Middle Ear Infections and Antibiotic Use in Children

One of the most common infections of childhood is a middle ear infection, or acute otitis media (AOM), in the normally air-filled space behind the eardrum. This disease is associated with many pediatrician and specialist visits, which often lead to treatment with antibiotics. However, parents in conjunction with their physicians certainly have the option of not treating uncomplicated AOM with antibiotics, at least not at the outset of the disease.

AOM generally means short-term pus behind the ear, usually but not always from a bacterial infection. This contrasts with, for example, otitis media with effusion (OME), in which there may be some clear fluid left behind the eardrum for some time (weeks to months), after the AOM has cleared.

If a child has very frequent episodes of AOM (for example, 6 episodes in a year), they may have recurrent AOM, or "RAOM." These patients often have one or more risk factors (see below).

What is a middle ear infection?

The ear is divided up into three compartments (see diagram). The outer ear extends from external part of the ear to the eardrum. When it is infected, that condition is called otitis externa. The middle ear contains the ear drum and the three ear bones and is connected to the back of the nose (and hence the throat) by the Eustachian tube. The inner ear, inside the skull, contains the body’s apparatus for maintaining balance.

When the middle ear is infected, pus builds up in that compartment and can create severe pain. Occasionally it even bursts through the ear drum and can leak out the ear. Fortunately, however, many AOMs resolve spontaneously.

Why are young children especially susceptible to ear infections?

Infants and young children are more prone to AOM than older children, probably because their Eustachian tube, which connects the back of the nose to the middle ear (see diagram) and equalizes pressure (it’s what "pops" when you fly and swallow), is more horizontal in babies. This positioning makes them prone to the "reflux" of milk from the back of the nose when swallowing, up the Eustachian tube into the middle ear space.

Documented risk factors that put some young children at more risk for AOM, including daycare, bottle-feeding, second-hand smoke exposure and genetic predisposition.

Why wait to treat your child?

Parents, in consultation with their physician, should consider waiting before filling a prescription for a child with an ear infection. Not only is it true that all drugs have side effects, but the problem of antibiotic-resistant bacteria is large and getting worse, in part because of over-prescribing of antibiotics.

Over-prescribing occurs in part because physicians are urged by their patients, subtly or overtly, to "do something," after they have gone to the trouble of making an appointment and seeing a doctor. The key point about the option of not medicating is for parents to understand the need for quick follow-up if symptoms do not improve within a few days.

There would likely be far less emergence of antibiotic-resistant organisms from over-prescribing of antibiotics if parents, in particular, were willing to tolerate several days of a child’s mild and usually self-limited ear infection, with the proviso to return to the doctor soon if the child doesn’t improve or worsens.

What are the possible complications of acute otitis media?

Occasionally RAOM leads to outpatient surgical intervention (tympanostomy or "pressure-equalization" tubes placed thru a small incision in the eardrum — a myringotomy). Rarely, AOM can cause serious complications such as meningitis (infection of the coverings of the brain) and related problems, when the infection extends beyond the ear itself.

What You Can Do

Parents, in consultation with their doctor, should consider waiting before giving their child an antibiotic for an uncomplicated ear infection.

In 2004, three U.S. physician specialty groups — the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) established the current treatment guidelines for treating AOM. These guidelines provide the option of no antibiotic treatment for uncomplicated, painless AOM, if the patient has no other medical problems and follow-up assessment by a doctor is available.

As noted in recent clinical guidelines published by the UK’s National Institute for Health and Clinical Excellence (NICE), patients not receiving antibiotics should be offered "a clinical review if the condition worsens or becomes prolonged." In other words, if the child isn’t getting better after several days, or is getting worse, see the doctor again!

If antibiotic treatment is started the guidelines recommend starting with the generically available antibiotic amoxicillin (AMOXIL), at a dose of 80-90 milligrams per kilogram per day (this would amount to 800-900 milligrams for a 22-pound infant).