Intended for healthcare professionals

Practice Clinical Updates

Acute middle ear infection (acute otitis media) in children

BMJ 2020; 371 doi: (Published 18 November 2020) Cite this as: BMJ 2020;371:m4238

This article has a correction. Please see:

  1. Roderick P Venekamp, general practitioner, assistant professor of primary care1,
  2. Anne G M Schilder, ear, nose, and throat surgeon, professor of paediatric otorhinolaryngology, NIHR senior investigator123,
  3. Maaike van den Heuvel, pharmacist and patient and public involvement representative4,
  4. Alastair D Hay, general practitioner, professor of primary care, and NIHR senior investigator5
  1. 1Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
  2. 2National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, UK
  3. 3evidENT, Ear Institute, University College London, London, UK
  4. 4FLeiR public Pharmacy, Leidsche Rijn Centrum, Utrecht, Netherlands
  5. 5Centre for Academic Primary Care, NIHR School for Primary Care Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
  1. Correspondence toR P Venekamp R.P.Venekamp{at}

What you need to know

  • Suspect acute otitis media in children with ear pain (ear symptoms can be subtle especially in young pre-verbal children), with or without fever

  • The presence of middle ear effusion on otoscopy is a prerequisite for diagnosis of acute otitis media

  • Confirming diagnosis by pneumatic otoscopy can reduce overdiagnosis and unnecessary antibiotic prescribing

  • The infection is generally self-limiting in otherwise healthy children in high income countries and can be managed with pain relief and watchful waiting

  • Offer oral antibiotics to children with acute otitis media who are systemically unwell and to those at high risk of complications because of pre-existing comorbidity. Oral antibiotics can be considered in children under 2 with bilateral acute otitis media and in children of any age with acute otitis media and acute ear discharge caused by a spontaneous rupture of the eardrum

Acute middle ear infection, otherwise known as acute otitis media, affects children in their early years. One in two children has had three episodes by age 3.12 It is characterised by middle ear effusion and ear pain or fever.3 More than one third of preschool children consulted a doctor for earache or ear discharge in a large prospective cohort study in England (13 617 children).4

Accurate diagnosis of acute otitis media can be challenging in young children.5 It tends to be overdiagnosed in primary care and can lead to unnecessary use of antibiotics.678 Recent changes in the delivery of primary care, brought about because of covid-19,9 have shown that not all children with suspected acute otitis media need to be managed in a healthcare setting. Indeed, a multidisciplinary panel of UK nurses, general practitioners, and emergency department consultants agreed that systemically well children with ear pain could be managed at home initially without primary care input. …

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