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.

Vitamin K at Birth

I'm here to talk about vitamin K deficiency bleeding in the newborn and its prevention. Is this a topic of general interest? Does it even concern you as a parent? Perhaps not, if your child is already two months of age or older. However, if you are expecting a baby, or have a newborn, this is something you should know about.

After birth an injection of vitamin K will be given to your baby. This routine, injected supplementation of vitamin K into the thigh muscle of a healthy newborn is extremely effective in preventing vitamin K deficiency bleeding and its resulting catastrophic effects. This practice is based upon reliable, scientific evidence that has been tested and retested over many years. I fully endorse, recommend, and request that all my patients accept the practice of providing an injection of vitamin K to newborns shortly after birth. My own children received their injection of vitamin K after birth with my full knowledge and consent. I rested easier knowing I had greatly reduced their risk of unpredictable severe hemorrhage or death due to vitamin K deficiency. I still am in awe, and filled with the wonder of a simple vitamin injection's ability to prevent such a terrible outcome.

Vitamin K deficiency bleeding in the newborn was formerly known as hemorrhagic disease of the newborn. There are several forms, which are usually described as "early" (or classic), and "late." Vitamin K deficiency can cause serious, life-threatening bleeding because vitamin K is an essential part of the blood's ability to form clots. Without vitamin K the blood will not clot properly, and the affected person will bleed excessively. Vitamin K deficiency bleeding is usually discovered when something catastrophic happens to the infant, such as bleeding into the brain (central nervous system hemorrhage).

Vitamin K deficiency bleeding has been recognized in infants for decades. In briefly reviewing the medical literature on this topic I found published articles dating as far back as the 1960s (I may have even seen the 1940's!) which deal with this topic.

The incidence (rate of occurrence) of unexpected bleeding due to vitamin K deficiency in apparently healthy neonates during the first week of life ("early") is 0.25% to 1.7% (ranging from 1 in 400 to 1 in 50 to 100 newborns). Late vitamin K deficiency bleeding (ages 2 to 12 weeks) rates have been reported from 4.4 to 7.2 per 100,000 births.

For some reason (and fairly often), there are newborns who are born deficient in vitamin K. This is discovered when they have a severe bleeding episode. These are major episodes of bleeding, such as bleeding into the brain. Although attempts have been made to correct this by giving supplements prenatally to the mother, this has not been consistently effective. Vitamin K does not cross the placenta well enough to ensure adequate vitamin K in the baby. In addition, breast milk does not reliably contain enough vitamin K to prevent vitamin K deficiency bleeding. Supplementing vitamin K to a breastfeeding mother will not consistently give enough vitamin K to prevent vitamin K deficiency bleeding. There is no readily available test that can be done on a newborn to tell if the infant is at risk for vitamin K deficiency bleeding. Obtaining a family history does not help determine if an infant is at higher risk for this condition.

The only way to be sure to reduce the risk of vitamin K deficiency bleeding in a newborn is to supplement with vitamin K. The most reliable and effective way to do this is a single injection of vitamin K shortly after birth. Oral supplementation has been presented as another option. However, the evidence shows that it is either less effective than injected vitamin K, or there is not enough evidence to be sure it is effective. Weighing the possible severe damage that can occur from vitamin K deficiency bleeding against unreliable evidence about how effective oral vitamin K will be in preventing it, it is clear that the best way to protect a newborn from early or late vitamin K deficiency bleeding is injected vitamin K.

For a while there was a flurry of concern about a possible link between injected vitamin K and childhood cancer. This evidence has been reexamined, and other studies have been done which show no association between the two. This concern has been put to rest by strong scientific evidence and should not factor into decisions regarding injections of vitamin K.

This is how I see it: A simple, small, one-time injection of a vitamin (vitamin K) into the thigh muscle of a newborn will drastically reduce the real risk of catastrophic, life-threatening, brain-damaging bleeding that can occur due to the fairly common state of vitamin K deficiency that occurs in newborns. Other methods of supplementing vitamin K have little evidence to recommend them, or have been found to be much less effective than injected vitamin K. How can we deny this simple, effective, preventative treatment to the most vulnerable and precious beings on earth, our newborns?

I have included some links which will give you a window into the world of scientific evidence on this topic.


http://pediatrics.aappublications.org/cgi/reprint/112/1/191

http://journals.lww.com/smajournalonline/Abstract/2006/11000/Intracerebral_Hemorrhage_due_to_Hemorrhagic.10.aspx

http://onlinelibrary.wiley.com/doi/10.1046/j.1442-200x.2000.01173.x/abstract

http://journals.lww.com/amjforensicmedicine/Abstract/1999/03000/Late_Form_Hemorrhagic_Disease_of_the_Newborn__A.12.aspx

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1346300/

Obesity Part II: Early Prevention (Prenatal through Preschool)

Is there anything you can do to prevent obesity in your child? YES, YES, YES!

First, look at your child's risk factors. Family history is important. One study showed that a child born to an obese parent (or parents) has an 80% chance of becoming obese herself. There could also be diseases in the family which are influenced by obesity. These would include diabetes, high blood pressure, cardiovascular disease, and stroke.

Conditions during pregnancy, such as gestational diabetes and maternal smoking, may contribute to a child's difficulty maintaining a normal weight. Babies born small for gestational age may have a predisposition to glucose intolerance. Breastfeeding may help reduce the chance of obesity.

By assessing risk factors I don't mean to introduce more guilt in your life as a parent. We all have a family history, we all have our own health issues, complications occur in pregnancies, and not everyone can breast feed their baby! I know all of this. However, in preventing obesity and its related diseases from happening it is important to know what the risk is from the beginning.

