February 25th, 2013
03:43 PM ET

Antibiotics less likely to be prescribed for kids' ear aches

Guidelines for diagnosing and treating ear infections are changing and the result may mean fewer prescriptions for antibiotics.

The American Academy of Pediatrics (AAP) on Monday released the new guidelines for diagnosing and managing acute otitis media (AOM), the most common form of ear infections.

Going forward, pediatricians should only diagnose acute ear infections if the child's eardrum is moderately to severely bulging or if there is discharge leaking from the ear, according to the recommendations. They may diagnose a middle ear infection if the child's ear drum is mildly bulging and there is recent onset of pain or intense redness.

Doctors should only prescribe antibiotics in children 6 months and older if there are severe signs or symptoms, which the academy defines as a temperature of 102.2 degrees or higher, or severe pain or if young children between 6 and 23 months have ear infections in both ears.

"Studies have shown that bulging (of the eardrum) is the best criteria for diagnosing an ear infection." says Dr. Allan Lieberthal, lead author of the guidelines and clinical professor of pediatrics at the Keck School of Medicine at the University of Southern California.

If a toddler or baby (older than 6 months) has an ear infection in only one ear, then antibiotics should be an option as well as simply watching the child to see if things clear up on their own. If observation is chosen and the child not better within 72 hours, then it's time to consider antibiotics again, experts say.

The key message is that parents should not be expecting antibiotics each time, Lieberthal says.

Observation has been proven to be very effective and has been recommended since the last time the AAP updated its guidelines back in 2004, says Lieberthal. But the previous guidelines recommended prescribing antibiotics under a definition of "uncertain diagnosis." That, says Lieberthal, no longer exists. The new guidelines very specifically lay out when and when not to diagnose and prescribe antibiotics for ear infections.

The guidelines are for uncomplicated acute otitis media in children aged 6 months to 12 years who are otherwise healthy and do not have recurrent ear infections.

AOM is a common condition where the middle ear is inflamed. Recurrence is defined by three separate infections in six months, or four in 12 months, with at least one of those infections occurring in the past six months.

"If a parent would not take their child to the doctor for a common cold, the parent does not need to take the child to the doctor worrying about an ear infection, except in those two instances (high fever and severe pain)," says Lieberthal. But, he notes, "even a child with that high a fever and severe pain may not have an ear infection."

That's because ear pain is common in young children and may be caused by teething, a cold, a sore throat, jaw problems, or an ear infection, says Dr. Rich Rosenfeld, co-author of the guidelines and professor and chairman of otolaryngology at SUNY Downstate in New York. “You can't tell which one it is without seeing your doctor, but since most of these go away on their own, it isn't always necessary."

Rosenfeld tells parents it's time to take their child to the doctor if any of the following are present: "severe ear pain, persistent ear pain that lasts more than two days, temperature more than 102.2 degrees or new onset of drainage (pus or blood) from the ear canal."

The goal here is to only use antibiotics when absolutely necessary and when it will actually help.

"There is also tremendous overuse of antibiotics," says Lieberthal. "Antibiotics can cause side effects to the child such as diarrhea (and) resistant bacteria; it also hurts the community because there are more bacteria that have become resistant to antibiotics.”

Antibiotics treat bacterial infections; they don't reduce pain. Over-the-counter pain medication can be helpful for that.

The question that still needs to be answered is how parents and pediatricians will adapt to the new guidelines.

“In my and many doctors' experience, patients are not requesting antibiotics and would welcome not getting them," Lieberthal says. "So parents in many cases aren't the driving force."

He acknowledges that is can be very difficult to change doctors' habits. "We hope the doctors take (the new guidelines) to heart."

soundoff (40 Responses)
  1. Else

    So...ignore the problem and it will go away or it won't...then go to the doctor but in the meantime a BABY SCREAMS in excruciating pain for 72 hours.

    The more of these articles that come out the more I am convinced of two things (1) modern medical science knows LESS than it did 50-75 years ago and (2) Doctors don't want to work.

    It is NEVER ok to let an infant exist in excruciating pain for days on end but that is exactly what this article is telling parents to do.

    February 25, 2013 at 21:37 | Report abuse | Reply
    • Nick

      No.. pretty sure the article says you treat with antibiotics in the case of excruciating pain.

