Ear infections can cause significant and sometimes serious ear pain, overnight awakening, missed school, missed work, and lots of parental heartache. For some children, infections in the ear can be a chronic problem and lead to repeated clinic visits, multiple courses of antibiotics and, rarely, a need for tube placement by surgery. For most children, ear infections occur more sporadically, just bad luck after a cold. Fortunately the majority of children recover from ear infections without any intervention. But about 20-30 percent of the time, they need help fighting the infection.
Ear infections can be caused by viruses or bacteria when excess fluid gets trapped in the middle portion of the ear, behind the eardrum. When that space fills with mucus or pus, it is put under pressure and it gets inflamed, causing pain. Symptoms of ear infections include pain, fever, difficulty hearing, difficultly sleeping, crankiness, or tugging and pulling at the ear. This typically happens at the time or soon after a cold -- therefore, the fluid in the ear can either be filled with a virus or bacteria.
The most important medicine you give your child when you first suspect an ear infection is one for pain. Antibiotics only help if bacteria is the cause. When a true infection is present, causing pain and fever, antibiotics are never the wrong choice. Often, you'll need a clinician's help in diagnosing a true ear infection.
There's been a lot of work (and research) over the last 15 years to reduce unnecessary antibiotics prescribed for ear infections. There has been great progress. Fewer children see the doctor when they have an ear infection (only 634 out of 1,000 in 2005 vs. 950 out of 1,000 back in the 1990s), and they're prescribed antibiotics less frequently. Recent data finds that less than half of children with ear infections receive antibiotics (only 424 of every 1,000 children with ear infections). However, the far majority who go in to see a doctor do still receive a prescription for antibiotic (76 percent).
The American Academy of Pediatrics(AAP) just released new guidelines to help physicians do a better job treating ear infections. Sometimes children really benefit from using antibiotics, and new research has led to an update on the 2004 previously-published recommendations. Overuse of antibiotics can lead to more resistant and aggressive bacteria, so we want to use them at the right time. These recommendations may help improve care for children.
In my opinion, NPR published the best article I've read covering the new recommendations. I especially liked the balance provided:
"When the diagnosis is correct, then antibiotic treatment is never wrong," says Dr. Ellen Wald of the University of Wisconsin School of Medicine and Public Health in Madison. "Kids tend to recover more often and they recover more quickly if they're treated appropriately with antibiotics."
That's especially important for working parents, Wald notes.
"We live in a society where there is so much pressure for both parents to be working outside the home and it's just complicated when our child is sick. Besides which, there's always parental anxiety and concern when their child is sick," she says.
Information For Parents: New Ear Infection Guidelines
Pain: Use medication like ibuprofen and/or acetaminophen to treat pain when a child has a suspected or confirmed ear infection. These infections really hurt and don't wait for antibiotics to "kick in" or make your child tough it out. Here's a summary on dosing pain meds for infants and children.
Diagnosis: The AAP recommendations apply more strict criteria for making the diagnosis of an ear infection. For true diagnosis they say, the ear drum has to be bulging, there has to be middle ear fluid and/or draining fluid from the ear. The ear can't just be red or have a bit of fluid behind it. It's important that the doctor confirm an ear infection is present before antibiotics are prescribed. If a clinician says to you, "It looks like an early ear infection," or "The ear drum is a little red," or "I think this may be an ear infection," chances are it doesn't meet criteria and shouldn't be treated with antibiotics. Press the clinician to explain to you if the ear drum is bulging and full of fluid. If no proof, antibiotics may not be necessary. Time may be the best medicine.
No Antibiotics: Many children don't need antibiotics to heal from ear infections. When a confirmed ear infection is discovered in a child over two years of age who has no fever or no severe ear pain, they can be observed without antibiotics. However, if pain is still present or symptoms not improved in 48 hours, it is suggested they have follow-up. Make sure you have a good follow-up plan or a prescription to use if you child isn't improving.
Follow up: the recommendations remind us that if you chose not to use antibiotics, you need to have a system in place for a follow-up visit or call or electronic visit in place 48-72 hours later. If symptoms of the ear infection resolve in two to three days with use of pain medications and time, the ear infection is likely healing. If symptoms (on or off medications) aren't better in two to three days, your child needs to be re-seen either to start antibiotics or switch medications.
Antibiotics: All infants under six months of age, children six-23 months of age with a double ear infection, those with severe infections, and those at risk for complications all need antibiotics. Penicillin (Amoxicillin typically -- the pink stuff) is the medication used first for ear infections. However, if your child has had Amoxicillin in the last month then the clinician should advance the antibiotics (typically to a penicillin with an ingredient called clavulanate to fight resistant bacteria that may be present). Lots of parents worry that Amoxicillin isn't the best first choice. Data continue to suggest it is. Read a summary of recent studies in The New England Journal of Medicine on treating ear infections.
Eye and Ear Infection: If your child has conjunctivitis ("Pink Eye") or drainage from their eyes along with an ear infection, they should immediately get a dose of amoxicillin-clavulanate (Augmentin) rather than amoxicillin (penicillin). Infections that cause both infections (ear and eyes) tend to be more likely to be resistant to amoxicillin.
Vaccines: Immunizations do a good job preventing many ear infections. Make sure your child is up-to-date on all vaccines but specifically ensure your child is up to date on Hib, Prevnar 13 (updated pneumococcal vaccine) and their annual Flu Shot. Both Prevnar 13 shots and expanded recommendations to use Flu Shots for all children over six months are attributed in part to decreasing rates of ear infections.
Prevention: Breast feeding and avoidance of cigarette smoke remain data-proven strategies to prevent ear infections in children.
Follow Wendy Sue Swanson, MD, MBE, FAAP on Twitter: www.twitter.com/SeattleMamaDoc