Title: Otitis Media or Middle Ear Infection - Current Standard of Care and Recommendations
Category: Child Care
Otitis media, or middle ear infections, peaks between six and twelve months of age. There is good evidence that breast feeding greater than 3 months decreases the incidence of otitis media for the entire first year. Males tend to have ear infections more than females. If older brothers and sisters had ear infections, then the infant is more likely to have ear infections. Early occurrence of middle ear infections, such as in the first 3 to 6 months is a bad prognostic sign and usually indicates a propensity to have recurrent ear infections - but not always. Day care exposure is also a major cause of the large number of ear infections see by all pediatricians and family doctors today. Children in day care age group frequently have upper respiratory viral infections and this leads to secondary ear infections. Since the children are in a closed space and closely exposed to other small children, they are susceptible to catching every virus, cold or sinus infection which comes into the day care.
There are several bacteria which cause the majority of middle ear infections. The three most common being pneumococcus, Hemophilus influenza, and rominella cataralis. These, in most cases, are responsive to the standard first line antibiotic, Amoxicillin. In some areas of the country, however, there is a high percentage of resistant strains to the betalactimase in the Amoxicillin. In these cases a greater than 10 % failure rate may occur and the doctor may choose a secondary antibiotic. Secondary antibiotics may include Augmentin, Ceclor, Suprax, Ceftin, Pediazole, and Trimethaprin sulfa (Septra or Bactrim).
Treatment with antihistamines and decongestants do not help to control, help or treat middle ear infections. They certainly may help a child feel better if there is a runny nose present or a lot of congestion present but studies show they do not help in any way to remove fluid from the middle ear or to prevent an infection from occurring. A child with many episodes of ear infections should be considered for a chemoprophylaxis. This means keeping the child on a low dose of continuous antibiotics through the high risk season such as through the winter or spring. The two antibiotics routinely used are Amoxicillin and sulphasostizole, or trade name Gantrisin. These are very effective and have been shown in numerous studies to be effective in most cases in preventing recurrent ear infections. It is considered safe to keep a child on a low dose of this, such as a 1/2 of normal therapeutic dose of either antibiotic, for up to six months in some cases. Other antibiotics have been used but these two are considered the safest and most well studied.
Another means of trying to prevent recurrent ear infections is immunoprophylaxis such as immunizing a child with a pneumonococcal vaccine and the H. Flu vaccine. This, in recent studies, has been shown to decrease the incidence of ear infections moderately (in other words about 40% decrease in recurrent ear infections) and is certainly worth trying in very high risk patients. Persistent fluid in the middle ear is the biggest concern to most pediatricians and young parents. Studies show that if the fluid is thick enough to obstruct the movement of the ear drum the child has difficulty hearing and may have a drop in ability to hear from 10 decibels to greater than 30 decibels. In the past, 10 to 15 decibels was considered mild and was not of too great a concern. New studies have shown that even this small a decibel hearing loss can effect a child's language development, perception of language and development of his language and ultimately of his scores in cognitive learning and performance in school at a later date.
As a means of trying to get the fluid out of the ears (other than the above mentioned methods), one way is to try pulsing the child with steroids such as Pediapred, along with antibiotic. This works in greater than 50% of children in some studies but is not always persistent and the fluid may recur. It is recommended that children who continue to have thick persistent fluid in the middle ear causing a definite decrease in their hearing ability over a period of time, usually greater than 3 months, have ear tubes. These are polyethylene tubes and sometimes stainless steel tubes and are placed in the ear by an ENT specialist in a surgical setting. Frequently the adenoids will be enlarged and it is definitely worthwhile to get the adenoids out at the same time as the tubes are placed. Studies show that this decreases the chance of having serious ear disease later after the tubes fall out, usually at one to two years.
There are numerous debates between pediatricians and ENT's on the pro's and con's of placing tubes or not placing tubes but ultimately the decision should be made with the pediatrician and ENT doctor and well informed parents. In children who truly need the tubes, it is probably smart to go ahead and have them placed prior to a period of poor hearing. In children who are borderline and who seem to be improving with conservative therapy, it is certainly reasonable to wait a few months and see in which direction the ear disease goes. Again, well informed parents and a good open relationship with the pediatrician and the ENT specialist is recommended.