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Education & Practice Online First, published on November 12, 2014 as 10.1136/archdischild-2013-305550
GUIDELINE REVIEW

The diagnosis and management

of acute otitis media:
American Academy of Pediatrics
Guidelines 2013
Joe Grainger, Somiah Siddiq
Department of ENT, Birmingham
Childrens Hospital NHS
Foundation Trust, Birmingham,
UK
Correspondence to
Somiah Siddiq, Department of
ENT, Birmingham Childrens
Hospital NHS Foundation Trust,
Steelhouse Lane, Birmingham B4
6NH, UK;
somiah.siddiq@nhs.net
Received 2 December 2013
Revised 23 September 2014
Accepted 1 October 2014

To cite: Grainger J, Siddiq S.

Arch Dis Child Educ Pract Ed
Published Online First: [ please
include Day Month Year]
doi:10.1136/archdischild2013-305550

INFORMATION ABOUT THE CURRENT

GUIDELINE
In February 2013, the American Academy
of Pediatrics (AAP) published a revised
clinical guideline on The Diagnosis and
Management of Acute Otitis Media in children aged 6 months to 12 years.1 This
guideline review summarises this guidance
and compares it with UK guidance on
acute otitis media (AOM).
The AAP guidance is specific to
uncomplicated AOM (see box 2) in an
otherwise healthy child. The guidance
does not apply to children with underlying conditions that may alter the
natural course of AOM, for example, the
presence of grommets, cleft palate,
immune deficiencies and craniofacial
abnormalities.
The revised 35-page AAP guidance culminates into 17 action statements and, of
particular note, clearer diagnostic guidelines and definitions for AOM and guidance on the management of recurrent
AOM. Furthermore, there have been
some changes in guidance in the use of
antibiotics. It was previously recommended that all children between
6 months and 2 years of age with a
certain diagnosis received antibiotics.
Now the guidance offers a choice of
either antibiotic therapy or initial observation for children with unilateral AOM
and mild symptoms. The intended audience for the guideline includes primary
care clinicians, paediatricians and family
physicians, emergency department physicians, otolaryngologists, physician assistants and nurse practitioners.
UK GUIDELINES
The National Institute of Health and
Care Excellence (NICE) as part of its

Clinical Knowledge Summaries (CKS)

service to primary care practitioners in
the UK has published an AOM CKS2 3
(see box 1). Of note, the AAP guidelines
are specific to uncomplicated AOM (see
box 2). However, NICE CKS does not
make this distinctionall children with
AOM are considered, as is their management (see figure 1). This includes potential admission in children <3 months of
age, and when to refer for specialist
assessment in cases of associated fever
(see box 3).
The Scottish Intercollegiate Guidance
Network (SIGN) published national guidance entitled Diagnosis and management
of childhood otitis media in primary
care in 20034 (see box 1). Both, NICE
and SIGN guidance recommend that children diagnosed with AOM should not
routinely be prescribed antibiotics as
initial treatment with emphasis on appropriate analgesia.
DIAGNOSIS OF AOM
Accurate diagnosis of AOM is essential for
appropriate management and high quality
research.
The most useful examination finding is the
position of the tympanic membrane (TM)
to distinguish AOM from glue ear/otitis
media with effusion (OME) (see figure 2).
Children have AOM if they present with a
moderate to severe bulging of the TM or
new onset ottorhoea not due to acute
otitis externa. Evidence quality: Grade
B. Strength: Recommendation.
Children may have AOM if they present
with mild bulging of the TM and <48 h
onset of ear pain (tugging, holding or
rubbing the ear in a non-verbal child) or
intense erythema of TM. Evidence quality:
Grade C. Strength: Recommendation.

Grainger J, et al. Arch Dis Child Educ Pract Ed 2014;0:15. doi:10.1136/archdischild-2013-305550

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Guideline review
Box 1

Resources

Link to full AAP Guidance: The Diagnosis and

Management of Acute Otitis Media
http://pediatrics.aappublications.org/content/early/2013/
02/20/peds.2012-3448
Link to NICE, AOM, Clinical Knowledge Summary
http://cks.nice.org.uk/otitis-media-acute#!topicsummary
Link to SIGN guidelines
http://www.sign.ac.uk/pdf/sign66.pdf
NICE, National Institute of Health and Care Excellence;
AAP, American Academy of Paediatrics; AMO, acute
otitis media; SIGN, Scottish Intercollegiate Guidelines
Network.
A diagnosis of AOM cannot be made in the absence of a
middle ear effusion based upon pneumatic otoscopy and/
or tympanometry (see box 2). Evidence Quality: Grade
B. Strength: Recommendation.

