Last updated March 14, 2022

Diagnosis and Management of Acute Otitis Media

Key Action Statements

Clinicians should diagnose acute otitis media (AOM) in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa. (B, Moderate)
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Clinicians should diagnose AOM in children who present with mild bulging of the TM and recent (less than 48 hours) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) or intense erythema of the TM. (C, Moderate)
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Clinicians should not diagnose AOM in children who do not have middle ear effusion (MEE) (based on pneumatic otoscopy and/or tympanometry). (B, Moderate)
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The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain. (B, Strong)
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Severe AOM

The clinician should prescribe antibiotic therapy for AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (ie, moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C [102.2°F] or higher). (B, Moderate)
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Nonsevere bilateral AOM in young children:

The clinician should prescribe antibiotic therapy for bilateral AOM in children 6 months through 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). (B, Moderate)
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Nonsevere unilateral AOM in young children:

The clinician should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision-making with the parent(s)/caregiver for unilateral AOM in children 6 months to 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms. (B, Moderate)
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Nonsevere AOM in older children:

The clinician should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision-making with the parent(s)/caregiver for AOM (bilateral or unilateral) in children 24 months or older without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms. (B, Moderate)
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Clinicians should prescribe amoxicillin for AOM when a decision to treat with antibiotics has been made and the child has not received amoxicillin in the past 30 days or the child does not have concurrent purulent conjunctivitis or the child is not allergic to penicillin. (B, Moderate)
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Clinicians should prescribe an antibiotic with additional β-lactamase coverage for AOM when a decision to treat with antibiotics has been made, and the child has received amoxicillin in the last 30 days or has concurrent purulent conjunctivitis, or has a history of recurrent AOM unresponsive to amoxicillin. (C, Moderate)
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Clinicians should reassess the patient if the caregiver reports that the child’s symptoms have worsened or failed to respond to the initial antibiotic treatment within 48 to 72 hours and determine whether a change in therapy is needed. (B, Moderate)
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Clinicians should not prescribe prophylactic antibiotics to reduce the frequency of episodes of AOM in children with recurrent AOM. (B, Moderate)
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Clinicians may offer tympanostomy tubes for recurrent AOM (3 episodes in 6 months or 4 episodes in 1 year with 1 episode in the preceding 6 months). (B, Weak)
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Clinicians should recommend pneumococcal conjugate vaccine to all children according to the schedule of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, American Academy of Pediatrics (AAP), and American Academy of Family Physicians (AAFP). (B, Strong)
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Clinicians should recommend annual influenza vaccine to all children according to the schedule of the Advisory Committee on Immunization Practices, AAP, and AAFP. (B, Moderate)
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Clinicians should encourage exclusive breastfeeding for at least 6 months. (B, Moderate)
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Clinicians should encourage avoidance of tobacco smoke exposure. (C, Moderate)
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Recommendation Grading

Overview

Title

Diagnosis and Management of Acute Otitis Media

Authoring Organization

Publication Month/Year

May 1, 2013

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Adolescent, Child, Infant

Health Care Settings

Ambulatory, Emergency care, Hospital, Outpatient

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Keywords

immunization, otitis media, otoscopy, otitis media with effusion, tympanostomy tubes, acute otitis media, breast feeding

Source Citation

Allan S. Lieberfall, et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013; 131 (3) e964-e999.