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It is 3am and your child wakes up complaining of ear pain. What can you do?
Ear pain is one of the most common complaints in the pediatric population. Parents exchange frequent stories about the number of times their child has taken a banana or cherry flavored antibiotic for one or more ear infections. It is the rare parent who sits by, not wanting to add to the anxiety of other parents, with the knowledge that their child has never taken an antibiotic for an ear ache. What’s more, the child has never had a serious problem resulting from not using antibiotics.
When I went through my medical school and residency training, we were warned about the serious complications of allowing an ear infection to progress without antibiotic treatmentmastoiditis, an inflammation and infection of the bony area behind the ear at the base of the skull, and meningitis, an inflammation and infection of the lining of the brain and spinal cord which could lead to permanent brain damage, not to mention, the possibility of permanent hearing loss.
Over the last 13 years, evidence from the European medical literature and observation of the medical practice of some of our own pioneering primary care providers and ENT (Ear, Nose & Throat) physicians, has taught us that the majority of cases of ear pain can and will resolve on their own. Without antibiotics. Without serious outcomes. With good clinical follow-up. Yet, many children receive antibiotics, and sometimes multiple antibiotics, for ear aches. And their ear aches continue to recur.
Are Ear Aches Really Ear Infections?
Inflammation occurs in the body as characterized by the following five observations--redness, swelling, heat, pain and loss of function. When a young child has an ear ache, the ear drum is usually found to be red (redness) with clear fluid or mucus buildup in the middle ear (swelling) causing pain, often accompanied by fever (heat) and occasionally accompanied by an acute loss of hearing; clearly a description of inflammation. Even if there were an infection, most studies confirm that viruses are the main organisms responsible for causing the development of these symptoms, not bacteria. Neither a viral infection, nor an inflammation in the ears responds to treatment with antibiotics. Only bacteria respond to antibiotic treatment. Therefore, in the majority of cases, antibiotics do not help. And, in many cases, antibiotics may cause more harm than good when they are used inappropriately.
A child is found on exam to have a red ear and no complaint of ear pain even though a fever is present. A pre-verbal infant or toddler with a red ear drum or fluid behind the ear appears well and is smiling. Another child presents with ear fluid and is no longer in pain. Most often these children are not suffering from ear infections and do not warrant antibiotic treatment. By definition, these children simply have inflamed ears which often respond better to other types of treatment.
Children who have infections, on the other hand, also present with these five signs of inflammation but, for the most part, do not look clinically well and often have an illness that is more serious than a simple ear infection. A child in pain who appears not to look well should be re-evaluated after the pain is relieved.
Early in my pediatric practice, I often gave a child a ten day course of an antibiotic for what I believed was a classic ear infection using the criteria I described for inflammation. More often than not, 2-3 days after completing the antibiotic, the child returned with the same symptoms. I would subsequently write another antibiotic prescription. Frequently, the same pattern would recur. Conventional training taught me that the child had an infection caused by a bacterium that was resistant to the antibiotic. Therefore, a different and stronger antibiotic was needed.
Eventually it occurred to me that perhaps the child never needed the antibiotic in the first place. Perhaps there was a different process going on that required a different set of treatments and understanding.