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.

HPV Vaccination: Prevent Cancer!

Yes, it’s time to talk about another vaccine. I guess I really love this topic, or perhaps it’s just that I think it’s really important. The one I’m referring to this time is the Human Papilloma Virus (HPV) Vaccine. The purpose of this vaccine is to prevent genital (including cervical) and anal cancers, and genital warts. I recommend this vaccine for all middle school students. My oldest child started the series at age 12 and was fully vaccinated at 13.

One commonly recognized brand of this vaccine is Gardisil, which prevents four types of HPV: HPV 6 and 11, which cause genital warts, and HPV 16 and 18, which cause anal and genital cancer and precancer. A more newly released vaccine is Cervarix. It covers HPV 16 and 18. Neither vaccine covers all forms of cancer-causing HPV, but HPV 16 and 18 cause approximately 2/3 of cervical cancers.

Have you heard of Human Papilloma Virus? Did you know that the lifetime risk of becoming infected with this virus is 80%? Are you aware that approximately 20 million people in the USA are infected with the virus? And 18% of 14 to 19 year-old girls are infected? Did you know the virus causes cervical cancer, anorectal cancer, and genital warts? Yuck, right? It’s a sexually transmitted disease (STD) that causes cancer and is PREVENTABLE.

The vaccine was introduced to the general public in 2006. By 2009 44.3% of adolescent girls in the United States had received at least one dose of HPV vaccine, and 26.7% had received all three recommended doses. In Australia, during the first year of a national HPV vaccination program, 75 to 80% of targeted girls had received all three doses! The vaccine is now recommended for girls AND boys, ages 9 to 26.

The vaccine has a good track record when it comes to side effects. Adverse effects shown to be caused by the vaccine are headaches, low-grade fevers, and a sore arm. Adolescents have been known to faint after receiving the vaccine. This reaction can be seen after any vaccine given to an adolescent, and is not limited to the HPV vaccine. Claims of more serious adverse effects have not been substantiated or shown scientifically to be more common in vaccine recipients than in the general public. You can find complaints about the vaccine on the internet, of course, but much of this is hearsay or linked to attempts at legal action.

Why is the vaccination rate so low? The vaccine prevents CANCER! What I hear from my patients’ parents are comments such as these: “We’re not going to give THAT vaccine.” “It’s too new.” “My daughter doesn’t need it because she isn’t going to have sex before marriage.” “If we give the vaccine then my child will think it’s ok to have sex.” “It hasn’t been around long enough for me to feel comfortable.” “I don’t know how long the immunity will last, so I want to wait until my child is older.”

I would like to respond to these comments.

1. First of all, scientific studies have shown that a fairly high percentage of kids ages 14 to 19 are already infected with the HPV virus (18% of girls in one study), so it is quite possible your child could be exposed to the virus during his or her teen years. Waiting until they are older could mean they become infected with the virus before they receive the vaccine. And you don’t have to have sexual intercourse to become infected. HPV can be transmitted via oral sex (among other ways) too! Also, there is evidence that there is more long-lasting immunity when the vaccine is given at a younger age.

2. Studies that have examined the rate of sexual activity among teenagers have shown that providing information about STD and pregnancy prevention, and even handing out condoms, has not led to an increased number of teenagers having sex. To me, therefore, it seems unlikely that giving the HPV vaccine will cause teenagers to become promiscuous.

3. Millions of doses of HPV vaccine have been administered to date, with proven safety. The vaccine is not new; it has been given to the general public since 2006.

4. Perhaps your child will wait to become sexually active until they are married. After all, you waited, right? But you don’t get to control the sexual activity of your child’s potential spouse. HPV infection (except in the case of genital warts) is not visible to the naked eye, and there is no test that can tell you if someone is infected with it.

5. I don’t want to offend anyone, here. But you should know that it is fairly common for me to see teenagers in my office who are having sex, and I don’t think most of their parents know they are sexually active. Don’t be naive. A 2002 study showed that by ages 15, 16, and 17 30-50% of teenagers were already having sexual intercourse! Talk about relationships, values and expectations with your child. But protect their health. I, too, don’t want my daughters (and I would say sons, if I had a son!) to become sexually active at such a tender age—but I will take a practical approach when it comes to preventing such a serious disease as cancer.

My Advice on Immunizations

Here is the blog I've been dreading, avoiding, and wishing I didn't have to write. It SHOULD be an easy one for me because it is a topic I know well, discuss daily, and am quite clear on where I stand--which is YES, you should fully vaccinate your child, on time, using the schedule recommended by the ACIP (Advisory Committee on Immunization Practices), AAP (American Academy of Pediatrics), and CDC (Centers for Disease Control), and endorsed by me and my colleagues in my pediatric practice. In fact, I believe that immunizing children is one of the most important contributions I can make to maintaining, or even improving an individual child's health as well as a vital contribution to the health of my community.

