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March 3, 2014

An ear infection, but no prescription

Q: I recently took my 18 month-old grandson to the doctor. They diagnosed him with an ear infection but said that he likely did not need antibiotics. Why didn’t he get antibiotics?

Q: I recently took my 18-month-old grandson to the doctor. They diagnosed him with an ear infection but said that he likely did not need antibiotics. I remember that any time my daughter had ear infections, she got amoxicillin. Why didn’t my grandson get antibiotics?

A: Up until about a decade ago, kids got amoxicillin or another antibiotic prescribed whenever they had ear infections. Over the last few decades, it’s become clear that 1) not all ear infections are caused by bacteria (some are caused by viruses) and that 2) even when ear infections are caused by bacteria, antibiotics are not always needed for improvement.

There have been many well-designed research studies that have evaluated whether children have worse outcomes if they do not receive antibiotics. The American Academy of Pediatrics modified its guidelines in 2013 to reflect the most recent knowledge. The idea behind recent changes is to minimize antibiotic use for children who are less likely to need them (older than 6 months in some cases, older than 24 months in most cases, and also based on severity of symptoms and whether both ears are infected).

Following these guidelines does not lead to complications or worse outcomes in our patients. On the plus side, this helps limit antibiotic resistance, prevents side effects of antibiotics (allergy, diarrhea), and avoids having to remember to give a toddler medication twice a day for 10 days.

But not to worry: There are treatments that are more likely to help your child feel better (and thus sleep better and recover). Ibuprofen and acetaminophen both help control fever and pain. There are also numbing eardrops that can be prescribed for many cases of ear infection. They do not treat the infection, but they relieve the pain and give us some time to see whether a child will fight off the ear infection without antibiotics – without causing them to have an increased amount of discomfort.

In many cases, if the ear infection does not begin to improve within 48 to 72 hours, your pediatrician will recommend starting antibiotics at that point, and there is clear evidence that this system poses negligible risk of complications when compared to treating immediately with antibiotics. When your pediatrician offers this treatment plan, discuss with him or her any concerns about the plan and also clarify what the plan will be to start antibiotics.

Brian Eichner is a general pediatrician and assistant professor of pediatrics at

Duke Children's Primary Care in Durham and the medical director of the

Duke Pediatric Diagnostic Clinic.

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