Why wasn’t my son treated with antibiotics for his red ear?

By Herschel Lessin, M.D.

Before entering the room, I looked at the chief complaint of my new 15 month old patient: pulling at his ear. I was also  seeing her 6 year old with an earache. Mom was concerned with her children’s frequent ear infections. They were always on antibiotics.

After my exam, I tell her that while her infant’s ear was a little red, it was not infected. Her 6 year old had an ear infection. Neither needed antibiotics.

Mom was most definitely not happy. The antibiotic seems to always help. Why weren’t they being treated this time?

The answer was that I was one of the good pediatricians who only used antibiotics when they were appropriate.

For decades, US physicians have been treating every red ear as an ear infection. There is now compelling evidence that not only is this practice wrong, but it is dangerous as well.

First of all, a mild red ear is absolutely NOT a sign of an ear infection. In order for the infection to be present, the entire structure of the eardrum must be distorted and bulging. In addition, there must be fluid behind the eardrum that restricts its movement with air pressure. The mild red ear does not meet any of these criteria and is not a sign of an infection that requires antibiotics. Most red ears are due to infants’ crying while being examined.

The indiscriminant use of antibiotics has resulted in many bacteria that are resistant to many antibiotics and can cause severe, difficult to treat illnesses that may be life threatening

Current American Academy of Pediatrics Policy is to not treat ear infections at any age unless examination reveals the bulging distorted ear drum that I mentioned earlier. Definite ear infections should be treated in children less than 2 years of age.

The recommendation that has caused the most resistance from both parents and pediatricians alike, is the “Observation Option”. Older kids can be observed with aggressive pain relief. If pain cannot be controlled or symptoms last more than 2-3 days, then antibiotics can be used. This idea has met with significant resistance from both parents and pediatricians alike.

Trying to teach old dogs new tricks has always been difficult. Add to this the fact that parents want us to DO SOMETHING! It is a brave pediatrician who does not give parents what they want. Finally, it takes a lot less time to write an antibiotic prescription than to explain to an angry parent exactly why it is not needed. Not to mention the fact that many adults with simple colds get antibiotics from their own physicians.

The indiscriminant use of antibiotics for viral infections and earaches must cease since it is causing enormous problems with bacterial resistance to our strongest antibiotics.

I explained to the parent that while there is a small chance that her son will go on to develop a real ear infection requiring a second trip to the doctor, that is a small price to pay to avoid exposing our children to unnecessary antibiotics that can cause real harm.

Many of us have used a compromise called the SNAP (safety net antibiotic prescription). A time limited prescription for antibiotics is provided to the parent to only fill if they really need it. We trust our parents to do this. Studies are ongoing to see how many actually do not fill the prescription.

Dr. Lessin has been a practicing pediatrician for 30 years. He is a founding partner and served as both Medical Director and Director of Clinical Research at the Children’s Medical Group.

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12 thoughts on “Why wasn’t my son treated with antibiotics for his red ear?

  1. I absolutely agree with everything you said. We often find ourselves pressured into treating the parent and not the child. This has got to stop. Parents have some distorted sense of what practicing good medicine actually is. The one who prescribes antibiotics for everything is the “good guy” and the one who doesn’t is the “bad guy.” In reality, the opposite is true.

  2. I absolutely agree with everything you said. We have to resist the compulsion to treat the parent rather than the child. It has got to stop. Parents have a distorted sense of what practicing good medicine actually is. Unfortunately, they believe that the doctor who prescribes antibiotics for everything is the “good guy” and the one who doesn’t is the “bad guy.” In reality the opposite is true.

  3. What about families with a history of trouble with ears? My family has been told that the tubes in our ears tend to be small. My grandfather was nearly deaf from frequent ear infections and problems with drainage. My older brother almost failed kindergarten because he was not advancing. Only for my mom to discover that his hearing was effected by fluid in his ears. He couldn’t hear. One of my sons had tubes at 18 months because I pushed. He had been having fluid in his ears for months and was put on antibiotics multiple times. His speech was being effected. After tubes he started talking much clearer. Sometimes parents have reasons for being push but are seen as over reactive.

