Ear Infections and Watchful Waiting
Robert P. Lindeman, MD, PhD
Natick Pediatrics, PC

I don’t know how many ear infections my two boys have had (their ages are 4 and 2). That doesn’t mean I’ve lost count, it simply means I don’t know how many ear infections they’ve had between them. But the statistics say that by age three, 83% of children have had at least one ear infection and 46% have had three or more. So are my boys just extraordinarily lucky?

The reason I don’t know how many ear infections they’ve had is that I know as a pediatrician that the overwhelming majority of ear infections go away on their own, without antibiotics. It could very well be that they’ve both had many ear infections: I simply haven’t looked, and I haven’t taken them to their own doctor to look, either!

Pediatricians in Europe, and increasing numbers of doctors in the U.S., treat ear infections using a method called "watchful waiting". If a child has a fever and feels lousy, and they have a bulging red ear drum, a pediatrician will usually suggest waiting and watching for two days to see if the child begins to feel better without antibiotics. The doctor will recommend keeping the child comfortable with over-the-counter medications like Tylenol and Motrin. The child may also be given a prescription for pain-killing ear drops. If the child is no better after two days of watchful waiting, the doctor will prescribe antibiotics. However, if the child looks particularly sick, or if he is less than two years old, the doctor may prescribe antibiotics right away.

"But doctor," you say, "my child had an ear infection and the pediatrician gave us amoxicillin and the next day he was back to normal". Of course it’s wonderful when a sick child feels better - but was it the amoxicillin that made him better, or was it time?

Antibiotics have saved millions of lives since they came into widespread use over 50 years ago. Perhaps because of this success, antibiotics have gained super-hero status. Today, many people believe antibiotics can do things these drugs were never meant to do: Antibiotics are not pain killers. They will not help a child sleep or improve his appetite (quite the opposite! Many antibiotics give children upset stomachs). Some antibiotics don’t even kill germs! They only prevent the germs from multiplying, allowing the body’s natural defenses, the immune system, to kill them. I tell patients that these antibiotics hold down the arms and legs of the germs while the body’s immune system jumps up and down on them!

The success of antibiotics has a dark side also: Antibiotic resistance. The germs are more clever than we give them credit for. They have developed ways to avoid being attacked by antibiotics by changing their structure, or mutating. It turns out that we’ve been helping the germs mutate into antibiotic-resistant forms by giving so many antibiotics! Now we are faced with a serious public health crisis: as more and more germs become resistant to antibiotics, we are running out of antibiotics to treat serious infections. The "nightmare scenario" we are facing is an epidemic of formerly treatable bacterial infections that are fast on their way to becoming untreatable multi-drug resistant bacterial infections.

Fortunately, we can do something about the problem. We can stop using antibiotics as often as we do. Studies in livestock suggest that when you take the antibiotics out of animal feed, you can reduce the amount of antibiotic resistance in the bacteria that normally grow in these animals. It will probably turn out to be the case that if we stop using antibiotics when they’re not really needed, we can reduce antibiotic resistance in people. And then we’ll be able to use these medications when we really need them.

So what should you do with a sick child who you think might have an ear infection?
Call your doctor. Tell the doctor what’s going on with your child: focus on how the child looks, not necessarily what the child’s temperature is. Is the child able to sleep, or is he/she up every hour screaming? Is the child eating and drinking normally, or is he/she refusing to eat or drink anything?

• Make the child comfortable.
  Make sure he/she has plenty to drink. Give Tylenol or Motrin according to your doctor’s instructions. Your doctor may prescribe pain-killing drops that go in the ears. Keep the child’s head elevated in bed. Two pillows usually do the trick.
• Keep in mind that antibiotics will not make your child better right away.
  You should never take a child to an emergency room for ear pain. If you suspect an ear infection, you should only go to the emergency room if your doctor tells you to go.
• Don’t demand antibiotics from your doctor.
  There have been more than a few occasions when an anxious mother has told me "I’m not leaving here without a prescription!" This puts me in an uncomfortable position. I can assure you that when I recommend holding off on antibiotics, I have the best interests of your child in mind. Above all, I want to do more good than harm.
• Talk to your doctor about alternative treatments, such as Echinacea.

As a father, I know that parents want their children to get better as soon as possible. As a pediatrician, I want all my patients to get the best treatment possible. Whichever hat I’m wearing, parent or pediatrician, I know that it’s usually better to watch and wait than to reach for that prescription pad.

For more information about Natick Pediatrics, or to talk to the doctor, please call the office at (508) 655-9699.

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Medical Office Building
MetroWest Medical Center
Leonard Morse Campus
67 Union Street, Suite 305
South Natick, MA 01760

(508) 655-9699
(508) 655-2984 fax

Posted: November 15, 2002