New research on ear infections confronts a challenging conundrum: What should pediatricians do for a toddler with a real-deal ear infection? Treat with antibiotics or “watch and wait?” New research and a nice editorial published in The New England Journal of Medicine this week add to the stew of information about how to manage ear infections in young children. The new research confers benefit to using antibiotics at initial diagnosis of a true ear infection in children under age 2 or 3.
But wait. Seemingly simple, treatment decisions for ear infections are far from it. It can be easy for a pediatrician to prescribe antibiotics, yes. But those of us working hard to perfect how we care for children think long and hard prior to writing a prescription for the pink stuff. Current guidelines from the AAP (published in 2004) make us pause. The AAP recommendations embody the “watch and wait” approach in most children with uncomplicated, acute, middle ear infections between 2 months to 12 years of age. The AAP recommendations include:
- Proper inspection
- Pain control (Tylenol or Advil, etc). Ear infections hurt!
- Observation (waiting for 48-72 hours for relief)
- Treatment with high-dose Amoxicillin first and foremost if selected to treat.
- Return check after 48-72 hours if no improvement (then moving to treatment with Amoxicillin or changing to Augmentin if child on Amoxicillin)
- Prevention efforts (encouraging breast feeding, no bottle propping, working to decrease exposure to cigarette smoke)
But the “watch and wait” approach can be challenging for parents, pediatricians and family practitioners alike. Particularly with a child in pain, a gnarly looking eardrum, and/or a fever. Because of this, studies have found that the majority of physicians who see ear infections in the US don’t necessarily subscribe to these recommendations; we all really like to do something to make our kids feel better…
First of all, I said “real-deal” ear infection above because the true controversy around treatment plans for ear infections resides in the diagnosis. Fluid in the middle ear may not represent an infection, and believe it or not, it can be very difficult at times to even see the middle ear (via the eardrum) to make the diagnosis. Further, doctors vary in their opinion of what defines an ear infection when looking at the ear drum. The enlightenment in this new research is the use of strict criteria for diagnosis: bulging eardrum, redness on the drum, pain, and an inventory of acute symptoms. The study highlights the essential challenge with ear infections–make a good diagnosis. Seeing the eardrum well is essential, but 2 year-olds will work very hard and be incredibly devious protecting themselves from an otoscope entering their ear canal. And as to removing wax? That’s like scaling a mountain in Nepal.
I have often said to families (while wrestling with their sweaty, screaming, uncomfortable child) that cleaning out earwax is the absolute worst part of my job. It is, HANDS DOWN, my least favorite thing to do in clinic. But we still do it, every day. If we didn’t, we’d be guessing at what’s going on and it’s truly not why families come into the office. Diagnosing ear infections can bankrupt our energy, yet this procedure remains a pillar in quality care for young children. Simple, it is not (thank you, Yoda)…
Ear infections are the most common bacterial infection in young children. In the last 6 years, because of the AAP recommendations, many pediatricians have worked hard to educate families about the option of “watchful waiting.” Because previous research had found that most ear infections in children heal without antibacterial treatment and use of unnecessary antibiotics may contribute to bacterial resistance, doctors have worked hard to use antibiotics only when necessary. The new studies may shift the pendulum again. Here’s why:
The two new studies (one in Pittsburgh, PA and one in Finland) found children recovered faster and had less recurrence of ear infections when treated initially with antibiotics (Amoxicillin in Finland, Augmentin in Pittsburgh). All children in the study were diagnosed with true ear infections using strict criteria. Children who were treated had more acute recovery. And the children who were treated with placebos had more clinical failure (they still felt crummy) and more recurrence (the infection came back). As Dr. Klein wrote in the editorial, “the answer is yes; more young children with a certain diagnosis of acute otitis media [ear infection] recover more quickly when they are treated with an appropriate antimicrobial agent.”
Okay, so using antibiotics may again be the right answer for young children. However, we have to know it’s a true ear infection to apply this research to practice. That’s where you come in.
As a parent or caregiver, your job is to push the doctor who’s looking at your child’s ear to really examine the eardrum. Treatment (and the benefit) is seen when true infection causing a bulging eardrum, pain, and discomfort are present. Many viruses and non-threatening fluid in the middle ear may not need treatment. An “early” ear infection or “fluid in the ear” may not be the right time to give antibiotics. More, it would be a time for pain relief with Tylenol or Motrin, comfort measures, and time. And then patience, too.
What To Do If Your Child Has A Suspected Ear Infection:
- See your pediatrician for an ear check if you are concerned about an ear infection in your child.
- When the pediatrician diagnoses an infection, push them on the appearance of the eardrum. It’s always okay to ask what it looks like! Ask if the eardrum is bulging, if it has pus behind it, or is red in color. It’s okay to ask the pediatrician to clarify and explain the difference between fluid in the ear and an ear infection. In combination with your child’s symptoms, it will be important for making a plan.
- If there is difficultly seeing the eardrum, expect the pediatrician to clear earwax from the outside of your child’s ear. Hold on. Remember that seeing the ear drum is the most important part of determining how to help your child.
- If the doc says its an “early infection” or “just a bit red,” or that they are unsure if it’s infected or not, consider asking about avoiding the use of antibiotics. Consider using just pain control and supportive care instead.
- If your child is not improved after 48-72 hours from when symptoms started (treated with antibiotics or not), return to see the pediatrician for another evaluation.
If you wanted a short blog post about these findings, this is what I would have written; Nice work, Richard Knox. Wish I was that good…
What’s your experience with the diagnosis and treatment of ear infections? Do you hate those ear cleanings, too?
