Table 2.

Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)

Subject	2004	2013	Rationale for 2013 Changes
Children <6 mo	Treat with antibiotic therapy	No recommendations
Diagnosis of AOM	Acute onset of signs and symptoms	Moderate to severe bulging of TM, or new-onset otorrhea not owing to acute otitis externa	2004 criteria allowed less precise diagnosis, provided treatment recommendation when diagnosis was uncertain.
	Presence of MEE	Mild bulging of TM and recentb onset ear painc or intense TM erythema
	Signs and symptoms of middle ear inflammationa	Must have MEE
Uncertain diagnosis	Expected and included in treatment guidelines	Excluded	Emphasized need for diagnosis of AOM for best management.
Initial observation option instead of initial antibiotic therapy	Option for observation: 6 mo–2 y: Option if uncertain diagnosis and nonsevere illnessd ≥2 y: Option if nonsevered and certain diagnosis	Option for observation: 6 mo–2 y: Unilateral OM without otorrhea ≥2 y: Unilateral or bilateral AOM without otorrhea	Favorable natural history overall.
	Observation recommended: ≥2 y and uncertain diagnosis	Observation recommended: None	Evidence of small benefit of antibiotics in recent trials that used stringent diagnostic criteria.
Initial antibiotic therapy recommended	Antibiotics recommended: <6 mo: All cases 6 mo–2 y: Certain diagnosis, or uncertain diagnosis if severee illness ≥2 y: Certain diagnosis and severee illness	Antibiotics recommended: 6 mo–2 y: Otorrhea or severee illness or bilateral without otorrhea ≥2 y: Otorrhea or severee illness	More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit.
	Antibiotics an option: 6 mo–2 y: Uncertain diagnosis and nonsevered illness ≥2 y: Certain diagnosis and nonsevered illness	Antibiotics an option: 6 mo–2 y: Unilateral without otorrhea ≥2 y: Bilateral without otorrhea or unilateral without otorrhea	Greater antibiotic benefit for bilateral disease, AOM with otorrhea.
			Two recent studies show small benefit of antibiotics for age 6–24 mo.
Recurrent AOM	No recommendations	Do not prescribe prophylactic antibiotics	Minimal benefit for prophylaxis and antibiotics come with risks (antibiotic resistance and adverse effects).
		May offer tympanostomy tubes	Modest reduction in AOM with tubes.

Abbreviations: MEE, middle ear effusion; TM, tympanic membrane.

^aSigns and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (‘discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep’).

^bRecent: <48 hours.

^cEar pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child.

^dNonsevere illness defined as mild otalgia and fever <39°C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to “mild otalgia for less than 48 hours and temperature less than 39°C.”

^eSevere signs or symptoms include moderate or severe otalgia or temperature ≥39°C in 2004 guideline; the 2013 guideline also includes otalgia for ≥48 hours.

Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–99; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):1451–65.