KIDS
October 12, 2009

Of Earaches And Antibiotics

Two major pediatrics societies have set policies recommending watchful waiting over immediate antibiotic treatment for many, if not most, children...

Winter is approaching, and many parents will soon be bringing their children to the doctor for the treatment earaches. What should they expect from the visit? Will their doctor prescribe antibiotics? Should he or she do so? Is there anything parents can do to protect their children from the discomfort of ear infections?

The Canadian Pediatric Society recently published guidelines for the evaluation and treatment of acute otitis media, or middle ear infections. This policy is virtually identical to that of the Policy.

This change in policy is part of an effort to decrease the unnecessary use of antibiotics that is leading to widespread drug resistance among common bacteria.

The most significant feature of both policies is the recommendation that not all middle ear infections should be treated immediately with antibiotics. Because most middle ear infections are caused by viruses which resolve by themselves and do not respond to antibiotic treatment, both policies recommend "watchful waiting" for some children with earaches. This change in policy is part of an effort to decrease the unnecessary use of antibiotics that is leading to widespread drug resistance among common bacteria. It also aims to decrease the unnecessary risk of side effects and allergic reactions in children who are being inappropriately treated with antibiotics for viral illnesses.

Although it is usually not possible to distinguish between an ear infection caused by a virus and one caused by bacteria by simple examination, the course of the child's illness over a few days will make it clear. But both Canadian and American pediatricians stress that this approach is only an option for children who are 6 months old or older, whose illness is not severe (their pain is mild and their fever is less than 39° C or 102° F), and who have no underlying genetic, immunologic, or anatomical problems, such as cleft palate, which increase their risk of severe infections.

Equally important, children who are not treated with antibiotics at the time of their first visit must have a reliable way to communicate with their doctor and to be reexamined if they don't improve, and a way to obtain a prescription if necessary. Whether or not a child is treated with antibiotics, the child should be treated with appropriate pain medication for the discomfort that accompanies middle ear infections. With or without antibiotic treatment, a child whose symptoms do not improve over 48−72 hours should be reevaluated. At that time, antibiotics may be started, or the antibiotic may be changed to a different one if the first doesn't appear to be treating the infection adequately.

The goal of limiting a child's unnecessary exposure to antibiotics is an important one, and both Canadian and American pediatricians also urge parents to do what they can to limit their children's risk getting ear infections. Breast −feeding for the first six months of life decreases the early episodes of otitis media. Avoiding propping the bottle while the child is lying down is also critical. Reducing exposure to sick children by having young children in smaller day care groups, being sure young children have their required immunizations as well as flu shots and eliminating passive exposure to cigarette smoke are similarly important and effective.

When a child is diagnosed with a middle ear infection, a parent should be prepared for the doctor to recommend watchful waiting, along with good pain control, over antibiotic treatment. Parents should ask the doctor how they will know if the child needs a revisit or antibiotics and confirm the doctor's after−hours and weekend coverage policies. If an antibiotic is prescribed, parents should be sure to give the child the full course of medication, even though the most uncomfortable symptoms will resolve before the medication bottle is empty. Parents should ask the doctor to review any particular risk factors that their child might have for recurrent infections. Ideally, children should receive care for both their acute illnesses and their well−child visits by a primary care physician who knows the child and the family and can provide comprehensive care and advice.

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