For years, antibiotics have been the go-to prescription for ear infections, one of childhood's most ubiquitous maladies. So it came as a bit of a surprise last week when the Canadian Paediatric Society issued new recommendations saying the routine prescription of antibiotics for children suffering from ear infections needs to stop. Pediatric infectious disease specialist Joan Robinson, who co-authored the society's report, explains why in most cases a prescription medication isn't needed.
If a parent thinks their child has an ear infection, what's the first thing they should do? It depends. If the child is under six months of age, or seems really quite ill, or has any other serious medical problems, they should see the physician as soon as possible.
If, however, the child is over six months of age, their temperature is less than 39 degrees Celsius, and does not seem ill, and is not in excruciating pain, it is reasonable to start the child on either acetaminophen or ibuprofen. Tylenol, Advil and Motrin would be the common names that parents know about.
What happens if those don't work? Certainly, if the child still has a horrible earache after one dose of medication, then they probably should see a doctor. Or if the child still has any earache or is still febrile [has a fever] after two days of treatment, then they should see a physician. Because maybe that is one of the small number of children who really does require antibiotics to get an improvement in their symptoms.
Are there any risks associated with not using antibiotics for an ear infection? Yes. There are always risks with not starting antibiotics for something that could be a serious bacterial infection. You can end up with mastoiditis, which is an infection in the bone behind the ear, or you can end up with a brain abscess, or with meningitis.
Those things sound pretty scary. These are all rare, rare complications. So one has to treat over 1,000 children with antibiotics to prevent one of these complications.
Interestingly enough, in Scandinavian European countries such as the Netherlands, they have not used antibiotics for the majority of ear infections for decades, and the incidence of serious complications there is really not much higher than it is here.
Should parents be wary of antibiotic prescriptions for medical conditions other than ear infections? Certainly if children have a sore throat, generally they should only have antibiotics if the doctor has done a throat swab and it came back showing the child has group A streptococcus bacterium. Otherwise, antibiotics should not be started for a sore throat. The exception for this rule is for children with scarlet fever, or children who are really quite ill.
Another situation is sinus infections, where, just like ear infections, many will resolve without antibiotics. Also, children should only be given antibiotics [for pneumonia] if a chest X-ray has been done confirming they have pneumonia. Just listening to a child's chest is not accurate enough.
Why do these recommendations only apply to children over six months old? There is very little data on children under six months of age. The other reason is the clinical assessment of children under six month of age is much less accurate than for older children.
What is the difference between an ear infection caused by a virus, compared to a bacterial infection? There is no way to tell them apart in terms of symptoms. We think about 20 per cent of ear infections are viral. The other 80 per cent are bacterial. But the child's immune system allows them to deal with these infections. These are kind-of wimpy bacteria that cause ear infections.
You list some things that can help avoid ear infections, including not bottle feeding a baby who is lying down. How can this lead to ear infections? The problem with feeding a baby with a bottle while the child is lying down, is that milk will run down the tube that goes from the back of the mouth towards the ear drum. It causes a bit of inflammation in that tube. So when they get a cold, they get way more inflammation. And it's the blockage of that tube that then often leads to an ear infection.
This is exactly why cigarette smoke exposure is a problem. It causes some inflammation of that tube.