Contrary to common practice, most children with ear infections should not be treated with antibiotics, according to powerful, 21st Century evidence-based guidelines released by the American Academy Pediatrics and the American Academy of Family Physicians. While some of us have been following this approach for years, currently in the United States there are still more than 10 million antibiotic prescriptions written for the ear infections in children each year. About half of all the antibiotic prescriptions in young children are for ear infections. Some kids really need them, but most do not. Each time a child takes a course of antibiotics, future infections become harder to treat. A typical healthy child carries a pound or two of rapidly evolving microscopic bacteria in his or her body. Antibiotics cause the selective breeding of the more resistant strains, which leads to the use of newer, harsher, more expensive antibiotics, with more side effects. For decades, this cycle has been getting worse. But with these new guidelines, it’s all about to change.

Focus on Pain

I’ve long said that doctors should be giving more pain medicines than antibiotics to children with ear infections – because every child with an ear that is inflamed enough to need antibiotics clearly deserves pain relief. In addition, many children who don’t need antibiotics also deserve relief for their sore ears. The March 2004 AAP/AAFP guidelines strongly recommend that we pay attention to children’s ear pain. Children should not suffer in silence. Actually, they are far from silent – but we doctors haven’t adequately listened. Every examination for an ear infection should also include an assessment of a child’s ear pain. And pain relief should be part of the treatment plan. Parents often want to start antibiotics for the ear infection because their child has woken up screaming in pain. They mistakenly think that starting antibiotics will reduce a child’s pain. Stunningly, however, in the first 24 hours, there is no difference in pain level whether or not the child gets antibiotics. The children deserve relief. Oral acetaminophen and ibuprofen are available over-the-counter, and do help. Topical drops specifically for earache relief are also now available over-the-counter in the eye/ear care section at most drugstores, grocery stores, and discount superstores throughout the U.S. These drops have a long history of use in other countries where antibiotic usage is not as prevalent.

The Antibiotic Hoax

Most parents are taught to think that if an antibiotic is given to their child for an ear infection, the medicine will help the child to recover. Not necessarily! Of the 10 million annual antibiotic prescriptions for ear infections, somewhere between 8.5 million and 9.5 million prescriptions didn’t actually help the children, according to the best medical research (and according to the American Academy of Pediatrics). Put another way, we have to treat between 7 and 20 children with antibiotics for ear infections before one child benefits from the medicine. About 80 percent of ear infections will clear up easily without antibiotics. For those that don’t, often the antibiotic won’t help either. Sometimes it does. In 5 to 14 percent of children, the antibiotics will take one day off the length of the ear infection. But by comparison, up to 15 percent of children who take antibiotics will develop vomiting or diarrhea and up to 5 percent will have allergic reactions, some of which may be quite serious. Wouldn’t it be great to limit antibiotic use to the children who really need it?

The 2004 AAP/AAFP guidelines aim to do this by improving the accuracy of ear infection diagnosis; by targeting antibiotic use for a select group of children with ear infections; by paying attention to pain relief for all children (especially during the first 24 hours of an infection); by improving our selection and timing of antibiotics; and by taking steps to prevent ear infections in the first place. A welcome change indeed!

The Diagnosis Secret

If your little girl has a stuffy nose, a slight fever, and wakes up crying, tugging on her ear, and saying, “My ear hurts!” – then she may have an acute ear infection. But it is almost as likely that she has a cold virus, with ear pain from pressure in the ear, and no acute bacterial infection at all. She may need earache relief, not ear infection treatment. Ear infections cannot be accurately diagnosed just based on the story, either by good doctors or by good parents. Physical evidence is needed to confirm the diagnosis. So, when was the last time you heard your doctor say, after looking into your child’s ears, “I think your child has an acute ear infection, but I’m not sure either way.”? If you’ve heard this, you may have a great doctor! As parents, we want our doctors to be accurate diagnosticians, certain of their findings. The secret truth is that the diagnosis of ear infections is often uncertain. An eardrum might be red just from crying. Even in the best of hands, uncertain diagnoses happen every day – and we would all be better served if we respected doctors’ honesty in this regard. An uncertain ear infection should be handled differently than one that is clear-cut. I applaud the 2004 AAP/AAFP guidelines for creating a treatment category for uncertain ear infections.

One Thing is Certain

Fluid must be present in the ear, behind the eardrum, for there to be an ear infection (what doctors call otitis media). The tiny eardrum is a sensitive structure, and can hurt for many reasons: including stretching, trauma, irritants, changes in pressure, changes in temperature, viruses, allergies, and ear infections. Many supposed-ear-infections aren’t ear infections at all, just earaches. Far too often people get antibiotics for earaches, when these are the last thing they need. Ear infections have fluid, by definition. Sometimes doctors can see this fluid through the eardrum by looking in the ear. Sometimes the view is obscured by wax, by a thickened eardrum, by a narrow canal, or by a screaming child. Sometimes the otoscope device the doctor uses doesn’t fit the child’s ear canal well enough to seal when she squeezes a little puff of air to try to flutter the eardrum to reveal fluid. Tympanometry is a test the doctor can use to measure fluid. An EarCheck is an inexpensive home device that parents can use easily to detect fluid behind the ear, using sonar-like technology. One thing is certain: no fluid means no ear infection. This can save many an unnecessary doctor visit, with over-the-counter treatment at home. If fluid is present, there are still important questions to be answered.

