Otitis Media in Children

Comments from Expert Advisory Committee

• Acute otitis media (AOM) is very common in children.
• The cause of the majority of AOM cases is viral.
• Illness resolves over 3 days in 80% without antibiotics
• AOM is usually self-limiting even if it from a bacterial cause.
  • It is often difficult to distinguish between viral or bacterial otitis media (both are often present at the same time).
• Pain relief and parent information are the most important factors.
• Treat pain with adequate and regular simple analgesia.
  • Regular paracetamol or ibuprofen at correct maximum dose for weight (see dosing tables for paediatric analgesia).
• Healthcare professionals can use their clinical judgement to decide when dosing by weight is more appropriate (e.g. for underweight children) as per the dosing charts.
  • Weight-based dosing for Paracetamol in Children PDF 785.3 KB
  • Weight-based dosing for Ibuprofen in Children PDF 781.7 KB

Consider no antibiotics in the majority of children

• GPs can use the Respiratory infection information leaflet (including self-care and safety-netting advice) (PDF 488 KB) during consultations with patients aged 3 months and above presenting with otitis media where there is no immediate need for an antibiotic.
• Children aged ≥ 2 years or children < 2 years with only 1 ear affected and no otorrhoea.
  • Consider no antibiotics, or, a back-up prescription to be used if no improvement in 3 days or if symptoms worsen.
• Those that may benefit from immediate antibiotics are children aged <2 years with bilateral infection or those with otorrhoea secondary to a perforated eardrum.
  • Other options in these patients include no antibiotic or a back-up prescription to use if symptoms worsen or fail to improve within 3 days.
• Advise parents:
  • Most children and young adults get better within 3 days without antibiotics.
  • Symptoms last for about 3 days but can last for up to 1 week.
  • To return if symptoms worsen rapidly or significantly.

Overall evidence on antibiotics in acute otitis media:

• Most children will get better within 3 days without antibiotics.
• Antibiotics make little difference to the number of children whose symptoms improve.
• Antibiotics make little difference to the time it takes for the symptoms to improve.
• Antibiotics have minimal impact on recurrence, short term hearing loss or eardrum perforation.
• Complications from otitis media i.e. mastoiditis are rare with or without antibiotics.
  • We would need to treat 2504 patients <20 years with antibiotics to prevent 1 case of mastoiditis.
• Complications from antibiotics including diarrhoea and nausea are relatively common.

Evidence for other medications in otitis media

• Decongestants, antihistamines and corticosteroids have not been shown to be effective in AOM.

Treatment

If antibiotics deemed clinically indicated:

Safe Prescribing (visit the safe prescribing page)

• Dosing in children quick reference dosage/weight guide
• Clarithromycin and other macrolides warning
• Penicillin allergy – tips on prescribing in penicillin allergy
• Renal impairment dosing table
• Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
• Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed August 2022, minor edit November 2024