Easing the Agony of Childhood Earaches
A New Study Questions the Use of Antibiotics
by Steven Findlay
About 70 percent of American children suffer through at least one earache by age 3. And a unlucky 10 percent of those kids go through endless rounds of earaches until the kindergarten years. Yet doctors still can't agree on the best way to handle the common earache, or otitis media. antibiotics are the pediatricians' usual choice, but the evidence that the drugs actually work has never been strong; for one thing, not all earaches are triggered by infections. Many experts also worry that indiscriminate use of antibiotics is spawning strains of resistant bacteria. Now a new study has cast the most serious doubt to date on antibiotics - and made life tougher for parents.
The study, published last month in the Journal of the American Medical Association, took a fresh look at data first presented in 1987. The original analysis, based on518 children at the Children's Hospital of Pittsburgh, concluded that kids who had prolonged bouts of otitis and took amoxicillin, a common prescription antibiotic, were twice as likely to be cured as kids who took sugar pills. Pediatricians seemed to have the proof they had long wanted; antibiotic sales soared. But last month's study, - conducted by the researchers who were part of the original Children's Hospital team - argues that the team failed to test the children's hearing and used insufficiently accurate methods to measure how well the children's ears had healed. The new study reached a far different conclusion: Children who take antibiotics fare no better than children who take placebos. In fact, kids on antibiotics were more prone to earache recurrences than those who took nothing at all.
The authors of the 1987 study stand by their conclusion, leaving both doctors and parents of earache-prone kids groping for clearer direction. No one argues that antibiotics will or should be abandoned, but pediatricians will be likely to use them ore judiciously.
Eroding faith in antibiotics also could lead parents and doctors to turn more often to two forms of surgery commonly used to treat otitis. Up to 1 million children a year undergo myringotomies, in which a tiny tube is inserted through the eardrum to drain excess fluid, or adenoidectomies, - removal of the adenoid glands at the back of the nose. The glands can become enlarged and exacerbate otitis by blocking the Eustachian tubes, which connect the nose and the middle ear. While both procedures work, they carry risks including, in myringotomy, accidental perforation of the eardrum in about 1 percent of kids.
The conflicting medical opinions and studies make it hard for parents to decide whether to begin antibiotic treatment, head for surgery or hope the earache will go away on its own. But some general guidelines have emerged:
No drugs - at first
Children with colds or the flu who have clogged or inflamed, fluid-filled ears - but who aren't experiencing lingering fever, ear pain or hearing loss - don't need an antibiotic right away, says John Bolton, a San Francisco pediatrician and frequent lecturer on otitis. He urges parents to see a doctor but to wait at least four weeks for the problem to clear up on its own before resorting to antibiotics. In 30 to 40 percent of kids, it probably will.
Symptoms, especially pain and haring loss, often indicate that infection has set in and suggest a 10-day course of antibiotics, whether the earache is the child's first or not. An antibiotic is also worth trying in children whose hearing has worsened four to six weeks after an initial bout of otitis - even if the child hasn't experienced significant pain or fever. Pediatricians usually prescribe mild antibiotics like amoxicillin or ampicillin first. But they may quickly resort to stronger medication, such as clavulante, erythromycin or cefaclor, if the first prescription fails. That is increasingly the case these days, as bacteria resistant to amoxicillin have spread. Some pediatricians may prescribe more powerful drugs initially. But they often cause diarrhea and stomach upset and cost $30 to $50, as opposed to $10 or so for a 10-day course of amoxicillan.
The Surgery Option
Most doctors agree that a child with an earache that has hung on for six weeks or more after two courses of antibiotics is a candidate for surgery. So are kids who have one or more bouts of otitis a month over three to six months. Robert Ruben, chief of otolaryngology at New York's Alvert Einstein College of Medicine, decries the practice of giving kids low "maintenance" doses of antibiotics to prevent recurrences. "When the antibiotics fail to work, they fail," he says. "It's a waste of time to put kids on them for months at a time."
The decision to insert tubes or remove adenoids, the experts say, needs to factor in age as well. otitis-prone kids ages 1 to 6 who attend day care or school, for example, are at much higher risk of exposure to the respiratory infections that can trigger earaches and may benefit from tubes. A toddler of 1 to 2 could experience a delay in language development due to an otitis-induced hearing loss, and would also be a candidate for tubes.
Nature usually intervenes when kids reach age 5 or 6 and maturing ear canals become less prone to inflammation. Most kids stop getting earaches after about the age of 8 - just in time for tonsillitis and other illnesses of prepubescent to worry parents anew.
Reprinted with permission.
US News and World Report, January 27, 1992.
The Growing Problem of Antibiotics - Pure Facts 1995