April 2004

Well, spring has finally arrived. 66 inches of snow fell at my house this winter. I hope you all get out and enjoy the weather. I also wish you all a happy Passover and Easter holiday.

Dr. Barenfeld

New Guidelines for the Treatment of Ear Infections---------------------------------------------

In the February 2003 Gazette I answered a parent question regarding the use of antibiotics to treat ear infections. The American Academy of Pediatrics has just published new guidelines on this subject. I have seen many reports recently on T.V. trying to explain the guidelines. These reports have been confusing to me and based on your questions I know they have been confusing to you.

Acute otitis media (AOM) or inner ear infection is the most common infection for which antibiotics are prescribed for children in the U.S. In 2000 alone more than 13 million prescriptions for AOM were written. Recently there has been much discussion as to the necessity of using antibiotics to treat AOM. While in the U.S. antibiotics for AOM are used routinely, in some countries in Europe antibiotics are frequently withheld and the child is treated with pain medication only. Without antibiotics many of these infections clear by themselves but some do not and antibiotics are ultimately needed. Also, some studies indicate that untreated infections are more likely to progress to more serious infections requiring stronger antibiotics and sometimes surgery. These serious complications are rare however. Concerns about the rising rates of antibiotic resistance and increasing costs of antibiotics have focused the attention of the U.S. medical community on the need for the judicious use of antibiotics.

The new guidelines include children from 2 months to 12 years of age who are otherwise healthy; without chronic medical problems. The guidelines were developed after reviewing thousands of articles on AOM from around the world.

This table leaves several questions unanswered:

1. Why should children less than 6 months always receive antibiotics? Children this young are more susceptible to severe illness and complications of AOM including meningitis.
2. What do we mean by severe illness? This is somewhat of a judgment call but involves moderate to severe ear pain or fever of 102° F or more.
3. What is the difference between certain and uncertain diagnosis? A certain diagnosis is one in which there is a sudden onset of symptoms and evidence of fluid and inflammation in the affected ear. Getting a good look in the ear of a crying, uncooperative young child, especially if there is a lot of wax present can be very difficult and can make the diagnosis of AOM uncertain.
4. What do we mean by “option”? This one is a little complicated. As defined in the guidelines an option is a course of therapy that may be undertaken when previous studies show no clear advantage of one therapy over another. Parental preference plays an important role in an option. For example, your 2 year old comes to the office with a complaint of mild ear pain and a temperature of 100° F for the past 24 hours. On examination the ear looks a little red. In this case we have the option of using antibiotics or simply observing the child for 1 -2 days without antibiotics. Tylenol and decongestants may be given. If the child’s condition does not improve or worsens then antibiotics would be prescribed.

I feel that, regardless of age, antibiotics should be given when the diagnosis is certain as it will make the child feel better sooner and allow for a quicker return to school. In an older child with an uncertain diagnosis, observation may be an option and we will discuss this with you during your office visit.