Dear Doctor Column, November 28, 2005

Watchful Waiting for Childhood Ear Infections

Question:

My 3-year-old daughter has a middle ear infection. The last time she had an infection (about a year ago), the pediatrician prescribed antibiotics that cleared it right up. We've moved and our new doctor says we should wait a couple days and see if she improves without antibiotics. Is this safe? Why doesn't he just refill her prescription?

Answer:

Your doctor is recommending "watchful waiting," a strategy of closely observing your daughter for 2 to 3 days to see if the infection improves on its own. Recent research shows many ear infections not associated with a high fever or severe pain resolve without antibiotics and children who are immediately treated with the medications usually reap only modest benefits. In addition, prescribing unnecessary antibiotics can produce antibiotic-resistant germs, which can make treating future infections more difficult. Children also can experience unpleasant side effects from antibiotics, including diarrhea, vomiting, and allergic reactions.

Ear infections are one of the primary reasons parents take their children to the doctor. There are different types of ear infections, but otitis media — inflammation and infection of the middle ear — is most common. Infections can be acute — a short painful episode — or chronic, which means they persist over time or frequently recur.

Children and infants are especially susceptible to ear infections because their eustachian tubes — the tubes connecting the middle ear to the back of the throat — are easily clogged with fluid that can build up and become infected. Colds, sinus infections, and second-hand tobacco smoke can irritate children's eustachian tubes and upper airways and increase fluid production, which can cause blockage and infection. Other conditions, such as enlarged adenoids, which can cause your child to snore or breathe through their mouth, conjunctivitis or "pinkeye," and allergic disorders, are sometimes associated with middle ear infections.

In the United States, more than 5 million children a year suffer from acute otitis media, and as a result, doctors write about 10 million annual antibiotic prescriptions, the National Institutes of Health reports. Recently, there has been a significant rise in antibacterial resistance to organisms that cause ear infections and other illnesses. The sharp growth of antibiotic-resistant bacteria is linked to overuse of the medications.

Once infected with a resistant strain of bacteria, children can pass the harder-to-treat germs to their friends, family members, and others they are in close contact with. Resistant bacteria must be treated with increasingly potent and expensive antibiotics that can require shots or hospitalization. In 2004, the American Academy of Pediatrics (AAP) issued updated guidelines for treatment of acute middle ear infections aimed at curbing unnecessary antibiotic use.

New AAP guidelines recommend:

• Careful diagnosis of ear infections to distinguish acute otitis media from otitis media with effusion — fluid in the middle ear without the inflammation and pain of an acute infection. The two conditions often require different treatments.
• Appropriate pain relief, especially in the first 24 hour of infection, with ibuprofen (Motrin) or acetaminophen (Tylenol).
• Minimizing antibiotic use by offering parents of carefully selected children (those without severe infections or complicating medical conditions) the option of watchful waiting. Pediatricians can start a course of antibiotics if children do not get better on their own. Children with nonsevere infections have only mild pain and fever.
• Prescribing initial antibiotics for children who are most likely to benefit from treatment.
• Encouraging parents to prevent ear infections by eliminating factors that increase risk for the condition such as second-hand smoke and "bottle propping" (feeding infants in a horizontal position can cause formula and other fluids to flow back into eustachian tubes). AAP also notes children who are breast fed for at least 6 months are less prone to ear infections.

Certain children with confirmed or suspected acute middle ear infections do need antibiotics. AAP recommends antibiotics for:

• Children aged 6 months and younger
• Children between 6 months and 2 years with severe symptoms (severe pain and high fever)
• Children between 2 and 12 years with particular types of acute middle ear infections and severe symptoms

Acute middle ear infections hurt, and the pain can cause children to have difficulty sleeping, rub their ears, or have temper tantrums. Pain-relieving medications are especially important in the first 24 hours of infection, when the condition is usually most painful. Most children feel better after the first day of illness, and 80% to 90% improve within a few days. Antibiotics do not relieve pain in the first 24 hours of infection and have only a small effect beyond that, AAP says.

AAP notes that about 80% of children with acute otitis media get better without antibiotics, and that postponing antibiotic treatment for a few days while observing your child is unlikely to lead to more serious illnesses. Following your doctor's recommendation of watchful waiting is safe, but you should closely monitor your child to make sure her symptoms do not worsen. If your daughter's symptoms do not improve or get worse, you should let her doctor know right away.