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Care priority and warning signs
Care priority
Routine Management / Treat with Antibiotic
Red flags
- Development of tender swelling behind the ear.
- High fever persisting despite antibiotics.
- Development of facial weakness.
- Development of danger signs.
- Failure to improve after 5 days of treatment.
Assessment
- Ask: Does the child have an ear problem?
- Ask: Is there ear pain?
- Ask: Is there ear discharge? If yes, for how long?
- Confirm absence of Tender Swelling behind the ear.
- Look: Look for pus draining from the ear.
- If discharge present, confirm duration is less than 14 days.
Classification
- (Ear pain OR Pus seen draining from ear for < 14 days) AND No tender swelling behind ear -> ACUTE EAR INFECTION
Key features
- Presence of Ear Pain OR Pus seen draining from ear for < 14 days.
- Absence of tender swelling behind the ear (ruling out mastoiditis).
- Requires oral antibiotic (Amoxicillin) and pain management.
Management
Non-pharmacological management
- If pus discharging: Teach mother how to dry the ear by wicking 3 times daily. Use clean absorbent cloth or soft, strong tissue paper rolled into a wick. Insert gently, remove when wet, repeat until ear is dry. Do not plug the ear.
- Advise adequate fluid intake and continued feeding.
Pharmacological treatment
- Give oral Amoxicillin twice daily for 5 days. Dosage: Age 2m-<12m (4-<10kg): 250mg dispersible tablet (1 tab) OR 250mg/5ml syrup (5ml) per dose. Age 12m-5y (10-<19kg): 250mg dispersible tablet (2 tabs) OR 250mg/5ml syrup (10ml) per dose.
- Give Paracetamol for ear pain (10-15 mg/kg). Dose (500mg tablet): 2-3m (<6kg): 1/4 tab. 4m-3y (6-<14kg): 1/2 tab. 4-5y (14-19kg): 3/4 tab (or 1/2 of 500mg tab from p15). Give every 6 hours as needed.
- If ear discharge present, check for HIV infection (refer to HIV assessment algorithm page 8).
Follow-up
- Follow-up in 5 days.
- At follow-up (Day 5): Reassess ear problem. Check temperature. Check for HIV.
- If tender swelling behind ear or high fever (≥38.5°C): Treat as Mastoiditis - Refer URGENTLY.
- If ear pain or discharge persists: Continue Amoxicillin for 5 more days (total 10 days). Continue wicking if discharge present. Follow-up again in 5 days.
- If no ear pain or discharge: Praise mother. Tell her to finish the 5-day course of antibiotic if not already completed.
Counselling points
- Explain the diagnosis (ear infection) and the need for antibiotic.
- Teach how to give Amoxicillin: correct dose, frequency (twice daily), duration (full 5 days).
- Teach how to give Paracetamol for pain.
- If discharge present: Teach dry wicking carefully, emphasizing not to plug ear and to wick 3 times daily.
- Advise when to return immediately: Child develops tender swelling behind ear, high fever, danger signs, becomes sicker.
- Advise on follow-up visit in 5 days.
Differential diagnosis
- Mastoiditis
- Chronic Ear Infection (discharge >= 14 days)
- Otitis Externa (pain often worse on moving outer ear, canal may be swollen/red)
- Foreign body in ear canal
- Referred pain (e.g., from teething, tonsillitis)
- No Ear Infection
Complications
- Mastoiditis
- Chronic Suppurative Otitis Media (CSOM)
- Hearing loss (usually temporary/conductive)
- Tympanic membrane perforation (may heal or become chronic)
- Facial nerve palsy (rare)
- Meningitis (rare)
Prevention
- Pneumococcal vaccination (PCV).
- Hib vaccination.
- Exclusive breastfeeding.
- Avoiding exposure to tobacco smoke.
- Prompt treatment of URTI (though AOM often complicates viral URTI).
References
IMCI Chart Booklet - Page 5, Page 8 (HIV check), Page 14 (Amoxicillin), Page 15 (Paracetamol), Page 18 (Wicking), Page 23 (Follow-up)