Treatment guidelines for acute otitis media in kids

am acad of pediatrics published clinical practice guideline on diagnosis and management of acute otitis media -- AOM  (see otitis media guideline peds 2013 in dropbox).  several points:
 
diagnosis:
--should dx AOM in kids with moderate to severe TM bulging or new onset otorrhea not due to external otitis.
--can dx AOM in children with mild TM bulging and <48 hour onset of ear pain or intense erythema of the TM
--Not dx AOM if no middle ear effusion (eg, by pneumatic otoscopy or tympanometry)
 
management:
--should prescribe abx if severe AOM in kids >6months old, with mod or severe otalgia, or otalgia for >48hrs or T>39C/102.2.F
--should prescribe abx in kids 6-24 months old with bilateral AOM without severe sx (eg mild otalgia <48hrs and temp <39C /102.2F)
--either abx or observation in kids 6-24 months old with non-severe unilateral AOM.  caveat is that observation appropriate only if mechanism in place to ensure followup and begin abx if kid gets worse or fails to improve in 72 hours after onset of sx (as a side note, i often give abx script in this case and suggest that the parent observe and give the abx if the above happens, but stress that it is better in general for the kid to avoid just giving the abx if it is not really necessary. my personal story is that my now 23 year old had AOM as a young kid. i decided to follow him clinically without abx. he then got a rash -- so, if i had treated him with abx, he would have been labelled allergic to them, yet he undoubtedly had a viral infection and then exanthem instead)
--either abx or observation in older kids with non-severe AOM, with above caveat
--abx of choice: amox. unless they received amox within past 30 days or have concurrent purulent conjunctivitis, or are allergic to amox
--b-lactamase abx if received amox in past 30 days, has concurrent purulent conjunctivitis, or has recurrent AOM unresponsive to amox
--reasseess kid if caregiver feels worsened or not respond to abx within 48-72 hours after start abx to see if should change rx
--NOT prescribe prophyllactic abx. consider tympanostomy tubes if recurrent AOM (3 episodes in 6 mo, 4 in one year)
--encourage exclusive breast-feeding for at least 6 months.
--flu and PCV vaccines

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