When an ear infection isn’t truly an infection

It used to be so easy – your child got sick, you took him to the doctor, an “ear infection” was diagnosed and an antibiotic was prescribed. And, sometimes, you were able to get an antibiotic “just in case” or over the phone. Nowadays the situation is so much more complicated it’s no wonder parents and doctors alike are confused. Not only is the diagnosis of an ear infection not as clear cut as you may think, antibiotics are not always needed even for a true ear infection and may only serve to promote further antibiotic resistance by bacteria.

In response to this ever-growing confusion, the American Academy of Pediatrics developed a task force on “acute otitis media” (AOM, or “ear infection”) and recently published guidelines to help make these waters a bit less murky. AOM visits places a huge burden on the medical system and account for more than 10 million yearly antibiotic prescriptions and 30 million doctor’s office visits per year.

One of the largest myths is that AOM can occur without symptoms. Fluid in the ear can and does occur with colds and develops after an AOM but alone are not diagnostic of a true AOM requiring antibiotics. In addition to fluid, pain and a certain “look” to the tympaic membrane need to be present. The tympanic membrane is like a piece of paper and separates the ear canal from the inside of the ear. It turns red with fever, crying and inflammation such as with an AOM. So, while alone none of these signs can stand alone for diagnosing an AOM, the diagnosis becomes much more certain if they occur together: recent onset of illness, middle ear fluid, and signs of middle ear inflammation – usually pain, fever and a red membrane.

You may be wondering, “what’s the harm of an extra day of an antibiotic”? (I do not understand the last part of the previous sentence) The bottom line is the more we use antibiotics in a child the more likely they are to develop resistance to that drug. This resistance is not just contained within that child but can actually passed from person to person spreading the problem even further. When resistance develops, the simple, inexpensive antibiotics no longer work and the child ends up on fancier and newer antibiotics, which are expensive and cover many more bacteria than occur with AOM. Many kids develop vomiting or diarrhea from antibiotics and can become dehydrated requiring intravenous fluids and additional doctor’s visits. Some kids end up having allergic reactions which can be very uncomfortable and sometimes life-threatening.

It also turns out that the older a child gets, the more likely AOM will be viral in nature – and go away on it’s own! The guidelines do take this in to account – an infant will definitely get antibiotics if AOM is suspected, an older infant and toddler may if he is sick or may be watched for a few days first, and an older child will usually be observed for a few days with pain control (Tylenol, Motrin or ear drops) unless very sick or with severe symptoms. So, rest assured if your child is miserable and appears very sick, an antibiotic will usually be given – just may not be in that first day. A true AOM will persist for 2-3 days but a viral AOM will go away.

So, next time your child has ear pain – don’t panic and rush off to the nearest ER or doctor’s office. Give some Tylenol or Motrin and let the scene play out for a couple days. Time is on your side with this one.

© 2005 Pediatrics Now.
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