A two-year-old child presents to your office with a runny nose and a temperature of 39°C (102.2°F); he’s tugging at his right ear. His mother reports that these symptoms have been present for a day. His appetite and fluid intake are good, and while a bit irritable, he does not appear lethargic or toxic. The tympanic membrane is dull but not erythematous. It has limited mobility. What would be the best way to manage this patient’s illness?

Evidence summary

The AAFP and the American Academy of Pediatrics recently released an evidence-based practice guideline that helps physicians provide the most up-to-date care for children with acute otitis media (AOM).¹ The committee of experts from both specialties, as well as experts in infectious disease, epidemiology and otolaryngology, reviewed the best available evidence before making its recommendations. All recommendations have been carefully substantiated by research evidence and each has been assigned a rating for the strength of the evidence.

The guideline applies to otherwise healthy children age two months to 12 years with uncomplicated AOM. It begins by defining acute otitis media: A definite diagnosis of AOM requires an acute onset of signs and symptoms, evidence of a middle-ear effusion, and signs and symptoms of middle ear inflammation. Patients suspected of having AOM who do not meet all three of these criteria are described by the guideline as having an uncertain diagnosis of AOM. It is also important to distinguish AOM, which may benefit modestly from antibiotics, from otitis media with effusion, which does not. The authors of the guideline strongly recommend that the physician include an assessment of the child’s pain, since this assessment is the first step to reducing pain. Too often, patients leave with an antibiotic but without a recommendation for analgesia.

The authors recommend acetaminophen and ibuprofen as the mainstays of pain relief, although topical and naturopathic agents also have evidence to support their effectiveness. Physicians should choose an agent based on their evaluation of its risks and benefits, taking into account parent or caregiver and patient preference.

The decision to prescribe antibiotics depends on the child’s age, the certainty of the diagnosis and the severity of symptoms. Severe AOM is characterized by severe otalgia and/or a temperature of 39°C (102.2°F) or higher. In certain circumstances, provided that follow-up in 48 to 72 hours can be assured and analgesia is provided, observation without antibiotics is an option. This should be considered in children who fall into one of the following categories: 1) age six months to two years with an uncertain diagnosis and nonsevere symptoms, 2) age over two years with a certain diagnosis but nonsevere symptoms, and 3) age over two years with an uncertain diagnosis. The guideline cites studies showing that the majority of children improve within three days of presentation, even without antibiotics,^2,3 and that the risk of complications is no higher with delayed antibiotic treatment.⁴ If antibiotics are needed, amoxicillin is recommended as initial management in a dose of 80 mg per kg per day to 90 mg per kg per day (in divided doses) for nonsevere illness, and amoxicillin-clavulanate is recommended in a dose of 90 mg per kg per day (in divided doses) for children with severe symptoms or for those who need additional coverage for beta lactamase positive H. influenzae and M. catarrhalis.

Applying the guideline

Based on the AAFP/AAP guideline, a suggested encounter form for children age two months to 12 years presenting with earache is shown below (and can also be downloaded). Using the encounter form, a physician could quickly conclude that the hypothetical patient described above has an uncertain diagnosis of AOM. Although there is evidence of effusion and an acute onset of symptoms, there is no evidence of inflammation. The illness is not severe, with a low-grade fever and non-specific tugging at his ear. It would be reasonable to provide analgesia in the form of acetaminophen and have the parents observe the child carefully for 48 to 72 hours. If he does not improve, or shows signs of worsening, they should return for reevaluation. If antibiotics are required and symptoms are not severe, amoxicillin at a dose of 80 mg per kg per day to 90 mg per kg per day is the best choice for non-allergic patients.