Julia Gibson says
If having to clean out earwax in order to even see the eardrum is common, I wonder if the accumulation of wax is part of the problem? As an adult, I got a nasty ear infection due to lake water getting trapped behind a build up of ear wax. How do we prevent build up in young children? I would imagine that the OTC dissolvers are not good for kids, and I know we shouldn’t stick anything in their ears. How about warm water? Every night I have to clean wax from my 17 month old’s outer ear during bath time, so I’m hoping he’s got nice soft wax, but I wonder if I could be doing anything to prevent future infections.
Julia says
This is interesting news to me. I had a lot of ear infections as a child and all of them were treated with antibiotics so just from experience I had no idea they could resolve on their own. Luckily, my daughter only had one at 6 months old. I wish my doctor had known this when I was a kid!
We had a fortunate miscommunication once that has since helped us with ear wax cleaning. When my daughter was about two years old she had three little bath toys: a frog, elephant and crocodile she named Croco, Ollie and Toadie. Once when she had a cold my husband said, “You sound like you have a frog in your throat,” and she grabbed her throat and said, “Toadie?” looking very concerned. Then she grabbed her ear and looked even more concerned and said, “Croco??!!” So even now at almost seven years old if the doctor needs to look in her ears we say the doctor is looking for Crocos. When the doctor or nurse play along it ends up going much more smoothly.
Don Deems DDS FAGD says
Thanks for your article. About 20 plus years ago, I treated about half a dozen kids with recurring ear infections by adding dental restorative material on top of their molar teeth to open their bite. This, in turn, opened the Eustachian tubes and allowed the ears to drain properly. Not amazingly, they quit having ear infections completely. Each of these kids were being slated for ear surgery before I treated them, and they had been on multiple rounds of antibiotics.
Unfortunately, I attempted to speak to a few local pediatric groups about this very simple treatment, but was turned away.
The dentist that developed this technique was from eastern Washington.
If you’re interested, all you have to do is look to see if the child has a deep overbite. If so, the problem might just be what I described.
Best wishes.
Dr Samit Bali says
If the above protocol is followed in India, the patients parent will run away to a next doctor.
Scott says
Great blog. My wife (@l8enough) clued me into your blog. The only thing I would add/love- your-opinion-on is to go over the data from the 2 articles. i don’t think the answer is as clear cut as the editorial and writers would have you believe. We continue to find that even most “true” ear infections resolve with no real evidence of poor long-term outcomes. The study did not show a large impact (12 hours to 1 day at most of AOM-SMS score differences) in the treated group. the untreated group was treated anyway at day 4 if they had clinical failure. I guess I was fairly underwelmed except to know that if i choose to treat in kids with true ear infection between age 6 months and 24 months it will actually do something. (my opinion -> https://iwashyna.com/?p=79 )
Wendy Sue Swanson, MD says
Scott (or should I call you Dr Spiky Hair?),
Thanks for your comment. I agree with you; the editorial did lean a bit, it read like results were more clear than they were (as if all kids treated with antibiotics improved rapidly and those left untreated,suffered). Maybe my blog post read the same. The numbers aren’t all that impressive and the efficacy of treatment in the Hoberman article not all that great. Also, I’m still trying to understand why they used Augmentin as first line as opposed to high dose Amoxicillin (which is first-line by AAP) in the US study. I wrote to a friend (Peds ID) that although the p value was positive in the study (particularly the one in Pittsburgh) the raw numbers of those kids who recovered from symptoms more rapidly just didn’t impress me. I liked your post.
I think discussing and reflecting confusion around diagnosing and treating Otitis media could be a book (more than a blog post) so I didn’t spend time writing on the points you mention. The post was already too long 🙂 but the point I wanted to drive home was to have parents know that it’s okay to ask to clarify what the doctor or nurse practitioner is seeing when they are looking in the ear. Many children still get antibiotics when unnecessary. But there really are some young children who I look at the ear drum, and the thermometer, and the parents’ concerns about pain and I do treat, particularly in young children like those studied… And these studies shed light on that clinical instinct. The take home remains for me: have a true conversation about decision to treat or not to treat if the ear drum really is inflamed, full of pus, or bulging. And if not, like you discuss, have a good follow-up plan.
Viki says
my daughter’s ear infections kept recurring and the allergist wanted to treat her for sinusitis before putting in tubes. (She’d had a bad sinus infection a few months earlier.) We went with it against the ped’s rec and the infections went away and we didn’t need tuned. Maybe sinusitis is one of those things allergists see more often?
It seems like our kids tend to have fluid in their ears for a while after a cold. I’m so tired of ear checks! We have regular audiology exams so I gave myself permission to wait for a fever before taking them in and manage the discomfort and balance issues at home.
Carrie Meyer says
Great post! As a parent of 3 and healthcare communications professional, I think it does a great job explaining how parents can take an educated role in this process. I shared it on my facebook page to my fellow parents! Keep up the good work, I love this blog!
Jackie says
I’m an adult and hate getting earwax removed! I can only imagine how much worse it is for a 2 year old.
Candice Major says
My son was diagnosed with an ear infection 4 days ago.
He is 1 year old and the only tell take sign for me was a discharge from his ear.
no fever anything. Just the discharge that looks like pus.
I obviously rushed him to the doctor out of concern and was given amoxicillin and something for the pain.
After four days on this medication he is getting a high fever at night. The fever lasts for about an hour. Discharge is still coming out of his ears and is now causing tiny sores. Is this normal?
So stressed about this
Christina Tinay says
What is the best medicine in ear infections?