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:

  1. Proper inspection
  2. Pain control (Tylenol or Advil, etc). Ear infections hurt!
  3. Observation (waiting for 48-72 hours for relief)
  4. Treatment with high-dose Amoxicillin first and foremost if selected to treat.
  5. Return check after 48-72 hours if no improvement (then moving to treatment with Amoxicillin or changing to Augmentin if child on Amoxicillin)
  6. 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?