Doctors revise child ear infection treatment

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The sudden onset of symptoms -- pain or fever or just grumpiness during a cold -- is more than enough to send parents and their children running straight to the doctor.

But too often, the result of those visits is a diagnosis of an ear infection and a prescription for an antibiotic, according to the American Academy of Pediatrics.

The AAP is releasing new guidelines that aim to reduce the number of diagnoses of ear infections. The guidelines, being published today in Pediatrics, have not been updated since 2004.

The new guidelines put more emphasis on distinguishing between an acute ear infection and just inflammation of the middle ear -- the difference being that antibiotics are effective against ear infections, but not inflammation.

Correctly diagnosing an ear infection isn't as easy as parents might think, said Farrel Buchinsky, director of pediatric otolaryngology at Allegheny General Hospital.

"Parents think that to make the call of an ear infection is just to stick the otoscope in the ear, as if there's someone standing there with a sign saying 'Ear Infection' or 'No Ear Infection' and you're done," he said. "The diagnosis of [an ear infection] is not half as straightforward as parents would believe."

It can be difficult to get a good look inside the ear of a squirming, crying child, he said, and the view of the eardrum might be blocked by earwax.

Whereas the previous diagnostic criteria focused on acute onset of symptoms, fluid in the ear and inflammation, the new guidelines recommend that doctors see at least some bulging of the eardrum or discharge from the ear. With just mild bulging of the eardrum, doctors also need to see either a sudden onset of pain or intense redness of the eardrum. Doctors also should only diagnose an ear infection if they see fluid in the middle ear.

Research, especially since 2004, clearly shows us that bulging of the eardrum "is the key to bacterial infections in the middle ear," said Allan Lieberthal, a professor of pediatrics at the University of Southern California and a co-author of the new guidelines.

Dr. Lieberthal said it wasn't possible to predict how much the new diagnostic criteria might cut down on the diagnoses of ear infections, noting that it depended how closely pediatricians followed the new guidelines.

Doctors, by nature, are drawn to want to help their patients, he said, but in the case of ear infections, medicine isn't necessarily the answer.

"When a child comes in who is sick, with a cough, runny nose, fever, maybe pulling at the ears, doctors always want to do something, so they prescribe antibiotics," he said. "Convincing doctors not to write a prescription or not to take active action is very difficult."

To reduce antibiotic use, the AAP also recommends that doctors consider observation instead of immediately prescribing antibiotics for children under 2 with a nonsevere infection in just one ear, or for older children without severe symptoms.

Under that approach, children will just be treated for pain with either acetaminophen (Tylenol) or ibuprofen, depending upon their ages. If they fail to improve in 48 to 72 hours, they will receive antibiotics.

"There have been numerous studies since 2004 showing that at least 70 percent of children get better without antibiotics," Dr. Lieberthal said.

The AAP guidelines also recommend that doctors choose a 10-day course of antibiotics for children under 2, a seven-day course for children 2 to 5 years and a five- to seven-day course for children older than 6.

The new guidelines also recommend against routine follow-up visits for ear infections and against long-term antibiotic use in children with recurring ear infections.

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Anya Sostek: asostek@post-gazette.com or 412-263-1308.


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