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?
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.
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