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The New Ear Infection Rules

Treating kids' ear infections used to be pretty straightforward: Your pediatrician simply handed you a prescription for an antibiotic. Maybe your child is now so familiar with "the pink stuff" that she can practically measure it into the dispenser herself. And you probably know a kid who got multiple ear infections that left his ear so clogged with fluid that it wouldn't drain, so he got ear tubes.

Both treatments are still important weapons in the seemingly endless battle against acute otitis media, the medical term for an infection (almost always bacterial) of the middle ear. Otitis media occurs when the narrow passage connecting the middle ear to the throat swells, and fluid and pressure build behind the eardrum, causing severe pain. But recent research suggests that drugs and surgery are overused. This worries experts, because handing out unnecessary antibiotic prescriptions fuels the rise of antibiotic-resistant germs.

As a result, many medical organizations, including the American Academy of Pediatrics (AAP), now have guidelines that recommend fewer medical interventions for ear infections. First issued in 2004, the guidelines are regularly bolstered by new research, and doctors have gotten on board. "There's been a major shift in thinking," says Allan Lieberthal, MD, a pediatrician with Kaiser-Permanente in Panorama City, California.

Here's the advice you're likely to get from your pediatrician these days -- and why it's best for your child.

"Let's watch and wait."

When you'll hear it: Most of the time.

Ear infections are the most common reason pediatricians prescribe antibiotics, and for some children, drugs are a good choice. But it's not a wise idea to be the parent who demands antibiotics every time your child tugs at his ear. Side effects such as diarrhea, stomach pain, and rashes affect around 7 percent of kids. And doctors worry that many forms of bacteria, including the strain that usually causes ear infections, are becoming resistant to antibiotics, making the drugs less effective against more serious infections. In a University of Texas Medical Branch study that compared watchful waiting with medication, children who received antibiotics were much more likely to carry drug-resistant bacteria by the study's end.

Another reason watchful waiting makes sense: Studies show that about 80 percent of ear infections clear up on their own within a week, since the immune system kills invading bacteria or viruses naturally anyway. In fact, 60 percent of kids feel better in just one day. "Often, a child begins crying and complaining during the night, and by the time I see him in my office the next morning, he's already fine," says Edward O. Cox, MD, director of the division of primary care at DeVos Children's Hospital, in Grand Rapids. "Why prescribe an antibiotic when a child gets better without one?" The AAP agrees and now suggests postponing medications for most ear infections, which spares parents the hassle of forcing kids to swallow syrups, remembering doses, and making sure that all caregivers follow the instructions.

This approach is only appropriate, however, when your child definitely has an ear infection; if it could be a serious illness such as pneumonia or bacterial meningitis, he needs an antibiotic immediately. So the first thing your pediatrician will do is look for telltale ear-infection symptoms: fussiness, crying, fever, and tugging at the ear. If he sees a swollen or stiff eardrum, redness, and fluid when he looks in your child's ear, that usually confirms the diagnosis. If you agree to take a watch-and-wait approach -- treat your child's pain as directed by his pediatrician and track his symptoms -- he should gradually get better over the next 48 to 72 hours. Definitely call the doctor if your child doesn't feel like playing or still has pain or a fever beyond that point.

When you'll hear it: Only in special circumstances.

Your child's age plays a big role in this situation. Babies under 6 months should get medication because they're at higher risk of contracting serious illnesses, including bacteremia, a blood infection. And most parents of children under 2 will walk away with a prescription because the consequences of antibiotic resistance or a bad reaction to an antibiotic outweigh the risk of a major illness.

Pediatricians will also usually prescribe an antibiotic if a child seems sicker than expected from an ear infection. "You wonder whether something more serious is going on when a child is extremely irritable, is less alert than you'd like, or isn't responding to her parent," says Dr. Cox.

Ear infections often begin after a cold that causes the eustachian tube to swell, trapping fluid inside, where bacteria like to breed. If your child's didn't start that way, it could be a sign of a more serious infection. In this case, a doctor might give her an antibiotic. She may also get one if you tried watchful waiting but she got another ear infection within 30 days -- she may need a continuous low dose of antibiotics to stop the recurrence, or antibiotic eardrops if her infections generate pus.

Because a certain amount of personal judgment goes into deciding whether to use antibiotics, doctors may write a "safety net" prescription that parents will fill if ear pain persists for 48 to 72 hours. "It's a joint decision," says Dr. Lieberthal. "The parent takes the prescription but waits a few days before filling it." You may not need it, since studies suggest that 70 percent of prescriptions aren't filled. When doctors do prescribe, they usually start with amoxicillin, which works more than 80 percent of the time. If it doesn't (possibly because of bacterial resistance), broader-spectrum and more expensive drugs such as Omnicef are often the second line of defense.

When you'll hear it: If this infection is one of many.

After an infection clears up, the fluid left in the middle ear -- what doctors call effusion -- can linger for weeks in some kids, often causing a degree of hearing loss during that time. Traditionally, doctors recommended a myringotomy (an operation to remove the fluid) and a tube insertion. The reasoning: Temporary hearing loss was thought to delay development in speech, language, and learning. But a 2005 University of Pittsburgh study found that hearing and speech are just as good in kids who don't get tubes as in those who do. "The best approach for many children is to see the doctor every month or two to see whether the fluid has cleared and wait it out," says study leader Jack Paradise, MD, professor of pediatrics and otolaryngology at the University of Pittsburgh School of Medicine. Most pediatricians can do this ongoing evaluation, though some doctors may refer you to a specialist at this point.

Eventually, most cases of effusion go away on their own within three months -- unless your child is hit with one ear infection after another so that his ears never get a chance to clear. If he has persistent fluid buildup for three months or more, or he suffers from language delays, learning problems, or a significant hearing loss, the AAP recommends getting a hearing checkup. If your child's hearing loss is moderate to severe and he's had poor hearing for four months or more, talk to your doctor about tubes.

If your child needs this operation, rest assured that the risks are minimal, says Debara Tucci, MD, a pediatric ear surgeon in the department of surgery at Duke University Medical Center, in Durham, North Carolina. "About 90 percent of children who get tubes do extremely well," she says. During the surgery, which is performed in about 15 minutes under a light general anesthesia, doctors will make a tiny hole in your child's eardrum using a small scalpel or laser and insert the tube to keep the incision open. The tubes fall out by themselves in eight to 12 months.

Swimmer's ear can turn a day at the pool into a washout. Protect your child from this painful condition with advice from pediatrician Alan Greene, MD, author of The Parent's Complete Guide to Ear Infections.

Symptoms: The outer ear becomes red, itchy, and extremely tender. Chewing is particularly painful, and you may see pus in your child's ear.

Causes: When the ear canal stays damp after swimming, bacteria can grow and lead to an infection called acute otitis externa -- which is different from typical middle-ear infections. Regularly cleaning your child's ears with cotton swabs can also remove protective wax and scratch the lining of the ear canal, which increases the chance of infection. Kids who've had swimmer's ear before, as well as those who have eczema or seborrhea, are at higher risk.

Treatment: Antibiotic eardrops (some formulations require just one dose a day) are more effective than oral antibiotics, according to new expert guidelines, and they don't lead to antibiotic resistance.

Prevention: Make sure your child dries his ears after swimming by tilting his head to each side while pulling on his outer ear. Wearing earplugs or a bathing cap pulled down over the ears also helps keep water out. Don't stick cotton swabs in your child's ears.