To me, this is a "no doubt about it" kind of recommendation. It's not an easy subject to write about, however, because it has become controversial. I don't like to have conflicts with families in my practice, or even with parents trying to decide if they should choose me as their pediatrician. It's hard for me to have to disagree. I don't think I'm very good at presenting my opposing point of view in a tactful way. I don't want to offend anyone, or make them feel bad. Still, I am going to write this blog, and I am going to be very clear about my recommendations for vaccinating your child.

I am asked daily to comment on the following questions or statements:

To vaccinate, or not to vaccinate...? Which vaccines are "the most important?" Do vaccines cause autism? What about thimerosol? What about mercury? Tell me about aluminum in vaccines? We were told at our new baby class to ask prospective pediatricians about vaccinations... Don't babies get too many vaccines these days? I don't what to overwhelm their immune system... We aren't taking the baby to day care, so they won't get exposed to any of these diseases. Can you look at this "alternative" vaccine schedule and make recommendations? We are going to vaccinate, we just want to "delay" the vaccines. The diseases we vaccinate for are pretty rare, right? I don't want to do anything that might hurt my child.

These are only some of the questions that come up every day. And it's understandable. After all, you should be an informed health care consumer, right? You just want to do the right thing. And vaccines are a hot topic right now for new parents. Many parents would feel they are not doing their job if they don't ask about or question their pediatrician about vaccines. However, in having these discussions, and responding to all of these details, I think we can lose sight of our goal (which, in my opinion, is a healthy and safe child).

I often get the impression that parents believe I am blindly following vaccine schedule recommendations, just spouting the "party line." When this happens, I don't think I am being given enough credit for doing my job. It is my responsibility to know about each disease and each immunization given to prevent the disease. I take this responsibility seriously.

My colleagues and I have built a schedule of vaccines for our patients that will effectively immunize them at the time when they are at most risk for the diseases. We regularly review this schedule, the type of vaccines we provide, and the benefits versus risk of every vaccine. Our decisions are made based upon scientific evidence, meaning they are supported by deliberate testing and study of the effects of each vaccine. We then recommend a routine vaccination schedule that we have created or actively given our endorsement. This schedule takes into account which vaccines can be given at the same time (to ensure a good immune response while minimizing potential side effects), proper intervals between vaccines, appropriate ages to give vaccines, and the number of actual injections given each time a patient is vaccinated. It becomes a routine part of our well child visits. Having a routine schedule helps minimize the possibility of errors such as a vaccine given at the wrong interval, or age.

Benefit versus risk is an important concept to think about. There are very few things we do that are without risk. We get used to certain risks and simply live with them. Common activities that involve some degree of risk include transporting our child in a car (what if there were an accident?), living in our homes (potential exposure to lead, radon, or carbon monoxide, burns from the stove, hot coffee, or curling irons, cuts needing stitches from falls against coffee tables, falls down the stairs...), taking any kind of medication (acetaminophen carries the rare risk of liver damage, ibuprofen can cause anaphylaxis in those who are allergic, or rarely can damage the kidneys, amoxicillin or any other antibiotic can cause an allergic reaction in some people), and allowing our children to play outdoors or participate in sports (the monkey bars are one of the most common sources of fractures in children, trampolines can lead to neck and spine injuries as well as fractures in the legs, head injuries occur all the time in sports and from falls (especially when unhelmeted) off of bikes/skateboards/scooters). There must be some kind of benefit that outweighs the risks involved in these activities, or we wouldn't be able to allow our children to live a "normal" life!

In thinking about vaccines you should think about benefit versus risk. Like any medication there are some small risks, and for most vaccines these risks are fever and the possibility of an allergic reaction. However, the benefits of the vaccines far outweigh any risk they present to a child. In looking at risks and benefits I think it is important to look at scientific evidence, not anecdotal reports. Anecdotal reports are the reports of a few individuals who tell their own story, these people may or may not have any background qualifications to lend credibility to their claims. Scientific evidence, on the other hand, is the result of deliberate study of the effects of an intervention or treatment (such as a vaccine). Scientific evidence is subject to peer review (scientific experts evaluating the evidence and methods of study), and to statistical evaluation to determine if the results could just be due to chance.

I think your child deserves to be treated according to recommendations made using scientific evidence. As an experienced, board-certified, pediatrician it is my job to do the best I can to provide this kind of care. I also think that you should expect your pediatrician to provide, at a minimum, the same level and quality of care that she would want for her own children. And my children were fully vaccinated, on time, in accordance with our recommended schedule of vaccines.

