It’s been nine years since the American Academy of Pediatrics published clinical guidelines for the diagnosis and treatment of ear infections (otitis media).  After a four year review, the guidelines have been revised and published in Pediatrics.

The goal is to minimize the chances of bacteria developing resistance to antibiotics by providing fewer antibiotics to children who may likely resolve their ear infections without them.  It’s preaching to the choir for pediatricians, but hopefully, it will sink in for providers at community emergency departments and the proliferating urgent care businesses, who don’t have the experience and/or comfort level with caring for sick children.

There is more detail within the recommendations, but briefly, here are the main points:

  • The ear had better look infected in order to make a diagnosis of acute otitis media (ear infection).  Simply having fluid behind the tympanic membrane (ear drum), or simply having a red ear drum is not enough.  The ear drum should be sufficiently inflamed (red) and bulging — if not perforated and draining — to be deemed acutely infected. 
  • The diagnosis can also be made if the ear doesn’t look so bad but the child is having pain within 48 hours of the visit.  In other words, complaining of pain 3 days ago but not now may not buy an antibiotic.
  • In young children ages 6-23 months, treatment of acute ear infections with an antibiotic is recommended most of the time.  If only one ear is infected — and not severely — in this age group, the choice of watchful waiting with close follow-up vs. antibiotics should be made as a joint decision between provider and parent.
  • Children older than two with non-severe symptoms of an acute ear infection can also be given the option of antibiotics vs. observation.  Here the symptoms dictate the management.  Kids with moderate-to-severe pain or fever greater than 102 should receive an antibiotic, while those with less pain or low-grade fever can be given the option.
  • High-dose amoxicillin should be the first-line antibiotic used for acute otitis media in children who are not penicillin-allergic, haven’t had amoxicillin in the past 30 days, or who don’t have a purulent conjunctivitis (pink-eye) with their ear infection.  Cefdinir is the first-line antibiotic for those who are allergic to penicillin.  Azithromycin (Zithromax) isn’t even mentioned due to its tendency to cause bacterial resistance.
  • Placement of tympanostomy tubes by an ENT surgeon should be considered after three acute ear infections in a six month period, or four acute ear infections in a year.
  • Prevention of ear infections should be attempted by giving pneumococcal and influenza vaccines to all children per the standard immunization schedule.  Breastfeeding infants exclusively for the first six months should be encouraged. Exposure to tobacco smoke should be avoided.


Also, the duration of antibiotic treatment can be considered age-dependent, dictated by  the clinical situation.  For instance, children under 2 years old should get 10 days of antibiotics.  Those between 2-5 years old can get 7 days of antibiotics, and kids older than 6 years old should be able to get by with as little as 5-7 days of antibiotics.  Longer therapy does not produce a better outcome.

So there it is.  If your child has an acutely infected ear causing significant pain and/or fever, an antibiotic should be offered.  All others may be given the option of antibiotics vs. observation.  Ears that simply have fluid (middle ear effusions) are not acutely infected and should not be treated with antibiotics.  It will be up to us to explain what we are seeing and why we think an antibiotic should or shouldn’t be used.  It will be up to parents to help us determine what is best for their child.  As it should be.

Read the AAP‘s newly revised Clinical Practice Guidelines on The Diagnosis and Management of Acute Otitis Media here.