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PHILADELPHIA - A sea change is under way in how American medicine deals with one of the most familiar banes of childhood, ear infections.
Doctors now are not so quick to call a red eardrum an ear infection or pull out the prescription pad.
At the heart of the new strategy is an approach called "watchful waiting" - delaying the start of an antibiotic to see if the child gets better without it.
Some parents are being given a prescription - a "Safety-Net Antibiotic Prescription" - but told to wait to fill it.
The change in diagnosing and treating is driven by concern about the overuse of antibiotics and the growth of drug-resistant bacteria. And doctors are becoming less worried about the long-term consequences of ear infections, which account for 30 million doctor visits a year.
"It's pretty clear that ear infections are overdiagnosed and there's been a certain amount of otitis phobia, where families and physicians are so afraid of ear infections that they go ahead and treat," said Allan Lieberthal, a California pediatrician helping draw up new professional guidelines on diagnosing and treating middle ear infections, called otitis media.
"One of the key points of the guidelines," he said, "is that you don't have to be afraid of most ear infections."
That vanishing fear factor will surely surprise parents whose children grew up in the 1980s and '90s, when ear infections suddenly seemed as common as colds, and antibiotics in various colors and flavors were readily dispensed.
It's not that doctors have grown cavalier about treating ear infections, or that parents should ignore a child's complaint of an earache (ear infections can in rare instances lead to serious complications). Rather, a more measured approach is becoming acceptable.
"We are probably setting a higher bar in making a judgment on whether a child truly has a bacterial infection in the ear," said John Magee, a pediatrician with Chestnut Hill (Pa.) Pediatric Group. "A red eardrum just doesn't do it."
The guidelines to be issued by the American Academy of Pediatrics and the American Academy of Family Physicians early next year will include a very specific definition of what constitutes an ear infection and how best to treat it.
"For certain children, one recommendation will be to observe without initial antibiotic treatment," said Lieberthal, who is co-chairing the committee writing the guidelines.
"The literature is showing that most children who have an acute ear infection will get better without antibiotic treatment, and in waiting two days to treat and only treating those who are not getting better, there is very little risk."
The guidelines will reflect changes already taking hold.
An analysis of health insurance data for 25,000 children in nine health plans across the country found a significant decline in the use of antibiotics between 1996 and 2000, and researchers said the decline reflected a decrease in diagnosing ear infections.
"Physicians have changed their threshold for what they are calling an ear infection," said Jonathan Finkelstein, assistant professor of pediatrics and ambulatory care and prevention at Harvard Medical School, who reported the study in Pediatrics in September.
For starters, doctors are better distinguishing between an ear infection and fluid in the middle ear, which builds up due to a cold without the presence of a bacterial infection.
"When you look at ears, there is actually a continuum of findings," Finkelstein said. "There is the flagrant, dramatic infection that everyone would agree on. The eardrum is bulging and there's pus behind it, and the kid is screaming. Ten out of 10 of us would say, 'There's an ear infection.'
"Then there are ears which are more subtle in their findings, where the diagnosis is less clear. The ear drum is slightly inflamed and there's a little bit of fluid and the kid has been uncomfortable on and off, but not screaming in pain.
"Whether you call that an ear infection or just a little bit of fluid in the ear with a cold, which is also what it could be, that's where the judgment comes in," he said.
The idea of watchful waiting has already gained some acceptance in Europe. Doctors aren't withholding antibiotics in cases where there is clearly an infection and the child is feverish and in pain, or in instances when the patient is a baby or has a history of frequent ear infections. It's with borderline cases that doctors are becoming more judicious.
Mark Warner, of Drexel Hill (Pa.) Pediatrics, said he'll sometimes tell a parent: "Look, give it a couple of days. If it's no better and getting much worse, here's a prescription to start.'"
Barbara Rolnick, a pediatrician with Kids First in Roxborough, Pa., said a provisional prescription gives parents a feeling of security because "if at 3 in the morning their child is screaming, they have that prescription and can go out to the all-night pharmacy and fill it."
Most parents are willing to go along with a wait-and-see approach, according to a recent study published in Pediatrics.
Researchers affiliated with Cincinnati Children's Hospital Medical Center looked at what happened when 175 parents of children with ear infections (very sick children were excluded from the study) were given a prescription and told not to fill it unless the child's condition didn't improve in 48 hours. The parents also were given pain relievers and ear drops.
Only a third of the parents filled the prescription.
"We wanted to find a strategy for going without antibiotics that parents would find acceptable," said Robert Siegel, a Kentucky pediatrician who headed the study. By getting a prescription, parents felt they had "control over the situation," he said.
One recent Friday, Patty Szipszky, of Newtown Square, Pa., took 19-month-old Brian to Kids First-Haverford, worried an ear infection was brewing. Pediatrician Bonnie Fass-Offit gave Szipszky an antibiotic prescription, but told her to hold on to it.
"It made me feel much better having it," Szipszky said. Brian got better on his own.
Rolnick said some parents may balk at not always getting a prescription for their child, but many parents are becoming savvy about the downsides of too much antibiotic use. Antibiotics also can cause stomach upset and diarrhea, unpleasant for child and parent.
Concerns over antibiotic overuse are also pushing other changes in how doctors deal with ear infections. Doctors are sometimes prescribing a shorter course of antibiotics; relying on basic antibiotics, such as amoxicillin, rather than broader-spectrum antibiotics; and moving away from daily low-dose preventive antibiotics for children who get many infections. Many doctors no longer do "rechecks" on every child who has an ear infection, figuring most children do get better.
For children with frequent ear infections, doctors will sometimes recommend ear tubes, or tympanostomy tubes - tiny devices inserted in the ear drum to help keep the middle ear clear of fluid and free of infections.
Kimberly Ganley of Clifton Heights, Pa., said she opted for ear tubes for daughter Carly, now 2, after she got an ear infection at 4 months and many more followed.
"She's been on antibiotics so many times, I've lost track," Ganley said. The ear tubes seem to have helped.
While the chances are good that parents will deal with a child's ear infection at one time or another, children often outgrow ear infections by the time they're 3. The trick for parents is to keep things in perspective.
"An ear infection is not a big deal for most children," Magee said.
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(c) 2003, The Philadelphia Inquirer. Distributed by Knight Ridder/Tribune News Service.
