Acute Otitis Media for the PEBC® Exam: Canadian Paediatric Guidelines and Practice Questions

• Acute onset of symptoms: ear pain in verbal children, or irritability, ear tugging, poor sleep or feeding in younger children.
• Middle ear effusion with inflammation. A bulging tympanic membrane is the most useful sign. Ear drainage through a perforation also supports a bacterial cause.
• Fluid behind the eardrum without inflammation (otitis media with effusion) is not AOM and does not need antibiotics.
• The CPS recommendations apply to children 6 months and older. Infants under 6 months need medical assessment.

Many cases resolve on their own, so the CPS supports observation for selected children. The deciding factors are how sick the child is and whether follow-up is reliable.

• Amoxicillin 75 to 90 mg/kg/day divided twice daily, or 45 to 60 mg/kg/day divided three times daily. These regimens keep middle ear levels high enough to cover pneumococcus, including some strains with reduced penicillin susceptibility.
• Most children improve within 24 hours and settle within 2 to 3 days of starting treatment.

Treatment failure means no symptom improvement after 2 to 3 days of antibiotic therapy. Reassess the diagnosis before switching.

• Amoxicillin-clavulanate is the second-line choice. It is also preferred first-line when the child had amoxicillin in the past 30 days, has concurrent purulent conjunctivitis, or relapses soon after treatment.
• The CPS prefers the 7:1 suspension (400 mg amoxicillin with 57 mg clavulanate per 5 mL). For children 35 kg or less: 45 to 60 mg/kg/day of amoxicillin, divided three times daily, for 10 days. Over 35 kg: 500 mg tablets three times daily for 10 days.
• Keeping the clavulanate dose low limits diarrhea. Do not simply add a 4:1 product on top of high-dose amoxicillin.
• Ceftriaxone 50 mg/kg IM or IV once daily for 3 days is an option if oral therapy cannot be taken or amoxicillin-clavulanate fails.

Take a careful allergy history. Many reported penicillin allergies are vague childhood rashes, and choosing a macrolide when a cephalosporin would be appropriate means weaker therapy.

• The CPS stresses that analgesic advice is essential, whether or not antibiotics are started.
• Acetaminophen 10 to 15 mg/kg per dose every 4 to 6 hours, or ibuprofen 5 to 10 mg/kg per dose every 6 to 8 hours, dosed by weight. Avoid ibuprofen if the child is dehydrated or has relevant contraindications.
• Decongestants and antihistamines do not help AOM and are not recommended for young children. Cough and cold products are not for children under 6.
• Do not put drops in an ear that may have a perforated eardrum unless a prescriber has confirmed a safe product.

• Using standard-dose amoxicillin (40 mg/kg/day) instead of the CPS regimen.
• Giving 10 days to an uncomplicated 3-year-old (5 days) or 5 days to an 18-month-old (10 days).
• Calling it failure on day 1. Failure is no improvement after 2 to 3 days.
• Choosing azithromycin for a child with a mild rash to penicillin, when a cephalosporin is preferred.
• Repeating amoxicillin for a child who took it in the past 30 days.
• Applying the CPS algorithm to an infant under 6 months.
• Mixing up mg and mL when the suspension strength changes. Always show the units.

For more weight-based calculation practice and how infection topics are weighted, see the exam guide. Immunization lowers pneumococcal and influenza-related ear infections, so link this case to vaccines.

• Age under 6 months with fever or suspected ear infection.
• Swelling, redness or tenderness behind the ear, or the ear pushed forward (possible mastoiditis).
• Stiff neck, lethargy, severe headache, facial weakness or a child who looks toxic.
• No improvement after 2 to 3 days of antibiotics, or worsening at any point.
• Frequent recurrences, or hearing or speech concerns.