New Guidance From AAP On Ear Infections

by Heidi Green
March 05, 2013

When your child seems to be sick, “wait and see” is about the last advice many parents want to hear. It’s hard to see a child’s pain and discomfort, difficult to watch him struggle to overcome the virus du jour.

But since the American Academy of Pediatrics (AAP) last published clinical guidelines for the treatment of ear infections in 2004, the “wait and see” approach has become increasingly common among pediatricians.

While it is true that many ear infections will resolve within about 10 days with or without antibiotics, the treatment of this common childhood malady has been inconsistent. Some doctors have continued to dole out prescriptions for antibiotics at very few symptoms, others have required waiting periods and follow-up office visits before getting out the prescription pads, and still others have found some middle ground. Many parents have expressed frustration, not understanding why their sick child didn’t receive an antibiotic—especially if they needed one after a couple of days.

Fortunately, ear infections have been the focus of several major studies in the past 10 years, adding clarity to our understanding of the problem and its optimal treatment. Now, the AAP has issued a new clinical practice guideline, seeking to provide clarification for health care providers—and parents—about The Diagnosis and Management of Acute Otitis Media.

As explained elsewhere on baby gooroo, middle ear infections are virtually a hallmark feature of early childhood, affecting three out of four children and resulting in millions of doctor visits annually. Fortunately, due to physical changes that occur in the ear, the infections become far less common after about 5 or 6 years of age (although they can occur even in adulthood).

Common symptoms of ear infections include:

• ear pain, especially while lying down
• problems sleeping
• low-grade fever, typically from 101°F to 102°F
• crankiness or fussiness
• difficulty hearing or responding to sounds
• loss of appetite
• vomiting or diarrhea
• loss of balance
• otorrhea (the leaking of fluid such as blood or pus from the ear)

Some ear infections are caused by viruses, while others are caused by bacteria. Since only bacteria responds to antibiotics and viruses resolve on their own over time, antibiotic treatment for viral illnesses has been controversial.

At 35 pages in length, the new guideline is an ambitious attempt to provide clarity. Its goals:

• Provide a new, clinical definition of ear infection. What is an ear infection?
• Address pain management. What can parents do to help their children feel better?
• Clarify when to use “wait and see” versus antibiotic treatments. What can doctors do for sick children?
• Identify benefits and risks of various antibiotic options. What should doctors prescribe when a prescription is appropriate?
• Discuss preventative measures, including “ear tubes” and lifestyle choices. What can be done to reduce the risk of ear infections?

It is important to realize—as lead author Dr. Allan S. Lieverthal and his colleagues note more than once—this document is to be used only as a source of guidance, not as a protocol. That is: “[t]he recommendations in this report do not indicate an exclusive course of treatment or serve as a standard of medical care.” Treatment decisions may differ from what’s written here, “taking into account individual circumstances.”

That said, the AAP’s current recommendations for the treatment of ear infections are as follows:

• Pediatricians should look at specific physical features for diagnosis, including bulging of the ear’s tympanic membrane (ear drum), fluid draining from the ear, pain, and inflammation. Parents should note that although the AAP has in the past pooh-pooh’ed the idea that ear tugging is a sign of infection, here “holding, tugging, rubbing of the ear” are recognized as indicators of ear pain “in a nonverbal child.”
• Pediatricians should recommend pain relief.
• Pediatricians should prescribe antibiotics, in some cases. Specifically, they should prescribe antibiotics for children 6 through 23 months of age with dual infections (in both ears) even when symptoms are not severe. They should also prescribe antibiotics for children 6 months and older with infections in one or both ears if accompanied by severe symptoms.
• Pediatricians should consider—with parental input—“wait and see” or antibiotics when symptoms are not severe. The AAP notes that, in some cases, pediatricians will write a prescription but ask parents to wait a day or two before filling it. Studies show that these prescriptions often prove to be unnecessary.
• Parents should seek follow-up care if symptoms worsen or fail to respond to antibiotics within 48–72 hours.
• Pediatricians should not prescribe antibiotics long-term but “may offer” ear tubes for children who have had three infections within six months, or four in a year with one in the past six months.

In its new guideline, the AAP also recognizes three steps parents can take to reduce their child’s risk of ear infections:

• Breastfeed your baby. Breastfeeding exclusively and for at least six months has been shown by multiple studies to provide protection against ear infections. This is a dose-response relationship, meaning that even partial breastfeeding provides some protection.
• Vaccinate your child. Specifically, be sure your children receive the pneumococcal conjugate vaccine and annual flu vaccine as scheduled to reduce the risk of becoming infected with viruses that most often lead to ear infections.
• Keep your child away from tobacco smoke. Second- and third-hand exposure to tobacco smoke is suspected to increase the risk of ear infections.
• Consider other factors. The AAP notes that using bottles (particularly “bottle propping” and bottle-feeding in a reclined position) and pacifiers (which can be a ripe environment for bacteria and germs) may increase the risk of ear infections.

In the throes of winter, illness can seem to come at a whim. This new release provides the clearest guidance yet for pediatricians and parents alike about how to treat ear infections when they happen—and how to try to prevent them from happening in the first place.