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Daily Dose

Ear Infections

1:30 to read

Musings from the very busy pediatric office:  with all of the advances in technology over the last 30 years why is it that examining a child’s ears and visualizing their eardrum continues to be challenging?  I started thinking about this while examining a very unhappy, strong and febrile toddler….probably the 20th patient of the day. 

 

During the “sick season” many of the patients who come to my office are young children whose parents are worried that they may have an ear infection.  This concern is one of the most frequent reasons for pediatric office visits. While I realize that many of my colleagues are in the operating room operating on brains or doing open heart surgery (truly saving lives) the one advantage that they have is that their patient is under anesthesia while they are doing complicated procedures. Which only means that they are not trying to wrestle, cajole, or coax a child into letting them look into their ear canal, and then only to find that you can’t see a thing as the canal is full of wax (cerumen).  

 

At times examining ears can be fairly simple and straight forward, but some days it seems that it may be easier to attempt to fly than to look at a 16 month old child’s ears. Today was one of those days. It seemed that every child I saw had a temperature over 102 degrees, and they all had “waxy” ears. While there are several ways to remove wax from the ear canal, none of them is easily done in a toddler, especially when the wax is hard and difficult to remove. Having 3 children myself and one who had recurrent ear infections and tympanostomy tubes, I know what it is like to have to hold your child on the pediatrician’s exam table while they irrigate or “dig” wax out of the ears.  Not fun….!!!  But, at the same time I realize that this is the only means to see if the ear is infected and if there is the need for an antibiotic. 

 

With the advent of the HIB and Pneumococcal vaccines the incidence of ear infections has dropped significantly, as these bacteria were common causes of otitis. But, ear infections are still the #1 reason that a child receives an antibiotic, especially in the first 2 years of life.  Therefore, a good ear exam is one of the most important things your pediatrician does, as I know you don’t want your child to receive an unnecessary antibiotic!

 

Please know that pediatricians do not enjoy making a child uncomfortable, but somehow that ear drum needs to be seen…especially in a sick child.   

 

So…why has some brilliant medical device inventor not found a way to wave a magic wand over a child’s ear to “tell me” if their ear is infected?  To date, I have not seen any “new” ways to accurately examine an ear other than with the otoscope…and a clean ear canal…which means unhappy children (and parents ) while I try to clean their ears.  

 

Remember, don’t use q-tips in your child’s ears and if your pediatrician has to struggle a bit to clean out  your child’s ears, it is only because they are doing a good job!!  I am waiting for the “easy” button.

   

Daily Dose

Treating Ear Infections

Plenty if ear infections going around, so what's the best treatment?It has been very busy in my office with plenty of ear infections going around.  Once you have taken your child to the pediatrician and they have indeed been diagnosed with an ear infection (otitis), what’s next?