Early in infancy it is important to feed your baby when he is hungry, and allow him to stop when he is full. Watch for signs of hunger such as rooting and crying. Listen for the cry that means hunger, versus the cry that means irritability or sleepiness. Feed your baby "on demand." If the baby just ate and seems to be acting hungry again try cuddling, soothing, swaddling, or a pacifier before offering another feeding. If your baby is bottle feeding, watch closely for signs of her being full. Don't try to get her to just finish that last ounce. If she stops sucking, lets milk pour out of her mouth, or pulls away and turns her head, recognize these as signs she has had enough. Hold your baby when you feed her a bottle. Never prop a bottle for a baby.

As your baby gets older and learns to smile and interact socially, you can try toys and other distractions to keep her happy when she is fussy but not really hungry. The more you interact with your baby, the more you will get to know her and understand what she needs. Often it will be hunger, but sometimes it will be boredom, fatigue, or loneliness that needs to be addressed.

TV is a very poor substitute for interaction with you. Children grow up in the presence of lots of media. They learn to be entertained, rather than to entertain themselves. They learn to be inactive, and to stop using their brains. Developing minds and bodies do not need TV. It does not benefit young children at all. Yes, babies will watch videos, and appear mesmerized and happy, but they aren't learning anything that will help them later. Instead they are learning from an early age to be what we all don't want to be--couch potatoes! Add snacks and beverages consumed while watching TV and we are thoroughly indoctrinating them into the inactive lifestyle led by many Americans. No TV at all until age 2 or older is the best way to go.

In the toddler years trouble spots for weight control seem to center around excessive juice, excessive milk, and "grazing." Grazing is allowing your child to nibble on things throughout the day. Usually these are foods like fishy crackers, cereal, fruit snacks, puffs, pretzels, and other foods that are mostly made up of carbohydrates. Sippy cups allow toddlers to walk around all day sipping on milk or juice. These practices cause lots of eating problems. Children can get too many calories from this constant sipping and nibbling. They never feel hungry, so then they don't eat well and are very picky at meal times. As soon as they are the slightest bit hungry they whine and cry about wanting food. To top it off, they even are learning to treat boredom (and possibly negative emotions) with food.

You can help your toddler control his weight, be less picky, and be hungry for meals by feeding three meals and two or three quality snacks ONLY per day. At other times the kitchen is CLOSED! Also, limiting milk to 16-20 oz. per day, and juice to 4-6 oz per day will help your cause. Make snacks count--serve fruits, cheese, yogurt sweetened with applesauce or fruit, vegetables, hard-boiled eggs, and more at snack time. Don't give your child anything else to drink other than milk, water, and a tiny bit of juice. Pop? Do you have to ask?

Allow your child to become hungry before meals, then serve the stuff that's good for him first! My sister-in-law always dished out big bites of broccoli to her kids and mine while they complained of hunger and the rest of the meal wasn't quite ready. Guess what? The broccoli (or peas, green beans, or carrots) was devoured by many picky little people who were also quite hungry!

Save the empty calories (fruit snacks, fishy crackers) for an occasional little treat, or a difficult part of the week (the check-out line at the grocery store). Allow your child to freely drink water from their sippy cup, and give the milk and juice at meal and snack time. Teach your child to drink milk and juice from a regular cup and ditch the sippy cup as soon as possible.

As your child gets older--into the preschool years--keep up the practice of three meals a day, and two snacks. Make your child what she likes to eat at breakfast and lunch. Then, at dinner (if this is your family meal) serve one meal to your family. Do not make your child a separate meal. A few items in your meal should be kid-friendly. You can always set out some fruit, or a bowl of applesauce. At first, aim for good table manners--no saying "yuck" or throwing or pushing the food off the plate. Your first goal is to get your child to tolerate the presence of the food in front of him. Then you work towards a taste of everything, and then a few bites (cut them very small and ask for three bites from a three year old, four bites from a four year old...) of a less desirable food. If your child leaves the table hungry, there is always tomorrow and a good breakfast around the corner. No guilt here--you served the food, it was your child's choice not to eat it.

Please consider avoiding fast food restaurants. If you can get the food at the drive through window I would really question its nutritional value. Watch the video Super Size Me. I have not taken my own kids to that fast food restaurant (and most others) since I watched that movie! Most toddlers (and definitely preschoolers) recognize the golden arches, and will happily eat a meal consisting of chicken nuggets and fries. But why develop those taste buds when you could be working on the taste buds that some day will hopefully enjoy salad, whole grains, fruits, and vegetables? Why cultivate a taste for fatty, high calorie, high salt food that is low in nutritional value?

Encourage free outdoor play. Allow your young child to run, climb, dig, race, throw and kick balls, twirl, swing, slide, swim, and be free outdoors. Limit time in front of the TV or any media screen to one hour a day on most days, and definitely no more than two hours a day. Try to have twice as much outdoor play time as time in front of the TV. Children under the age of two should not watch TV.
Children should have a minimum of one hour a day of very active play.

Take care of yourself, too. Are you eating healthy food? Exercising? Limiting your time in front of the TV? It is much easier to help your child be healthy if you are also living a healthy lifestyle.

I am trying to give you ideas to help keep your child at a healthy weight with a good level of fitness, to minimize the risk of obesity related diseases, and to promote better self-esteem and enjoyment in life. All of us are a work in progress, and this goal is something to work toward. I hope I have given you something to think about, and some practical ideas you can put to use. As always, the advice in my blog is quite general, and is not meant to substitute for more specifically tailored instructions from your own personal pediatrician! Good luck.

As far as resources I used--the same ones I sourced in my first Obesity blog (Part I) were used here, as well relying heavily on my own experience as a pediatrician in general practice.