Ear Infections: What's New?

You may have heard the news: this year the American Academy of Pediatrics published a revised, updated set of guidelines for the diagnosis and initial treatment of acute otitis media in otherwise healthy children ages six months to twelve years.

http://pediatrics.aappublications.org/content/113/5/1451.full

You might be wondering what this means for you and your child.

The purpose of the new guidelines was to consider the substantial amount of research done since 2004, when the last guidelines were published, in order to assist primary care clinicians in the diagnosis and initial treatment of acute ear infections according to scientific evidence.

Evidence-based medical practice is important because we want to provide care to your child that is necessary, effective, and beneficial. Accurately diagnosing an ear infection is the first step in this process. The first part of the new guidelines addresses the importance of making the correct diagnosis of acute otitis media, and determining if it is a severe or not severe infection. The guidelines go on to address treatment and prevention.

DIAGNOSING ACUTE OTITIS MEDIA AND DETERMINING IF IT IS SEVERE
Acute otitis media is diagnosed when there is fluid in the middle ear (fluid behind the ear drum, a middle ear effusion) PLUS one of the following circumstances:
1. There is moderate to severe bulging of the ear drum (tympanic membrane), OR new ear drainage that is not caused by swimmer's ear (otitis externa).
2. There is mild bulging of the ear drum PLUS severe ear drum redness or recent onset of ear pain (or signs of ear pain such as holding/tugging/rubbing the ear in a child who cannot talk).

The guidelines further define acute otitis media as SEVERE if there are severe signs or symptoms such as moderate to severe pain, over 48 hours of pain, or fever of equal to or greater than 102.2 degrees.

NONSEVERE acute otitis media is diagnosed when the pain is mild, less than 48 hours, and fever is less than 102.2 degrees.

PAIN RELIEF
The recommended first step in management of acute otitis media is assessment and treatment of pain. Over-the-counter pain relievers such as ibuprofen and acetaminophen are the first choice because they are effective, best tolerated, easiest to give, and most available of all the options. Managing pain is important even when antibiotics are used to treat acute otitis media, because pain may continue for 48 to 72 hours after starting an antibiotic.

DECIDING TO USE ANTIBIOTICS
The next step in managing acute otitis media is deciding if antibiotics will be necessary. That's right, not all children with ear infections need antibiotics! The guidelines state that children who are 24 months of age and older, who have NONSEVERE acute otitis media in either one or both ears, may be safely and effectively treated with initial observation and pain management. The decision to hold off on antibiotic treatment is made jointly between the pediatrician and parent. A plan is put in place to ensure follow up or treatment if symptoms get worse or are not improving in 48 to 72 hours.

In general the guidelines recommend antibiotic treatment for SEVERE acute otitis media at any age, or for children under 24 months of age with NONSEVERE acute otitis media that is BILATERAL (on both sides).

DECIDING WHICH ANTIBIOTIC TO USE
Amoxicillin is the first choice if the decision has been made to treat with an antibiotic AND the child has not had amoxicillin in the last 30 days, is not allergic to penicillin, and does not have signs of bacteria that is resistant to amoxicillin (such as repeated poor response to amoxicillin or purulent conjunctivitis--"pink eye" with lots of thick, crusted, colored drainage).

Raising the amoxicillin dose from the traditional 40 milligrams of amoxicillin per kilogram of the child's weight per day to 80-90 mg per kilogram per day will overcome most common bacterial resistance to amoxicillin seen in acute ear infections.

If amoxicillin has been used in the last 30 days, the child is allergic to penicillin, or the bacteria is believed to be resistant to amoxicillin, then amoxicillin-clavulanate (Augmentin) or a cephalosporin (such as cefdinir, cefuroxime, cefpodoxime, cefixime, or ceftriaxone) are the next choices.

Of note, recently (as of 4/14/2013) there have been back-orders on certain cephalosporins, or a delay in pharmacies being able to supply prescribed liquid cephalosporins to our patients. Effectiveness, availability, taste, and cost affect the choice of the prescribed antibiotic.

FOLLOW UP
If symptoms worsen or do not respond to initial antibiotic treatment in 48 to 72 hours, then the child may need to be reevaluated. Even with effective antibiotic treatment pain may worsen for the first 24 hours or not improve for 48-72 hours. Most of the time pain will be treated with ibuprofen or acetaminophen.

PREVENTION
All children are recommended to receive the pneumococcal conjugate vaccine when they are eligible (the routine vaccination schedule for pneumococcal conjugate vaccine is ages 2 months, 4 months, 6 months, and 12-15 months). Annual flu vaccine is recommended for all eligible children (starting at age six months). Six months of breastfeeding is encouraged. Avoidance of tobacco smoke exposure is important. Avoiding giving a bottle while the child lays flat on her back may help prevent ear infections. Reducing or eliminating pacifier use after the age of six months may also help. Decreasing the frequency of viral upper respiratory infections may help reduce ear infections--the only identified way to do this is to reduce exposure to group day care.

