03/04/2022
Most ear infections don’t require antibiotics.
Hear me out.
No exaggeration: every time I prescribe a course of antibiotics for a kiddo, no matter what the reason, I cringe a little inside. Seriously. And yes, the antibiotics are absolutely necessary in most cases. But still, I cringe.
And I hold myself accountable. And I try to explain to parents my reasoning for them. And I try my very best not to use them when I don’t think they’re absolutely needed.
Why? Because I am a firm believer that:
- Antibiotics in general are prescribed wayyyyy too often. The majority of childhood infectious illness is viral - and viruses don’t get better with antibiotics.
- Human beings are becoming increasingly burdened with “superbugs” - bacteria that no longer respond to antibiotics, because of how much we’re over-using them. They are starting to kill us more and more.
Don’t believe me? Read this: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext
- In particular, I worry about our gut microbiome. Those are the trillions of organisms that live in our gut. They help us digest, they protect us, and they learn and teach us friend from foe.
They are one of the reasons babies put everything and anything in their mouths - to help the body learn our environment.
And antibiotics kill them off. And killing off the microbiome can lead to things like more autoimmune and allergy issues (I think antibiotic use plays a big role in the rise of food allergies. But that’s another article for another day. Read more here: https://pubmed.ncbi.nlm.nih.gov/30468878/).
Warning: quick topic change. Keep up with me.
In 2000, a vaccine for pneumococcal disease came out. You may know it as Prevnar.
What a great vaccine. OH I LOVE THIS VACCINE. But I digress.
Anyway, Prevnar protects your kids from numerous strains of Streptococcus pneumoniae. It causes - you guessed it - pneumonia. And sepsis. And sinus infections. And throat infections. And was the leading cause of EAR INFECTIONS.
Thanks to this vaccine, we’ve seen drastic reduction in S. Pneumo causin’ ear problems. So much reduction that now two other bad boys - Haemophilus and Moraxella - seem to cause most of the trouble in kid’s ears.
Stay with me.
What is an ear infection? Short version: an ear infection is what happens when snot gets stuck deep in your kid’s ear. See the picture. Since little kid eustachian tubes don’t drain snot from their ears as well as ours do, the snot gets stuck in there awhile, and sometimes bacteria finds the snot, and a bacterial snot party ensues.
When the congestion from a cold starts to go away, the Eustachian tubes un-swell, and the goop leaves the inner ear.
Unlike S. Pneumo, who needed antibiotics often to kill his party, Haemophilus and Moraxella actually clear on their own most of the time. Clinical data actually shows that post-Prevnar vaccine, ear infections clear themselves 78-85% of the time without antibiotics (sources below).
Let that SINK IN.
So why do a lot of us still treat ear infections with 10 days of antibiotics? Well, maybe it’s time to re-think things. And science is constantly changing, and old habits are hard to change.
Some thoughts:
When do I hesitate to treat an ear infection with antibiotics?
1. If the ear drum looks mildly inflamed, and has a little bit of clear fluid in it. I see this nearly all the time when a kid has a cold, or bad allergies. I GUARANTEE you that your child has had fluid in his ears before. And I guarantee you it has cleared out on its own without you even knowing about it!
2. If a child doesn’t seem to be in pain or bothered by it
3. When a child is older than 6 months (the older they get the better the chance the fluid will start to clear out once the cold gets better).
If I’m on the fence, or the child has a history of bad ear infections, I love the “wait and see” approach - I’ll send in an antibiotic, but I ask the parents to wait 48-72 hours before they pick it up. Often, the kiddo improves with time. If fever still burns or the child seems more uncomfortable, the option to get the med is there.
I consider antibiotics if:
1. The eardrum looks really red, and is bulging impressively (see my instagram stories highlights for pictures of this) and seems to be getting worse instead of better.
2. The child seems to be in a lot of pain (fussiness, not sleeping)
3. The kiddo is young and both ears are infected (under age 6 months especially)
4. The child has any history of speech delay, or is immunosuppressed in any way.
Dr. Michelle Marcincuk, our ENT director at Cook Children’s, agrees. She says, “I tend to treat a child if they have pain and fever for more than 3 days, any type of baseline hearing loss, children who are at risk for speech delay, kids with a prior complicated ear infection (where the infection spread to other parts of the body), and any immunocompromised kids.”
I could dive waaaaayy more into the details, but I’m trying to keep this short and not lull you to sleep.
The down and dirty is - have a conversation with your trusted provider when it comes to your kid's ear infection. Trust their knowledge and experience, but also don’t be afraid to ask, “why?” when an antibiotic is being prescribed. Any doc worth your time will happily explain their reasons.
😊DA
Some more fun reading (to put you to sleep):
Rethinking Our Approach to the Management of Otitis Media: https://jamanetwork.com/journals/jamapediatrics/article-abstract/2789347
Clinical Practice Guidelines, 208 update: https://www.sciencedirect.com/science/article/pii/S0385814620301383
Picture source: https://www.ausmed.com/cpd/articles/otitis-media