ANALGESIA
An assessment of pain should be made in all patients
with AOM and appropriate analgesia recommended
regardless of antibiotic use. Evidence quality: Grade
B. Strength: Strong recommendation.
Antibiotic therapy alone does not provide symptomatic
relief in the first 24 h.
The mainstay of analgesia in AOM is ibuprofen and/or
paracetamol.

ANTIBIOTICS
Antibiotics should be prescribed in AOM (bilateral or
unilateral) in children 6 months and older with severe
AOM. Evidence quality: Grade B. Strength: Strong
recommendation.

Box 2

Definition of terms

Uncomplicated AOM: AOM without ottorhoea.

Severe AOM: AOM with moderate to severe otalgia, or
fever 39C.
Non-severe AOM: AOM with mild otalgia and a temperature below 39C.
Recurrent AOM: Three or more documented episodes
in the preceding 6 months, or 4 or more episodes in
the preceding 12 months, with at least 1 episode in
the past 6 months.
Tympanometry: Measuring transfer of acoustic energy
of the ear as a function of ear canal air pressure.
Pneumatic otoscopy: Standard tool used in diagnosing
otitis media by applying negative and positive pressure to assess mobility of the eardrum.
AOM, acute otitis media.
2

Antibiotics should be prescribed in non-severe bilateral

AOM in children aged 6 to 23 months. Evidence quality:
Grade B. Strength: Recommendation.
Antibiotic therapy or close observation may be considered in non-severe unilateral AOM in younger children
(623 months), and in bilateral or unilateral non-severe
AOM in older children (over 24 months). Appropriate
arrangements should be in place to start antibiotics if
there is no improvement, or the child worsens within
4872 h following onset of symptoms. Evidence quality:
Grade B. Strength: Recommendation.
First-line antibiotic choice remains high-dose amoxicillin.
Evidence quality: Grade B. Strength: Recommendation.
NICE guidance suggests a dose of 40 mg/kg per day in 3
divided doses compared with the higher doses recommended in the AAP guidance with the rise of penicillinresistant Streptococcus pneumoniae (see Table 5 in full
guidance1). NICE guidance suggests either erythromycin
or clarithromycin in penicillin allergy.
Additional lactamase cover may be required in concurrent conjunctivitis, history of recurrent AOM or recent
treatment with amoxicillin in the last month. Evidence
quality: Grade C. Strength: Recommendation.
Consider changing antibiotics if persistent, severe symptoms and signs beyond 4872 h of initial antibacterial
therapy. Evidence quality: Grade B. Strength:
Recommendation.
In failure of initial therapy, amoxicillinclavulanate is
recommended, or a second-generation or thirdgeneration cephalosporin in penicillin allergy.
The optimal duration of treatment is unclear with recommendation for 10 days in children under 2 years of
age or with severe symptoms and a 5-day to 7-day
course in children above 2 years of age with mild to
moderate symptoms. NICE guidance suggests a duration
of 5 days initially, increased in duration if symptoms are
severe.

RECURRENT AOM
Current guidance does not recommend long-term
prophylactic antibiotics as only modest benefits are
achieved while on treatment with no longer-lasting
benefit after cessation of antibiotics. Evidence quality:
Grade B. Strength: Recommendation.
The small reduction in frequency of AOM episodes
while on long-term antibiotics must be balanced against
the increased risk of adverse effects from antibiotics, cost
and bacterial resistance.
Controversy still exists around the use of grommets for
AOM due to limited data, but grommet insertion has
been shown to improve disease-specific quality-of-life
measures in children, such as hearing loss, speech impairment, emotional distress and activity limitations.
Evidence quality: Grade B. Strength: Option.

PREVENTION OF AOM
The guidance recommends pneumococcal conjugate
vaccine (Evidence quality: Grade B. Strength: Strong

Grainger J, et al. Arch Dis Child Educ Pract Ed 2014;0:15. doi:10.1136/archdischild-2013-305550

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Guideline review

Figure 1 Comparison of NICE, CKS and AAP guidelines (for details regarding dosing and duration of antibiotics refer to original
guidelines in box 1). NICE, National Institute of Health and Care Excellence; CKS, Clinical Knowledge Summaries; AAP, American
Academy of Paediatrics; AMO, acute otitis media.

recommendation) and annual influenza vaccine to all

children (Evidence quality: Grade B. Strength:
Recommendation).
Breast feeding should be encouraged for a minimum of
6 months, but ideally should continue for the first year.
Continue to encourage avoidance of tobacco smoke
exposure.

