Giving antibiotics too soon can be a real pain in the ear

by Claire McCarthy on November 23, 2010

Claire McCarthy, MD

Your 3-year-old is cranky, has a little fever, and is telling you that his ear hurts. Time to call the doctor and go get a prescription for antibiotics, right?

Well, maybe not.

It turns out the most ear infections get better all by themselves, without antibiotics. We’ve known this for a while. In fact, way back in 2004 the American Academy of Pediatrics came out with a clinical practice guideline for the treatment of ear infections, saying that for generally healthy children over the age of 6 months who don’t have severe infections, it’s a good idea to wait 48 to 72 hours before starting antibiotics. By then, most children will be better and won’t need them anymore.

Pediatricians have largely ignored this guideline. Parents too.

As a pediatrician, I understand why. I’ve had my own difficulties adopting it, although I agree with it completely. It can be hard to tell parents who have been up all night with a toddler with ear pain that I’m not going to give them anything but Tylenol. It’s hard not to worry that there will be a situation when a child gets worse without antibiotics and the parents don’t call. It’s hard not to worry that if I give parents a prescription with instructions not to fill it unless their child isn’t better in two to three days that they won’t understand, or they’ll lose it, or that they’ll keep it and fill it during some other illness without telling me (which is a really bad idea). It’s understandable that many pediatricians take the better-safe-than-sorry approach.

And as a parent, the better-safe-than-sorry approach has real appeal. I, too, want to use every available treatment to get my kid feeling better and out of any danger as quickly as possible; I don’t like taking chances with my child’s health.

If things keep going the way they are, we’re going to have infections that no antibiotic can cure. That’s terrifying.

But better-safe-than-sorry can’t always be how we make medical decisions. The mantra for doctors these days is evidence-based medicine. This means making decisions based on facts—on studies, good ones and lots of them—instead of on what feels right or what we’re used to. Giving antibiotics for ear infections isn’t risk-free. Many children experience side effects, many of which are uncomfortable, some of which can be serious. And the more we give antibiotics, the more opportunities we give bacteria to figure out ways around them. We are seeing more infections caused by these resistant bacteria. If things keep going the way they are, we’re going to have infections that no antibiotic can cure. That’s terrifying.

This past week, an article came out in the Journal of the American Medical Association with more facts to help us make decisions. Here’s what researchers working with the Agency for Healthcare Research and Quality summarized after looking at more than a hundred studies on the treatment of ear infections: out of 100 generally healthy children with ear infections, around 80 will get better in about three days, without antibiotics. If you gave those same 100 children antibiotics, only 12 more would get better—but between three and 10 would get rashes, and five to 10 would have diarrhea.

If you’re thinking that with your luck your kid would be one of the 12 that needed the antibiotics, remember that according to the guidelines he would get them, just a couple of days later (sooner if he got worse). Better that than going through 10 days of diarrhea because of antibiotics your kid didn’t need.

This doesn’t mean that you should skip calling the doctor the next time you think your child has an ear infection, since you aren’t going to get that prescription anyway. You still need to call the doctor. But what you and your doctor end up deciding to do should be based on what lots of really smart people have spent years figuring out, not on habit or anxiety. That’s how we make decisions that really keep our children, and all children, safe—not just now, but in the future.

That’s the best kind of better safe than sorry.

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