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Playing It By Ear: Infections Don't Always Require Antibiotics

No parent wants to see their child rub their tiny ears in pain.

So it's understandable that when many parents see their pediatrician about a possible ear infection, they want fast relief for their child.

But new guidelines for the treatment of middle ear infection, also known as acute otitis media, suggest that the best route to recovery might not always be via antibiotics.

Middle ear infection is the most common bacterial illness in children. Concerns about the widespread use of antibiotics leading to antibacterial resistance prompted the development of the middle ear infection guidelines for otherwise healthy children, which were issued on March 9th by the American Academy of Pediatrics and the American Academy of Family Physicians. Antibacterial resistance can cause hard-to-treat infections that can spread throughout communities.

"The approach here is groundbreaking in that this is the first time national organizations are recommending withholding antibiotics for what is mostly a bacterial infection," says guideline coauthor Richard M. Rosenfeld, MD, director of pediatric otolaryngology at Long Island College Hospital in Brooklyn, New York. "We're trying to balance the benefits and harms of antibiotics to help target the antibiotics to the kids who benefit most."

An accurate diagnosis is one of best ways to ensure antibiotics are used appropriately.

According to the guidelines, a diagnosis of middle ear infection requires the abrupt onset of the illness within the last 24 to 48 hours; the presence of middle ear fluid or pus; and signs and symptom of inflammation such as ear pain or a reddened ear drum.

It's particularly important for pediatricians to distinguish between middle ear infections and a condition called middle ear fluid, which can accompany upper respiratory infections, does not cause pain, and does not respond to antibiotics.

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Determining which children need antibiotics depends on the certainty of diagnosis, the child's age, the illness severity and the likelihood that the parents will follow-up with a call or second visit.

For example, the immediate use of antibiotics is recommended in children with a certain diagnosis and in all children under six months old, even if they don't have a confirmed diagnosed; very young children are more likely to have infection complications such as meningitis. In children who are between six months and two years old, antibiotics are recommended if there is certain diagnosis or a suspected diagnosis with severe symptoms. And in children over two, antibiotics are recommended for a certain diagnosis with severe symptoms, such as a fever over 102 F or severe ear pain.

In other children, the guidelines say, the parents and pediatricians may choose to observe the child to see if they get better within 48 to 72 hours before giving an antibiotic.

Some physicians may even give a parent a "safety net prescription" that they can fill at a later date if the child is not recovering.

According to Dr. Rosenfeld, studies show that most children will get better on their own, though it may take about a day longer than it would if they were being treated with antibiotics, which can cause stomach upset or a rash in some children.

Studies have not shown a higher incidence of infection complications such as mastoiditis, or inflammation of the bone, or meningitis, in children who did not receive immediate antibacterial treatment.

It is important, however, that parents of children who do not improve fill their safety net prescription or follow up with their pediatricians.

For all children, the guidelines stress the importance of pain relief. "I think pain relief is not emphasized to the extent is should be in middle ear infections and in infections in children in general," Dr. Rosenfeld says. "The mainstay of treatment is pain relievers such as ibuprofen or acetaminophen, not antibiotics. This is especially true in the first 24 hours."

By consolidating the research on middle ear infections, the joint guidelines provide parents and pediatricians with options. "We're not encouraging people to do things they're not comfortable with," Dr. Rosenfeld says. "We're allowing people to make an informed decision based on the best evidence."

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