Children's doctors have new guidelines to help them diagnose and treat children's ear infections. The American Academy of Pediatrics issued the guidelines February 25. One goal is to reduce the use of antibiotics, which often are not needed. The guidelines were last updated in 2004. The new ones include the results of research done since then. They describe a more precise way to diagnose an ear infection. And for the first time they say it's OK sometimes to wait before giving antibiotics to children ages 6 to 23 months. Immediate antibiotics are still recommended for children with severe infections or high fever. They also should be given when kids don't get better within 48 to 72 hours, the guidelines say. Doctors are urged to give medicine for pain, especially during the waiting period. Some doctors now prescribe antibiotics for prevention to children who get frequent ear infections. The guidelines do not recommend this. The journal Pediatrics published the guidelines. HealthDay News wrote about them.

By Claire McCarthy, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

When it comes to ear infections, antibiotics aren't always a good idea. This was the whole reason the American Academy of Pediatrics (AAP) issued a policy guideline in 2004.

Many ear infections are caused by viruses. They don't need antibiotics, which kill bacteria, not viruses. Also, many pediatricians diagnose an infection when the ear is not infected but only contains fluid. This is called otitis media with effusion, or OME.

Ear infections are the most common condition for which antibiotics are prescribed in the United States. The hope with the 2004 guidelines was to decrease overprescribing of antibiotics. Prescribing has gone down somewhat, but not a lot. And not only that, surveys have shown that doctors are not reliably following the guidelines.

So the AAP has issued the guidelines again -- with a few things added and clarified. Here's what the guidelines are asking doctors to do:

1. Be sure it really is an ear infection. The signs are:
   
   • Ear pain that comes on all of a sudden and stays
   • An eardrum that is full and doesn't move when air is blown on it using a special device


2. Ask about pain, and be sure to treat it if it's there. Pain is what parents usually want to make go away, and that's why they ask for antibiotics. But if it's caused by a virus the antibiotics won't do anything. Even if the infection is caused by bacteria, it can take up to three days to see an effect.



3. Be thoughtful about whether an ear infection really needs antibiotics. Here's what the AAP recommends:
   
   • If the pain is severe or there is a high fever, give antibiotics.
   • If the child is 6 through 23 months old and has infections in both ears, give antibiotics even if it's not a severe infection.
   • If the child is 6 through 23 months old and has a milder infection in one ear, or is older and the infection isn't severe, consider holding off on antibiotics. Wait for 48 to 72 hours to see how things go. If they get worse, or don't get better, use antibiotics.


4. Use amoxicillin to treat ear infections, unless:
   
   • The child just had amoxicillin in the last month
   • The child also has conjunctivitis (often called "pinkeye"), which can be a sign of some bacteria that don't respond to amoxicillin
   • The child is allergic


5. If any of the above is the case, use a stronger antibiotic. The guidelines give specific advice about which one.



6. Whatever antibiotic is given, if the child isn't getting better in 48 to 72 hours, consider changing it.



7. Don't give antibiotics to prevent ear infections in kids who get them often. It doesn't really help and increases the chance of antibiotic resistance.



8. Consider ear tubes in kids who get frequent infections (3 in 6 months, or 4 in a year with 1 in the last 6 months).



9. Make sure children get the pneumococcal vaccine. It makes a difference.



10. Make sure children get a yearly flu shot. It makes a difference, too.



11. Encourage mothers to breastfeed for at least 6 months.



12. Do everything possible to make sure that kids aren't exposed to tobacco smoke.

What Changes Can I Make Now?

If you take your child to the doctor with ear pain, talk to your doctor about these guidelines. Make sure he or she is following them. Most importantly, be willing to leave without a prescription for an antibiotic. Doctors can follow the guidelines more easily if parents don't ask for or expect antibiotics for every earache.

What Can I Expect Looking to the Future?

We are seeing more and more bacterial infections that don't respond to antibiotics. The main reason is that we are using too many of them. If we want our antibiotics to work, we need to use them only when absolutely necessary -- and we need to use the one most suited to the infection.

Guidelines like these can help us do just that -- if doctors and patients follow them.