Acute Otitis Media (AOM) in Children

Background

• Acute otitis media (AOM) is an infection of the middle ear characterized by the rapid onset of signs and symptoms of middle ear inflammation.
  • It frequently presents with ear pain, which may manifest as ear pulling or rubbing in young preverbal children. Other common symptoms include fever, irritability, and difficulty sleeping.
  • Symptoms of an upper respiratory infection often precede ear symptoms.
  • AOM in children with tympanostomy tubes typically presents with otorrhea without ear pain or fever.
• AOM is very common in children, especially those < 5 years old.
• The infection is usually due to a viral or bacterial pathogen, and viral/bacterial coinfection is common. The most frequent bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.

Evaluation

• Suspect AOM in a child presenting with ear pain (or symptoms suggestive of ear pain in a preverbal child).
• Otoscopy findings are usually sufficient to confirm the diagnosis.
• Diagnose AOM in a child with any of the following:
  • moderate-to-severe bulging of the tympanic membrane (Strong recommendation)
  • new onset of otorrhea not due to acute otitis externa (Strong recommendation)
  • mild bulging of the tympanic membrane and recent (< 48 hours) onset of ear pain (holding, tugging, or rubbing of ear in nonverbal child) or intense erythema of the tympanic membrane (Strong recommendation)
• AOM should not be diagnosed in the absence of middle ear effusion (based on pneumatic otoscopy and/or tympanometry) (Strong recommendation).
• Include pain assessment as part of the evaluation (Strong recommendation).
• Diagnose mild AOM in children with mild otalgia and a temperature that is < 39 degrees C (102.2 degrees F), and severe AOM in children with moderate-to-severe otalgia or a fever that is ≥ 39 degrees C (102.2 degrees F).
• Consider tympanocentesis for AOM with repeated treatment failure.

Management

• Assess and treat pain (Strong recommendation); oral analgesics (ibuprofen for infants ≥ 6 months old or acetaminophen) are the mainstay of treatment.
• Antibiotics
  • Antibiotics are usually indicated for infants < 6 months old and children at increased risk for complications due to an underlying condition.
  • Antibiotics should also be given to children aged 6-24 months with bilateral AOM, and any child with moderate or severe otalgia, otalgia for ≥ 48 hours, or temperature ≥ 39 degrees C (102.2 degrees F) (Strong recommendation).
  • Manage other children with either antibiotic therapy or observation with close follow-up (Strong recommendation).
  • If the decision is made to start antibiotics, use amoxicillin for most children; use amoxicillin-clavulanate if the child received amoxicillin in the past 30 days, has concurrent purulent conjunctivitis, or has a history of recurrent AOM that was unresponsive to amoxicillin (Strong recommendation).
  • Consider a cephalosporin if the child has a nonsevere allergic reaction to penicillin.
  • Consider an antibiotic duration of 5 to 10 days, depending on the age of the child and AOM severity.
• Reassess if symptoms worsen or fail to improve within 48-72 hours (Strong recommendation).
• Tympanostomy tubes may be considered for children with recurrent AOM (Weak recommendation), but should not be offered to children with recurrent AOM who do not have middle ear effusion in either ear at the time of assessment for tube candidacy, unless they are at risk for speech, language, or learning problems, are immunosuppressed, or have a history of severe or persistent AOM, otitis-related complications, or antibiotic allergy or intolerance (Strong recommendation).
• Do not use prophylactic antibiotics to reduce the frequency of AOM episodes in children with recurrent AOM (Strong recommendation).