UNDERLYING EVIDENCE BASE/METHODOLOGY

The AAP guidance literature review involved searches
from 1998 through June 2010 of PubMed, Cochrane
Database of Systematic Reviews, Cochrane Central
Register of Controlled Trials and Education Resources
Information Centre. Seventy-two articles were

included, which were quality rated against established

criteria ( Jadad, QUADAS and GRADE). Decisions
were made on the basis of systematic grading of the
quality of evidence and strength of recommendations
as well as expert consensus when definitive data was
not available (see figure 1 and Table 1 in full guidance1 for definitions of evidence quality and recommendation outcome and evidence-based statements).
WHAT DO I NEED TO KNOW?
What should I stop doing?
Routine use of antibiotics is not warranted in non-severe
AOM.

Grainger J, et al. Arch Dis Child Educ Pract Ed 2014;0:15. doi:10.1136/archdischild-2013-305550

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Guideline review
Box 3

Referral for admission NICE CKS2

Admit for immediate specialist assessment:

Children younger than 3 months with a temperature
of 38C or more.
Children 36 months of age, with a temperature of
39C or more.
Consider admitting:
Children younger than 3 months of age with suspected AOM.
AOM, acute otitis media; CKS, clinical knowledge summaries; NICE, National Institute of Health and Care
Excellence.

What should I start doing?

Review young children with non-severe AOM at 48
72 h, as some may require the initiation of antibiotics if
symptoms do not resolve, or worsen.
Ensure adequate assessment and management of pain,
particularly in children under 2 years of age.
Familiarise yourself with the new immunisation schedule
in England, particularly changes to flu vaccination intervals in children.5

and tympanometry is not always available.

Furthermore, attempting such techniques in a distressed infant is challenging and may give false results.
The development of cost effective, easy-to-use video
pneumatic otoscopes may help this issue and is discussed within the guideline.
Both, training and the use of a high-quality, wellilluminated otoscope is crucial to obtain an accurate
diagnosis of AOM, particularly in observing the loss
of normal landmarks and in identifying the characteristic bagel or doughnut-shaped appearance4 (see
figure 2).
The effectiveness of more recently licensed
pneumococcal (PCV13) and influenza vaccines on
AOM remains to be ascertained.5 Of interest is the
series of changes to Englands national immunisation
programme6 to be introduced over the course of
2013/2014, including annual flu vaccination for all
children aged 216 years, and the impact this may
have on the incidence of AOM.
The revised guidelines do not address management
of AOM in children under 6 months of age and neonates7 which is further compounded by limited clinical evidence and potentially outdated practice. NICE
guidance provides limited extrapolated advice in children under 6 months of age.2

What can I continue to do as before?

Amoxicillin should be considered the first-line antibiotic
in the absence of penicillin allergy.
Refer children with recurrent AOM for further otolaryngology assessment.
Encourage breast feeding during the first year and offer
smoking cessation advice and support.

What should I do differently?

Assess more closely the extent of the bulging of the TM
to accurately diagnose AOM.

UNRESOLVED CONTROVERSIES
A gold standard for the diagnosis of AOM is a challenging goal, in part, because OME often precedes
and follows AOM. Also, in children where wax
obscures the TM and removal is not possible, there
may be further diagnostic uncertainty. Pneumotoscopy
is not widely used or taught in UK clinical practice,

Clinical bottom line

The AAP guidance provides the most recent evidencebased guidelines in the management of acute otitis
media. It is intended to provide a framework for the
management of children with AOM but must be
taken in context with previous national guidance in
the UK.
Greater clarity is provided on the physical diagnostic
criteria for AOM on otoscopy, in particular, the position of the normal versus the bulging tympanic
membrane. The three-criteria approach for the diagnosis of AOM: position, opacification and discolouration, has been previously suggested as a simple and
rapid approach when examining the tympanic membranes of young children.8

Figure 2 (A) Normal tympanic membrane (TM). (B) TM with mild bulging. (C) TM with moderate bulging. (D) TM with severe
bulging. Courtesy of Alejandro Hoberman MD.

