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Ear Infection? Antibiotics
May Not Be the Best Choice

Your toddler's been up half the night, crying and tugging on his ear, and by now you know the routine. Call the doctor, get a prescription for an antibiotic, race to the pharmacy and get him on the road to recovery from that ear infection.

Not so fast. Until recently, that scenario was common. Your pediatrician would probably prescribe an antibiotic ASAP. But under new guidelines, your doctor may suggest waiting a while -- and even skipping antibiotics altogether.

Concern about the rising rate of antibiotic use, leading to resistance of the germs that cause middle ear infections, has prompted the new guidelines encouraging lower use of antibiotics.

Middle ear infection -- called acute otitis media -- is the most common bacterial illness in children and the one most commonly treated with antibiotics. More than five million cases of acute middle ear infections occur annually in the United States, according to the American Academy of Pediatrics. And more than 10 million antibiotic prescriptions are written each year to manage those infections.

But that number will hopefully decline, without an adverse effect on children's health, in the wake of the new guidelines, issued earlier this year by the American Academy of Pediatrics and the American Academy of Family Physicians.

While the goal is to cut down on unneeded antibiotics, "this is not a recommendation not to give antibiotics," said Dr. Allan Lieberthal, a pediatrician at Kaiser Permanente in Panorama City, Calif., and lead author of the new guidelines.

Rather, the goal is to postpone or sometimes eliminate the use of antibiotics. Parents should also understand the guidelines cover basically healthy children only. "The key part of this is, it is for selected children," Lieberthal said.

The guidelines are primarily intended for children 2 years of age or older who aren't seriously ill or have some underlying condition, Lieberthal said. Excluded from the guidelines are children with chronic illnesses that affect the ear. This would include, for instance, children born with a cleft palate, which predisposes them to chronic middle ear infections. Also excluded are children with genetic conditions such as Down syndrome, immune system disorders and hearing-impaired children with cochlear implants, he said.

There are three key components to the new guidelines, according to Lieberthal. "The first is accurate diagnosis. The second is treatment of pain," he said.

Then, the doctor must decide if antibiotics are needed at all. "Selected children with ear infections may not need antibiotics," said Lieberthal. "More than 80 percent of the children who meet the guideline definition [of those who might not need antibiotics] get better without antibiotics."

Here's what the new guidelines recommend:

  • Accurately diagnosing acute otitis media and differentiating it from otitis media with effusion (middle ear fluid), which requires different management.
  • Relieving pain, especially in the first 24 hours, with ibuprofen or acetaminophen.
  • Giving parents of healthy children the option of fighting the infection on their own for 48 to 72 hours, then starting antibiotics if they do not improve.
  • Encouraging families to prevent acute otitis media by taking steps to reduce risk factors. For babies and infants this includes breastfeeding for at least six months, and eliminating exposure to passive tobacco smoke.
  • If antibiotic treatment is agreed upon, the doctor should prescribe amoxicillin for most children.

It's also crucial, Lieberthal said, for parents to observe the child closely and to keep the doctor informed about their child's condition, so antibiotics can be prescribed if needed.

Another expert, Dr. Dennis Woo, chairman of pediatrics at Santa Monica-UCLA Medical Center in California, said the new guidelines "give credibility to what a lot of us were already doing."

Antibiotics should still be prescribed under certain conditions, according to the guidelines. For instance, children 6 months old or younger should receive the drugs is they have a diagnosed or suspected middle ear infection.

For children age 6 months to two years, antibiotics should still be prescribed if the diagnosis is a suspected or certain middle ear infection with severe symptoms. If the symptoms aren't severe and the diagnosis is suspected or uncertain middle ear infection, observation is an option.

For children ages 2 to 12 years, antibiotic treatment is recommended for certain middle ear infections with severe symptoms, and observation is an option for suspected or non-severe middle ear infection without severe symptoms.

Putting the guidelines into operation may work best in a practice setting where the doctor knows the families and the parents understand the importance of keeping the doctor posted on the child's status, Woo said.

Both Woo and Lieberthal agreed there is no danger to postponing antibiotics in healthy children if they are watched closely.


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