Like many things in medicine there is not one right answer to that question and there continues to be a debate on the treatment of ear infections.  The many articles that have been published in past years have looked at the prevalence of certain bacteria in causing ear infections, the role of viruses as a cause of ear infections and even when and if to treat an ear infection. The articles did not seem to have a clear consensus.  You may have noticed that too if you have seen different doctors who have different opinions about otitis treatment. Now, two recent articles in the New England Journal of Medicine (Jan. 2011) once again looked at antibiotic use for the treatment of ear infections.  In two double blind, placebo controlled, randomized trials (the gold standard for studies) researchers defined otitis as the “acute onset and presence of middle-ear effusion (fluid), bulging tympanic membrane (ear drum), erythema (redness) and pain. The studies were done in Europe and the United States, and looked at whether children between 6 months and 35 months of age improved more quickly if they received an antibiotic rather than a placebo (no antibiotic). This debate had been ongoing, and both of these studies showed that the children who received antibiotics had symptom resolution more quickly than those who were given placebo.  The study also showed that those who received antibiotics were more likely to develop diarrhea. (bummer, hate those side effects!) Given these recent studies I think that the consensus would be that young children with documented ear infections should receive a course of antibiotics. That would typically mean children 2 and under. But, these studies did not look at the practice of what is called “watchful waiting” which has been advocated for older children. When a child over the age of two complains of ear pain, and is then examined and found to have an ear infection it may not always be necessary to prescribe an antibiotic. If the child is old enough to easily evaluate and does not appear ill it may be appropriate to be conservative about antibiotic use, and to provide pain relief with topical ear drops and oral pain relievers such as acetaminophen or ibuprofen. In many cases in an older child, the pain and infection will resolve over several days and an antibiotic will not be necessary. I often write a prescription for a parent to use if their child seems to become more uncomfortable, or the pain persists. In most cases these prescriptions have not been used. Doctors should take into account the history of previous ear infections, parental concerns as well as concerns about excessive use of antibiotics. “Watchful waiting” requires educating parents and having a discussion as to the pros and cons of antibiotic use. Each case may be a little different. Ear infections are still one of the most common reasons a child receives an antibiotic. These two articles now help clear up the debate about antibiotic use in younger children. “Watchful waiting” may still be appropriate for an older child with a simple ear infection. That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Oh, The Things That Get Stuck In Your Ear!

The adage "never put anything smaller than your elbow" rang true today in my office during a patient visit. But this time it was a patient's mom! I could not wait to get home from work today to write about my afternoon. Even as a pediatrician, I sometimes get “coaxed” into seeing an adult patient, usually the parent of one of my patients.

So, I got a phone call, an email and a text (how many ways can you find your doctor?) from an anxious adult.  This mother had been cleaning her own ears with a Q-tip and the tip of the swab had come off in her ear!!  She was “freaking out” and wondered if I might be able to look in her ear and get the swab tip out? After calling her back and chastising her for using a Q-tip, I told her to come in and we would attempt to get the cotton out of her ear. It wasn’t supposed to be a “big deal”. When she came in I looked in both her ears, they were the cleanest ears you could imagine. She told me she loved to use a Q-tip in her ears after a shower, even though she had been “told” not to use Q-tips in her own children’s ears, the old adage, “nothing smaller than an elbow should go in the ear”. At any rate, the entire tip of a cotton swab was lodged in her ear canal. Now it seems like it would be easy to get that big piece of cotton out of her ear canal, right? I mean I have taken beans, rocks, raisins, puzzle pieces, bugs and many other foreign objects out of ears…honest! This was an adult, who wasn’t squirming or crying, with a piece of cotton stuck and I thought this should be a piece of cake.  Well, I have to tell you, that very large piece of cotton Q-tip was as far back in the ear canal as you can get and it didn’t want to budge!! It can be quite uncomfortable to remove a foreign body from an ear, especially when it is deep in the canal and also touches the entire ear canal.  She had brought along her 5 year old daughter, who ended up serving as her hand holder and emotional support (role reversal).  After much to do, I could get the cotton moved up closer to the opening of the canal, but could not get it out. By now it was soggy and looked like a huge cumulus cloud in the previously very clean ear. So, I decided to abort the mission, and we would regroup the next day and decide if we might need the help of a friendly ENT. The best part of the story is listening to her daughter who kept telling her things like “ I can’t wait to tell all of my friends” or “didn’t the doctor tell us not to put stuff in our ears?”  Out of the mouth of babes has never been more true. The good news is that she saw the ENT today and she said the cotton just “slipped right out” after my mini surgery. I guess what I need to do is keep my practice limited to children, these adults are harder than you think!? Any crazy thing stuck in you or your child’s ear? Leave your story below and we’ll all laugh together! We’ll talk again tomorrow!

Daily Dose

Oh, The Things That Get Stuck In Your Ear!

The adage "never put anything smaller than your elbow" rang true today in my office during a patient visit. But this time it was a patient's mom! I could not wait to get home from work today to write about my afternoon. Even as a pediatrician, I sometimes get “coaxed” into seeing an adult patient, usually the parent of one of my patients.

