Ear Infections Treatment Guidelines

To Treat with Antibiotics or Not to Treat...

doctor examining crying child's ear
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Ear infections are the most common bacterial infection in kids, and one of the most common reasons for children to see their Pediatrician and be prescribed antibiotics. With the current concerns about the overuse of antibiotics and that they may not work as well because of resistance, cutting back on antibiotic prescribing for kids with ear infections is likely a good idea.

The latest clinical practice guideline from the American Academy of Pediatrics on the Diagnosis and Management of Acute Otitis Media offers help to parents and pediatricians who want to avoid giving kids antibiotics when they aren't needed.

To understand the guideline, it is important first to understand what it doesn't say. The guideline specifically does not say that antibiotics can't be used to treat ear infections anymore. Instead, they offer guidelines so that you can choose which children may not need antibiotics to treat their ear infection and may be simply observed instead.

The clearest part of the guidelines is that children under six months of age should always be treated with antibiotics when they have an ear infection. For children between six months and two years of age, they should also be prescribed antibiotics if your pediatrician is sure of their diagnosis, or if they are unsure, but your child has severe symptoms, like severe ear pain or fever at or above 102.2 degrees Fahrenheit. Older children, over two years of age, usually don't need antibiotics at first, unless they have severe symptoms, and can instead be managed using an 'observation option'.

The Observation Option

If your child meets the criteria described above and does not have any other medical problems, like Down syndrome, immune system problems, cleft palate, or a cochlear implant, then they may qualify to be observed without being treated with antibiotics. If these children do not improve or worsen over the next 48 to 72 hours, then they should be prescribed antibiotics.

This may mean a return visit to your Pediatrician in some cases, but this may also be done over the phone, or by use of a 'safety-net' antibiotic prescription which your doctor gives you to fill just in case.

This method of observation instead of prescribing antibiotics right away has been working successfully in many other countries and has few risks. It works because most kids with ear infections will likely get better on their own anyway. These children aren't simply left in pain, though. The guidelines strongly recommend steps be taken to reduce the child's pain using acetaminophen or ibuprofen.

If your child has had an ear infection in the previous 30 days or has chronic fluid in their ears, then they will need antibiotics and won't qualify for the 'observation option'.

Diagnosis of Ear Infections

For parents who read the full guidelines, one of the most surprising things is going to be the talk about the 'uncertain diagnosis' of ear infections. The 2004 guidelines used this criterion, while the 2013 guidelines decided that was too fuzzy and set more stringent diagnostic criteria based on the otoscopic exam.  It should seem like a clear cut thing. You look inside a child's ear, and you can tell if it is infected or not, right?

It isn't always that simple, though. Younger children's ears can be difficult to see, especially for health professionals who don't treat a lot of children. The doctor may mistake fluid in the ear for an infection, not even see the ear drum because of ear wax, or they may confuse an ear that is red from fever or crying to be from an infection.

If your doctor has said things like 'it looks a little red' or 'I see a little fluid' then they may not have been making a 'certain' diagnosis of an ear infection. This is especially true if the diagnosis was made when your child had no other symptoms at all.

With a true ear infection, in addition to having fluid in their ear, your child should instead have the more classic symptoms of 'a history of rapid onset of signs and symptoms such as otalgia (or pulling of the ear in an infant), irritability in an infant or toddler, otorrhea, and/or fever.'

Antibiotics for Ear Infections

When required, these new ear infection treatment guidelines also offer specific recommendations about which antibiotics should be used. In most cases, the AAP recommends that children be treated with amoxicillin, using a high or double the typical dose of 80 or 90 mg/kg/day. If the amoxicillin doesn't work after 48 to 72 hours or if the child has a fever at or above 102.2 degrees Fahrenheit, then high dose Augmentin or Augmentin ES should be used instead. After that, or as an alternative if the child is also vomiting, one or three days of intravenous or intramuscular ceftriaxone (Rocephin) can be used.

Other antibiotics specifically mentioned in the guidelines as alternatives for children with penicillin allergies include cefdinir (Omnicef), cefpodoxime (Vantin), and cefuroxime (Ceftin). If the allergy to penicillin included hives or anaphylaxis, then they should be given azithromycin (Zithromax), clarithromycin (Biaxin), or clindamycin.

When prescribed, the guidelines also state that children under age six, and those with severe symptoms, should continue to be prescribed a full ten-day course, while older kids may do just as well with just five or seven days of antibiotics.


The AAP guidelines also recommend trying to reduce risk factors by promoting breastfeeding for at least six months, avoiding exposure to passive smoke, not using a pacifier after six months, and not letting your baby have a bottle while lying down.

Will the guidelines make a big difference? Probably not. There are already specific guidelines about treating kids with sinusitis that aren't always followed, and antibiotics continue to be overused to treat colds and sore throats.

The guidelines do offer parents and Pediatricians some 'ammunition' when they want to decrease the use of antibiotics in their children.

Many children are going to meet the criteria of 'severe symptoms' though and will need antibiotics. After all, it is usually the severe ear pain that brings your older child to the doctor, right? And how often has your child had an ear infection and a fever below 102.2?

Still, if your child has an ear infection and you don't think that he needs antibiotics, be sure to ask your Pediatrician if they are necessary or if your child can simply be observed instead.


Allan S. Lieberthal, Aaron E. Carroll, Tasnee Chonmaitree, Theodore G. Ganiats, Alejandro Hoberman, Mary Anne Jackson, Mark D. Joffe, Donald T. Miller, Richard M. Rosenfeld, Xavier D. Sevilla, Richard H. Schwartz, Pauline A. Thomas, David E. Tunkel. Clinical Practice Guideline The Diagnosis and Management of Acute Otitis Media. American Academy of Pediatrics, February, 2013.

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