In this issue I’d like to address the most common diagnosis for a sick child in the pediatrician’s office, the dreaded ear infection. Approximately 30 million children are treated each year for ear infections, and in any given year, approximately 15-20% of all children in the U.S. will be diagnosed with it. It is most common between ages 6 and 36 months with a second peak of infections between 4 and 6 years. Interestingly, boys seem to be more susceptible than girls. Risk factors for developing an ear infection include exposure to cigarette smoke, daycare attendance and malformations of the head and palate. The most important risk factor is the presence of a cold. Ear infections tend to occur most often in the winter and early spring, paralleling the occurrence of most colds. The only known natural protection against the development of ear infections is breast-feeding, but this produces only a slight decrease in infection rates.
Every parent is all too familiar with how an ear infection starts. Often there are a few days of cold symptoms and then the child sometimes spikes a fever and becomes very irritable. Sometimes the child will pull at the infected ear. Swelling in the Eustachian tube prevents the fluid that the middle ear normally produces from draining. The fluid builds up and allows the bacteria that normally live in the upper reaches of the mouth to multiply inside that fluid and eventually to produce the symptoms of ear infections. When your pediatrician looks in your child’s ears he or she will note that the eardrum is red, often bulging, and opaque instead of clear. In certain cases, the bacteria multiply so fast that the sheer volume of bacteria pressing against the eardrum can actually rupture the eardrum, and the parent will see pus draining from the ear.
Bacteria cause about 60-70% of cases of ear infections, but the remainder of cases is caused by viral infections. Because it is virtually impossible to tell the difference between viral and bacterial ear infections, your pediatrician will treat all infections with antibiotics. However, your pediatrician may recommend waiting a day or two before treating to see if the infection resolves spontaneously. The American Academy of Pediatrics has endorsed this approach as a means to prevent overuse of antibiotics. Of course, if the symptoms do not resolve or if they worsen, everyone would agree to immediately treat the infection with a course of antibiotics.
The antibiotic of choice for ear infections is amoxicillin. Eighty to eight-five percent of all cases of ear infections will clear with a 10-day course of amoxicillin, and amoxicillin carries with it the advantage of few side effects. Unfortunately, bacteria that have become resistant to amoxicillin will cause 15-20% of cases and your pediatrician may have to use a second, stronger antibiotic to clear up the infection. One might ask why not just start with the stronger antibiotic to begin with. The answer is that the more one uses an antibiotic, the more resistance to that antibiotic is created. If we only used stronger antibiotics, pretty soon the bacteria would adapt and then we would have no means of curing these resistant infections. Additionally, the stronger antibiotics such as Cefzil, Augmentin and Omnicef are much more likely to cause diarrhea than is amoxicillin. Therefore, in most cases your pediatrician will start with amoxicillin.
We hope this helps answer some questions as to the symptoms of ear infections, the causes and treatments.
By Robert Jawetz, MD, FAAP,
Tenafly Pediatrics
