Tuesday, October 18, 2011

Ears Lookin' at You, Kid!*

Last week, JoJo spiked a temp to 102.7.  Since he was already scheduled for his 18-month visit, I had the pediatrician gave him the once over.  She diagnosed him with otitis media, or middle ear infection, but her diagnosis was essentially just an FYI.  Since ear infections often get better on their own, the doc recommended antibiotics only if he didn't improve in the next 48 hours.

I knew she was right.  But dadgammit, I wanted to start those antibiotics so he could get back to daycare ASAP, and I could get a good night's sleep!  It's times like these when it's tough to be an Evidence-Based Mommy.

Here's the argument against routine antibiotics:  Some ear infections are caused by viruses, and as you know, antibiotics don't kill viruses.  Even mild bacterial infections self-resolve at times.  Antibiotics can shorten the course of illness and prevent rare complications such as bone infection and hearing loss, but at the cost of increasing drug resistance.  So what may help a patient on the individual level may hurt patients on a societal level.

A recently updated meta-analysis of eleven randomized, double-blinded trials of over 2000 children with ear infections found only a small benefit with antibiotics: 78% in the placebo groups recovered spontaneously within 2 to 7 days, compared to 84% in the antibiotic groups.  There was no difference in serious complications.  Those on antibiotics also had a 4% absolute increase in vomiting, diarrhea and rash.   So taking the 6% benefit and subtracting the 4% detriment, you get, on balance, a measly 2% absolute benefit from taking antibiotics. A review of four other trials found that there was no difference in starting antibiotics immediately versus waiting 48 hours for spontaneous improvement.  So even from the standpoint of an individual child, you could make a strong argument to watch and wait. There were certain subgroups that benefited more from immediate antibiotics: children under 2 who had infections on both sides, or those with pus pouring out of their ears.  In general, though, antibiotics were almost a wash.

Contrast these results with those of a study published this year.  In this randomized trial of children with ear infections, treatment failed in 45% in the placebo group, compared to 19% in the antibiotic group, with an absolute benefit of 26% - much better than the 4% reported in the past.  Not only that, but antibiotics led to resolution of fever within 6 hours, as well as fewer days of missed work in parents whose kids were in daycare.  Sadly, these benefits still came with a price: a 25% increase in diarrhea in the antibiotic group. So pick your poison: irritable baby or irritable, diaper-changing parent?

Still, you might wonder why the results of this trial were so much more impressive than that of previous studies. The 2011 study had very strict criteria for middle ear infection, which included a pneumatic otoscopic exam (basically, blowing air into the canal and looking for decreased movement of the eardrum).  Although medical students learn this technique, I can tell you that it's rarely used in the primary care setting.  Most of the time, pediatricians are just trying to grab a 1-second peek into a screaming baby's ear, and crying itself pinks up the eardrums by dilating blood vessels.  Studies have shown that these infections tend to be overdiagnosed, especially when earwax is obstructing the view, so it's no wonder that antibiotics are often of marginal benefit.

So what's a parent to do with all this conflicting information?  If your kid's doctor wants to prescribe antibiotics for a middle ear infection, ask her two questions:

1)  Is this a pretty clear-cut diagnosis?  When doctors are "certain" of their diagnosis, the probability of a "real" otitis media is actually 76% -- which believe it or not, is pretty accurate for a diagnosis based purely on history and physical exam.

2)  Do you think it's safe to wait 48 hours to see if my child gets better on his own?

In JoJo's case, I waited, as his doctor thought it would be safe to observe him off antibiotics.  He was better within two days  This time at least, it looks like I picked my poison wisely.**

*Sorry, I know this is a groaner of a title.  As Fred said to George after his ear was sectum sempra'd off, "Pathetic!  With the whole wide world of ear-related humor before you....?"

**Which hasn't always been the case.  I decided not to give my oldest son the antibiotics prescribed to him for an ear infection.  He seemed to improve, but on a routine visit a few weeks later, his pediatrician found he had a persistent infection.  When he puzzled aloud over why my son "didn't respond" to the antibiotics, I was forced to come clean.  My son was deemed cured after a week's worth of treatment/diarrhea, but I've always wondered if my poor maternal decision-making was to blame for his current, frequent refrains of "But Mom, I didn't hear you!"

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