When It Comes to Kids' Ear Infections, Hold the Antibiotics

crying babyYour infant is running a fever and has been
clingy and inconsolable most of the night. You immediately think “ear
infection,” and rush to the doctor’s office for a prescription for an

At least that used to be the drill. But under new guidelines,
pediatricians are more apt to recommend treating the pain but holding
off on the amoxicillin. In fact, they may not prescribe an antibiotic at

That’s a message many pediatricians are sharing during February, Kid’s ENT (Ears, Nose, & Throat) Health Month.

The guidelines address the growing public health threat of antibiotic
resistance. Because repeated and inappropriate antibiotic use creates
“superbugs” — bacteria that resist even the strongest antibiotics —
medical professionals are being urged to limit the overuse of these

Many parents seem to appreciate the new approach, according to Dr.
Kathi J. Kemper, a professor of pediatrics at Wake Forest University
School of Medicine.

“I find that a lot of parents aren’t in a hurry to give antibiotics
and are reassured by knowing that 80 percent of ear infections are cured
by the child alone without any meds,” said Kemper, author of the book, The
Holistic Pediatrician: A Pediatrician’s Comprehensive Guide to Safe and
Effective Therapies for the 25 Most Common Ailments of Infants,
Children, and Adolescents

Middle ear infection, known as acute otitis media, is the most common
bacterial illness in children and the one most commonly treated with
antibiotics, according to the American Academy of Pediatrics (AAP). More
than 5 million cases occur annually among kids in the United States,
resulting in more than 10 million annual antibiotic prescriptions and
about 30 million annual visits to doctors’ offices.

This type of infection starts when germs spread to the middle ear,
resulting in a build-up of pus or fluid that can cause painful pressure
on the eardrum in some children. The infection can be either bacterial
or viral, according to the American Medical Association.

Parents should not confuse ear infection with fluid in the middle
ear. This chronic condition, called otitis media with effusion, often is
picked up in a physical exam of the child because it does not cause
discomfort. It has a different set of management guidelines

To treat middle ear infection, the AAP and the American Academy of
Family Physicians guidelines, adopted last year, emphasize pain relief
over antibiotics. Parents are given the option, in many cases, to let
their kids fight the infection on their own for 48 to 72 hours, and to
start antibiotics after that if there is no improvement.

“The whole purpose of these guidelines was to give people a way to
intelligently and safely use this option of observing an ear infection,”
said Dr. Richard M. Rosenfeld, professor and director of pediatric
otolaryngology at Long Island College Hospital in New York City.
Rosenfeld served as a consultant to the AAP subcommittee that developed
the guidelines.

Some health professionals avoid using antibiotics at all, while
others favor more liberal use of the drugs. Each position has its
downside, explained Rosenfeld. Untreated bacterial ear infections can
lead to serious complications, including mastoiditis — when infection
spreads to the mastoid bone of the skull — and meningitis — an
infection of the brain. On the other hand, treating every ear infection
with antibiotics is unnecessary, and every course can make it more
difficult to treat future infections in a given child, he said.

Rosenfeld sees room for a middle ground. Under the guidelines, for
example, antibiotics are recommended for any child under 2 or who has
severe symptoms, he said. These are the kids who benefit the most, he

But for a child who is 2 or older with mild symptoms or whose
diagnosis is unconfirmed, it’s best to watch and wait. The physician may
write a prescription for an antibiotic with the stipulation that the
parent should observe the child’s progress before having it filled.

Parents needn’t worry that they are causing their child undo misery.
Studies show that antibiotics do not make the kids feel better in the
first 24 hours compared with observation, assured Rosenfeld.

For pain relief, all children should be given ibuprofen or
acetaminophen, especially in the first 24 hours, the guidelines
recommend. Kemper prefers ibuprofen for kids who don’t have a
contraindication to it, since it lasts longer — about 8 hours — so
fewer doses are needed each day.

Your pediatrician also may prescribe anesthetic ear drops to reduce
pain in the ear. “I know some folks recommend them and there’s good data
to support them, but as a mother of a former toddler, I just couldn’t
get excited about holding him down and putting something in the ear,”
Kemper said. Gentler alternatives include using a hot water bottle
swaddled in a towel or an ice bag wrapped in a wash cloth, she said.

For children requiring repeated courses of antibiotics or antibiotic
injections to treat ear infections, parents may need to consider having
ear tubes implanted in their child to drain liquid from the middle ear,
said Rosenfeld, who discusses the regimen in his new book, A Parent’s Guide to Ear Tubes.

AAP has not surveyed members to determine whether their prescribing
habits have changed. But based on calls to the academy, most
pediatricians are complying with the guidelines, a spokeswoman said.
Many were cautious about prescribing antibiotics even before the
guidelines were released, she added.

So it your child wakes up at 3 a.m. with a suspected ear infection,
feel free to reach for the ibuprofen but don’t worry about paging your
pediatrician in the middle of the night.

“You don’t have to panic,” Rosenfeld insisted, “but certainly
persistent symptoms need attention and clarification by the doctor.”

More information

To learn more about the new guidelines for managing ear infections, visit the American Academy of Pediatrics.

SOURCES: Kathi J. Kemper, M.D., M.P.H., professor,
pediatrics, Wake Forest University School of Medicine, Winston-Salem,
N.C.; Richard M. Rosenfeld, M.D., M.P.H., professor and director,
pediatric otolaryngology, Long Island College Hospital and State
University of New York Downstate Medical Center, Brooklyn, N.Y.;
American Academy of Pediatrics, Elk Grove Village, Ill.; American
Medical Association

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