So, I got a phone call, an email and a text (how many ways can you find your doctor?) from an anxious adult.  This mother had been cleaning her own ears with a Q-tip and the tip of the swab had come off in her ear!!  She was “freaking out” and wondered if I might be able to look in her ear and get the swab tip out? After calling her back and chastising her for using a Q-tip, I told her to come in and we would attempt to get the cotton out of her ear. It wasn’t supposed to be a “big deal”. When she came in I looked in both her ears, they were the cleanest ears you could imagine. She told me she loved to use a Q-tip in her ears after a shower, even though she had been “told” not to use Q-tips in her own children’s ears, the old adage, “nothing smaller than an elbow should go in the ear”. At any rate, the entire tip of a cotton swab was lodged in her ear canal. Now it seems like it would be easy to get that big piece of cotton out of her ear canal, right? I mean I have taken beans, rocks, raisins, puzzle pieces, bugs and many other foreign objects out of ears…honest! This was an adult, who wasn’t squirming or crying, with a piece of cotton stuck and I thought this should be a piece of cake.  Well, I have to tell you, that very large piece of cotton Q-tip was as far back in the ear canal as you can get and it didn’t want to budge!! It can be quite uncomfortable to remove a foreign body from an ear, especially when it is deep in the canal and also touches the entire ear canal.  She had brought along her 5 year old daughter, who ended up serving as her hand holder and emotional support (role reversal).  After much to do, I could get the cotton moved up closer to the opening of the canal, but could not get it out. By now it was soggy and looked like a huge cumulus cloud in the previously very clean ear. So, I decided to abort the mission, and we would regroup the next day and decide if we might need the help of a friendly ENT. The best part of the story is listening to her daughter who kept telling her things like “ I can’t wait to tell all of my friends” or “didn’t the doctor tell us not to put stuff in our ears?”  Out of the mouth of babes has never been more true. The good news is that she saw the ENT today and she said the cotton just “slipped right out” after my mini surgery. I guess what I need to do is keep my practice limited to children, these adults are harder than you think!? Any crazy thing stuck in you or your child’s ear? Leave your story below and we’ll all laugh together! We’ll talk again tomorrow!

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Ear Infection Treatment

Best Treatment for Ear Infections

Daily Dose

Recurrent Ear Infections

1:30 to read

It is winter and fortunately while there is not much flu to date, there are certainly colds and coughs throughout the country.  It seems that every child I see has a runny nose.  Remember, a toddler will get anywhere from 5-10 colds a year for a couple of years as they start to have playmates and pass those pesky viral upper respiratory infections back and forth.  But for some young children, (especially those in daycare) those frequent colds may lead to recurrent ear infections (otitis).

Otitis media is an infection of the middle ear. In children,  an ear infection typically follows a common cold, which may be caused by a plethora of viral illnesses. It seems that the virus changes how the middle ear “functions” lots of complicated science about cilia, and mucous and eustachian tube function) which then leads to secondary bacterial infection and an acute ear infection.  It typically takes a few days to weeks of a cold, before developing an ear infection. I tell my patients, “you don’t usually see an ear infection in a young child on day 1 or 2 of a cold”.  If everything else seems okay, you might want to watch your child for a few days before having their ears checked.

The guidelines for treating acute otitis media (AOM) changed several years ago after studies showed that not all ear infections were caused by bacteria, especially in older children, and that with “watchful waiting” many ear infections would improve on their own.  So, for children between the ages of 6-23 months of age with bilateral or unilateral ear infections and signs and symptoms of pain (tugging on the ear, rubbing the ear, irritability and sleep interruption) and fever the recommendation is to treat the infection with antibiotics.  The recommendations get a bit trickier for children who do not have bilateral infections and who are considered to have “non-severe” AOM, in which case the doctor and parent may discuss the pros and cons of antibiotic therapy and in some cases may decide to defer the use of antibiotics for 48-72 hours and observe the child for worsening of symptoms or failure to improve at which time an antibiotic may be started.  “Watchful waiting” has helped to decrease the number of antibiotics prescribed for children.

