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 and a cautious approach to antibiotic use.

Paracetamol or ibuprofen are recommended for pain relief, as both have been shown to reduce pain at 48 hours compared to placebo, with number needed to treat of 7 and 6 respectively ¹.

Antibiotics are not routinely prescribed immediately because most children improve within 3 days without them. A 'watchful waiting' approach is advised, with a back-up antibiotic prescription if symptoms do not improve within 3 days or worsen at any time ¹.

When antibiotics are indicated, amoxicillin is the first-line choice due to its effectiveness, acceptable resistance risk, and convenient dosing schedule ¹.

Alternative first-line antibiotics include clarithromycin and erythromycin, with erythromycin preferred during pregnancy due to safety data ¹. Azithromycin is generally reserved for more serious infections and is not recommended as a first-line agent ¹.

The recommended antibiotic course duration is 5–7 days, with the shortest effective course preferred to minimize resistance risk ¹.