The management of acute otitis media (AOM) in childhood has evolved considerably during recent years as a result of the new insights provided by publication (in 2004) of the American Academy of Pediatrics and the American Academy of Family Physicians guidelines for the treatment of AOM. The new treatment guidelines establish a clear hierarchy among the various antibacterials used in the treatment of this disease and also the use of an age-stratified approach to AOM by recommending an observation strategy ('watchful waiting') without the use of antibacterials for some groups of patients with AOM. Infants and young children aged <2 years represent a target population characterized by a high incidence of AOM (and in particular of recurrent disease), lack of anatomic and physiologic maturity of airways, age-related immune humoral and cellular deficiencies, the presence of antibacterial-resistant pathogens, and a less efficient response to antibacterial treatment. Presently, the evidence accumulated in the literature is not sufficient to conclude that the role of antibacterials is only minimal in the management of AOM and that the watchful waiting policy is the most appropriate choice for patients aged <2 years with a certain AOM diagnosis. However, adherence to such a policy in patients with an uncertain or questionable AOM diagnosis and/or mild-to-moderate symptoms, in addition to its implementation in patients aged >2 years, could reduce substantially the use of antibacterials in children and play a major role in the strategy of decreasing antibacterial resistance.