Treating Earaches In Children

As a pediatrician, many of my days in the office start with a child who has been up all night with ear pain or a baby who has been fussy all night with a temperature. In fact, ear pain is one of the most common reasons for visits to the doctor's office. Of course babies can't tell us their ear hurts, so parents need to rely on other signs. Fussiness, especially when lying down, fever, cold symptoms, vomiting, diarrhea, ear tugging, and lethargy can all signal an ear infection in an infant. Most ear infections occur in the context of an upper respiratory infection, but not always. Occasionally, the only sign of an ear infection is drainage from the ear canal.

Most ear pain is caused by a middle ear infection otherwise known as acute otitis media (AOM). The middle ear is a small bony area covered by the eardrum (tympanic membrane), which plays an important role in allowing us to hear sounds. Sound passes through the eardrum to the middle ear bones and finally on to the inner ear, where nerve impulses carry the sound to the brain. The middle ear is connected to the back of the nose and throat by a tiny opening called the Eustachian tube. This tube helps to aerate and drain the middle ear, balancing the air pressure inside and outside the middle ear.

When the Eustachian tube gets blocked or does not work well (for example, if you have a stuffy nose from a cold or allergies), fluid builds up in the middle ear and it is unable to drain. Sometimes bacteria or viruses then grow in this fluid, causing an infection and a buildup of pressure in the middle ear. The eardrum becomes red, swollen, and painful. The middle ear fluid usually goes away once the infection is gone and the Eustachian tubes can drain properly.

It may take several weeks to months for the fluid to completely drain, even though the infection is gone. If the fluid stays in the middle ear too long after the infection clears, it is known as otitis media with effusion (OME). This is a fancy term that simply means that there is fluid in the middle ear. OME does not mean that the fluid is infected; it is simply not draining out of the middle ear well. OME can reduce hearing on the side with the fluid build up, but it generally does not cause pain or other symptoms.

Antibiotics for an ear infection?
Doctors and parents usually think an antibiotic should be prescribed for an ear infection. However, most ear infections, even those thought to be caused by bacteria, can get better in a few days without antibiotics. Since OME is not an infection, it generally does not need to be treated with antibiotics.

The latest guidelines from the American Academy of Pediatrics and the American Academy of Family Physicians urge doctors to first make a careful diagnosis remembering that not all ear pain is an infection. Doctors should focus on pain relief and consider not using antibiotics right away, especially in otherwise healthy children who are older than 2 years of age and have mild or moderate findings. Note that these recommendations are not meant for children with certain medical conditions that could make ear infections more difficult to treat (such as cleft palate, Down syndrome or cochlear implants), children who just had an ear infection within the past month, or those children with chronic OME.

Watchful Waiting
Many parents (and even providers) may feel uncomfortable with the decision to wait before giving an antibiotic to their child, but it is important to remember that antibiotics could cause your child more harm than good.

While treating AOM, antibiotics also kill normal bacteria that are always found in the mouth and throat, intestine, skin, and vagina. When these everyday bacteria are eliminated, other potentially harmful bacteria strains can develop, which may be resistant to antibiotics. Bacteria that are resistant to an antibiotic prescribed for your child will survive treatment. They can live and multiply in your child's nose and airway, and can eventually cause an infection that may not respond to usual treatment.

However, children with complicated infections?ear infections in children younger than 6 months or in older children with more severe symptoms ? should be treated with antibiotics.

It is still important to speak with your child's doctor if your child has symptoms of an ear infection. A careful exam and a good history help to make an accurate diagnosis of a middle ear infection. You can help your doctor to decide whether your child's ear infection is severe enough to need an antibiotic. Take your child's temperature and record it. If the doctor has specified a safe dose of acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) for your child, try treating symptoms before the doctor examines your child, so that the effectiveness of pain medicines can be evaluated.

If you and your child's doctor together decide not to give an antibiotic right away, the doctor will want to know if your child has more pain or fever or is not improving as expected. This is called "watchful waiting". Keep in touch with the doctor because if the symptoms are not improving after waiting 48 to 72 hours, antibiotics may then be suggested.

What is your experience with these troublesome ear infections? Has your doctor suggested not using antibiotics right away? What has been your reaction?

 

Family Health Guide
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