February 25, 2013
Pediatric Group Cautions Against Antibiotic Use In Children’s Ear Infections
Lawrence LeBlond for redOrbit.com - Your Universe Online
Millions of children are treated with antibiotics for ear infections each year in the US. In fact, an ear infection is one of the most common reasons kids end up going to a doctor and receiving antibiotics. But new guidelines set forth by the American Academy of Pediatrics (AAP) are asking doctors to be more guarded in how they diagnose and treat the often painful condition.
The AAP is calling for pediatricians to adhere to stricter diagnostics and more careful observation before prescribing antibiotics specifically for acute otitis media (a middle-ear infection) in children ages 6 months to 12 years of age who are otherwise healthy and without tympanostomy tubes, cleft palate, Down syndrome, immune deficiencies or cochlear implants.
The new guidelines, published in the March issue of Pediatrics, also recommend against pediatricians prescribing antibiotic prophylaxis for children with recurrent ear infections.
The 2013 update follows guidelines by the AAP in 2004, then recommending that watchful waiting is perhaps the best policy when it comes to ear infections.
The new guidelines “really attempt to clarify who are the best kids to observe and who are the best to treat right away,” wrote Richard Rosenfeld, professor and chairman of otolaryngology at SUNY Downstate Medical Center in Brooklyn, N.Y., and a co-author of the recommendations.
"We've been waiting for these guidelines for some time," said Andrew Hertz, MD, medical director of the UH Rainbow Care Network in Cleveland. "There's been a movement for a number of years for pediatricians to provide less antibiotics for ear infections and simply observe those children with mild findings on physical examination.
"Hopefully, now that there is a practice guideline ... that you don't have to prescribe an antibiotic for every ear infection, this will decrease the use of antibiotics and thereby make antibiotics more successful and more useful when they are prescribed," he said in an interview with MedPageToday´s Crystal Phend.
The guidelines recommend that children do need immediate antibiotics for an ear infection that is associated with severe pain or a fever of 102.2 degrees or higher, or if they have a ruptured ear drum with drainage, or any infection in both ears for children under 2 years old.
While these cases account for a much smaller percentage, Rosenfeld said "we know from studies that they get the most benefit from an antibiotic right away“¦ Kids without these symptoms tend to get well on their own and can be safely observed for a few days."
Rosenfeld explained most parents want something for their kids who are “up all night screaming and tugging at the ear.” But about 70 percent of these children get better on their own within a few days, and about 80 percent are better within a week, he added.
And there are downsides to using antibiotics when used unnecessarily, he noted. They can cause upset stomachs, allergic reactions and other side effects. One particular problem with taking antibiotics is it can contribute to the development of superbugs–infections that become resistant to future treatment.
"The bacteria that do survive the antibiotic get tough and next time you get an ear infection or any other type of infection they're harder to manage," Rosenfeld told Rob Stein of NPR.
And as a parent, Rosenfeld explained, it doesn´t help to “freak out.” Most often, ear infections go away on their own, and “quite often with just some pain medicine.”
Generally, ibuprofen or acetaminophen works well to relieve pain associated with an ear infection. “If it's going to improve, it will happen in 72 hours. If a child's symptoms get worse or don't improve in that time, they should be given antibiotics," Rosenfeld said.
And while ear infection is one of the most common reasons children are prescribed antibiotics in the US, many times pain in the ear comes from another source rather than an infection. A new molar in a young child´s mouth, a cold or sore throat, or even viral inflammation can cause ear pain, Rosenfeld explained.
Careful examination of the ear drum is necessary to make an accurate diagnosis. "If it's big and bulging, that's a sign of a middle-ear infection," he added.
The guidelines have been applauded by some health experts. But others have raised concerns the recommendations might lead some pediatricians to remain too guarded when it comes to prescribing antibiotics when it really is needed.
"When the diagnosis is correct, then antibiotic treatment is never wrong," said Beth Wald of the University of Wisconsin School of Medicine and Public Health. "Kids tend to recover more often and they recover more quickly if they're treated appropriately with antibiotics."
She noted this is especially important with parents who both hold down full-time jobs. "We live in a society where there is so much pressure for both parents to be working outside the home and it's just complicated when our child is sick. Besides which, there's always parental anxiety and concern when their child is sick," she explained to NPR in an interview.
Rosenfeld stressed doctors should be free to figure out what is best for each child. But in many cases, they can offer a “safety net” for parents by handing them an antibiotic and asserting that pain meds should be used for a few days first. If the pain persists and the infection doesn´t go away, then the doctor should be notified and antibiotics administered, he explained.
The 2013 guidelines also offer advice in protecting children from recurrent ear infections. Among the most common protective efforts are breastfeeding for a minimum of four months, and eliminating exposure to tobacco smoke. For kids who do have recurrent acute middle-ear infections, ear-tube surgery may be necessary. It has been shown to be an effective measure in reducing onset of infection, especially for those who hold on to fluid between infections.
The AAP also said infections may be reduced in children who receive pneumococcal conjugate vaccine and annual flu shot.
The AAP maintained middle ear effusion is required for diagnosis of an infection, however it now has to be used on tympanometry or pneumatic otoscopy. Although early acute otitis media can occur without effusion, the academy said “the risk of over-diagnosis supersedes that concern.”
In patients who require antibiotic treatment, amoxicillin remains the first line of defense. In recurrent episodes, further treatments may include stronger beta-lactamase drugs.