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Most Ear Infections Improve, But What About the Ones that Don't?

Ballard, Dustin MD

doi: 10.1097/01.EEM.0000395832.88424.60
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I you're a parent, does the following scenario sound at all familiar? Your 18-month-old child catches a cold, and after a few days of seemingly harmless sniffles, she morphs from a happy and inquisitive ­toddler into a dreadful beast: fragile, volatile, and screaming when she should be sleeping. Once a water baby, she's now deathly afraid of the bath, not wanting water within an American Girl's reach of her head. Already a picky eater, all of a sudden the only food she'll accept is dried fruit, and the resulting “runs” obliterate the family's diaper reserves. Acetaminophen calms the situation, but a couple hours later it's back to hysteria-hood.

No, not ringing any bells? Consider yourself fortunate (and warned) because this exact metamorphosis happened to my daughter several years ago. Of course, like any parent, I attempted to diagnosis the situation. After considering some possibilities (such as personality inception and possession by the devil), I settled on the most likely malady: otitis media. Ear infections are quite common in children under 3 primarily because the anatomy of the young ear doesn't allow for effective fluid clearance. In youngsters with the sniffles, middle ear fluid often bottlenecks, allowing bacteria from the nose and throat to migrate into the ear and take hold.

So, suspecting an ear infection, I decided to … do nothing. I thought I was being astute; I was following the advice of the American Academy of Pediatrics. I was in “watchful waiting” mode, considered a viable alternative to antibiotics for many children with ear infections because the majority of these infections get better on their own. Unfortunately, after 48 hours, watchful waiting had turned into witchful watching, and even though my daughter had not developed a fever, it was time to stop playing doctor with my own family. The pediatrician who examined her ears observed that they looked “extremely painful,” and asked, “Wow, does she scream all night long?” Yes, I replied, she sure does!

Hayley took her first dose of antibiotics that afternoon, and by the next morning the beast was gone, replaced by a (mostly) happy and inquisitive toddler. I was shocked by how quickly her symptoms improved, and suddenly appreciated the words of dozens of parents who had sworn to me that antibiotics did help with ­otitis media. With this experience in mind, I can't say I was particularly surprised by the recent study that ­provided, for the first time, solid evidence that some children with ear infections do, in fact, get better faster with antibiotics.

Published in the New England Journal of Medicine, the study was led by Alejandro Hoberman, MD, from Children's Hospital of Pittsburgh. (2011;364[2]:105.) In it, the researchers examined the symptoms of 291 children (6-23 months) with ear infections who either did or did not receive an antibiotic (amoxicillin–clavulanate) for 10 days. They found across ­several measures (including the composite Acute Otitis Media Severity of Symptoms scale) that the group receiving antibiotics fared better in the short-term with a faster time to symptom improvement and significantly lower rate of persistent infection. On the other hand, the kids receiving antibiotics ­suffered a 25 percent rate of diarrhea versus 15 percent in the placebo group, and there was no significant difference between two groups in the amount of painkiller used.

The authors summed up their study: “Among children 6 to 23 months of age with acute otitis media, treatment with amoxicillin–clavulanate for 10 days affords a measurable short-term benefit … [that] must be weighed against concern not only about the side effects … but also the contribution of antimicrobial treatment to the emergence of bacterial resistance. These considerations underscore the need to restrict treatment to children whose illness is diagnosed with the use of stringent criteria.”

It is with these stringent criteria that the issue gets tricky. The investigators in Hoberman's study were specially trained in examining the middle ear, and in some cases, their diagnoses were assisted with otoscopic photographs. In a normal clinical setting, such ideal circumstances do not always exist, and ­children often require protracted wrestling and earwax removal before a doctor can even get a glimpse of the middle ear. Decisions about antibiotic treatment must sometimes be made with imperfect information. There also is the part about bacterial resistance, a major concern in general and in particular with broad-spectrum antibiotics like Augmentin. Typically, and in the case of my daughter, initial treatment for otitis media is with a more targeted antibiotic such as amoxicillin, with Augmentin reserved for children who do not improve. To use Augmentin in all children with ear pain would eventually lead to a major resistance problem.

So where does this lead us regarding antibiotics for ear infections? I asked Cindy Chung, MD, the chief of pediatrics at San Rafael Kaiser, and she noted that 60 percent to 75 percent of ear infections do get better by themselves. “It is not wrong to ‘watch and wait,’ but this approach is best reserved for kids older than age 2 due to a higher complication rate in younger kids, and the fact that children are harder to interpret when they can't speak!”

From personal experience, I have learned that there are ways that young children communicate — such as persistent screaming — that indicate a certain treatment plan loud and clear.

Dr. Ballard is an associate physician at Kaiser-­Permanente in San Rafael, California and the chair of the CREST ED Research Network. His writing credits include co-authorship with Angela Ballard of the award-winning travel narrative A Blistered Kind of Love: One Couple's Trial by Trail (Mountaineers Books, 2003) and authorship of The Bullet's Yaw (IUniverse, 2007). Dr. Ballard writes a biweekly ­medical column for the Marin Independent Journal, which he posts ­­on his blog: http://incisionanddrainage.blogspot.com

© 2011 Lippincott Williams & Wilkins, Inc.