Do I Need to Give Antibiotics for my Child’s Ear Infection?

Many parents of young children have experienced first hand the frustrating ineffectiveness of antibiotics and growing power of infections when trying to address the ubiquitous childhood ear infection. Ear infections occur when bacteria or viruses get into the small air pocket behind the eardrum (middle ear) and cause an infection which leads to a buildup of pus accompanied by pain, fever, and possibly drainage of pus from the ear. There is a small tube called the Eustachian tube which connects the middle ear to the throat and which lets air move in and out of the middle ear; in children less than 3 the Eustachian tube is very small and less able to keep bacteria out. That is why small children are particularly susceptible to ear infections.

When my teenage daughter was still in her single-digits, she repeatedly got ear infections. The pain in the ear led to crying (who could blame her?), and we would take her to the pediatrician, who would dutifully write a prescription for an antibiotic like amoxicillin. After treatment, her symptoms would go away and she’d feel fine for a few weeks. Then, the pain and infection would come back and the whole cycle would begin again. The repeated doctor visits and treatments were expensive, time consuming and inconvenient. The antibiotics also killed the normal bacteria in her ear, and selected the worst bacteria that were even harder to treat the next time. We repeated this useless cycle for several years, but my daughter actually just grew out of getting ear infections.

For years doctors in Holland have been using the “wait and see” approach with much success. It turns out that antibiotics have minimal impact on ear infections, and that, unless a child is toxic (very visibly ill and unresponsive), that simple ear infections are best treated with ibuprofen, a local pain killer for the ear, and otherwise left alone. If the child does not show improvement after three days, then it is time to go to the doctor. In years of treating children this way there have been no adverse outcomes. I wish they followed the wait and see approach when my daughter was a child.

Children treated with antibiotics for ear infections have a three-fold increase in re-infection. This is related to the fact that normal bacteria in the ear are killed off by antibiotics, creating an environment where pathogenic bacteria can grab a foothold. In spite of the fact that guidelines state not to treat some types of ear infections with antibiotics, many doctors do it anyway. A type of ear infection where there is fluid discharge from the ear, without evidence of acute infection (bulging ear drum, extreme pain, high fever) is often treated with antibiotics, although it increases the risk of re-infection.

What is the worst thing that could happen if your child got an ear infection? Well, the infection could possibly spread to her brain, causing meningitis (which can be fatal, or cause brain damage). It could cause hearing loss, or infection of the mastoid sinus. However none of these things have happened where treatment was delayed for no more than three days. In other words, if you adopt the wait and see approach, and wait until three days are up (assuming your child does not look like she is about to die or in other ways looks really sick, such as extremely high fever or repetitive vomiting) you will be fine. Just give her pain medications like Tylenol, or if you have them local medications to reduce ear pain.

Research studies bear out the advantages of the wait and see approach. One study of 240 children age 6 months to 2 years showed that treatment with amoxicillin compared to placebo reduced duration of fever from 3 to 2 days and symptoms at day 4 by 13%, with no difference in pain on ear examination. The authors concluded that “this modest effect does not justify prescription of antibiotics at the first visit, provided close surveillance can be guaranteed.” (3)

Another study of 315 children age 6 months to 10 years showed that unless there was high fever, more than 37.5 C, or vomiting, the antibiotics had no effect on pain. And they did not help the children sleep through the night – even three days after the start of the treatment (1). A meta analysis of all studies showed that 60% of children treated with a placebo have no pain after 24 hours. Early use of antibiotics reduced pain by 41% compared to placebo at 2-7 days. Antibiotics doubled the risk of vomiting, diarrhea, or rash. Seventeen children had to be treated to reduce pain in one child. Based on these studies I recommend waiting two days before treatment unless the child has high fever, is vomiting, or is in a lot of pain.

Talk to your doctor about waiting for three days and using local pain relief during your child’s next ear infection unless your child looks toxic, is vomiting, or has very high fever.

1. Little, P., Gould, C., Moore, M., Warner, G., Dunleavey, J., Williamson, I. Predictors of poor outcome and benefit from antibiotics in children with acute otitis media: Pragmatic randomised trial. British Medical Journal. July 6, 2002 2002;325(7354):22.

2. Little, P., Gould, C., Williamson, I., Moore, M., Warner, G., Dunleavey, J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. British Medical Journal. February 10, 2001 2001;322:336-342.

3. Damoiseaux, R.A.M.J., van Balen, F.A.M., Hoes, A.W., Verheij, T.J.M., de Melker, R.A. Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years. British Medical Journal. February 5, 2000 2000;320(7231):350-354.

4. Spiro, D.M., Tay, K.Y., Arnold, D.H., Dziura, J.D., Baker, M.D., Shapiro, E.D. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. Journal of the American Medical Association. Sep 13 2006;296(10):1235-1241.

Reposting of an article published here that was based on my book.