      "Doctors should only prescribe antibiotics in children 6 months and older if there are severe signs or symptoms, which the academy defines as a temperature of 102.2 degrees or higher, or severe pain or if young children between 6 and 23 months have ear infections in both ears."
      "If a parent would not take their child to the doctor for a common cold, the parent does not need to take the child to the doctor worrying about an ear infection, except in those two instances (high fever and severe pain),"

      Simply stunning...

      February 25, 2013 at 21:53 | Report abuse |
    • Tom Hartman

      Anyone who has taken a kid to a doctor in the last ten years knows it is like pulling teeth to get a prescription for an antibiotic, this "overuse" thing is no longer true and hasn't been for a long time.

      February 26, 2013 at 00:02 | Report abuse |
    • my two cents (probably worth less than that)

      Do you have any idea how MRSA came into existence?

      February 26, 2013 at 00:39 | Report abuse |
    • Pam

      I've had ONE earache in my life and I was about 6. The pain was so intense, I remember exactly how it felt & the level of pain I endured, and I'm almost 40.

      An earache requires antibiotics...end of story. Unless of course you enjoy the feeling of someone forcing a sharp pencil through your eardrum.

      February 26, 2013 at 17:50 | Report abuse |
  2. mdf

    this article is telling parents to use tylenol, motrin etc to control the pain. having seen the consequences of antibiotic resistant bacteria, waiting is a really prudent action.

    there are measures you can take to help lessen ear problems, check w/ a pediatric specialist for what's right for the age of your child.

    February 25, 2013 at 22:05 | Report abuse | Reply
  3. Jay

    We use 1/4 tsp of peroxide in the ear. Lie on your side, pour the scant amount in your ear (you will hear fizzing and bubbling but no discomfort) and keep in for 10-15 minutes. Put tissue on ear to drain when standing to catch the peroxide. You can do both sides but you probably won't hear any fizzing in the unaffected ear (I don't anyways). Don't do this on ruptured eardrums. I was amazed how well it worked.

    February 25, 2013 at 23:01 | Report abuse | Reply
  4. LORI

    I'm a pediatrician – so where does the cut-off of 102.2 come from? And since when does teething cause severe pain? I doubt the specialist are the ones getting the calls in the middle of the night that now the temp is over 102.2 and by the way I don't want to come back in and pay another co-pay, but sometimes I do question the ivory tower docs.

    February 25, 2013 at 23:02 | Report abuse | Reply
    • Peds Steve

      Perhaps, as a pediatrician, you should get updates on guidelines and recommendations from the journals that they are published in, and NOT major media outlets. The new published guidelines reference the studies that the guidelines are based upon. I could tell, but everyone hates a spoiler!

      February 26, 2013 at 01:05 | Report abuse |
  5. Parent-of-Five

    We found that our Doctor would hesitate to prescribe antibiotics because of research like this. When we started having kids with burst ear-drums, we stopped waiting and started advocating for immediate treatment BEFORE the true damage occurred.

    Hopefully, doctors will trust the parents of the kids and the parents will know their child's "normal" responses. Regardless of the research, I insist that my kid gets antibiotics because it works for them.

    February 25, 2013 at 23:04 | Report abuse | Reply
    • Jacksonian4350

      The research is done for a reason. Yes you know what is normal for your child much better than the doctor. But you are making your assessment from anecdotal information, not from thoroughly researched guidelines and a medical degree. Don't forget we are trying to prevent dangerous antibiotic resistant strains of bacteria, not deny you of the antibiotic you insist.

      February 26, 2013 at 12:26 | Report abuse |
  6. Lisa B

    If I'd followed these guidelines with my son, he'd likely be deaf now. I agree that over-prescribing of antibiotics is a real issue. However, my son had no signs of pain or fever when he first got an ear infection that would not clear, even with antibiotics. Only tubes and the removal of his adenoids took care of the problem. Doctors have to be able to use common sense and not just adhere to some strict, but seemingly arbitrary guideline.