A few studies have show xylitol (which is "birch sugar") is effective in reducing ear infection frequency by 25 percent for children in group day care. The best way to give it is in chewing gum or lozenge form, 3-5 times a day, every day throughout the cold and flu season. Gum and lozenges are not appropriate to use in young children because they are a choking hazard. Xylitol does not help treat an active ear infection and does not work if used only occasionally. Of note, xylitol is not really considered a practical solution for the prevention of ear infections at this time due to the limitations in availability for younger children and the difficulties in regular and consistent administration.

Preventative antibiotics (such as a daily small dose of an antibiotic) should NOT be used because they are likely to be more harmful than helpful.

Ear tubes may be an option for recurrent acute otitis media (three episodes in six months, or four episodes in one year with one episode in the preceding six months), however the benefits versus the risks of the procedure must be considered.

ALTERNATIVE MEDICINE
The new guidelines point out that many families turn to complementary or alternative medicine for the treatment and prevention of ear infections. However, in the comprehensive review of the available research-based evidence, no good studies of the effectiveness of such treatments have been published. The guidelines made recommendations about the need for research in this area, and cautioned about the potential costs of treatments that have not been proven to be effective.

It's Flu Season!

image from wikimedia.org

It is flu season (and has been since December)! The media tells us that influenza (flu) is on the decline. Maybe so--but there is still plenty of it out there. 

Friday in the office I evaluated 8-10 children with flu-like symptoms: sudden onset of high fever, cough, body aches, headache, runny nose, sore throat, and fatigue. They all looked miserable, with fever and sometimes chills, slightly glassy and reddish eyes, cough, and exhaustion.

Flu looks different from a cold. Kids with the flu are not usually smiling and perky in the office. Sometimes there is vomiting and loose stools--but these are just part of the whole picture, not the main symptoms.

Flu vaccines ARE helping this year--though we have had a few break through infections even in those who were immunized. Overall, the majority of children with confirmed influenza have not had their flu shots. Even if the vaccine did not completely prevent the flu, the symptoms in the immunized have been less severe and lasting for a shorter amount of time.

The high fever, cough, body aches, headache, runny nose, sore throat, and fatigue that come with the flu often last for a full week. It is important to be sure the patient gets enough fluids throughout their illness so they do not become dehydrated. Rest is also important. People with flu and fever should not go to school or other activities. Even if the fever comes down with some ibuprofen or acetaminophen the patient is still contagious to others and needs to rest to achieve a full recovery.

Medication for the flu includes Tamiflu, an antiviral antibiotic. In cases of influenza, if started within the first 24-48 hours of the symptoms, it can reduce the severity and length of the symptoms. Unfortunately, Tamiflu suspension tastes terrible and it has been quite difficult for parents to get their young children to take it. In addition, sometimes Tamiflu can be hard to find in the community. Tamiflu is not as good for flu as amoxicillin is for strep throat--it's definitely not an instant cure. Although pediatricians are encouraged to prescribe it for flu patients, I have found parents have a very difficult time getting it into their children. I tried it with my own kids a few years ago, and it is not a happy memory (as the doctor did not succeed in getting her own children to take it!).

Get a flu vaccine for your children if you are able to do so. Keep your children at home, resting, and drinking lots of fluids if they have the flu. Go to the doctor's office early in the illness if you think your child might benefit from Tamiflu. Good luck, I hope it's over soon!

Babies Coughing and Wheezing: Does Your Baby Have RSV?

It's late.  Your baby is coughing and wheezing.  Everything seems worse in the middle of the night.  What kind of cough is it?  What is going around this time of year?  What should you do?

A common virus has really taken off in the last month or two.  You have probably heard of it:  RSV.
RSV stands for Respiratory Syncytial Virus.  For older kids and adults it usually just causes a bad cold.  However, infants and toddlers can be hit hard by this virus.  RSV causes a lot of mucous drainage.  This is hard for babies because they greatly prefer to breathe out of their noses.  The infection causes wheezing and congestion in the lungs of small children.  RSV can cause a fever and may lead to ear infections and prolonged cough.

Sometimes I have called this "baby bronchitis."  Although that comparison helps people understand the condition a little better, bronchiolitis is not actually the same thing as bronchitis.  Bronchitis affects the larger airways in the lungs (the "bronchi") and leads to a significant productive cough.  Bronchiolitis affects the smaller airways, deeper in the lungs.  These flexible, narrow airways are called bronchioles.  They collect mucous and then tend to tighten up with each breath.  This leads to wheezing and a painful sounding, tight cough.

Here are some examples of the symptoms of bronchiolitis.  You will hear wheezing (both with inhale and exhale) and see retractions.  When the skin sucks in above the sternum (breastbone) or between the ribs with each breath, these are retractions. 

This video shows a baby with bronchiolitis who has retractions in her neck (called suprasternal retractions), wheezing with inhaling and exhaling, nostrils flaring with each breath, and a tight little cough (at the end of the video).  Although the dad mentions during the video that she has croup, actually this is a better video of bronchiolitis.




