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.

Swimmers' Ear

What do you get when you combine kids with hot weather and non-stop swimming? The answer is Swimmer's Ear, also known as Otitis Externa. In my office the conversation goes something like this:

Mom: "I think he has an ear infection."
Me: "Does your ear hurt?"
Swimmer: "Yes, my right ear. It hurts to touch it or lay on it. Plus I can't hear out of it very well"
Me: "Have you been swimming a lot?"
Mom: "We were just on vacation at a lake"
Me: "Do you have a runny nose or a cold?"
Mom & Swimmer: "Not really"

This is repeated multiple times a day in my office, all summer long. I see it even more often when the weather is hot, like it is right now. Some days I see so many kids with Swimmer's Ear that I have dreams about it. Really, I do.

Swimmers' Ear, or Otitis Externa, is completely different from what most people think of when they say "I think my child has an ear infection." Swimmers' Ear is an infection of the ear canal, which starts at the hole in your ear and ends at the ear drum. The skin in the ear canal becomes red and swollen, and can even produce pus. Anything that moves the ear canal (touch, pressure, and sometimes even chewing) can cause pain.

Swimmers' Ear is usually associated with getting the ear canal wet and is more commonly seen in people who put their heads under water (school age children and up). The name Otitis Externa would also apply to other skin conditions and infections in the ear canal. For my purposes, however, I am focusing on the most common condition caused by getting the ear canal wet.

The standard ear infection (or Otitis Media) takes place behind the ear drum (tympanic membrane). The usually hollow, air-filled chamber becomes full of fluid and pus. This hardly ever has anything to do with swimming (the tympanic membrane protects the middle ear chamber from water outside the ear), tends to be associated with congestion and nasal drainage, and is more commonly seen in younger children and infants. Many parents worry that their baby or toddler's otitis media is caused by swimming lessons or by getting the baby's ears wet during bathing. This is not very likely.

Swimmer's Ear happens when the normal protective barriers in the ear canal are broken down. A healthy environment in the ear canal is dry, acidic, with a light protective coating of wax. When the canal is constantly wet the skin becomes soft, the pH in the canal becomes alkaline, and the wax is less protective. Bacteria like to grow in the skin in this wet, alkaline environment.

First the ear will get itchy, and feel funny. Scratching or digging at the ear may follow. The ear canal becomes inflamed and will look red. Then it swells and produces pus. It can be very painful.

There are several approaches to preventing Swimmer's Ear. You can try to keep the ear dry, using ear plugs or petroleum jelly coated cotton balls. In my experience kids don't put up with that for very long. You can dry out the ears after swimming, by tapping the side of the head to let the water out, using a cool blow dryer 12 inches from the ear, or placing 3 to 4 drops of isopropyl alcohol in each ear canal when swimming is done (or several times through the day if it's an all day long swim). You can make a mixture of 50% isopropyl alcohol and 50% white vinegar (to both dry the ears and re-acidify them) to use throughout the day or after swimming (3 to 4 drops in each ear). You can buy your own dropper at the pharmacy, or just drip the drops in from a medicine syringe. Instead of that homemade mixture you could use commercially available drops (such as auro-dri, or swim-ease).

Treatment of Swimmer's Ear involves a prescription for antibiotic ear drops to be used 2 to 3 times a day for a week to ten days. You will first need a doctor's appointment to determine what kind of ear infection your child has, and how severe it is. It would be unusual for this diagnosis to be made, or treatment prescribed without first seeing your child in the office. Your child will need to keep her ears dry during the initial part of this treatment.

Very early in the course of this illness you might be able to get things under control at home simply by keeping the ears dry and using the commercially available drops, or the mixture of isopropyl alcohol and white vinegar mentioned previously. If that does not work in a few days, or your child gets worse, then you should make an appointment in our office.

On a side note, the worst cases of Swimmer's Ear that I have seen have all been in teenagers. I have always wondered if they are trying to tough it out, or just don't have time for a doctor's appointment. Also, it doesn't seem to matter if you have been swimming in a lake or a pool, or just dunking your head under water in the bath tub. In my experience the type of water is not the important part, it's just the presence of moisture in the canal that matters.

Remember that wax in the ears is protective. No one should put cotton swabs (or anything other than drops) into their ear canals at home.

Please remember that the purpose of this blog is to provide you with more information and insight into how I personally think about health and illness. I am not trying to personally diagnose or treat your child. For that you need to discuss the problem with your medical professional. Other sources of information on the web could include www.uptodate.com/patients, or childrenshealth.org.