buildup and infection, especially after upper respiratory infections. The most recent and highest quality study, published in 2022, supports the approach of watchful waiting for children with recurrent AOM without MEE, as it found that only 34% of children went on to require tympanostomy tube placement, and two-thirds of children were managed successfully without requiring tympanostomy tube insertion 1.
From the FDA Drug Label
The safety of re-dosing azithromycin in pediatric patients who vomit after receiving 30 mg/kg as a single dose has not been established. The FDA drug label does not answer the question.
From the Research
Discharge to Parent for Recurring Otitis Media
- The decision to discharge a child to their parent's care for recurring otitis media should be based on the severity of symptoms and the child's overall health status 2.
- For children younger than two years of age with severe symptoms of otitis media, antibiotics such as amoxicillin may be considered 2.
- Azithromycin has been shown to be comparable to amoxicillin/clavulanate in treating otitis media in children, with a lower risk of adverse events 3.
- The choice of antibiotic should be based on the child's medical history, current health status, and the potential risks and benefits of treatment 4.
- Studies have shown that azithromycin may be associated with a decreased risk of treatment failure overall, but may have an increased risk of failure during the first few days of treatment 5.
- Parents should be educated on the signs and symptoms of otitis media, how to manage their child's pain and discomfort, and when to seek further medical attention 2, 3, 4, 5.
- It is essential to consider the potential for antibiotic resistance and the need for judicious use of antibiotics in treating recurring otitis media 2, 3, 4, 5.