What doctors are supposed to do when your child has an earache

What doctors are supposed to do when your child has an earache

Your child has an earache. You are worried it is an ear infection. You call the doctor and make an appointment. After all, he needs antibiotics, right?

Maybe not.

We have a real problem of antibiotic overuse in our country–and because we are overusing our antibiotics, many bacteria are getting smarter and stronger. Because ear infections is the diagnosis that kids in the United States are most commonly prescribed antibiotics for, the American Academy of Pediatrics (AAP) tried in 2004 to encourage doctors to rethink their prescribing habits.

The thing is, it turns out that ear infections don’t necessarily need antibiotics. Many are caused by viruses. Many will get better by themselves.And not only does overuse of antibiotics cause resistance, antibiotics can have side effects. The guidelines were supposed to help doctors make better decisions–the problem is, many doctors don’t follow them. So the AAP is trying again; they have reissued guidelines, with some clarifications and additions.

Here is what your doctor is supposed to do when you bring your child in with that earache:

Check to see if it’s really an infection. Not only can the common cold or tooth problems cause earaches, you can also get pain from having fluid in the middle ear, something called otitis media with effusion (OME). OME can look like an infection, but it’s not–so it doesn’t need antibiotics. Your doctor is supposed to look for the signs of a true infection: ear pain that comes on suddenly and persists, and an eardrum that is full or bulging with pus behind it, one that doesn’t move when you blow air into it–or an eardrum that is draining pus.

Ask about and treat pain. This sounds obvious, but sometimes we doctors get so caught up in the diagnosing and antibiotic stuff that we forget to really talk about pain–and it’s pain that brings parents in the first place. Whether or not there is an infection that needs antibiotics, there is an earache that needs soothing–so your doctor should be talking to you about how you can help your child’s pain.

If there really is an infection, figure out if it’s severe. Again, sounds obvious–but it’s important for deciding if antibiotics are needed. A severe infection is one where there is a lot of pain, the child seems ill, or there is a fever of 39 degrees Celsius (102.2 degrees Fahrenheit) or higher.

Decide if antibiotics are necessary. Here is who should definitely get antibiotics:

  • Anybody with a severe infection
  • Anybody with other health problems that put them at risk of complications
  • Children under 6 months old
  • Children 6-23 months who have infections in both ears

If antibiotics aren’t definitely needed, talk with parents about waiting and watching for 48-72 hours. I do this a lot. I give parents a prescription, but I tell them not to fill it unless the child either gets worse or doesn’t get better in 2-3 days. In my experience, most don’t need to fill the prescription. Pain medication and some patience very often do the trick.

To make this work, parents need to understand exactly what they are looking for, need to be able to get the prescription if needed, need to be able to reach the doctor easily if they have any questions–and the doctor needs to be able to reach them easily to check on the child. These are not gimmes in life sometimes–sometimes, to be on the safe side, we need to just go ahead and give antibiotics. But when we can wait, we should wait.

If an antibiotic is prescribed, it should be amoxicillin. To fight antibiotic resistance, it’s important to use just the right antibiotic–the one that will kill only the bacteria likely to cause the infection. For ear infections, that’s amoxicillin, unless the child’s allergic, just had amoxicillin in the past month (which might mean amoxicillin isn’t strong enough), has conjunctivitis too (which can be a sign of bacteria that amoxicillin doesn’t kill), or doesn’t get better in 48-72 hours. The guidelines tell doctors what to do in those situations.

There are a few more things in the guidelines, such as discouraging prescribing antibiotics for prevention of infections in kids who get them a lot, and advice as to when it’s a good idea to send kids to get ear tubes. To prevent ear infections from happening in the first place, the AAP suggests immunizing kids against pneumococcus and influenza, encouraging breastfeeding for the first six months of life, and keeping kids away from tobacco smoke.

So the next time your child has an earache, check to see if your doctor does these things — if not, ask why. And — this is just as important — if your doctor suggests waiting instead of giving antibiotics, don’t freak out. It may really be the better choice.

