The Treatment of Ear Infections
“Best Practice” Guidelines NOT Being Followed…!
Jonathan Wood, MD
If there are clear guidelines about the best way to treat one of the most common diseases in pediatrics, why aren’t we doing it? This month, in the journal Pediatrics, a study indicates that, unfortunately, management has not changed as a result of such guidelines published over tree years ago. Read below to find out why this may be…
Three years ago, Erik Steele spoke on WABI about the new (1994) guidelines concerning the treatment of ear infections in children. The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) made a series of strong statements and clear recommendations aimed at avoiding unnecessary or poorly chosen antibiotics for this very common pediatric illness. For a synopsis of his well spoken summary of this issue, please refer to his article (http://healthyliving.emmc.org/archive/05.11.2004.asp) in the Healthy Living archive.
Antibiotics are frequently not necessary to treat acute ear infections. This is because the underlying cause is often a virus, something that antibiotics do not treat.
Pain control should be the first priority in the treatment of ear infections and is often effective enough to provide relief while the body takes care of the infection itself. Typical choices include oral pain killers (e.g. acetaminophen or ibuprofen) and/or topical ear drops
There is a clear and rational sequence of choices that should be used by doctors to decide on first and second antibiotic options, when such medicines are indicated.
Parents should continue to bring their children to the doctor for evaluation of fevers or ear pain, but should be aware of these recommendations. In cases where children are not given antibiotics, close follow-up either by phone or in person is critical.
After the guidelines came out in 1994, a study indicated that primary care pediatricians and family practitioners were (1) aware of the guidelines and (2) supportive of the change in practice. A re-survey of the same group of doctors 2 years later (and published this month) indicates that although the vast majority continued to be supportive of the “observation without antibiotics” option, only a minority are actually managing patients that way…!
Why the discrepancy?
Why would doctors support a management approach and then not practice that way?
The recently published survey may also provide some explanations. When asked to provide reasons for the discrepancy between theory and practice, the most common reason given (65%) was “Parental expectations/demand for antibiotics”. This reason was in the top three in almost 85% of the 300 doctors surveyed!
Is this true? Do we as parents expect or demand some sort of treatment when we bring little Billy to the doctor? Well… yes and no…
As pointed out in Dr Steele’s 2004 article, previous studies indicate that “parents who pressure the health care practitioner for antibiotics are more likely to get them for the child. In doing so, they may get what they want for their child, but they may not get the best treatment.” So, yes, there is likely a considerable element of parental pressure that results in unnecessary antibiotics being prescribed. Still, the health care practitioner bears much responsibility as well. They (we!) are responsible of effectively educating their families and helping them to understand and accept the best treatment options for children. This issue is truly one involving “shared responsibility”.
Be aware of this common and important issue
Go to the doctor with an open mind - - be willing to hear about new and improved approaches
Accept that often “less is more”... i.e. sometimes the best treatment is reassurance, careful watching, and close follow-up (not medicine!)
Have conversations with your doctor about this and other confusing issues around the treatment of you and your family. Sometime the best time to have these discussions is when you are well, not when you are sick.
All of us need to keep our ears and minds open to new approaches to old illnesses…!