Ear infections

New guidelines call for limiting antibiotics for ear infections


Special to the Miami Herald

When they were toddlers, Sallie James’ twins suffered such painful ear infections they would wake up in the middle of the night screaming.

The pain was caused by fluid build-up behind the eardrum that caused the eardrum to swell. It seemed every time her twins, Cameron and Gabby, caught a cold, it would lead to one of the killer ear infections.

The Tamarac single mother was growing frustrated with the never-ending cycle of taking her kids to the doctor, getting a diagnosis of ear infection and being prescribed antibiotics. After awhile, the medications didn’t work, so they turned to increasingly stronger antibiotics. Ultimately, even those didn’t work.

Eventually, when her kids were about 3, doctors recommended the surgical implantation of ear tubes, which drain the fluid, eliminate the pain and, eventually, the infection. Thankfully, that alleviated the problem.

“I didn’t want to do it because I wasn’t a fan of surgery,” saId James, a marketing specialist. “But it made a huge difference. Before the surgery, the situation was horrendous.”

James’ experience is anything but unusual. The most common reason parents take their toddlers to the pediatrician is for ear infections, also called otitis media or middle ear infection. The most common age for the painful affliction to strike is between 1 and 3 years old; by 5, the child usually outgrows the condition.

New guidelines issued last year by the American Academy of Pediatrics question whether doctors are treating ear infections too aggressively, and call for more limited and conservative use of antibiotics.

The guidelines encourage observation with close follow-up instead of antibiotic treatment for many children, including some under the age of 2. They also encourage children suffering three ear infections within six months or four within a year be referred to an ear, nose and throat specialist for the implantation of ear tubes.

The guidelines also state that amoxicillin should be the antibiotic of choice unless the child is allergic to penicillin or has been treated with amoxicillin during the past month.

Additionally, the guidelines make recommendations for proper pain management with analgesics, noting that it takes 24 to 48 hours before symptoms improve from antibiotics. They also take note that breastfeeding can reduce the incidences of ear infections and that secondhand smoke can be a contributing factor.

The new guidelines are prompted by concerns in the medical community that pediatricians are overprescribing antibiotics in the child and adult population and that the overuse is leading to a resistance to antibiotics.

“We are running out of antibiotics,” noted Dr. Adriana Cadilla, a pediatrician at Miami Children’s Hospital. “We do need to be more cautious. We don’t want to abuse the antibiotics.”

The hardest part of the new guidelines is educating parents, said Cadilla,, adding that “it takes more time to educate a parent than to just hand them a prescription.”

Dr. Sandeep Dave, an otolaryngologist and ENT surgeon at Miami Children's Hospital, agrees that doctors have been overprescribing antibiotics. But, he added, parents are starting to move away from wanting prescriptions every time their children develop ear infections.

“I think there’s a movement, a trend of parents not wanting to give their kids so many antibiotics,” he noted.

Proper diagnosis is critical in determining whether children have ear infections or simply fluid in the ear, or swimmer’s ear. Just because children have fluid in their ears doesn’t mean infection is present. However, if the fluid is accompanied by pus behind the eardrum, a bulging eardrum, pain and possibly fever, then ear infection is the probable diagnosis. The child may also have muffled hearing and the speech may be slightly affected in serious cases.

If the doctor does not diagnose ear infection, he or she will advocate taking a watch-and-wait attitude to see if the fluid clears up on its own, particularly under the new guidelines. Although fluid can be removed from adults’ ears through a procedure that involves piercing the eardrum to drain the fluid, there is really no way to remove the fluid from the ear of a squirmy child, notes Dave.

While it’s not as serious as inner ear infection and requires no antibiotics, Dr. Ramzi Younis, University of Miami/Holtz Children’s Hospital pediatric otolaryngologist, by no means takes swimmer’s ear, or outer ear infection, lightly. “You would not wish this on anyone,” he says, referring to the accompanying pain.

He says the condition is common in the summer months, when children are swimming frequently, and in Florida in general. He often prescribes strong painkillers to treat the pain and advocates using a hair dryer to dry the ears after swimming. Parents can also put a small amount of alcohol and vinegar in a child’s ear to disinfect it and dry up any fluid.

“Everyone has some bacteria in their ears, but when kids are swimming frequently … it can wash the wax or protective lawyer out of the ears, leading to the infection,” notes Younis.

For chronic ear infections, ear tubes — which came into use in the 1960s — have been a godsend, say doctors. Dave, the Miami Children’s Hospital doctor, places 400 to 600 ear tubes a year, in children as young as 1 year old, up to 18. The plastic tubes wind up falling out on their own and do not require removal.

Do the tubes always work?

“I don’t say always,” says Dave. “But almost always. They buy time for the body to outgrow the condition.”

Sometimes, parents are resistant to the tubes, Younis says.

“It’s hard for parents to hear the word surgery,” he says. “But it’s a very simple thing to do, done under general anesthesia. It’s magnificent. It will improve their hearing and their speech.”

Dave has another recommendation for parents of children with chronic ear infections, but it’s not necessarily a practical one. He recommends they take a “day care vacation,” removing their children from day care for several weeks to allow any infections to clear up.

“I joke that day care keep me in business,” he says. “A lot of kids are passing germs back and forth. It all starts with an upper respiratory infection and then moves into the ears.”

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