Confirm the diagnosis first
Diagnose acute otitis media only with a bulging eardrum or new otorrhea, or mild bulging with recent ear pain or intense redness of the eardrum. Antibiotic decisions depend on getting this step right.
Once the diagnosis is secure, decide whether the child needs antibiotics now or can be safely observed, then choose the drug based on recent amoxicillin use, conjunctivitis and any penicillin allergy history. Dose by weight in kilograms and keep to the per-dose maximums below.
Treat now or observe?
Treat with antibiotics:
- Under 6 months
- 6–23 months with bilateral AOM or severe symptoms
- Any age with otorrhea, temperature 39 °C or higher, or pain for more than 48 hours
- Observation with a safety-net prescription is an option for 6–23 months with unilateral, non-severe AOM, and for 2 years and older with non-severe AOM, if follow-up is assured.
First-line amoxicillin dose
Use high-dose amoxicillin unless the child had amoxicillin in the last 30 days or has purulent conjunctivitis. Either suggests beta-lactamase–producing organisms, so use high-dose amoxicillin-clavulanate (ES 600 mg/5 mL) instead, dosed by the amoxicillin component.
Example: a 20 kg child gets 900 mg of amoxicillin twice daily. Children from about 45 kg reach the 2 g per dose cap. If the child is vomiting or oral treatment fails, ceftriaxone can be given IM or IV.
| Drug | Dose | Maximum |
|---|---|---|
| Amoxicillin PO | 45 mg/kg twice daily (90 mg/kg/day in 2 doses) | 2 g per dose, 4 g/day |
| Amoxicillin-clavulanate ES PO | 45 mg/kg of amoxicillin twice daily (90 mg/kg/day) | 2 g amoxicillin per dose |
| Ceftriaxone IM/IV | 50 mg/kg daily for 1–3 days | 1 g per dose |
Penicillin allergy alternatives
For a low-risk history (rash without hives, swelling or breathing trouble, or a remote vague history), use an oral cephalosporin. For a high-risk history (anaphylaxis, hives, angioedema, or a severe skin reaction such as SJS or DRESS), use azithromycin or clindamycin. Azithromycin is less effective and is only for when beta-lactams cannot be used.
| Allergy history | Drug | Dose |
|---|---|---|
| Low risk | Cefdinir PO | 14 mg/kg/day once daily or in 2 doses, max 600 mg/day |
| Low risk | Cefuroxime axetil PO | 15 mg/kg twice daily (30 mg/kg/day), max 500 mg per dose |
| Low risk | Cefpodoxime PO | 5 mg/kg twice daily (10 mg/kg/day), max 200 mg per dose |
| Low risk, oral fails | Ceftriaxone IM/IV | 50 mg/kg daily for 1–3 days, max 1 g per dose |
| High risk | Azithromycin PO | 10 mg/kg day 1 (max 500 mg), then 5 mg/kg days 2–5 (max 250 mg) |
| High risk | Clindamycin PO | 10 mg/kg three times daily (30–40 mg/kg/day), max 450 mg per dose |
How long to treat and follow-up
Duration depends on age and severity. Younger children and those with severe symptoms get the full 10-day course. Reassess any child who is not improving after 48 to 72 hours.
- Under 2 years or severe symptoms: 10 days
- 2–5 years: 7 days
- 6 years and older: 5–7 days
- Not better in 48–72 hours: switch to amoxicillin-clavulanate, then ceftriaxone 50 mg/kg daily for 3 days.
- Pain relief for all children: acetaminophen or ibuprofen.
Use the free tool
First-line and allergy alternatives with weight-based doses for otitis, strep, sinusitis, pneumonia, skin, bone and bites.
Open Antibiotics →Common questions
What is the amoxicillin dose for an ear infection in children?
High-dose amoxicillin, 90 mg/kg/day divided into 2 doses (45 mg/kg twice daily), with a maximum of 2 g per dose and 4 g per day.
When should I use amoxicillin-clavulanate instead?
When the child had amoxicillin in the last 30 days or has purulent conjunctivitis, or when AOM is not better after 48 to 72 hours of amoxicillin. Use the ES 600 mg/5 mL formulation at 90 mg/kg/day of amoxicillin in 2 doses.
How long should a child take antibiotics for otitis media?
10 days under 2 years or with severe symptoms, 7 days at 2 to 5 years, and 5 to 7 days at 6 years and older.
Which children can be observed without antibiotics?
Children 6 to 23 months with unilateral, non-severe AOM, and children 2 years and older with non-severe AOM, if follow-up is assured. Give a safety-net prescription and pain relief.
Sources
Lieberthal AS, et al. AAP guideline: acute otitis media. Pediatrics 2013;131:e964. AAP Red Book 2024–2027.
For education only, not medical advice. Always confirm against current guidelines and your local protocols. Pedemy is independent and not affiliated with or endorsed by the organizations cited.