Article - New Guidelines Outline Appropriate Treatment of Ear Infections

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New Guidelines Outline Appropriate Treatment of Ear Infections

March 10, 2004 - Millions of children every year suffer painful ear

infections. And every year, parents look to their child's doctor for help in

easing the pain. The American Academy of Pediatrics (AAP) and the American

Academy of Family Physicians (AAFP) have released new guidelines to help

physicians and parents decide on the best treatment for acute otitis media

(AOM), or middle ear infection.

AOM is the most common bacterial illness in children and the one most

commonly treated with antibiotics. Says Allan Lieberthal, M.D., FAAP,

co-chair of the guideline panel, " Accurate diagnosis of AOM is the key to

this guideline. We need to make sure that the child has AOM before

prescribing an antibiotic. If a child is given an antibiotic and doesn't

need it, he or she may build up an antibiotic resistance and not respond to

them when needed for a more serious infection, such as pneumonia or

meningitis. " The guidelines stress that about eight in 10 children with ear

infections get better with no antibiotics at all.

According to Ted Ganiats, M.D., a family physician in San Diego, Calif., and

co-chair of the guideline panel, the most important step to take in the case

of any ear infection is to relieve the child's pain. " We want parents and

doctors to first make the child comfortable with pain relievers such as

ibuprofen and acetaminophen. Antibiotics do not relieve pain during the

first 24 hours and do not reduce fever any quicker or better than pain

medicines, " he said.

Antibiotics may be the right choice for children up to the age of 2 who have

ear infections, not just fluid in their ears. They may also be appropriate

if a child is very sick or has a high fever. The guideline provides an

option to observe select children and start antibiotic treatment only if

symptoms have not improved in 48-72 hours. The guideline also notes that 80

percent of children whose ear infections are not treated immediately with

antibiotics get better on their own and have no increased risk of a serious

infection.

What are the new guidelines?

The new guidelines define acute otitis media (AOM), or middle ear

infections, and outline appropriate diagnosis and treatment standards -

including pain management - based on a child's age and other factors.

Why were these new guidelines developed?

Acute otitis media (AOM) is the most common bacterial illness in children

and the one most commonly treated with antibiotics. There has been a

significant increase in, and concern about antibacterial resistance of the

organisms that cause AOM. These factors suggested the need for a detailed

evaluation of AOM and its management.

While the number of office visits for otitis media with effusion - middle

ear fluid - (OME) have decreased over the past decade from 25 million in

1990 to just 16 million in 2000, the number of antibiotic prescriptions to

treat AOM has remained constant. At the same time, concerns about the rising

rate of antibiotic - or antibacterial - use and resistance have emerged.

What do the new guidelines recommend?

Accurately diagnose AOM and differentiate it from OME, which requires

different management.

Relieve pain, especially in the first 24 hours, with ibuprofen or

acetaminophen.

Minimize antibiotic side effects by giving parents of select children the

option of fighting the infection on their own for 48-72 hours, then starting

antibiotics if they do not improve.

Prescribe initial antibiotics for children who are likely to benefit the

most from treatment.

Encourage families to prevent AOM by reducing risk factors. For babies and

infants these include breastfeeding for at least six months, avoiding

" bottle propping, " and eliminating exposure to passive tobacco smoke.

If antibiotic treatment is agreed upon, the clinician should prescribe

amoxicillin for most children.

Do the guidelines apply to all children?

No. The guidelines apply only to an otherwise healthy child without

underlying conditions that may alter the natural course of AOM. These

conditions include, but are not limited to, anatomic abnormalities such as

cleft palate, genetic conditions such as Down syndrome, immune system

disorders, and cochlear implants. Also excluded are children with a clinical

recurrence of AOM within 30 days or AOM with underlying chronic OME.

What is acute otitis media?

A diagnosis of acute otitis media requires:

Recent, usually abrupt, onset of illness.

The presence of middle ear fluid, or effusion.

Signs or symptoms of middle ear inflammation.

Over 5 million AOM cases occur annually in US children, resulting in more

than 10 million annual antibiotic prescriptions and about 30 million annual

visits to doctor's offices. Fifty percent of antibiotics for preschoolers in

the US are prescribed for ear infections. Using an observation option could

reduce antibiotic prescriptions annually by up to 3 million and would

significantly reduce the prevalence of resistant bacteria.

What are the harmful effects of antibiotics?

Each course of antibiotic given to a child can make future infections more

difficult to treat. The result is an increase in the use of a larger range

of - and generally more expensive - antibiotics. In addition, the benefit of

antibiotics for AOM is small on average, and must be balanced against

potential harm of therapy. About 15 percent of children who take antibiotics

suffer from diarrhea or vomiting and up to 5 percent have allergic

reactions, which can be serious or life threatening. The average preschooler

carries around 1 to 2 pounds of bacteria - about 5 percent of his or her

body weight. These bacteria have 3.5 billion years of experience in

resisting and surviving environmental challenges. Resistant bacteria in a

child can be passed to siblings, other family members, neighbors, and peers

in group-care or school settings.

When should antibiotics be prescribed?

For children age 6 months and younger - for certain or suspected AOM.

Children age 6 months to 2 years - for certain AOM or suspected AOM with

severe symptoms; observation is an option for suspected or uncertain AOM if

non-severe.

Children age 2 to 12 years - antibiotic treatment for certain AOM with

severe symptoms; observation is an option for suspected or non-severe AOM.

The guideline provides an option to observe select children and only start

antibiotic treatment if symptoms have not improved in 48-72 hours.

Approximately 80 percent of children with AOM get better without

antibiotics. And children whose ear infections are not treated immediately

with antibiotics are not likely to develop a serious illness.

What if a child with a middle ear infection is in great pain and discomfort?

The mainstay of pain management for AOM is medications such as acetominophen

and ibuprofen, not antibiotics. Most children with AOM have significant ear

pain, which may manifest in young children as ear rubbing, sleep disruption,

or temper tantrums. Analgesics are most important in the first 24 hours

after diagnosis, especially before the child's bedtime. Fortunately, by 24

hours about 60 percent of children feel better, rising to 80-90 percent

within a few days. Antibiotics do not relieve pain in the first 24 hours,

and have only a small effect after that.

Is my child at risk for developing other infections if she is not treated

with antibiotics?

Published trials of observation, placebo, or non-antibiotic AOM therapy have

shown no increased rate of complications, provided that children are

followed carefully and receive antibiotics if symptoms persist or worsen.

These studies vary in the age of children studied and the severity of

illness, factors taken into consideration in determining which children are

suitable for the observation option.