Claire McCarthy is a primary care physician and the medical director of Boston Children’s Hospital’s Martha Eliot Health Center.  She blogs at Thriving, the Boston Children’s Hospital blog, Vector, the Boston Children’s Hospital science and clinical innovation blog, and MD Mama at Boston.com, where this article originally appeared.

Image credit: Shutterstock.com

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  • buzzkillerjsmith

    Good post, useful post.

  • Janell Chandler

    If a child has any ear pain, whether you give antibiotics or not, and especially if they have reoccurring ear infections, please send them to a chiropractor who works with children. It is so sad to see children who have suffered for months and years with ear infections, and surgery to put tubes in, just to see them get well with chiropractic care. If you don’t know about chiropractic, please call a chiropractor’s office and ask.

    • buzzkillerjsmith


    • Virginia

      No thank you. I prefer science-based medical care over woo.

    • http://www.facebook.com/profile.php?id=1338422225 Tom Garvey

      Is this a joke?

      • EE Smith

        I have seen chiropractors in our area advertizing that if your child gets earache you should bring them there to be treated. In a subtle way they use the AMA advice that antibiotics are not always useful for children’s earache to insinuate: “See? The ‘establishment’ medical-industrial complex is clueless and admits that they cannot help your child, so this is where WE come in!”. We stick to children’s tylenol, a hot water bottle and lots of TLC ourselves.

    • Docbart

      Do you mean we should do that before calling the naturepath, the homeopath, the herbalist, the Reiki specialist and the local shaman?

      • C.L.J. Murphy

        I expect it depends on the phase of the moon, Docbart. Also, the child’s star sign.

    • Fay

      Really? Answer me this. I’m not a doctor. My child is hearing impaired, and had infections for the first year and a half of his life, non-stop. We had put in tubes, tried every med available, and nothing worked. So I finally caved and went to the best chiropractor in town.

      After a full day and night of shrieking I took my child back to the pediatrician – the ear infections were still present, along with a broken arm. Seems like the chiropractor pushed too hard. I considered suing for malpractice, but I had too much on my plate, and didn’t have the time and energy.

      The second set of tubes was the charm, he is now infection free.

      Chiropractors should come with a sign, “Poison! Keep away from children!”

  • http://www.facebook.com/profile.php?id=1338422225 Tom Garvey

    Good article, but please, don’t refer to antibiotic as ‘strong.’ An antibiotic that works is not stronger. It is just the right key for the right lock. If a patient thinks an antibiotic is ‘stronger’ they will think you’re holding out on them when you don’t prescribe an inappropriate, broad-spectrum one.

  • Abby

    While we should treat ear infections appropriately, please dont forget all the antibiotic overuse that takes place in livestock that leads to far more resistant and dangerous bugs and has much less oversight and guidance. This is similar to trying to stop global warming by turning off the lights when you leave a room for 10 mins – a good idea and worth doing, but will do very little to fix the bigger problem.

    • Mandy

      It’s not just about antibiotic resistance, it’s also about not unnecessarily subjecting a child to to powerful medications. Antibiotics are not Pez, they have very real side effects. In the case of some infections, the cost-benefit analysis works out that the benefits are > than the costs. But if there are no benefits to be had at all, then any costs are too high a price to pay.

      I don’t selflessly refuse antibiotics because I want to save the world, I do it because when my child is already miserable with an earache I don’t see the point in needlessly adding a potential upset tummy and the runs to that. P.S. I also don’t turn off the lights when I leave the room so as to “stop global warming”, I do it for the same reason my parents and their parents did it – because there’s no point in being gratuitously lazy or wasteful.

      • Frustrated Pediatrician

        Your child is very lucky. So is your pediatrician.


    Good post. One thing though, pneumatic otoscopy is the best way to do a complete evaluation of the tymapanic membrane, and is often not done. Mobility is a key sign. I am a pediatric ENT.

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