What are the recommended first-line treatments for acute otitis media in children?

First-line treatment for acute otitis media (AOM) in children primarily involves symptomatic management with analgesia. Oral analgesics such as paracetamol or ibuprofen are recommended to relieve pain, as both have been shown to be more effective than placebo at 48 hours (paracetamol NNT=7, ibuprofen NNT=6) ¹.

Antibiotics are not routinely recommended initially for most children with AOM, as the condition is usually self-limiting and improves within 3 days without antibiotics. A watchful waiting approach with a backup antibiotic prescription is advised if symptoms do not improve within 3 days or worsen ¹.

When antibiotics are indicated as first-line treatment, amoxicillin is the preferred choice due to its efficacy, acceptable resistance risk, and convenient dosing schedule. Phenoxymethylpenicillin is effective but less convenient, and macrolides such as clarithromycin or erythromycin are alternatives, especially in cases of penicillin allergy or pregnancy (erythromycin preferred in pregnancy) ¹.

The recommended antibiotic course duration is 5–7 days, with the shortest effective course preferred to minimize resistance risk. Longer courses reduce short-term treatment failure slightly but have no long-term benefit ¹.

Immediate antibiotic treatment is recommended for children who are systemically unwell, have signs of serious illness, or are at high risk of complications, including children under 2 years with bilateral AOM or any age with AOM and ear discharge. Clinical judgement is important in these cases ¹.

Topical analgesic ear drops containing an anaesthetic and analgesic may be used in children aged 3 years and over without eardrum perforation to provide additional pain relief. Their use is associated with a significant reduction in pain shortly after administration and may reduce antibiotic use ¹.