Ear Infections - Are Antibiotics Necessary?

Ear infections are a big problem for children and their parents. 

In 1995, it was estimated that the direct cost of this problem in the U.S. including doctor's bills and medicines  was $1.97 billion while the indirect cost including lost work time and forfeited daycare payments was estimated at $1.02 billion. And THAT was in 1995 - like everything else, this cost is likely higher now!

There aren't many families with children that will be able to avoid the drama of a child awakening with ear pain and when that happens, sick leave must be used,  a doctor's visit must be scheduled, or worse yet - the hours long wait at the med center is entered among hoards of the community's sick. Ugh.

But however you see the doctor, antibiotics and pain relievers have been the standard treatment.  That is until 2004 brought with it new wisdom and the option for skipping the antibiotics in uncomplicated children's ear infections - a controversial move.

So - what are the different sides of this story?

When are antibiotics a good idea?

This blog will discuss the issue.

Diagnosing an Ear Infection

The diagnosis of an ear infection (acute otitis media or AOM)  is based on a few different factors.  The primary consideration is a child's symptoms.  AOM is characterized by ear pain, often with a fever and preceding nasal congestion.  The ear drum will need to be visualized.  An effusion (fluid behind the ear) and inflammation are found in AOM.  An effusion without inflammation is called serous otitis media (SOM) and can also cause pain in the ear.  The presence of a normal ear drum with an inflamed ear canal is seen in swimmers' ear (otitis externa or OE).  Other historical factors may support the diagnosis of AOM.  A past history of ear infection makes one more prone to subsequent infections.  AOM is more common in kids who are in daycare and who are exposed to second-hand smoke.  A genetic predisposition can exist for AOM due to the shape of the skull and placement of the eustacian tubes (flesh conduits between the middle ear canal and the back of the throat important in keeping the middle ear aerated and depressurized).  Persons with Down's syndrome and cleft palate are more predisposed to AOM.

The Great Antibiotic Debate

Because of our past trends in antibiotic use for various bacterial infections (and non-bacterial infections), resistance has developed to many antibiotics.  In the public, an awareness has developed that running to an antibiotic for a presumed infection is not necessarily the best thing.  In the medical community, awareness and guidelines have been put forth to promote more prudent habits in antibiotic use.  Further, relying on the body's defenses as first line treatment is now acceptable.  Thus, the 2004, American Academy of Pediatrics, American Academy of Family Physicians Guidelines on the Treatment of Acute Otitis Media allow for observation in uncomplicated AOM.

The following are the guidelines for acceptable observation in AOM:

1. The child is older than six months
2. The finding of AOM is uncertain or non-serious based on observation of the tympanic membrane (ear drum)
3. Pain is addressed and treated
4. Follow-up is available after the observational trial in 48-72 hours.

As a physician, I would like to note that these guidelines leave a lot to interpretation and preference.  Age less than six months, significant infection or chronic infection/predisposition do not make for an option to merely observe.  Doctors or parents with strong feelings toward antibiotic treatment will get antibiotic treatment for the child.  I chose to use these guidelines as a platform for discussion with the parent about options.  I find that some parents are eager to get the child better by any means due to the child's discomfort, their need to return to work or their desire to get the child back to school/daycare.  Some parents express a concern about antibiotic use and resistance and are open to an observational trial.  In the right conditions and with the right supportive treatment, success is often found without antibiotics.  These options fit nicely into what I call the "new art" of medicine-- treating each patient individually based on their preferences, tailoring therapy based within evidenced-based guidelines.

What Should I Do?

So, now, what to do if you have a child over the age of six months who wakes up with an ear infection?  Assume that there is a moderate fever and no drainage from the ear.  It is of course fine to schedule that doctor's appointment for an exam and possibly an antibiotic.  Know, though, that it is also fine to give some tylenol or ibuprofen, push the fluids and observe how they do over the next couple days.  I would also add letting the child chew gum if this is an option in order to work the jaw and wiggle the eustacean tubes that sit atop the jaw bone.  This will hopefully massage the pressure and fluid out of the plugged/inflamed middle ear canal.   If the pain worsens despite this conservative therapy, ear drainage develops or you feel uncomfortable the doctor is still there to call. 

Different people have different feelings about antibiotic use.  These guidelines regarding the treatment of early or non-serious acute otitis media open the option for observation without antibiotics.  More information can be found at http://www.aafp.org/online/en/home/clinical/clinicalrecs/children/otitismedia.html .  

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