Grainger J, et al. Arch Dis Child Educ Pract Ed 2014;0:15. doi:10.1136/archdischild-2013-305550

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Guideline review
Competing interests None.
Provenance and peer review Commissioned; externally peer
reviewed.

REFERENCES
1 Lieberthal AS, Chonmaitree T, Ganiats TG, et al. The diagnosis
and management of acute otitis media. Pediatrics 2013;131:
e96499.
2 NICE Clinical Knowledge Summaries (CKS)Otitis media
Acute. http://cks.nice.org.uk/otitis-media-acute#!topicsummary
3 NICE. Respiratory tract infections: antibiotic prescribing.
Prescribing of antibiotics for self-limiting respiratory tract
infections in adults and children in primary care (NICE

4
5

7
8

guideline). Clinical guideline 69. National Institute for Health

and Clinical Excellence. 2008a. http://www.nice.org.uk
SIGN. Diagnosis and management of childhood otitis media in
primary care. A national clinical guidance. February 2013.
Principi N, Baggi E, Esposito S. Prevention of acute otitis
media using currently available vaccines. Future Microbiol
2012;7:45765.
Department of Health. Gateway reference 00157. https://www.
gov.uk/government/uploads/system/uploads/attachment_data/file/
207008/130613_Flu_Letter_v_29_Gateway_GW_signed.pdf
San LB. Management of acute otitis media in afebrile neonates.
Pediatr Ann 2012;41:2258.
Block SL. Improving the diagnosis of acute otitis media:
Seeing is believing. Pediatr Ann 2013;42:48590.

American Academy of Otolaryngology: head and neck surgery

foundation clinical practice guideline on acute otitis externa 2014
This American guideline updates previous 2006
recommendations providing guidance for primary
care and specialist clinicians for treating children of
2 years and older with acute otitis externa (AOE): a
diffuse inflammation of the external ear canal
pinna and tympanic membrane.1 2

underlying disease, for example, diabetes, HIV and

other immunosuppression, where there is a risk of
necrotising otitis externa
Reassess after 4872 h if there is no response to initial
treatment.
Philippa Prentice

KEY POINTS: WHAT SHOULD I BE DOING?

Distinguish diffuse AOE from other causes of otalgia
and otorrhoea, for example, dermatitis (inflammatory,
contact, allergic), viral infections, furunculosis and
referred pain from other sites
Appropriately assess pain and treat with analgesia such
as non-steroidal anti-inflammatories. There are no specific indications for using anaesthetic ear drops, which
may mask disease progression
Prescribe topical ear drops for uncomplicated AOE for
at least 7 days. Topical preparations include antibiotics
(aminoglycosides, polymyxin B, quinolones), steroids
(hydrocortisone, dexamethasone) and low-pH antiseptics, for example, acetic acid. There is no good evidence to recommend one topical ear drop from
another or monotherapy versus combination treatment
If there is perforation of the tympanic membrane (iatrogenic or disease related), prescribe non-ototoxic ear
drops
Provide education to patients and families to help
delivery of drops and maximise adherence
Do not prescribe systemic antibiotics as initial therapy,
although these may be needed in patients with

Correspondence to
Dr Philippa Prentice, Department of Paediatrics, University of Cambridge,
Box 116, Level 8, Addenbrookes Hospital, Hills Road, Cambridge CB2
0QQ, UK; pmp24@medschl.cam.ac.uk

Competing interests None.

Provenance and peer review Not commissioned; internally
peer reviewed.

To cite Prentice P. Arch Dis Child Educ Pract Ed Published Online First:
[ please include Day Month Year] doi:10.1136/archdischild-2014-307676
Received 7 October 2014
Accepted 8 October 2014

REFERENCES
1 Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical
practice guideline: acute otitis externa executive summary.
Otolaryngol Head Neck Surg 2014;150:1618.
2 Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical
practice guideline: acute otitis externa. Otolaryngol Head
Neck Surg 2014;150(1 Suppl):S124.

Grainger J, et al. Arch Dis Child Educ Pract Ed 2014;0:15. doi:10.1136/archdischild-2013-305550

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The diagnosis and management of acute

otitis media: American Academy of Pediatrics
Guidelines 2013
Joe Grainger and Somiah Siddiq
Arch Dis Child Educ Pract Ed published online November 12, 2014

Updated information and services can be found at:

http://ep.bmj.com/content/early/2014/11/05/archdischild-2013-305550

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