Otitis Media in Young Children
Published April 9, 2025
N Engl J Med 2025;392:1418-1426
DOI: 10.1056/NEJMcp2400531
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This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.
An otherwise-healthy 9-month-old girl in whom symptoms of an upper respiratory tract infection had developed 4 days earlier presents with a 1-day history of increased fussiness and difficulty sleeping reported by a parent. On examination, she is afebrile and slightly fussy. Her right tympanic membrane, which can be visualized only partially owing to the presence of cerumen, appears opacified. How would you treat this child?
The Clinical Problem
Acute otitis media remains one of the most frequently diagnosed infectious diseases in children younger than 2 years of age. By 2 years of age, 41% of children will have had at least one episode of acute otitis media and 13% will have had at least three episodes.1 Although the incidence of acute otitis media, and particularly of recurrent and refractory cases,2 has been decreasing,3,4 approximately 15 million cases are diagnosed each year in the United States.3 The decrease in the incidence of acute otitis media, especially among children younger than 2 years of age,4 is likely to be attributable to universal vaccination with pneumococcal conjugate vaccines5 and to increased stringency in the diagnostic criteria.6 Exposure to large numbers of other children (e.g., in day care), male sex, shorter duration of breast-feeding, exposure to tobacco smoke, Down’s syndrome, and immunologic deficiencies (e.g., hypogammaglobulinemia) are associated with an increased risk of acute otitis media.7-9
Key Clinical Points
Otitis Media in Young Children
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Acute otitis media is a bacterial infection that occurs almost exclusively after a viral upper respiratory tract infection.
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Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
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Bulging of the tympanic membrane is a defining feature.
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High-dose amoxicillin (80 to 90 mg per kilogram of body weight per day, divided into two doses) remains the first-line treatment. Amoxicillin–clavulanate therapy warrants consideration in children in whom H. influenzae is likely to predominate (i.e., those who have received antibiotics in the previous 30 days, have conjunctivitis–otitis syndrome, or have spontaneous rupture of the tympanic membrane).
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Treatment with antibiotics for 10 days resulted in less treatment failure and less use of rescue antibiotics than treatment for 5 days.
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Tympanocentesis is indicated in children with acute otitis media who have had treatment failure with multiple rounds of antibiotic therapy.
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Among children with recurrent acute otitis media, the incidence of acute otitis media during a 2-year period was similar among those who had placement of a tympanostomy tube and those who received episodic antibiotic treatment.
Source JNEJM 4/10/205, there is more information