For Common Ear Problem, Antibiotics Often Unhelpful

I still cringe at the memory of the pediatrician diagnosing "fluid in the ears" when my daughter was a toddler, a phrase that seemed to lead inevitably to antibiotics, diarrhea, and diaper rash, even though the kid hadn't seemed one bit sick. In years past, doctors have been aggressive in using antibiotics to prevent asymptomatic effusion, as it's called, because of fears that the fluid accumulation interfered with young children's hearing and language development.

But in most cases, antibiotics don't reduce the risk of children developing fluid in the ears, according to a new analysis in the February Archives of Otolaryngology—Head and Neck Surgery. That's particularly true for the children who are most likely to have effusion, those who are under 2 years old and who have recurrent ear infections. "If parents are worried about effusion, they shouldn't give antibiotics," says Maroeska Rovers, a clinical epidemiologist and assistant professor at the University Medical Center Utrecht, in the Netherlands. Rovers and her colleagues examined five studies with 1,328 cases to see if giving antibiotics helped prevent effusion. The risk of side effects, including bacteria developing resistance to antibiotics, outweighed any small benefit of treatment, they found.

This is no small issue; 90 percent of children develop fluid in their ears at some point before age 6. Effusion is exceedingly common after acute ear infections, but it usually goes away on its own within three months. Still, 30 to 40 percent of children have recurrent effusion, and in 5 to 10 percent of cases it can last for a year or more. Thus the concern about how it may affect children's hearing long term. And since effusion is so frequently associated with ear infection that it is used to diagnose the infections, experts thought that treating the ear infection would make the fluid go away. Alas, that doesn't seem to be true.

These latest findings jibe with the American Academy of Pediatrics's 2004 recommendation that pediatricians treat effusion with "watchful waiting" for three months in most cases, while warning parents that the child may have temporary hearing loss, particularly if both ears are affected. (The AAP also recommended waiting two to three days before giving antibiotics for ear infections when children don't have severe symptoms, particularly when the child is over age 2.) Although the watchful waiting recommendation has been in effect for almost four years, many pediatricians still routinely give children antibiotics to prevent effusion. And parents still often ask for the medicine. Rovers hopes that parents will learn to differentiate between the pain of acute ear infections, which needs to be treated with medicine like ibuprofen or acetaminophen, and effusion, which doesn't hurt and usually won't lead to complications. "Antibiotics may not be the best option, but painkillers are important," she says. "We're not saying do nothing. You can treat the pain."

And what to do if that fluid doesn't go away? The AAP recommends having a child's hearing tested when effusion lasts for more than three months or whenever language delays or learning problems seem to be an issue. Surgery to install tubes in the eardrums, which drain fluid from the middle ear, is an option for children who have had effusion for at least four months and have persistent hearing loss or middle ear damage.

But in many cases, we parents can say, "Let's take a pass on the antibiotics."