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

Reach for a pain reliever, at least initially, experts now say

TUESDAY, Feb. 22, 2005 (HealthDayNews) -- Your 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 antibiotic.

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 all.

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 drugs.

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 said.

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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