For the younger children 6-23 months who are more likely to be “sicker” than an older child with AOM, the first line antibiotic to be prescribed is still Amoxicillin (unless the child is known to be penicillin allergic). Amoxicillin is the gold standard, “pink medicine” that many parents remember from their childhood…..tastes like bubble gum and needs to be refrigerated.  For children who have had recurrent ear infections other antibiotics know as “second line” drugs may be used.  Again, there are pros and cons to many antibiotics as well in terms of taste, how often they need to be given and side effects….so discuss this with your own pediatrician. 

For children 2 and older I am a big believer in “watchful waiting” and pain control.  So many of these children will do well with over the counter acetaminophen and ibuprofen as well as topical ear drops for analgesia.  I would guess that in my practice (not a valid scientific study) about 80% of my older patients do not fill a prescription for antibiotics….which as you know is a good thing (no one wants to be on an unnecessary antibiotic).

Unfortunately, there seems to be a “group” of children (typically the younger ones) who get recurrent AOM and spend many of their winter months in the pediatricians office.  More about those infections in another post.  

Daily Dose

More on Ear Infections

1:30 to read

It is winter and fortunately while there is not much flu to date, there are certainly colds and coughs throughout the country.  It seems that every child I see has a runny nose.  Remember, a toddler will get anywhere from 5-10 colds a year for a couple of years as they start to have playmates and pass those pesky viral upper respiratory infections back and forth.  But for some young children, (especially those in daycare) those frequent colds may lead to recurrent ear infections (otitis).

Otitis media is an infection of the middle ear. In children, an ear infection typically follows a common cold, which may be caused by a plethora of viral illnesses. It seems that the virus changes how the middle ear “functions” (lots of complicated science about cilia, and mucous and eustachian tube function) which then leads to secondary bacterial infection and an acute ear infection.  It typically takes a few days to weeks of a cold, before developing an ear infection. I tell my patients, “you don’t usually see an ear infection in a young child on day 1 or 2 of a cold”.  If everything else seems okay, you might want to watch your child for a few days before having their ears checked.

The guidelines for treating acute otitis media (AOM) changed several years ago after studies showed that not all ear infections were caused by bacteria, especially in older children, and that with “watchful waiting” many ear infections would improve on their own.  So, for children between the ages of 6 -23 months of age with bilateral or unilateral ear infections and signs and symptoms of pain (tugging on the ear, rubbing the ear, irritability and sleep interruption) and fever the recommendation is to treat the infection with antibiotics.  The recommendations get a bit trickier for children who do not have bilateral infections and who are considered to have “non-severe” AOM, in which case the doctor and parent may discuss the pros and cons of antibiotic therapy and in some cases may decide to defer the use of antibiotics for 48-72 hours and observe the child for worsening of symptoms or failure to improve at which time an antibiotic may be started.  “Watchful waiting” has helped to decrease the number of antibiotics prescribed for children.

For the younger children 6 - 23 months who are more likely to be “sicker” than an older child with AOM,  the first line antibiotic to be prescribed is still Amoxicillin (unless the child is known to be penicillin allergic). Amoxicillin is the gold standard , “pink medicine” that many parents remember from their childhood…..tastes like bubble gum and needs to be refrigerated.  For children who have had recurrent ear infections other antibiotics know as “second line” drugs may be used.  Again, there are pros and cons to many antibiotics as well in terms of taste, how often they need to be given and side effects….so discuss this with your own pediatrician.   

