The ear infection debate

Do antibiotics help or hinder healing?

Kids’ ear infections not helped much by antibiotics – CTV News, Nov. 18, 2010
Antibiotics best for treating ear infections – CTV News, Jan. 12, 2011

Confused by conflicting headlines like these? No wonder. Even doctors are divided over how to apply the research findings. So how do you decide what to do when your baby gets her first ear infection? All you know is that your little one is ill and in pain — and you want her to feel better.

Until about 10 years ago, there was no question what would happen if your child had an ear infection. “The recommendation was to treat ear infections with antibiotics,” says Joan Robinson, an Edmonton paediatrician and Canadian Paediatric Society (CPS) spokesperson. The reasoning? This prevented potential complications, including rupture of the eardrum, spread of infection into the mastoid bone of the skull, and permanent hearing loss.

Fast-forward a few years to when experts began to realize that liberal antibiotics use was causing problems. The more frequently children took antibiotics, the less likely these drugs would work when they were really needed. Overuse of common antibiotics was causing many bacteria to become immune to these medications, meaning once-easily-treated infections were becoming much harder to cure.

At the same time, research was beginning to reveal that most ear infections clear up without treatment. According to these studies, “if 10 children were diagnosed with ear infections, nine would get better, and one would eventually need the antibiotics,” explains Robinson. What’s more, it turned out complications were rare even when doctors took a wait-and-see approach to treatment. And, since antibiotics can cause tummy upset and diarrhea, this method would save lots of kids additional discomfort.

Based on this information, in 2009 the CPS issued new guidelines for treating ear infections. Now the CPS recommends prescribing antibiotics immediately only for certain groups of children. According to Elizabeth Shaw, child health committee co-chair for the College of Family Physicians of Canada, “a lot depends on how sick the child is.” For example:

• Kids who have severe pain that doesn’t respond to acetaminophen or ibuprofen, fever of 39ºC (102.2ºF) or greater, vomiting or lethargy need prompt treatment. Ditto for babies six months and under, and those who run a higher risk of complications, including kids with recurrent ear infections or asthma, and children with Down syndrome.

• If a child over six months of age has a suspected ear infection but only mild symptoms, the CPS now suggests giving acetaminophen or ibuprofen for the pain, and holding off on antibiotics for 48 to 72 hours. If, in that time, the symptoms worsen or the child seems sicker, antibiotics can be started. Otherwise, “if things seem to be settling down, even if the child complains of some intermittent ear pain but it’s not getting any worse, those kids usually do pretty well without antibiotics,” says Shaw.

It gets complicated for parents because, despite these guidelines, not all doctors approach the situation the same way. Some physicians still pull out the prescription pad at the first sign of a sore ear. Why? “Some docs do it because they’ve always treated ear infections that way, and don’t believe most will get better without treatment,” Robinson says.

But another group of doctors may have joined the immediate-treatment camp because of two recent studies that found ear infections in children under three cleared up quicker, stopped hurting sooner, and were more likely to resolve completely within 10 days when they were treated with antibiotics. Mind you, the kids in these studies all had definite signs of a true ear infection, like a bulging eardrum.

There’s even variation among docs who believe in the wait-and-see approach. Some insist on seeing the child twice, scribbling a prescription on the second visit if necessary. Others get some information over the phone, and schedule an appointment a day or two later so they can make the call then. And many physicians simply write a prescription, to be filled only if the child starts getting sicker, or still seems to have an earache two days down the road. “I think that works well for everyone because parents feel like they’ve got this insurance in their back pocket, and they don’t have to make another appointment,” says Robinson.

So what should you do when your child gets an earache? While the CPS guidelines are a good starting point, ultimately, you’ll have to use your best judgment — whether that means pocketing a prescription you don’t intend to fill or asking if you can have one, just in case.

Signs of an ear infection

A baby can’t tell you her ear hurts. So when should you suspect she has an ear infection? Fussiness, crying (especially when you lay her down), fever and difficulty sleeping are strong hints, particularly when they come on a few days after the start of a cold.

What about ear tubes?

Even after an infection has cleared up, fluid may remain trapped behind the eardrum, which can interfere with hearing. Over time, the liquid can also become thick and gluey, worsening the problem.

If it’s severe enough, the resulting hearing loss can hinder a baby’s ability to learn to talk. Consequently, if the fluid lingers in both ears for more than three months, and a child has a hearing loss of more than 20 decibels in his “good” ear, most ear, nose and throat specialists recommend placing tiny tubes in both eardrums. The tubes temporarily take over for the middle ear’s natural ventilation system, the Eustachian tube, which gets blocked up easily in babies and toddlers. Ear tubes improve hearing, cut down on infections, and prevent possible long-term complications of “glue ear,” which include thinning and collapse of the eardrum.

How it’s done: The operation takes about 10 minutes and is typically performed under general anaesthetic, to ensure the child stays completely still. Using a microscope to view the area, the surgeon makes a small slit in the eardrum and suctions out the fluid. The tube is slipped into the hole, and flanged edges hold it in place. Kids usually go home within a few hours, and can return to daycare the next day. Tubes typically stay put for 12 to 18 months, before falling out on their own.

Risks: There’s a small chance that when the tubes fall out, the eardrum won’t heal normally, and thus may require a second procedure to “patch” it; or that a tube won’t fall out naturally after the need for it has passed, and may need to be removed.
If water gets into the middle ear, it can trigger an ear infection, which is easily treated with antibiotic drops. Rarely, a skin cyst can grow in behind the eardrum, which can cause complications similar to those of glue ear.

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