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Daily Dose

All About Ear Infections

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One of the most frequent reasons for a visit to the pediatrician continues to be ear infections (otitis). In fact, I think my otoscope (device used to look into the ear) is getting worn out!

Over the years there have been literally thousands of articles published on the diagnosis and treatment of ear infections.  Parents continue to ask, “how do I know if my child has an ear infection?” and the answer to that question has yet to change, the only way to diagnose otitis is by looking in the ear and visualizing the ear drum.

There is not a symptom, or a combination of symptoms that will lead to the diagnosis of an ear infection without looking at the ear drum itself. So, babies that pull on their ears, or awaken at night, or children with a fever and cough, or even those who say their ears hurt, do not always have an ear infection.

There are many days that a 2-4 year old child will have said, “my ear hurts” and are therefore brought to my office. When I visualize their ear drum it looks perfectly normal, so ear pain (otalgia) does not always mean infection. The pain may be due to pressure behind the ear drum, or referred pain from a sore throat, or tooth, or even just a passing feeling in the ear after putting their finger in their ear canal.   You have to look, and therefore the diagnosis may not be made over the phone (maybe one day there will be an App for visualizing the ear drum remotely?).

When the doctor looks down your child’s ear canal, they are looking for an ear drum that is either bulging, or red (if the child is not crying or does not have high fever as this may cause redness of the ear drum), or for fluid behind the ear drum (called an effusion). In most cases it is a combination of findings that one sees when looking at the ear drum. For a practicing pediatrician, visualizing an ear drum in a squirming, screaming, toddler who has waxy ears, is an art. Yes, ears can be full of wax and you don’t even realize it. (don’t use a Qtip it just makes it worse!)

Cleaning out a child’s ear is necessary and not always fun for the child or the doctor.  One of the hardest skills to learn in early pediatric training is how to look at an ear drum.  I remember it taking months and months of practice and instruction before really believing that I was getting better and better with the otoscope.

Many parents ask if they can look in their child’s ears at home with an otoscope that they bought on line?  “Sure”, I reply, if you want to spend a year in the ER looking in thousands of ears!! Just like I am sure I could learn how to “tune up my car” if I went and worked in a garage for months, or tried to learn to speak a language by immersion, the skill of using an otoscope is based upon repetition and practice. (like most things in life I guess). Parents tell me that there are even some “swanky” otoscopes that purportedly talk to you and tell you if the ear is infected, but none of these devices are accurate, you have to rely on the old fashioned otoscope and know what you are looking for.

So, ear pain and ear infections are not synonymous and the “gold standard” of visualizing the ear drum is the only accurate way to diagnose an ear infection.

Daily Dose

All About Ear Infections

Lots of ear infections going around. What every parent needs to know.One of the most frequent reasons for a visit to the pediatrician continues to be ear infections (otitis). In fact, I think my otoscope (device used to look into the ear) is getting worn out!

Over the years there have been literally thousands of articles published on the diagnosis and treatment of ear infections.  Parents continue to ask, “how do I know if my child has an ear infection?” and the answer to that question has yet to change, the only way to diagnose otitis is by looking in the ear and visualizing the ear drum. There is not a symptom, or a combination of symptoms that will lead to the diagnosis of an ear infection without looking at the ear drum itself. So, babies that pull on their ears, or awaken at night, or children with a fever and cough, or even those who say their ears hurt, do not always have an ear infection. There are many days that a 2-4 year old child will have said, “my ear hurts” and are therefore brought to my office. When I visualize their ear drum it looks perfectly normal, so ear pain (otalgia) does not always mean infection. The pain may be due to pressure behind the ear drum, or referred pain from a sore throat, or tooth, or even just a passing feeling in the ear after putting their finger in their ear canal.   You have to look, and therefore the diagnosis may not be made over the phone (maybe one day there will be an App for visualizing the ear drum remotely?). When the doctor looks down your child’s ear canal, they are looking for an ear drum that is either bulging, or red (if the child is not crying or does not have high fever as this may cause redness of the ear drum), or for fluid behind the ear drum (called an effusion). In most cases it is a combination of findings that one sees when looking at the ear drum. For a practicing pediatrician, visualizing an ear drum in a squirming, screaming, toddler who has waxy ears, is an art. Yes, ears can be full of wax and you don’t even realize it. (don’t use a Qtip it just makes it worse!) Cleaning out a child’s ear is necessary and not always fun for the child or the doctor.  One of the hardest skills to learn in early pediatric training is how to look at an ear drum.  I remember it taking months and months of practice and instruction before really believing that I was getting better and better with the otoscope. Many parents ask if they can look in their child’s ears at home with an otoscope that they bought on line?  “Sure”, I reply, if you want to spend a year in the ER looking in thousands of ears!! Just like I am sure I could learn how to “tune up my car” if I went and worked in a garage for months, or tried to learn to speak a language by immersion, the skill of using an otoscope is based upon repetition and practice. (like most things in life I guess). Parents tell me that there are even some “swanky” otoscopes that purportedly talk to you and tell you if the ear is infected, but none of these devices are accurate, you have to rely on the old fashioned otoscope and know what you are looking for. So, ear pain and ear infections are not synonymous and the “gold standard” of visualizing the ear drum is the only accurate way to diagnose an ear infection. Check out Friday’s Daily Dose: to treat or not to treat? That's your daily dose for today. We'll chat again tomorrow.

