Middle ear infections, commonly referred to as acute otitis media (AOM) by healthcare professionals, are the most common childhood infections in the United States. Approximately 75-80% of all children will experience a case of AOM before the age of 3 years.
AOM can be caused by either viruses or bacteria. Most commonly, AOM appears as a complication of an upper respiratory tract infection or it can appear as a stand-alone infection.
Symptoms of AOM can begin rapidly and encompass ear pain, fluid spilling out of the ear (otorrhea), bulging eardrums, fever, and/or tugging of the ears as an expression of discomfort.
Depending on the etiology of AOM, different treatment courses can be tried. Observation is an important first step for many children that have milder cases of AOM. If symptoms worsen or don’t improve, then antibiotics can be started if the infection is thought to be of bacterial origin.
The American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP) together produced a guideline that discusses optimal ways to treat AOM in children. It provides recommendations for the management of children from 6 months through 12 years of age with uncomplicated AOM. Highlights of the guideline are discussed below in addition to insights from other resources.
Observation
For many cases of AOM, observation is recommended for 48-72 hours after symptoms begin. However, this observation period is also dependent on the child’s age, extent of infection, and concurrent medical conditions. This period is to evaluate if symptoms can subside naturally. In many cases, they do. If symptoms do not improve, then antibiotic therapy can be considered.
If a child has moderate-severe ear pain for more than 48 hours or if they have a temperature higher than 102.2℉ (39℃), then observation typically isn’t appropriate and treatment should be started. Similarly, if a child between 6-23 months has symptoms in both ears, then observation generally isn’t advisable.
It may seem counter-intuitive to initially not treat a suspected infection, especially in a young child. However, observation is beneficial to avoid over-treatment and/or needless treatment. By avoiding unnecessary treatment, medication side effects can be avoided and it’s a helpful step toward minimizing antibiotic resistance. Overuse of antibiotics is leading to diseases that are becoming resistant to the medication, making it harder to treat patients.
TIP: it is common for parents or caregivers to take their children to their pediatrician for evaluation for a suspected ear infection. In many cases, even if observation is warranted, a pediatrician will give the parent or caregiver a prescription for antibiotics and to “wait a few days” prior to potentially filling the prescription. If the pediatrician offers this advice, it’s important to follow that advice rather than immediately filling the prescription.
Antibiotic Treatment
Antibiotic treatment is typically started if symptoms persist after 48-72 hours of observation and if the cause of AOM isn’t deemed to be of viral origin.
First-line antibiotic options to treat AOM are amoxicillin or Augmentin (amoxicillin/clavulanate). Both of these medicines fall into the penicillin family of antibiotics.
If a child has a true penicillin allergy, then cefdinir, cefuroxime, cefpodoxime, or ceftriaxone can be considered. These medicines are classified as cephalosporins. Cephalosporins generally have a 10% risk of cross-reacting in patients with a penicillin allergy.
For children that have frequent, recurring cases of AOM, antibiotics should not be used in a preventative (prophylactic) manner. Antibiotics should only be used for treatment. The pediatrician will determine the most optimal antibiotic for a child when needed.
Antiviral Treatment
For cases of AOM caused by a virus, antibiotics will be ineffective. The best treatment for viral AOM is supportive care for pain and fever. This commonly takes the form of acetaminophen (Tylenol) and/or ibuprofen (Advil). Supplemental remedies can also be trialed, such as using warm compresses or standing tall to aid ear drainage. Limited antiviral therapy options are available for AOM.
It is hard for the average parent to distinguish between a bacterial infection and a viral infection. A best practice is to let the pediatrician determine the cause of AOM and how treatment should proceed.
Vaccination Considerations
The Centers for Disease Control and Prevention (CDC) publishes vaccine schedules for children and adults that are updated on an annual basis. Specific vaccinations, namely pneumococcal and influenza vaccines, can help to decrease the frequency and/or severity of AOM.
The pneumococcal conjugate (PCV13, Prevnar 13) vaccine is recommended for all children starting at 2 months of age. This is a 4-dose series. The pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23) may be considered in select high-risk children at 2 years of age or older. High risk encompasses children that have chronic heart disease, chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus, cerebrospinal fluid leaks, and/or cochlear implant(s).
The annual influenza vaccine should be given to all patients greater than 6 months of age who do not have a contraindication to the vaccine.
Although AOM is very common amongst children in the United States, it is also highly treatable. Although AOM can occur at any age, it is most commonly seen between the ages of 6 to 24 months.
References:
- Lieberthal AS, Carroll AE, Chonmaitree A, et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. March 2013, 131 (3) e964-e999; DOI: https://doi.org/10.1542/peds.2012-3488
- Nokso-Koivisto J, Marom T, Chonmaitree T. Importance of viruses in acute otitis media. Curr Opin Pediatr. 2015;27(1):110‐115. doi:10.1097/MOP.0000000000000184
- Ear Infections in Children. NIH: National Institute on Deafness and Other Communication Disorders (NIDCD). Last Updated 12 May 2017.
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