New ear infection guidelines mean fewer prescriptions

Every few years, the American Academy of Pediatrics reviews its guidelines for the diagnosis and management of ear infections based on the evolving understanding of the risks and benefits of treatment, as well as the nuances of the clinical features that determine the diagnosis and the recommendations change.

I’m sure parents must think that ear infections are the easiest thing in the world for us to diagnose. As pediatricians, we look at literally 20-30 sets of ears every day and yet it can be difficult at times to decide if the ear drum we see that we know isn’t normal is abnormal in appearance due to infection or merely due to fluid from a cold or red due to crying or opaque due to previous infections. Sometimes making the diagnosis is simple. A bulging ear drum with pus behind it in a crying child with a fever, five days into an upper respiratory illness who is complaining of ear pain is a slam dunk. But more often, the symptoms are subtle and ear findings less dramatic. It takes clinical experience, a good history, and good exam skills to put together the whole picture and determine whether or not the abnormal ear drum we see is truly infected and even if it is infected, whether or not it warrants treatment. This challenging grey area is what the guidelines addressed with the goal of decreasing antibiotic use in those patients for whom the diagnosis is less certain.

In the past, the recommendation was to treat all ear infections with antibiotics. Ear infections were defined broadly and there was a large overlap between what is now understood to be non-infected fluid (otitis media with effusion) and acute otitis media, which is caused by bacteria. As a result a lot of kids received antibiotics who didn’t need them. A few years ago, the AAP revised the recommendations to both better describe how to diagnose an ear infection to exclude most of the children who had non-infected fluid and also recommended that if a child over age 2 years had only one ear infected, didn’t have severe pain or high fever that withholding antibiotics was an option. In that scenario, offering a prescription to the parent that could be filled if the symptoms worsened over the subsequent 2-4 days would allow for the 60 percent or so of children who could get over an ear infection on their own to do so without antibiotics. Either way, a follow up appointment to confirm resolution of infection was needed.

It turned out, though, that very few pediatricians actually implemented this guideline. I’m not sure why exactly; the families in our practice embraced it. But apparently teaching old dogs new tricks is tough, and few pediatricians shifted away from treating all ear infections with antibiotics.

With the latest guidelines being published in March, the AAP is going even a step further. The diagnostic criteria for ear infections requiring treatment are even stricter requiring a bulging ear drum with impaired movement, pus containing fluid behind the ear drum and evidence of significant distress or illness in the child. The new guidelines encourage the use of a tympanometer or a bulb attached to the otoscope that can deliver a puff of air to the ear canal to assess ear drum movement when the mobility of the ear drum is in question. With the new guidelines, if a child comes in for a well visit and we discover an ear infection but the child hasn’t had any symptoms, this wouldn’t demand treatment even in a very young child. In addition, the AAP has expanded the recommendation to withhold antibiotic treatment to children as young as 6 months who have only one ear infected and mild symptoms. These children should be offered a prescription as a backup and have close follow up. All children should have a reassessment to ensure resolution of the ear infection whether the antibiotic is used or not regardless of age.

The choice of antibiotic for first line treatment didn’t change with these guidelines. If the child hasn’t had an antibiotic in the last month and has no eye discharge or penicillin allergy, amoxicillin at high doses is first line. Amox-Clav (Augmentin) would be the choice if amoxicillin had been used in the last month or eye discharge is present. If penicillin allergy is present, the choice was left to the discretion of the provider.

By encouraging stricter guidelines for diagnosis and including fewer children in the possible treatment category, the AAP has done a good service to children and the providers who examine them. I am hoping that by reinforcing the withholding treatment approach and expanding it to children as young as 6 months, more pediatricians will see it as the new normal and begin to embrace it. It can be difficult at times to know when to treat when the ear drum is abnormal but not flagrantly so, but with these new guidelines, erring on the side of not treating makes more sense. Side effects, risk of allergic reaction, and antibiotic resistance are all real issues with antibiotic use and with good follow up and a rescue antibiotic prescription that can be used if things aren’t getting better, watching and waiting makes a lot of sense.