Ever wonder what goes into the decision to prescribe antibiotics? A pediatrician and mom explains all the factors to consider before deciding on the best treatment.
When to Worry: Ear Infections
When you have a child with an earache, you want to make it go away. Now. Completely.
Ear infections are the second most common illness of childhood behind colds, which means that nearly all of us have shown up at the doctor's office with a cranky child who is holding his ear(s). I've actually been there on both sides: as a mom raising five kids and as a pediatrician.
It's natural to expect a prescription for an antibiotic. After all, your child has an infection, right? But it doesn't always work that way. Doctors today are less likely to pull out that prescription pad, because the germs that cause ear infections (and other infections) are becoming resistant to antibiotics. It's important to understand these points.
Not every earache is an infection.
The congestion of a cold can make a child's ears feel clogged and painful, but that's not necessarily an ear infection. Sometimes ear pain can actually be pain from a tooth problem, for example. (Teething doesn't cause ear infections, but it can lead to earaches.)
Bacteria aren't always to blame.
Some infections are caused by viruses, like the germs that are responsible for colds. While a higher fever and an inflamed eardrum are more likely to indicate that bacteria are causing a child's pain, it's not always easy for us doctors to tell the difference. (And even if there isn't a fever, a child could still have an ear infection.)
Not all ear infections need antibiotics to get better.
Turns out that even if it is caused by bacteria, an ear infection can go away by itself. In fact, more than half of kids will start to feel better in a day with or without antibiotics, and in a week that number goes up to three-quarters.
But as a parent of a kid with an earache, you don't want to wait, especially if it means missing days of school and/or work. If there's a chance that the wonderful Pink Medicine (that's what many of my patients
and their families call amoxicillin, the antibiotic recommended for ear infections) will make your child feel better quickly, that's what you want.
I totally get that, as a mom and a doctor. However, there are two real problems with giving out the Pink Medicine for every ear infection: side effects and antibiotic-resistance.
Antibiotics can cause stomachaches, vomiting, diarrhea, rashes, and sometimes allergic reactions or more serious problems. While major side effects are rare, stomach upset isn't; one in ten kids taking antibiotics ends up with diarrhea. We can justify that with illnesses that are contagious, or if the treatment is really necessary—but it's a shame for a child to get diarrhea when her earache would've gotten better by itself in a couple of days.
It's the antibiotic-resistance that has us doctors worried. Bacteria want to survive, just like any other living thing. As they get exposed to antibiotics, they adapt and change over time so that the drugs become less effective. And as the weaker strains of bacteria get killed off by antibiotics, the stronger ones multiply and spread. This is exactly the public-health problem we're seeing as a result of our overuse of antibiotics: strains of bacteria that defy any treatment.
To help pediatricians decide when to use antibiotics, the American Academy of Pediatrics came out with guidelines. This is what your doctor is supposed to do when faced with a cranky child who has ear pain.
Find out if it's really an infection.
Find out if it's really an infection.
To be sure, we should check for three criteria. The first is symptoms such as ear pain or fever that has come on abruptly (as opposed to a steady cold that a kid has had for a few days). The exact temperature doesn't matter; the fact that there's a fever at all is what's important. We also check the middle ear for fluid; the third criterion is signs of inflammation, like a red, bulging eardrum. This sounds straightforward, but it's not always so clear in the exam room. Some kids are easier to examine than others. Earwax can make it harder to see inside the ear, and screaming or having a fever can make a child's eardrum appear red. But the point is that we should do our best to be sure that an infection is really there.
Assess for and treat pain.
Parents want antibiotics so their child will get better. And yet sometimes pain medication, such as acetaminophen or ibuprofen, ends up being all that is needed. Consider giving your child one of these drugs even when she's on antibiotics, because it can take two or three days for the prescription to work enough to make her more comfortable. Anesthetic eardrops can also help, although I rarely find them necessary. Talk to your doctor about them if your child has a very bad earache.
Consider holding off on antibiotics for a couple of days.
