Saturday, April 25, 2015

Coping with ear infections

Only about half of the children with ear infection-like symptoms actual turn out to need antibiotics. Here is how to tell and what to do.

Coping with ear infections

When antibiotics first became available, doctors over-used these drugs, which made them ineffective in many cases. (AP Photo/Gene J. Puskar)
When antibiotics first became available, doctors over-used these drugs, which made them ineffective in many cases. (AP Photo/Gene J. Puskar)

by Gary A. Emmett, M.D.

It’s a creepy-crawly fact: Humans have 10 times the number of bacteria in our bodies than we have human cells. In some sense, that makes each of us just 9 percent human. These bacteria exist in symbiosis (Greek for “living together”) with us. They’re vital to many of our basic functions – including digestion, helping keep immunity strong and more. Maintaining these important “commensal” (Old Latin for “food sharing” – yes, they eat what you, or your kids, eat!) bacteria should always be in a doctor’s mind when he or she treats a patient.

I was thinking about good bacteria when the mother of Madison, an 18 month-old, emailed to tell me her daughter had been up all night —crying on and off and holding her right ear. Madison had a fever, but her mother did not have a thermometer to measure it, and she had had a runny nose and a cold for 3 days. She went to day-care. Her father smoked, but “only outside.” I asked her to come in so I could look in her ear.

In the office Madison had a temperature of 101.4, she was tired and clearly in pain, but she would smile if I acted silly. She was happy to get a lollipop after I was done. On exam there was puss in the discharge from her nose and her right eardrum was red and swollen with fluid behind it. All you parents out there know this could mean an ear infection. We immediately gave her some medicine for her pain and fever (acetaminophen also call Tylenol), e-prescribed some ear pain drops to kill the ear pain and, after thinking about it, e-prescribed some amoxicillin for 10 days.

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This simple case should raise many questions for both parents and healthcare providers – questions you’re probably asking yourself right now such as:

1) Why didn’t I just prescribe amoxicillin on the phone when Madison’s mom contacted me?

a. When antibiotics first became available, doctors over-used these drugs, which made them ineffective in many cases. Doctors should only use them when we know they can help a good deal.

b. Antibiotics can have serious side-effects such as allergy and profound diarrhea

c. Only about half of the children with the symptoms mentioned in the mother’s email actual turn out to have a middle ear infection and need antibiotics

d. We also know that children who get an antibiotic before their first birthday are more likely to get asthma later because the antibiotic disturbs the body’s bacteria and that disturbance changes how we react to lung irritation

2) What should be prescribed on the phone?

a. Pain killers such as acetaminophen or ibuprofen because we should treat the problem, which is a painful ear

b. Lidocaine containing ear drops, if we know there is not an ear-tube in place or that the ear drum is not broken

3) Why do you have to think twice about giving antibiotics?

a. In children after their second birthday the current recommendation for ear pain with middle ear infections is treat with just pain killer for 3 days, and if not getting better start antibiotics. Almost 80 percent of children with ear infections get better even if they are not treated with antibiotics.

b. Not using antibiotics is more questionable before the second birthday, because the immune system is not complete until the end of the second year of life and we are afraid an ear infection may spread even to the brain.

4) What does all this have to do with the commensal (or normal) “good” bacteria?

a. We each are born sterile of bacteria and get our first dose as we come down the birth canal. From then on we pick up over 500 different species of bacteria that help us digest our food, teach our immune system how to distinguish between ‘good” and “bad” microorganisms, and generally work with our bodies to protect us against the dangers in the world.

b. When we give antibiotics, we can kill the bad bacteria causing the infection, but we also kill some of the good bacteria we need.

5) If a child needs antibiotics, how can we protect his or her good bacteria?

One good preventative is to take some normal bacteria (“probiotics”) such as in live-culture yogurt or the commercial products containing lactobacillus and others available over the counter. A recent study shows that taking live-culture yogurt every day while on antibiotics markedly decreases abdominal pain and diarrhea.

The take-home lessons for parents: See the big picture if your child’s doctor doesn’t prescribe antibiotics immediately. And when she or he does give you or your child antibiotics, remember to also be nice to those friendly bacteria in your body and think about taking some probiotics.

What do you think? Do you give your children yogurt or a probiotic supplement when they’re taking antibiotics?

Garry A. Emmett, M.D., F.A.A.P., has been a primary care pediatrician in South Philadelphia and Center City since 1979. He is currently an attending pediatrician at Nemours Pediatrics, Philadelphia and Director of Hospital Pediatrics at Thomas Jefferson University Hospital.

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The Healthy Kids blog is your window into the latest news, research and advice around children's health. Learn more about our growing list of contributors here.

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Anna Nguyen Healthy Kids blog Editor
Sarah Levin Allen, Ph.D., CBIS Assistant Professor of Psychology at Philadelphia College of Osteopathic Medicine
Stephen Aronoff, M.D., M.B.A. Chair of the Department of Pediatrics at Temple University Hospital
Peter Bidey, D.O. Medical Director of Family Medicine at Philadelphia College of Osteopathic Medicine
Christopher C. Chang, MD, PhD, MBA, FAAAAI, FACAAI Associate Professor of Medicine in division of Rheumatology, Allergy and Clinical Immunology at UC Davis
Katherine K. Dahlsgaard, Ph.D. Lead Psychologist of The Anxiety Behaviors Clinic at Children's Hospital of Philadelphia
Gary A. Emmett, M.D., F.A.A.P Director of Hospital Pediatrics at TJU Hospital & Pediatrics Professor at Thomas Jefferson Univ.
Magee DeFelice, M.D. Division Chief of Allergy and Immunology at Nemours/Alfred I. duPont Hospital for Children
Hazel Guinto-Ocampo, M.D. Chief of Pediatric Emergency Services at Nemours duPont Pediatrics/Bryn Mawr Hospital
Rima Himelstein, M.D. Adolescent Medicine Specialist at Crozer-Keystone Health System
Jessica Kendorski, PhD, NCSP, BCBA-D Associate Professor in School Psychology/Applied Behavior Analysis at Philadelphia College of Osteopathic Medicine
Anita Kulick President & CEO, Educating Communities for Parenting
Janet Rosenzweig, MS, PhD, MPA VP for Programs & Research for Prevent Child Abuse America
Beth Wallace Smith, R.D. Registered Dietitian at Children's Hospital of Philadelphia
Emiliano Tatar, M.D. Pediatrician at Einstein Healthcare Network Roxborough Plaza
Jeanette Trella, Pharm.D Managing Director at The Poison Control Center at CHOP
W. Douglas Tynan, Ph.D., ABPP Director of Integrated Health Care for American Psychological Association
Flaura Koplin Winston, M.D., Ph.D. Scientific Director of the Children’s Hospital of Philadelphia’s Center for Injury Research and Prevention
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