OBJECTIVE. The goal was to determine the predictors of a prolonged course for children with acute otitis media. METHODS. A meta-analysis of data with the observation groups of 6 randomized, controlled trials was performed. Participants were 824 children, 6 months to 12 years of age, with acute otitis media. The primary outcome was a prolonged course of acute otitis media, which was defined as fever and/or pain at 3 to 7 days. RESULTS. Of the 824 included children, 303 had pain and/or fever at 3 to 7 days. Independent predictors of a prolonged course were age of <2 years and bilateral acute otitis media. The absolute risk of pain and/or fever at 3 to 7 days for children <2 years of age with bilateral acute otitis media (20% of all children) was 55%, and that for children ≥2 years of age with unilateral acute otitis media (47% of all children) was 25%. CONCLUSIONS. The risk of a prolonged course was 2 times higher for children <2 years of age with bilateral acute otitis media than for children ≥2 years of age with unilateral acute otitis media. Clinicians can use these features (ie, age of <2 years and bilateral acute otitis media) to inform parents more explicitly about the expected course of their child's otitis media and to explain which features should prompt parents to contact their clinician for reexamination of the child.