    February 25, 2013 at 23:36 | Report abuse | Reply
  7. professor

    Parent-of-five: YOU are the problem!
    –First, antibiotics do not "work" for your kids. Antibiotics kill bacteria- whether they are in your kid or in a petri dish.
    –Second, if the problem is NOT a bacteria- as indicated by a fever of 102 etc- then antibiotics do NOTHING (except create antibiotic resistant bacteria to infect others or maybe your kid).
    –Third, you "insist" the kid gets antibiotics? For what? Do you have an Otoscope? Do you even know what one is? Or what a healthy ear drum looks like?

    All the "new" guidelines say is what we have known for a long time- if is not Red and only "slightly" bulging then antibiotics are not indicated.

    February 25, 2013 at 23:50 | Report abuse | Reply
    • Tom Hartman

      This kind of logic sees many people each year go into pneumonia from what the doctor terms a "simple" cough (you could be coughing up green stuff for a week and they'll tell you take cough syrup). Then they start treating you with Cipro, after you have pneumonia, when the AB would have prevented the "colds" progression. It's nonsense, there hasn't been an overuse of antibiotics in a decade.

      February 26, 2013 at 00:05 | Report abuse |
    • Peds Steve

      @Tom: glad you brought up pneumonia. Also more often than not a viral infection with a natural course lasting upwards of 2 weeks. Not coincidentally, most people seek treatment after 3-5 days of illness, demand antibiotics, and lo and behold, towards the end of the ten day course of antibiotics, are better. 4 + 10 = 14 days, aka 2 weeks. Now, we are mostly talking about kids who, pound for pound in comparison to adults, are resilient and mostly healthy, and have not been beating the crap out of their bodies for decades with smoking, obesity, sedentary lifestyles, and on and on, increasing their risk for more serious or invasive infections.

      February 26, 2013 at 01:15 | Report abuse |
    • PediDocKS

      Amen to the Professor!! The majority of ear infections are caused by viruses! Parents SHOULD NEVER INSIST on an antibiotic. I am thankful that the families I work with have learned that viral illness DO go away on their own and those requests, which used to be frequent, are much less common in our practice now. FYI ruptured ear drums heal. Way to go to the AAP for putting out these guidelines that were way overdue!

      March 5, 2013 at 22:57 | Report abuse |
  8. lisinopril

    It is amazing how stupid most parents are.

    February 26, 2013 at 00:28 | Report abuse | Reply
  9. Dag

    Decades later I still remember being five years old and writhing in agony with an ear infection until my eardrum finally burst. What a relief when it did. But the resulting scar tissue from the tear in the eardrum certainly does not help ones hearing. To this day as a result of that I've no doubt, and a number of other abuses that my ears have suffered, I have tinnitus.

    Article says, "it's time to take their child to the doctor if any of the following are present: "severe ear pain, persistent ear pain that lasts more than two days, temperature more than 102.2 degrees or new onset of drainage (pus or blood) from the ear canal."

    No, the time to take your child to the doctor was well before pus or blood starts running from the ear canal, morons. I speak from experience.

    February 26, 2013 at 00:44 | Report abuse | Reply
  10. william antrim

    The article is correct about the overuse of antibiotics. However, their overuse is not in humans but animals. Giving antibiotics to birds, pigs, cattle in the food chain is causing the biggest problem. The rest is propaganda.

    20 years and billions of dollars of research in HIV treatments and the medical industry still doesn't have a descent tool for addressing the common virus. Tamaflu isn't even close to a real solution.

    February 26, 2013 at 01:17 | Report abuse | Reply
  11. Gina Rao

    I work in a rural clinic and we are closed on Fridaysand weekends. The nearest hospital is an hour away, in good weather.
    I tell the parents that the child should start the antibiotic only if the symptoms of fever, congestion and ear pain do not improve in 2 days. But by then our pharmacy is closed, and the parents may have to take the child through the mountains to the nearest ER, in icy weather.So they do get an antibiotic if I see that the ear or the chest congestion doesn't look like it will improve in 48 hours. You get a sense of this type of thing after working for as long as I have (20 years)The local setting and the specific situation often dictate how ready we are, as providers to write the antibiotic script.

    February 26, 2013 at 01:53 | Report abuse | Reply
  12. Jacob Ransome

    Truly, the AMA should be embarrassed at the stupidity of this.

