Ear infections: Why is this problem so common among children?
By Warren King
On most days, he is one of the happiest babies around: He smiles, chuckles, babbles, bats his eyes and sleeps like a log.
On days when his ears were aching from infection, however, it was a relentless ordeal. He tugged his ears, whined for hours and generally was inconsolable.
"He would cry when I put him down and wake up in the night with pain," said Isaiah's mother, Julie Robinson-Jasper, a West Seattle resident. "It's so hard to see children ill, especially when they're that young."
About this time last year, Isaiah, now 22 months, was going through the worst of his recurrent ear infections. Such infections mostly affect children and are especially prevalent in winter. After several rounds of antibiotics weren't successful, a specialist recommended ear tubes be surgically inserted to quell his infections.
In the winter and chill of spring, colds sometimes lead to a buildup of fluid in the middle ear of children. The fluid then becomes infected, and the miseries ensue.
"It's an incredible problem for kids," says Dr. Dianne Glover, a veteran pediatrician at Swedish Medical Center. "It's a very common reason for them to be brought to a physician. It keeps parents home from work, children home from day care."
By age 3, about 85 percent of children will have had at least one ear infection, called "otitis media." It is the most frequent childhood illness after the common cold, accounting for 30 million doctor visits a year, according to the Centers for Disease Control and Prevention.
Colds and allergies are often involved in ear infections because they stimulate production of fluid in the eustachian tube, which runs from the back of the nose and upper throat to the middle ear. Germ-laden fluid from the nose and throat can flow into the tube and stimulate a pus-filled infection. The infection may occur in one or both ears.
The shape of a child's eustachian tube itself is big part of the problem. In young children, it is relatively straight and horizontal, a perfect sphere for holding the fluid. By age 5, it has become more curved, allowing fluid to drain.
Sometimes germs don't migrate from the nose and throat, and the fluid buildup doesn't lead to infection. The fluid will then usually drain on its own within a few weeks. But when it does contain bacteria or viruses, an infection can give a child a hard time.
Besides crying and pulling at the ear, symptoms of ear infection may include fever, irritability, mild hearing loss, vomiting and diarrhea. Ear pulling isn't always a symptom of infection, however, Glover says.
"Sometimes the baby may just be bored, and it's something to pull. Or sometimes, they do it when teething or with a sore throat," she said.
Antibiotics: yes or no? Deciding whether to use antibiotics for an ear infection can be a challenge for a physician.
The doctor first examines the eardrum through an otoscope to determine the likelihood of infection. If the eardrum is bulging, red and doesn't move when the physician sends a puff of air through the instrument, an infection is present in the middle ear.
Still, there is no way to know for certain whether the infection is caused by bacteria or a virus, because the fluid is behind the eardrum and not accessible for testing without using a needle and general anesthesia. Up to 40 percent of all ear infections are caused by viruses, which are not killed by antibiotics.
Doctors are increasingly reluctant to prescribe antibiotics for a first ear infection because of the significant number of viral infections and because no antibiotic is effective against all bacteria. More than half of the infections heal on their own without drugs, said Glover.
Physicians especially worry about overprescribing because an increasing number of bacteria are becoming resistant to antibiotics: About 25 percent of all pneumococcus bacteria strains, the most common bacterial cause of infections, are resistant to penicillin, and 10 to 20 percent are resistant to amoxicillin, according to the American Academy of Otolaryngology — Head and Neck Surgery. Antibiotics also have side effects, including nausea, diarrhea, rashes and, sometimes, allergic reactions. The American Academy of Pediatrics and the American Academy of Family Physicians are expected soon to recommend antibiotics only for patients with severe ear pain or fever of 102.6 degrees, according to The Associated Press.
Glover said many parents already choose not to give their children antibiotics.
"Some are saying they want antibiotics only as a last resort. And we've had some whom we've had to convince to give the medications," said Glover.
Still, some parents ask for antibiotics, even though there may be no infection. Glover said treatment decisions must be individualized, based on the likelihood of infection and parents' concerns.
If it appears the ear has only fluid without infection, the doctor may ask that the child return in a few days, or that the parents call the physician. Or the doctor may prescribe an antibiotic with instructions to use it only if the child's condition worsens, for example if there is a high fever and severe pain. Pain from infection may range from a dull ache to very acute pain, when there is a lot of pressure on the eardrum.
Particularly bad infections may result in the child's eardrum bursting, relieving the pressure and pain and draining the infected fluid. There are usually no long-term consequences. In very rare cases, an infection can cause permanent hearing damage by damaging the bones of the middle ear that conduct sound.
4 infections in 3 months Back when he was 9 months old, the first infection in Isaiah Robinson-Jasper's ear clearly called for an antibiotic. He took the medication over about 10 days, the infection cleared up, but then the infection in his fluid-filled ears returned in less than a week. And Isaiah still wasn't finished.
"He was on antibiotics on and off for three months," said his mother. "He had four infections over three months."
Isaiah had none of the classic risk factors for the infections. He doesn't have allergies and wasn't in day care, where he would be exposed to more colds than usual. He wasn't exposed to second-hand cigarette or fireplace smoke, which can irritate the respiratory tracts of children and cause ear-fluid buildup. And he wasn't a bottle feeder, so he didn't miss out on immune cells passed from his mother. Continuous sucking during bottle feeding also creates a negative pressure in the middle ear, pulling fluid from the nose and throat into the eustachian tubes.
Why ear tubes? No one really knows why Isaiah had the recurrent infections. They just happen with some children. The ear specialist recommended Isaiah be treated with ear tubes to continuously drain the fluid.
Physicians say tubes usually are needed when a child has had more than four or five infections in a year, if fluid (even without infection) has remained in the ear for more than three months, and the child is experiencing hearing loss. Speech development can be affected by prolonged hearing impairment.
With the child under general anesthesia, the tiny metal or plastic tubes, less than the thickness of a nickel, are inserted through the eardrum in an operation taking only about 10 minutes. A flange on each side of the eardrum holds it in place. As the eardrum grows, the tube works its way out into the ear canal where it falls out or is removed by the doctor. About 15 to 25 percent of children will have problems with the devices and need a second set, according to the Mayo Clinic. Sometimes, the tubes may also leave a tiny scar on the eardrums, but that does not affect hearing, Glover said. One of the two tubes Isaiah received in May 2003 became clogged with blood from the surgery and ear wax. He received a replacement the next month, and "he hasn't had an ear infection since," said his mother.
Like most kids approaching their second birthdays, Isaiah's eustachian tubes are developing a curve and he is unlikely to have more ear problems from a buildup of fluid. Unlike most children, he needed extensive treatment.
Even though they number among childhood's most frequent illnesses, ear infections are also among the easiest to overcome.
"The odds are it will clear up on its own," said Glover.
Warren King: 206-464-2247 or firstname.lastname@example.org
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