Do Kids Really Need Antibiotics for Ear Infections?

Sometimes a wait-and-see approach is best for treating an ear infection

Ear infections are the most common bacterial infection in kids, and one of the most common reasons for a pediatrician to prescribe antibiotics. Given what we now know about how the overuse of antibiotics may cause bacteria to become resistant to them, however, it makes sense for doctors to be less quick to prescribe them. 

That's why the American Academy of Pediatrics (AAP) issued guidelines in 2013 to help pediatricians and parents make smart decisions about when antibiotics are really necessary to treat ear infections.

So the next time your baby starts yanking on her ear or your 5-year-old suddenly runs a fever, keep these guidelines in mind. 

Diagnosis of Ear Infections

The first thing to know about ear infections is that it's not always clear a child actually has one, even to a doctor. It seems it should be a straightforward thing to diagnose: You look inside a child's ear and you can see if it's infected or not, right? But it can be tough to get a clear view of the inside of a younger child's ear. And it's easy to mistake fluid in the ear for an infection, to label redness caused by fever or crying as a sign of infection, or to not be able to even see the ear drum because of ear wax.

One clue that a kid truly has an ear infection is that she's also had some of the classic symptoms: rapid onset of an earache (otalgia), pulling on the ear (something babies will do in response to ear pain), irritability, the drainage of fluid from the ear (otorrhea), and fever.

When Antibiotics Really Are Needed

According to the AAP guidelines, all babies under 6 months who develop an ear infection should be treated with antibiotics. Kids between 6 months and 2 years also should get antibiotics if their pediatrician is certain they have an ear infection. (Remember, it can be a deceptively tricky diagnosis to make.) A child who has severe symptoms, such as extreme pain or a fever over 102.2 F, also should be treated with antibiotics even if the doctor isn't 100 percent certain she has an ear infection.

Most children with certain chronic health issues also should be put on antibiotics for an ear infection. This includes kids with Down syndrome, immune system problems, cleft palate, or a cochlear implant. The same holds true for any child who's had an ear infection in the previous 30 days or has chronic fluid in her ears.

The Observation Option

Older kids and those who are healthy in general usually don't need antibiotics to clear up an ear infection, at least not at first. For them, the AAP guidelines advise using an "observation option." This means simply watching a child carefully for the first 48 to 72 hours after she's diagnosed. If her symptoms get worse, or don't improve at all, then it's time to call in a prescription for antibiotics. Pediatricians handle this scenario in different ways. Some have parents come back to the office, others will prescribe the medication over the phone, and some doctors will write out a "just-in-case" prescription for parents to have on hand.

This method of observation instead of prescribing antibiotics right away has been working successfully in other countries and has few risks. It works because most kids with ear infections will likely get better on their own anyway.

Kids aren't left to suffer, however: The guidelines recommend giving acetaminophen or ibuprofen for pain relief.

When Wait-and-See Doesn't Work

If after the observation period a child's ear infection symptoms don't lessen and it's clear she needs an antibiotic to treat it, the AAP guidelines recommend starting with amoxicillin, and moving on to a stronger medication after 48 to 72 hours if amoxicillin doesn't relieve symptoms or a child's fever stays at 102.2 F or above. After that, or as an alternative if a child is vomiting, she may need one or three days of an intravenous or intramuscular antibiotic, such as Rocephin (ceftriaxone).

For kids with certain allergies, the AAP guidelines list alternative antibiotics that will be safe for them to take. 

Regardless of the specific antibiotic prescribed, according to the AAP children under 6 and those with severe symptoms should stay on medication for a full 10 days. Older kids may do well with just five to seven days of antibiotics.

Preventing Ear Infections in the First Place

The AAP also recommends taking measures to reduce risk factors for ear infections, especially during infancy. These include breastfeeding for at least six months, never giving a baby a bottle while she's lying down, and weaning from a pacifier after six months. And kids of all ages should be kept away from second-hand smoke.

Source:

Allan S. Lieberthal, Aaron E. Carroll, Tasnee Chonmaitree, Theodore G. Ganiats, Alejandro Hoberman, Mary Anne Jackson, Mark D. Joffe, Donald T. Miller, Richard M. Rosenfeld, Xavier D. Sevilla, Richard H. Schwartz, Pauline A. Thomas, David E. Tunkel.  Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis MediaPediatrics. 2013. doi:10.1542/peds.2012-3488.

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