For children 2 and older I am a big believer in “watchful waiting” and pain control.  So many of these children will do well with over the counter acetaminophen and ibuprofen as well as topical ear drops for analgesia.  I would guess that in my practice (not a valid scientific study) about 80% of my older patients do not fill a prescription for antibiotics….which as you know is a good thing (no one wants to be on an unnecessary antibiotic).  

Unfortunately, there seems to be a “group” of children (typically the younger ones) who get recurrent AOM and spend many of their winter months in the pediatricians office.  More about those infections in another post.

Your Baby

Infant Ear Infections Declining

2:00

Ear infections in infants are very common and can be quite unsettling for parents. The good news is that ear infections among U.S. babies are declining according to a new study.

Researchers found that 46 percent of babies followed between 2008 and 2014 had a middle ear infection by the time they were 1 year old. While that percentage may seem high, it was lower when compared against U.S. studies from the 1980s and '90s, the researchers added. Back then, around 60 percent of babies had suffered an ear infection by their first birthday, the study authors said.

The decline is not surprising, according to lead researcher Dr. Tasnee Chonmaitree, a professor of pediatrics at the University of Texas Medical Branch, in Galveston.

"This is what we anticipated," she said.

That's in large part because of a vaccine that's been available in recent years: the pneumococcal conjugate vaccine, Chonmaitree said. The pneumococcal conjugate vaccine protects against several strains of pneumococcal bacteria, which can cause serious diseases like pneumonia, meningitis and bloodstream infections.

Those bacteria are also one of the major causes of children's middle ear infections, Chonmaitree said.

She added that flu shots, which are now recommended for children starting at 6 months, could be helping as well. Many times an ear infection will follow a viral infection such as the flu or a cold.

Vaccinations "could very well be one of the drivers" behind the decline in infant ear infections, agreed Dr. Joseph Bernstein, a pediatric otolaryngologist who wasn't involved in the study.

Other factors could be having a positive impact as well, such as rising rates of breast-feeding and a decrease in babies’ exposure to secondhand smoke.

"The data really do suggest that breast-feeding -- particularly exclusive breast-feeding in the first six months of life -- helps lower the risk of ear infections," said Bernstein, who is director of pediatric otolaryngology at the New York Eye and Ear Infirmary of Mount Sinai, in New York City.

There's also the fact that breast-fed babies are less likely to spend time drinking from a bottle while lying down, Bernstein noted. That position can make some infants more vulnerable to ear infections, he said.

The study findings were based on 367 babies followed during their first year of life. By the age of 3 months, 6 percent had been diagnosed with a middle ear infection; by the age of 12 months, that had risen 46 percent, researchers found.

Breast-fed babies had a lower ear infection risk, however. Those who'd been exclusively breast-fed for at least three months were 60 percent less likely to develop an ear infection in their first six months, the study showed.

But whether babies are breast-fed or not, they will benefit from routine vaccinations, Chonmaitree said. "Parents should make sure they're on schedule with the recommended vaccines," she said.

Parents can have a difficult time recognizing an ear infection in an infant or a child to young to tell them that their ear hurts.

Some symptoms to watch for are:

·      Tugging at the ear

·      Fever

·      Crying more than usual

·      Irritability

·      Child becomes more upset when lying down

·      Difficulty sleeping

·      Diminished appetite

·      Vomiting

·      Diarrhea

·      Pus or fluid draining from ear

Treatment for ear infections rarely requires medication, such as antibiotics, except when an infection is severe or in infants. 

According to the American Academy of Pediatrics (AAP), most children with middle ear infections get better without antibiotics, and doctors often recommend pain relievers -- like acetaminophen -- to start. But with babies, Bernstein said, antibiotics are often used right away.

The AAP recommends antibiotics for infants who are 6 months old or younger, and for older babies and toddlers who have moderate to severe ear pain.

The study was published online in the March edition of the journal Pediatrics.

Story source: Amy Norton, http://www.webmd.com/children/news/20160328/infant-ear-infections-becoming-less-common

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Can q-tips harm your baby's ear?

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