Vanilla Ear Infections/Red Hot Ear Infections

With garden-variety ear infections (what doctors call otitis media with effusion, or OME), germ-filled fluid is present in the middle ear. Most ear infections in children are OME. We’ve known for about a decade that antibiotics are not necessary for these vanilla ear infections (as I like to call them). In fact, it is perhaps even more important for these children to avoid antibiotics than it is for their peers, to avoid selectively breeding their most virulent bacteria. An acute ear infection (what doctors call acute otitis media, or AOM) can hurt like hell! These acute infections start abruptly, with the normally delicate eardrum becoming suddenly tender, red, hot, swollen, and painful – like an inflamed appendix. The ear may be filled with pus. The revolutionary 2004 AAP/AAFP ear infection guidelines teach us that even these red hot ear infections (as I like to call them) are often better treated without antibiotics! The body is usually able to kill and drain the infection on its own. But no wonder that soothing relief for the inflamed eardrum is such a priority in these guidelines. Something that is too often neglected.

Who Should Get Antibiotics for Ear Infections?

The consensus, evidence-based 2004 guidelines recommend that children under 6 months of age with red hot ear infections should be treated with antibiotics for 10 days and pain relief for at least the first 24 hours, whether or not the diagnosis is certain. Remember, antibiotics do not help pain during the most painful first 24 hours, and help pain only minimally after that. Kids 6 months to 2 years should receive 10 days of antibiotics and at least 24 hours of pain relief for a red hot ear if the diagnosis of an acute ear infection is certain (it must be an abrupt onset, with physical certainty of fluid in the ears, and clear evidence of an inflamed eardrum – all 3). If the diagnosis of an acute infection is uncertain in these kids, they can be treated with pain relief and observed without antibiotics, (we’ll talk about what this means soon), unless they’ve had a fever of 102.2 or higher in the last 24 hours, or severe symptoms. Once children have reached their second birthdays, pain relief and antibiotics are recommended if both the diagnosis of an acute infection is certain and the illness is severe with a fever of at least 102.2 or symptoms of severe illness. Otherwise, observation and pain relief can be the better course of action. Most kids without a high fever don’t need antibiotics for ear infections.

What Does Observe Mean?

Ask your doctor if the observation option is appropriate for your child. It’s the best option for many children, even many of those with red hot ear infections. In the absence of antibiotics, the child receives treatment tailored to her symptoms – especially toward relieving her pain. Pain relief is part of the observation option, especially for the first 24 hours. In addition, a responsible, available adult is needed to be able to take action if the child is getting worse or has not improved within 48 to 72 hours. The doctor may ask the adult to call if there is a problem. Or a visit may be scheduled in 48 to 72 hours, in case the child isn’t improving. Or the doctor may call in 48 to 72 hours to check in over the phone. Or the doctor may give the child a SNAP at the initial visit – a Safety Net Antibiotic Prescription – to be filled if the child is getting worse or has not improved within 48 to 72 hours. The observation option doesn’t leave the child to suffer. It just gives the body a chance to work at fighting off the infection before intervening with antibiotics, if necessary. I recommend choosing this option whenever it is appropriate.

The Bottom Line: How Well Does Observation Work?

Investigators have compared matched children with acute, red hot ear infections who were treated initially with observation (including earache relief) and those who were treated initially with antibiotics. How did the two groups fare? I’d rather be treated with observation! The two groups felt the same as each other after 24 hours, and again after 4-7 days. Persistent fluid in the ear was the same in both groups. Pain duration was the same in both groups, although those in the observation group were more likely to get pain medicine. The average number of days of fevers were somewhat shortened by antibiotics. However, the difference was not substantial. For example, there was only a one day difference in days of fever between the two groups. The risk of spreading bacterial infection or bacterial complications was statistically the same in both groups, although the numbers were too small to see a real difference. The trend, though, was more than 3 times as many spreading or complicated infections in those who got antibiotics.

The bottom line is that antibiotics are appropriate for a select group of children with ear infections. For others, antibiotics may not only be ineffective, they can expose a child to added risks such as serious allergic reactions and the breeding of more resistant bacteria in that particular child. Careless use of antibiotics can also lead to more resistant bacteria in the environment, making common infections harder to treat in everyone. Whenever it’s appropriate to treat with pain relief rather than antibiotics, the choice is clear: No contest.