Pediatric Ear Infection: Updated AAP Treatment Guidelines

Laurie Barclay, MD

February 25, 2013

Updated American Academy of Pediatrics (AAP) clinical practice guidelines address the diagnosis and management of uncomplicated acute otitis media (AOM) in children aged 6 months to 12 years. The new recommendations, which offer more rigorous diagnostic criteria to reduce unnecessary antibiotic use, were published online February 25 and in the March issue of Pediatrics.

"Although OM remains the most common condition for which antibacterial agents are prescribed for children in the United States, clinician visits for OM decreased from 950 per 1000 children in 1995–1996 to 634 per 1000 children in 2005–2006," write Allan S. Lieberthal, MD, and colleagues. "There has been a proportional decrease in antibiotic prescriptions for OM from 760 per 1000 in 1995–1996 to 484 per 1000 in 2005–2006."

The guideline updates the 2004 AOM guideline from the AAP and American Academy of Family Physicians, based on a comprehensive literature review in 2009 by an expert panel from the AAP, the Agency for Healthcare Research and Quality, and the Southern California Evidence-Based Practice Center. The panel used systematic grading of evidence quality and benefit-harm analysis to develop the guideline, which underwent comprehensive peer review.

Taking into account patient age and symptom severity, AOM may be managed with antibiotics and analgesics or with observation alone. The guidelines cover pain management, antibiotic options, prevention, and recurrent AOM (an addition to the 2004 guideline).

Specific action statements include the following:

  • AOM should be diagnosed when there is moderate to severe tympanic membrane (TM) bulging or new-onset otorrhea not caused by acute otitis externa.

  • AOM may be diagnosed for mild TM bulging and ear pain for less than 48 hours or for intense TM erythema. In a nonverbal child, ear holding, tugging, or rubbing suggests ear pain.

  • AOM should not be diagnosed when pneumatic otoscopy and/or tympanometry do not show middle ear effusion.

  • AOM management should include pain evaluation and treatment.

  • Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least 6 months with severe signs or symptoms (moderate or severe otalgia or otalgia for 48 hours or longer or temperature 39°C or higher) and for nonsevere, bilateral AOM in children aged 6 to 23 months.

  • On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in children aged 6 to 23 months or nonsevere AOM in older children may be managed either with antibiotics or with close follow-up and withholding antibiotics unless the child worsens or does not improve within 48 to 72 hours of symptom onset.

  • Amoxicillin is the antibiotic of choice unless the child received it within 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin. In these cases, clinicians should prescribe an antibiotic with additional β-lactamase coverage.

  • Clinicians should reevaluate a child whose symptoms have worsened or not responded to the initial antibiotic treatment within 48 to 72 hours and change treatment if indicated.

  • In children with recurrent AOM, tympanostomy tubes, but not prophylactic antibiotics, may be indicated to reduce the frequency of AOM episodes.

  • Clinicians should recommend pneumococcal conjugate vaccine and annual influenza vaccine to all children according to updated schedules.

  • Clinicians should encourage exclusive breastfeeding for 6 months or longer.

The AAP supported development of these guidelines and addressed disclosures of the guidelines authors.

Pediatrics. 2013;131:e964-e999.