We call this "watchful waiting," and this is where things get a bit complicated. Assuming a child is generally healthy (unlike kids with health problems that affect their immune system, who should always get antibiotics), doctors need to consider certain factors when deciding whether to prescribe. How old is the child? Are we certain there's an infection? Is the illness mild or severe?
If a child is younger than 6 months, we nearly always give an antibiotic. Babies can't tell us how bad they feel; it's not always easy to get a good look in their ears; and serious infections can be very risky for that age group.
If the child is between 6 months and 2 years old, though, our decision depends on a few things. If we are certain there's an ear infection, we give antibiotics. If we're not—if what we see in the ear could just be from a cold, for example—we only give meds right away if the child seems really ill, say with a fever above 102°F or bad ear pain.
For kids over age 2, we're supposed to be more stingy with antibiotics. (The guidelines say between ages 2 and 12 actually, because ear infections are uncommon in kids older than 12 and deserve a closer look.) Even if we're positive there's an ear infection, we're advised to give them only if the illness is severe. If it's mild, or if we're not sure, watchful waiting is best.
Watchful waiting only works, however, if we can be certain that the child will get antibiotics if he gets worse or doesn't improve in the next couple of days. Some doctors might give the parent a prescription and tell her not to fill it unless it's necessary. Others might ask her to call the office for either a prescription or another appointment if things don't improve.
That type of follow-up sounds straightforward enough, but sometimes it's not. Even good and loving parents may not be the most accurate judge of how their child is doing. Some tend to minimize problems (perhaps because they don't like giving medication), and some tend to exaggerate them (maybe because they are worriers or simply feel better if their child takes an antibiotic). This isn't a judgment of anyone's parenting abilities; as a mom I know just how hard it can be to determine how your child is doing.
The treatment of ear infections, I think, underlines two important truths about medicine. First, it's just as much art as science—there are so many variables, so much that isn't always clear, so much that can't be predicted. Answers are far more elusive than most people realize.
Second, medicine is all about teamwork. Pediatricians rely just as much on parents as parents rely on them. After all, you're the caretaker of your children and the one who knows them better than anyone. We all do our best when we work together.
The lowdown on ear tubes, and tips for kids who hate medicine.
The Lowdown on Ear Tubes
Myringotomy or tympanostomy tubes are very tiny tubes placed through the eardrums that allow air into the middle ear and let fluid drain out. We usually suggest tubes when a child has repeated infections (the specifics depend on the child) or has persistent fluid in the middle ear, especially when he also has hearing loss. Tubes have been shown to reduce the number of infections kids get and also to improve their hearing. A child will need to have general anesthesia, but the surgery is quick and easy and he'll go home the same day. Having tubes shouldn't change life at all, although kids need to take certain precautions to be sure germs and other things don't get in through the tubes. Tubes usually fall out by themselves within around six months, and the hole in the eardrum usually heals. Complications are rare.
Does Your Kid Hate Medicine?
Lots of us know (or have) at least one kid who flat-out refuses, spits out his meds, or vomits them up. I'll share a few tricks I've learned over the years:
- Be clear that you mean business and that taking the medicine is non-negotiable.
- For liquid medication, try to get the smallest volume possible (for example, a dose of 250mg could either be 2 teaspoons of 125mg/5mL or 1 teaspoon of 250mg/5mL). Ask your doctor about this.
- Use a medication syringe instead of spoon. Not only does it measure precisely, but you also don't need as much participation and cooperation from your child to insert and squirt it into his mouth.
- Talk to the pharmacist about using flavorings. Not all pharmacists can do this and not all flavorings will mask a bad taste, but it's worth a shot.
- Try a chaser of something sweet. I've had good luck with chocolate syrup.
- Consider chewables or crushing pills and mixing them with a small amount of something sweet like pudding, or with lots of textures such as carrot cake.
- Use "incentives." Let your kid earn prizes or privileges for taking the meds—but do this judiciously.
- If all else fails, talk to your doctor about injectable antibiotics. It's not an ideal option: At least two shots are needed, the procedure hurts, and it may not be effective. We only do this as a last resort.
Doctor Examines a Child with an Earache
Originally published in the December 2012 issue of Parents magazine.