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.

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

1.1.3 Give advice about:

  • the usual course of acute otitis media (about 3 days, can be up to 1 week)

  • managing symptoms, including pain, with self-care (see the recommendations on self-care).

1.1.4 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.

Children and young people who may be less likely to benefit from antibiotics (those not covered by recommendations 1.1.8 to 1.1.11)

1.1.5 Consider no antibiotic prescription or a back-up antibiotic prescription (see recommendation 1.3.1 for choice of antibiotic), 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.

1.1.6 When no antibiotic prescription is given, as well as the general advice in recommendation 1.1.3, 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.

1.1.7 When a back-up antibiotic prescription is given, as well as the general advice in recommendation 1.1.3, 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.

See the evidence and committee discussion on no antibiotic and back-up antibiotics.

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)

1.1.8 Consider no antibiotic prescription with advice (see recommendation 1.1.6), a back-up antibiotic prescription with advice (see recommendation 1.1.7) or an immediate antibiotic prescription (see recommendation 1.3.1 for choice of antibiotic), 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.

1.1.9 When an immediate antibiotic prescription is given, as well as the general advice in recommendation 1.1.3, give advice about seeking medical help if symptoms worsen rapidly or significantly, or the child or young person becomes systemically very unwell.

See the evidence and committee discussion on no antibiotic, back-up antibiotics and choice of antibiotic.

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

1.1.10 Offer an immediate antibiotic prescription (see recommendation 1.3.1 for choice of antibiotic) with advice (see recommendation 1.1.9), or further appropriate investigation and management.

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

  • a severe systemic infection (see the NICE guideline on sepsis)

  • acute complications, including mastoiditis, meningitis, intracranial abscess, sinus thrombosis or facial nerve paralysis.

See the evidence and committee discussion on choice of antibiotic.

1.2 Self-care

All children and young people with acute otitis media

1.2.1 Offer regular doses of paracetamol or ibuprofen for pain, using the right dose for the age or weight of the child at the right time, and maximum doses for severe pain.

1.2.2 Explain that evidence suggests decongestants or antihistamines do not help symptoms.

See the evidence and committee discussion on self-care.

1.3 Choice of antibiotic

1.3.1 Follow table 1 when prescribing an antibiotic for children and young people with acute otitis media.

Table 1 Antibiotics for children and young people under 18 years

Antibiotic 1

Dosage and course length 2

First choice

Amoxicillin

1 to 11 months, 125 mg three times a day for 5 to 7 days

1 to 4 years, 250 mg three times a day for 5 to 7 days

5 to 17 years, 500 mg three times a day for 5 to 7 days

Alternative first choices for penicillin allergy or intolerance 3

Clarithromycin

1 month to 11 years:

  • Under 8 kg, 7.5 mg/kg twice a day for 5 to 7 days

  • 8 to 11 kg, 62.5 mg twice a day for 5 to 7 days

  • 12 to 19 kg, 125 mg twice a day for 5 to 7 days

  • 20 to 29 kg, 187.5 mg twice a day for 5 to 7 days

  • 30 to 40 kg, 250 mg twice a day for 5 to 7 days

12 to 17 years, 250 mg to 500 mg twice a day for 5 to 7 days

Erythromycin

1 month to 1 year, 125 mg four times a day or 250 mg twice a day for 5 to 7 days

2 to 7 years, 250 mg four times a day or 500 mg twice a day for 5 to 7 days

8 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

Second choice (worsening symptoms on first choice taken for at least 2 to 3 days)

Co-amoxiclav

1 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day for 5 to 7 days

1 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 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 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

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

2 The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction 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.

3 Erythromycin is preferred in young women who are pregnant.

See the evidence and committee discussion on choice of antibiotic and antibiotic course length.

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)