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AAP/AAFP guideline for acute otalgia in children

Clinical Question:
What is the best approach to the diagnosis and management of acute ear pain in children?

Bottom Line:
According to this guideline from the American Academy of Pediatrics and the American Academy of Family Physicians, the trick to diagnosing acute otitis media (AOM) in children with signs of ear pain is to identify the children most likely to respond to antibiotic treatment and treat only them. When antibiotics are used, amoxicillin is the way to go for most children. Further guidance is outlined below. The full guidelines, available at: http://tinyurl.com/aqpjc5q, provide even more detail. (LOE = 5)

Lieberthal AS, Carroll AE, Chonmaitree T, et al. Clinical practice guideline. The diagnosis and management of acute otitis media. Pediatrics 2013;131(13):e964-e999.  [PMID:23439909]

Study Design:
Practice guideline

Self-funded or unfunded

Outpatient (primary care)

These guidelines are a revision of the 2004 guidelines from the same groups. The guidelines were developed following an extensive literature review. The guideline development group was composed of members from both professional societies that, for the most part, had no intellectual or financial conflicts of interest. There was a risk of professional conflict of interest, given that there were no patients or nonphysicians in the group. The group issued the following guidance: Diagnosis: All ear symptoms are not AOM, at least not AOM that will benefit from antibiotic treatment. Signs and symptoms that predict a benefit of antibiotic treatment include bulging eardrum or otorrhea with signs of pain or intense erythema, along with objective evidence of middle ear effusion. The guidelines suggest AOM not be diagnosed without the presence of this effusion. Treatment: Provide pain relief. Antibiotics should be used in children older than 6 months with moderate to severe pain or pain for at least 48 hours and a fever, or children 6 months to 23 months of age with nonsevere bilateral AOM. Either observation or antibiotic treatment is recommended for children older than 6 months without severe signs or symptoms. Amoxicillin should be used for most children; amoxicillin/clavulanate is an option, especially if the child has been treated within the past 30 days or has concurrent conjunctivitis. Cefdinir, cefuroxime, and cefpodoxime are alternatives, especially in children allergic to penicillins. Clindamycin with or without third-generation cephalosporin can be used as an alternative in patients not responding to the initial treatment choice. Macrolides and sulfonamides are not recommended. The duration of treatment should be 10 days for children younger than 2 years and children with severe symptoms. Children aged 2 to 5 years can be treated for 7 days. Children 6 years and older can be treated for 5 to 7 days. Prophylactic antibiotics are not recommended for children with frequent infections.


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