Daily Dose

Vaccine Offers More Coverage Against Pneumococcal Disease

New Prevnar vaccine offers more coverage against pneumococcal diseaseThe FDA recently approved Prevnar 13 (PCV13) which is a “broader” spectrum vaccine than the currently used Prevnar 7 (PCV7).  Prevnar is a vaccine that is routinely administered at 2, 4, 6 and 12-15 months of age.

PCV7 was first approved in the U.S. in 2000 for the prevention of pneumococcal meningitis, pneumonia, and bacterial blood infections. The Prevnar 7 vaccine covered 7 different serotypes (strains) of S. pneumonia, a bacteria that also often causes otitis media (ear infections) in children. Since the introduction of PCV7 there has been a dramatic decrease in the number of invasive pneumococcal diseases seen in children,  as well as a reduction in the incidence of ear infections caused by the S. pneumonia bacteria that are due to serotypes in the vaccine. The new PCV13 now covers an additional 6 serotypes of the bacteria which should provide even more coverage and protection against pneumococcal disease, and therefore even better protection for young children.  For many parents this will be a “non” event as the doses of PCV7 that had been used until March  are now being returned to the drug company and are being routinely replaced with PCV13 . PCV13 will ultimately replace PCV7 in the routine immunization schedule throughout the country.  The side effect profile is no different for the vaccines. The new recommendations for PCV13 are important for those that have children who are between 12 – 15 months of age, and who have finished the 4 dose PCV7 series.  For those children, it is now recommended that those over 15 months and up to 6 years of age, receive a 5th dose of Prevnar, but with the newer PCV13. This will provide some immunity to the 6 additional serotypes in the newer vaccine and give these young children broader protection against invasive pneumococcal disease. So the next time you see your pediatrician and you have a child over the age of 1 but under the age of 6, ask your doctor about getting a 5th dose of Prevnar, with PCV13.   I f you have an infant, I would ask your pediatrician’s office if they have started using PCV13 for routine vaccination.  The continued science involved in developing better and more protective vaccines is one more step toward preventing serious childhood illnesses. That's your daily dose.  We'll chat again tomorrow. Send your question to Dr. Sue right now!

Daily Dose

Ear Infections: Take A Look Inside

Ear infection: make sure your doctor takes a lookMore coughs and colds today in the office and a lot of emails with questions about ears infections.

There is really not a way to diagnose an ear infection without your doctor looking in your child’s ears. With that being said, once your child reaches about the age of 9 -12 months, and they have had several colds, you get an idea if your child seems to be ‘otitis prone’. In other words, do they get an ear infection with each cold or runny nose, or have you taken them in to the doctor and they always have clear ears. Despite what ‘many mothers say’ not everyone gets an ear infection with a cold, and in fact, most children don’t.  Parents also want to ‘prevent’ an ear infection and studies continue to show that antihistamines and/or decongestants do not seem to have a role in preventing the development of an ear infection or in the treatment of otitis.  Antihistamines and decongestants also have side effects and are not recommended to use in children younger than 5-7 years. Once your child is older and they may now be able to tell you that their ear hurts (typically 2 and older), they still need to have their ears looked at. Ear pain (otalgia) is not always due to an infection of the middle ear.  There are many times that a child (or adult) will complain about their ears hurting, but they may have referred pain from a sore throat, or they may have fluid behind the ear drum (serous otitis) and feel as if their ears are full, but they are not infected.  I also see teens who complain of ear pain and may be grinding their teeth. All ears that HURT are NOT due to an infection. A new approach to treating ear infections in a child over 2, who is not ‘otitis prone’ and does not appear to be terribly sick is to treat the painful ear with pain relieving ear drops and oral Tylenol or Motrin.  This is termed “watchful waiting”. There have been several studies, in older children, to compare immediate versus delayed antibiotic treatment.  The studies to date have shown little difference in symptoms by watchful waiting and may indeed limit unnecessary antibiotics.  There is still the need for further research in this area, but I  must say, I have used this approach in a lot of children. I will write the antibiotic prescription as well as a pain relieving ear drop and instruct a parent to wait a few days before filling the antibiotic. If their child is improving they will not need to even take an antibiotic. I really have had a lot of success with this approach, but only in older children, who do not seem to be very ill.  More to come on this issue. One last point, I do not recommend that parent’s buy an otoscope to try and diagnose an ear infection at home.  Looking in ears (otoscopy) is one of the hardest things to learn during residency. It takes thousands of ears to be seen to become really proficient in examining an ear drum. It really is practice, practice, just like many other professions. If you really think that your child’s ears are infected, you must let your pediatrician take a look. Surely we will have a better method someday?? That’s your daily dose. We’ll chat again soon.

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