Recommendations

1.1 Managing acute otitis media

All children and young people with acute otitis media

1.1.1

Be aware that:

acute otitis media is a self-limiting infection that mainly affects children
acute otitis media can be caused by viruses and bacteria, and it is difficult to distinguish between these (both are often present at the same time)
symptoms last for about 3 days, but can last for up to 1 week
most children and young people get better within 3 days without antibiotics
complications such as mastoiditis are rare. [2018]

1.1.2

Assess and manage children under 5 who present with fever as outlined in the NICE guideline on fever in under 5s. [2018]

1.1.3

Give advice about the usual course of acute otitis media (about 3 days, can be up to 1 week). [2018]

1.1.4

Offer regular doses of paracetamol or ibuprofen for pain. Use the right dose for the age or weight of the child at the right time, and use maximum doses for severe pain. [2018]

1.1.5

Consider eardrops containing an anaesthetic and an analgesic for pain (see recommendation 1.2.1 for choice of treatment) if:

an immediate oral antibiotic prescription is not given (see recommendations 1.1.8 to 1.1.14), and
there is no eardrum perforation or otorrhoea.

Review treatment if symptoms do not improve within 7 days or worsen at any time. [2022]

1.1.6

Explain that evidence suggests decongestants and antihistamines do not help symptoms. [2018]

1.1.7

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

alternative diagnoses, such as otitis media with effusion (glue ear)
any symptoms or signs suggesting a more serious illness or condition
previous antibiotic use, which may lead to resistant organisms. [2018]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the evidence and committee discussion on non-antimicrobial treatments.

Full details of the evidence and the committee's discussion are in the evidence review.

Children and young people who may be less likely to benefit from antibiotics (those not covered by recommendations 1.1.11 to 1.1.14)

1.1.8

Consider no antibiotic prescription or a back-up antibiotic prescription (see recommendation 1.2.1 for choice of treatment), taking account of:

evidence that antibiotics make little difference to symptoms (no improvement in pain at 24 hours, and after that the number of children improving is similar to the number with adverse effects)
evidence that antibiotics make little difference to the development of common complications (such as short-term hearing loss [measured by tympanometry], perforated eardrum or recurrent infection)
evidence that acute complications such as mastoiditis are rare with or without antibiotics
possible adverse effects of antibiotics, particularly diarrhoea and nausea. [2018]

1.1.9

When no antibiotic prescription is given, give advice about:

an antibiotic not being needed
seeking medical help if symptoms worsen rapidly or significantly, do not start to improve after 3 days, or the child or young person becomes systemically very unwell. [2018]

1.1.10

When a back-up antibiotic prescription is given, give advice about:

an antibiotic not being needed immediately
using the back-up prescription if symptoms do not start to improve within 3 days or if they worsen rapidly or significantly at any time
seeking medical help if symptoms worsen rapidly or significantly, or the child or young person becomes systemically very unwell. [2018]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the evidence and committee discussion on no antibiotic and back-up antibiotics.

Full details of the evidence and the committee's discussion are in the evidence review.

Children and young people who may be more likely to benefit from antibiotics (those of any age with otorrhoea or those under 2 years with infection in both ears)

1.1.11

Consider no antibiotic prescription with advice (see recommendation 1.1.9), a back-up antibiotic prescription with advice (see recommendation 1.1.10) or an immediate antibiotic prescription (see recommendation 1.2.1 for choice of treatment), taking account of:

evidence that acute complications such as mastoiditis are rare with or without antibiotics
possible adverse effects of antibiotics, particularly diarrhoea and nausea. [2018]

1.1.12

When an immediate antibiotic prescription is given, give advice about seeking medical help if symptoms worsen rapidly or significantly, or the child or young person becomes systemically very unwell. [2018]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the evidence and committee discussion on no antibiotic, back-up antibiotics and choice of antibiotic.

Full details of the evidence and the committee's discussion are in the evidence review.

Children and young people who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high risk of complications

1.1.13

Offer an immediate antibiotic prescription (see recommendation 1.2.1 for choice of treatment) with advice (see recommendation 1.1.12). [2018]

1.1.14

Refer children and young people to hospital if they have acute otitis media associated with:

a severe systemic infection (see the NICE guidelines on suspected sepsis in under 16s and suspected sepsis in people aged 16 or over)
acute complications, including mastoiditis, meningitis, intracranial abscess, sinus thrombosis or facial nerve paralysis. [2018]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the evidence and committee discussion on choice of antibiotic.

Full details of the evidence and the committee's discussion are in the evidence review.

1.2 Choice of treatment

1.2.1

Follow table 1 when prescribing treatment for children and young people with acute otitis media. [2018, amended 2022]

**Table 1 Treatment for children and young people under 18 years**
Treatment	Choice, dosage and course length
Eardrops containing an anaesthetic and an analgesic	Phenazone 40 mg/g with lidocaine 10 mg/g: Apply 4 drops two or three times a day for up to 7 days Use only if an immediate oral antibiotic prescription is not given, and there is no eardrum perforation or otorrhoea
First-choice oral antibiotic	Amoxicillin: 1 month to 11 months, 125 mg three times a day for 5 to 7 days 1 year to 4 years, 250 mg three times a day for 5 to 7 days 5 years to 17 years, 500 mg three times a day for 5 to 7 days
Alternative first choice for penicillin allergy or intolerance (for people who are not pregnant)	Clarithromycin: 1 month to 11 years: under 8 kg, 7.5 mg/kg twice a day for 5 to 7 days 8 kg to 11 kg, 62.5 mg twice a day for 5 to 7 days 12 kg to 19 kg, 125 mg twice a day for 5 to 7 days 20 kg to 29 kg, 187.5 mg twice a day for 5 to 7 days 30 kg to 40 kg, 250 mg twice a day for 5 to 7 days 12 years to 17 years, 250 mg to 500 mg twice a day for 5 to 7 days
Alternative first choice for penicillin allergy in pregnancy	Erythromycin: 8 years to 17 years, 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 to 7 days Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.
Second-choice oral antibiotic (worsening symptoms on first choice taken for at least 2 to 3 days)	Co-amoxiclav: 1 month to 11 months, 0.25 ml/kg of 125/31 suspension three times a day for 5 to 7 days 1 year to 5 years, 5 ml of 125/31 suspension three times a day or 0.25 ml/kg of 125/31 suspension three times a day for 5 to 7 days 6 years to 11 years, 5 ml of 250/62 suspension three times a day or 0.15 ml/kg of 250/62 suspension three times a day for 5 to 7 days 12 years to 17 years, 250/125 mg or 500/125 mg three times a day for 5 to 7 days
Alternative second choice for penicillin allergy or intolerance	Consult local microbiologist

See the BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.

The age bands apply to children of average size. In practice, the prescriber will use the age bands along with other factors such as the severity of the condition and the child's size in relation to the average size of children of the same age. Doses given are by mouth using immediate-release medicines, unless otherwise stated. [2018]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the evidence and committee discussion on choice of antibiotic and antibiotic course length.

Full details of the evidence and the committee's discussion are in the evidence review.