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.