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Ask Dr. Mom: Now Ear This

Q. Our 15-month-old is just getting over her fourth ear infection. Each time, I give her the prescribed antibiotic and she gets better for a while, only to develop another within a few months. And now the doctor says that my daughter has fluid behind her eardrum that may affect her hearing. What's the difference between this and her past infections? I loathe the idea of giving her antibiotics so often.

A.
Parents and babies aren't the only ones who deal with frequent ear infections. A pediatrician uses an otoscope -- the special instrument used to examine the ear -- almost as often as her trademark stethoscope. That's because inflammation of the middle ear, known as otitis media (OM), is the most common illness diagnosed in childhood next to the common cold: By 12 months of age, nearly three-quarters of all children have had at least one infection, and almost half endure three or more by the time they're 3 years old.

Despite its prevalence, OM is tough to diagnose and manage correctly. It is a general term that refers to both acute otitis media (AOM), infected fluid behind the eardrum in the space known as the middle ear, which is associated with fever, ear pain, and irritability; and otitis media with effusion (OME), an accumulation of fluid behind the eardrum that usually produces no symptoms of illness. Doctors often confuse the two: One study found that pediatricians misdiagnosed OME as AOM about 50 percent of the time. And since they are treated differently, it's important that your doctor get this one right.

Acute Otitis Media

AOM often begins with a cold that causes inflammation and swelling of the eustachian tube (a narrow passage between the middle ear and the throat), allowing fluid to accumulate behind the eardrum in the middle-ear space. This trapped fluid can serve as a breeding ground for bacteria that cause an infection with painful inflammation and bulging of the eardrum. Pain can be worse when the baby is sucking, swallowing, and lying down, due to pressure changes in the middle ear.

Symptoms often include a runny nose and congestion as well as fever, which can range from 100°F to 104°F. Ear pain can cause a preverbal child to tug at her ear, be irritable, have a hard time sleeping, and feel uncomfortable during feedings. If the infection is severe and goes untreated, you may see blood-tinged fluid and pus in the ear canal, indicating a ruptured eardrum. This will usually heal withoutcomplications, but you should report any such symptoms to your pediatrician.

AOM in young children is treated with an antibiotic (usually a ten-day course of amoxicillin, given in higher doses than in the past). Ear pain and fever should be gone within three days, and children are usually symptom-free by seven days. Nevertheless, it's extremely important to complete the full course of medication to eradicate all the infecting bacteria and prevent a recurrence.

Occasionally, an ear infection does not respond to the first antibiotic, and if symptoms have not improved within 72 hours, the pediatrician will likely prescribe an alternative antibiotic that will be effective against the resistant strains of bacteria. Your baby's doctor may also recommend using an over-the-counter, nonaspirin pain medication (such as acetaminophen or, if your baby is over 6 months, ibuprofen) to relieve your child's earache and reduce her fever. It's important not to give your child aspirin, however, because it has been linked to Reye's syndrome, a serious illness in children affecting the brain and liver.

Marianne Neifert, M.D., is a pediatrician, the mother of five adult children, and the author, most recently, of Dr. Mom's Prescription for Preschoolers.

Otitis media with effusion

OME refers to the painless collection of watery or mucus-like fluid in the middle ear, without symptoms of an ear infection. Most, but not all, cases of OME are diagnosed when persistent middle-ear fluid is discovered during an examination following AOM, but it can also be caused by a faulty eustachian tube, upper respiratory infections, and allergies. OME lasts an average of 40 days after AOM, but it often tends to persist longer in younger children. Unlike the signs of illness that usually accompany AOM, the main symptom of OME is diminished hearing, which can be hard to notice in babies. Older children may report a sense of fullness or "popping" in their ears.

OME ordinarily does not require treatment with antibiotics. Most cases of OME that follow an ear infection will clear up on their own within three months. Some physicians will prescribe antibiotics to try to get rid of the fluid if it persists beyond three months. If you have any concerns about your child's hearing, an audiologist experienced in working with children can test her.

Recurrent Ear Infections

I understand your concern about having your child on antibiotics so frequently. Because an ear infection is the most common diagnosis for which children are given antibiotics, it contributes significantly to the growing problem of antibiotic resistance. For example, more than 20 percent of S. pneumoniae bacteria that cause AOM have developed resistance to penicillin.

Various strategies have been proposed to deal with this problem. First, physicians must take steps to more accurately distinguish AOM from OME by gathering better information from parents about their child's symptoms and by gaining greater skill in examining children's eardrums. A bulging eardrum is a telltale sign of bacteria-filled fluid in the middle ear, signaling AOM. One suggestion has been to withhold antibiotics in some or all cases of AOM in children over 2 years of age unless symptoms persist or worsen. Indeed, studies have shown that most cases of AOM, when not treated with antibiotics, will resolve on their own within four to seven days. Another proposed strategy is to shorten the duration of treatment for AOM from ten days to five to seven days, since a shorter course of antibiotics can also be effective. However, because more serious infections occur in children under 2 and young children have more complications from untreated illness, I agree with those experts who argue that it is still most prudent to treat AOM in children under 2 with a full ten-day course of antibiotics.

New guidelines are being prepared by a panel of experts convened by the American Academy of Pediatrics and the American Academy of Family Physicians. They are expected to give physicians the option of withholding antibiotics for children over 2 with AOM or children who are not seriously ill, or in situations in which the diagnosis is unclear. Treatment with antibiotics will continue to be recommended for all infants younger than 6 months of age and for those babies over 6 months who have moderate to severe pain or a fever over 102°F.

Children with recurrent AOM or OME lasting longer than three months (along with temporary hearing loss) are often referred to an otolaryngologist (ear specialist), who may recommend ear tubes. Ear-tube placement, in which a doctor puts tiny ventilation tubes in the eardrum to help drain and aerate the middle ear, is the second most commonly performed surgical procedure among U.S. children. It restores hearing and helps prevent further infections. Typically, the tubes come out on their own 6 to 18 months after they are inserted.

Prevention

Some children are just more prone to ear infections. Risk factors include being male, being of Native American or Eskimo descent, having a family member who has chronic OM, or having allergies or Down syndrome. Even if your child is at high risk, you can reduce her susceptibility to ear infections by breastfeeding, maintaining a smoke-free home, and avoiding large group daycare.

Vaccination can also be effective. The new conjugate pneumococcal vaccine Prevnar has been shown to reduce ear infections by about 7 percent and to decrease the need for ear tubes by about 20 percent in children with recurrent AOM. The influenza vaccine may also prevent some cases of AOM, since infection with respiratory syncytial virus (RSV) or influenza virus makes a child more susceptible. And it's true that your child will eventually "grow out of it": Most children outgrow the tendency to get ear infections by 4 years of age.

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