In writing this blog I also have to say something about trust, and the doctor-patient relationship. Do you trust your pediatrician? Do you value her advice on growth, developmental milestones, sleep habits and position, feeding issues, how to start solid food, pacifiers, thumbsucking, stooling, urinating, behavioral concerns, potty training, car seat recommendations, among other issues often discussed at well exams? Do you call your pediatrician for advice on what to do when your child has a fever, is vomiting, or is otherwise ill? Do you take your ill child to be evaluated by your pediatrician, and place your trust in her to determine what is wrong and how best to treat it? Do you value all of your pediatrician's education, training, ongoing efforts to keep up with current science, and her expertise in helping you raise a healthy child? If you do, then why would you so easily dismiss your pediatrician's advice on immunizing your child? And if you don't trust your pediatrician, then why do you keep bringing your child to her office? Isn't preventing meningitis, polio, measles, and pertussis (among others!) more important that the correct order in which to introduce solid food?

If you are inundated with anti-vaccine messages, considering Dr. Sears' advice on delaying or altering the vaccine schedule, feeling overwhelmed and worried about vaccinating your child, and spending a lot of time researching the issue, then you should also look at the case FOR immunizations, and at sources that use scientific evidence to back up their claims. The following websites can be very helpful:

http://www.chop.edu/service/vaccine-education-center/home.html

http://www.cdc.gov/vaccines/

http://www.aap.org/immunization/


And, for an interesting article in the lay press (not a scientific journal):

http://www.wired.com/magazine/2009/10/ff_waronscience

Flu and Flu Shots

Hey, I got my flu shot today! Tina (one of Trestlewood's nurses) gave it to me in my left arm about an hour and a half ago. I feel fine. I could hardly tell the needle went in, and my arm doesn't hurt a bit. I don't ache, I don't have a fever, I didn't catch flu from the vaccine, and I am so happy to be protected from this season's flu viruses. I am sure to be exposed to them many times this year.

My girls had their flu vaccines on Sunday, just two days ago. They prefer the FluMist (a flu vaccine that is given via drops squirted in the nose). My husband will probably drop by my office soon and surprise one of Trestlewood's nurses to get his vaccine. Everyone in my family gets a flu vaccine every year. We started this tradition after my oldest got the flu in first grade. It was quickly followed by pneumonia, and then in her weakened state, strep throat. It was awful, and I never wanted a child of mine to go through that again. Unfortunately, my middle daughter had the flu a few years ago. She was coughing, had fevers upwards of 104, and was utterly miserable for a week.

I also take flu shots to Indiana to give to my parents and my mother-in-law. I think giving out flu shots each year is one of the biggest contributions I can make to the health of my community and my loved ones. The other big impact I have on public and individual preventive health is the rest of the recommended childhood vaccines--but that's for another blog.

Flu, at least the flu we vaccinate for, is NOT the stomach flu! I am told daily how this or that family had "the flu" last week, or last month, or last year. Or how they never get "the flu." Or, how the flu vaccine didn't work for them because they still got "the flu." When pressed for details it is clear that most people mean gastroenteritis when they say "the flu." Gastroenteritis is an illness that is very contagious, lasts a day or two, and involves vomiting and diarrhea. The flu I am talking about is influenza, a RESPIRATORY illness.

The symptoms of influenza are fever, severe muscle aches, coughing, sore throat, runny nose, extreme fatigue, chills, with occasionally some stomach symptoms. It lasts for about a week. It is also very contagious. Flu weakens and can kill its victims, especially those who are already debilitated. It can lead to complications, such as pneumonia. At the very least it is a miserable week to spend in bed with a box of tissues, cough drops, and other cough/cold/anti-fever medicines.

Flu vaccine is recommended yearly for everyone who is six months or older who does not have an allergy or other contraindication to the vaccine. While it is especially important for people with chronic illnesses such as asthma or diabetes, it is recommended for all of us. We can all benefit from a yearly flu vaccine.

Have you and your children had your yearly seasonal flu vaccine? Get yours as soon as you can!

The following are some links to reliable information about the flu and flu vaccine. This year's vaccine includes the H1N1 subtype, so a separate shot for that one isn't necessary. Children under age nine who are getting the flu vaccine for the first time, or who have not had at least two previous seasonal flu vaccines plus one of last year's H1N1 vaccines, will need two doses of flu vaccine spaced one month apart to be completely immunized.

http://www.cdc.gov/flu/

http://www.healthychildren.org/English/tips-tools/Symptom-Checker/Pages/Influenza.aspx