    February 26, 2013 at 01:58 | Report abuse | Reply
    • A41nj

      This has nothing to do with the AMA it's the AAP. It's right in the first paragraph.

      February 26, 2013 at 09:34 | Report abuse |
  13. john


    February 26, 2013 at 17:03 | Report abuse | Reply
  14. Pedsdoc

    Parents are clearly the problem here, as seen in many of these posts. Antibiotics only work on bacterial infections, and since most AOM are viral, prescribing antibiotics serves NO role, other than creating the resistance we struggle to now keep up with in real bacterial infections (for example, MRSA, VRE, other multicenter resistant organisms). Medical research is conducted for a reason, and to think you are smarter than the scientific community who produces these guidelines is foolish and unsafe for your child and community.

    February 27, 2013 at 00:46 | Report abuse | Reply
  15. Melissa

    If a doctor says no to antibiotics it is because they aren't warranted at that time, You can and should still ask about pain medicine, and how long to wait to see if things improve before suspecting they might be needed. Also, lots of parents stop kids pain medicine with the first dose of an antibiotic, instead of asking what is safe to take with the antibiotic.

    March 1, 2013 at 16:22 | Report abuse | Reply
  16. Melissa

    Parents also need to make sure that their kids take all of the prescribed antibiotic s, so often parents will not finish the course because of minor side effects that go away in a couple of days, because they don't know enough about expected common side effects are, This is the kind of thing you can ask the pharmacist. Knowing this information and passing it on is their job.

    March 1, 2013 at 18:12 | Report abuse | Reply
  17. Blueangel

    It's all about getting the office visit money, but not providing any service. I say, if they say there is nothing to do, then they don't get paid. Or at least if you have to return you don't have to pay again. The insurance companies are paying too much for office visits, it causes greed to take over. When my kids were little, a doctor visit was 20 bucks, and you submitted your reciept to the insurance company to be reimbursed. If the problem was not helped by what the doctor did, a simple FREE phone call was all it took for him to call in whatever else he had in mind. I have four kids. Ear infections is one of the things that does NOT go away on it's own.

    March 6, 2013 at 16:17 | Report abuse | Reply
  18. Sarah

    I was put on antibiotics for months at a time when I was a child and had bad ear infections. Instead of the simple procedure of putting tubes in, I was loaded up with antibiotics. Growing up I was constantly having sinus and throat infection, respiratory infections, bronchitis, and recurring ear infections. More and more antibiotics were given. I now suffer very bad eczema. I use a bar of goats milk shampoo and neem bar soap. I can't shower or be in water for very long. I'm allergic to sls so I have special hand soap I carry with me and I can't do dishes or use cleaning products without gloves. I have to be careful with laundry detergent and anything that touches my skin. I can't have some foods, tomatos are the biggest offenders, because due to tree allergies they cause eczema. Makeup is also a no go. At 23, thanks to my own research and asking for specific tests, it's mostly under control. I blame excessive use of antibiotics. No one else in my family has eczema or food allergies or anything close to what I've had. It's been very difficult for me.

    May 8, 2013 at 11:23 | Report abuse | Reply
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  20. Eardoc

    Many of the things said in the article are correct, and in most cases it is the stress the parents and the doctors are under that makes them give unnecessary antibiotics. The human body is an amazing machine, and it can heal from a lot of things if we just give it the time and maybe some assistance (a good rest for example).
    Not every kids needs antibiotics, and not every kid should be denied antibiotics. The guidelines (and the parents) count on the doctor to do what's right for the child.

    July 14, 2013 at 09:46 | Report abuse | Reply
  21. Eardoc

    Reblogged this on ear infections guide & assistance and commented:
    If only everyone listened to the doctor rather than looking for a quick and simple treatment. Many of the antibiotics are not needed, and people should be aware of it.

    July 14, 2013 at 09:47 | Report abuse | Reply
  22. mark

    This is condition our society for substandard care as a result of government healthcare. The sheeple will buy the articles about doing nothing but managing the pain and hope these things go away without medicine or turn into a major infection. THIS IS HORRIBLE DESENSITIZING OF OUR SOCIETY

    November 19, 2013 at 11:33 | Report abuse | Reply
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