The next video shows a baby with head bobbing.  It is a sign of difficulty breathing in young infants.  Because he is using his neck muscles to help him breathe it pulls his head forward with each breath.




Here is a pretty good example of a bronchiolitis cough.  It starts about 20 seconds into the video.  You might also notice that the baby seems to cough up mucous into her mouth, which she then chews on for a while before she swallows it.  Sometimes babies with bronchiolitis gag on the phlegm and actually throw up after coughing.




RSV bronchiolitis can be mild, moderate, or severe.  Mild bronchiolitis causes wheezing and coughing, but babies can still smile, laugh, drink, and eat.  More severe bronchiolitis can cause rapid breathing, significant retractions, pale or bluish skin tone, prolonged coughing spells, gagging and vomiting with cough.

In another blog post I will discuss some home treatment for RSV bronchiolitis, and what can be done for a child in the office, emergency room, or hospital.  Please remember that my blog is not intended to substitute for the advice of your own personal pediatrician!  Words on a page cannot replace your own observations, or those of the doctor who knows your child.

Croup and a Croupy Cough

It's easy to be scared when you wake up in the middle of the night to hear your baby or young child coughing with a deep, loud, barky cough and making raspy sounds when she breathes. Chances are this is croup!

It's important to hear what croup sounds like. The following videos are from YouTube. All give a pretty good idea of the distinct barky, croupy cough. It sounds like a barking seal.

CROUPY COUGH
A croupy cough sounds loud and barking, like a seal's bark:





STRIDOR
Raspy breathing, also known as stridor, is another characteristic of croup:



This next link is to a video that demonstrates a significant case of stridor, just click on the link to go to YouTube (the video did not allow itself to be embedded):
http://www.youtube.com/watch?v=Z1_uKqmPyLA


Croup is usually caused by a virus (a common one is parainfluenza virus). It causes cold symptoms (runny nose, stuffy nose, cough, fever) and it likes to settle in the upper airway. It causes swelling in the upper airway and vocal cords, giving the funny sounding cough, causing raspy breathing, and a hoarse voice (laryngitis). The barky cough and raspy breathing are always worse at night.

Croup often sounds much worse than it is. In two of the videos above, the ones demonstrating stridor, you can see completely happy babies who have raspy breathing. They look pink, are smiling or talking, and are not bothered by the "trouble" they are having with their breathing. Croup can be serious, and require a trip to the emergency room. However, usually it is manageable at home.

For a croup attack, first sit your child up, and then calm him down. Sitting up usually helps the airway stay open. Crying and panicking tend to make the airway close even more. Take your child into a steamy bathroom. To do this--run the hot water in your shower and don't turn on the fan. Sit in the bathroom and sing to your child, rock her, read to her. Try this for about fifteen minutes at a time. If it works, you can put your child back to bed--then repeat the treatment as needed through the night.

Another home treatment is taking your child outside into the cold night air (assuming it is cold outdoors!). The point is to try the opposite of hot steam, if the steam wasn't working for her. You can also put a cool mist vaporizer into your child's room.

If a croup attack is very severe, your child can't breathe despite home treatments, or is looking quite pale, bluish, or lethargic, you should go to the emergency room. There your child can receive breathing treatments (to temporarily open the airway), oxygen (if required), and steroids (to reduce swelling in the airway). Remember, however, that croup can look and sound much worse than it really is--so if your child is happy and playful, able to nurse or drink from a bottle or sippy cup pretty well, it's unlikely that you need to go to the emergency room for croup.

If you make it through the night, but had a rough time getting to morning (needing recurring steam or outdoor treatments) you should bring your child to the office the next morning. Symptoms may appear to be gone in the daytime, but croup comes back each night for a few nights before it turns into a regular cold.

After a few days of the croupy stage the cough will change into a phlegmy, wet cough. This almost always happens with croup, and is a sign that the croup is starting to clear up. However, when the cough changes into something else, every parent worries that it is turning into something more serious. When it changes, watch your child closely. If she is sleeping better, is more playful, more hungry, and the fever is mostly gone, then your child IS improving and you can handle the rest of the croup illness at home, like you would for the average cold virus.

Croup is contagious in the way a regular cold is contagious. It is spread by respiratory droplets (mucous, cough, sneezing), and is most contagious in the first 2 to 3 days of the illness. If there is no fever, and the child is sleeping pretty well at night, croup is not a reason to keep kids out of daycare or school.

As always, my blog is designed to give you general information about your child's health and illness. One of the main reasons I posted this topic is to provide the links to videos of a croupy cough and stridor. My advice here is not meant to replace the more personal advice you can receive from your child's own pediatrician.

Lots of information about croup is available on the web. Here are some possible links, if you want more information:

http://www.askdrsears.com/html/8/t084200.asp

http://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/Croup-Treatment.aspx

Post updated 1/26/2014 (a new video added to replace one no longer available, two links replaced with embedded videos).