    • Sara,

      Sorry it took a while for me to respond, but I was on a trip and haven’t checked the comments. In any case, here it goes: A family history of ear infections is indeed one of history items that needs to be considered. However, I am unaware of any type of inherited pattern of small ear tubes, since that cannot be determined without surgery. That being said, there are some inherited patterns of mild immune deficiencies that do result in frequent ear infections. Frequent ear infections which are untreated can cause hearing loss, so, if that is the case and standard medical treatment with antibiotics have failed, a trip to the ENT may be be indicated. Beware of “frequent red ears” that are called ear infections. They are not, and are not a reason for surgical insertion of tubes. The indications for tubes are persistent fluid for more than 3 months duration AND hearing loss. 90% of fluid will go away by itself, unless it keeps getting reinfected. As you can see, this is not as simple a decision as it appears to be on the surface. A good pediatrician will use antibiotics appropriately and refer appropriately. Some kids do have dramatic improvement in language after tube placement, but several recent studies have demonstrated, there was no difference in speech outcome at age 4-6 years between those who got tubes and those who did not. Every patient must be handled individually and not be “the cookbook” that many think so called “simple” problems like ear infections represent. This is why a good pediatrician is needed. The cookbook is a good place to start, but clinical judgement needs to be present at well.

      • Thank you for your words of wisdom. I agree with the overall meaning of the article. Antibiotics are often prescribed without cause other than an “over reactive” parent. More education is needed for parents and the public. I am thankful that my pediatrician posted this article to his Facebook page. There are parents that just want to treat with a pill. Articles such as this and the discussion that it has prompted are needed to get information out. I feel that I am like many parents and when my child is crying and in pain I want them to feel better. That is what a doctor wants also. Help parents to know what can be done for relief. How long should a parent let “fluid” go before becoming more persistent about a solution? Sometimes pain medication only does so much. Ear drops are many times ineffective. What is the next step? I feel that because of my family history with ear problems I am more sensitive. What about the parents that don’t know what to watch for? What happens when there are more children in speech therapy or delayed in school because their hearing is effected?

  4. Sara,
    Your family history brings up an important point – all of the guidelines that Dr. Lessin describes above are just that, guidelines. We use them to help decide what to do, but they are not “recipes” or “rules.” In the case of a child under 2 with fluid behind his ears for many months, most pediatricians would recommend tubes – it’s (almost always) the right thing to do. The antibiotics won’t get rid of the fluid, just the bacteria that like to live in the fluid. But the take home message is: each child’s case has to be considered individually, with guidance from our experience with many children. No pediatrician that I know and trust would say antibiotics are NEVER useful for ear infections, just that we can probably use a lot less antibiotics, and in the long run, we’ll all be better off – including the child with the ear infection. This is something you need to be able to talk to your pediatrician about, when these sorts of questions and issues come up.

  5. Dear Sara,
    Keep advocating for your child – it is important. A good pediatrician will listen carefully to what mom has to say. But parents need to listen too. All action has risk and benefit. That goes for antibiotics and ear tubes as well. Your post also brings up the importance of having a medical home and well care visits. A child’s language development, hearing, school performance, etc. should all be addressed at regular intervals with a pediatrician who knows the child’s medical history.

  6. Sara, thanks for speaking up on the blog and for your kids. Like Dr. Lessin, I am not very concerned about a child whose ear drum simply looks red. A child with persistent fluid behind his ears and evidence of hearing loss is much more concerning.

    When grading diamonds, jewelers look at the 4 Cs; eardrums are kind of like that too. There’s certainly Color (although infected ears often look more yellow or orange than red), but also Contour (is the eardrum nicely flat, or bulging outward, or retracted inward?) and Clarity (can I see a”light reflex” on the drum or not?) To an experienced pediatrician, true ear infections look abnormal in all three respects. A red-looking ear drum with a flat shape and a nice light reflex doesn’t warrant antibiotics.

    However, an inexperienced or too-hasty examiner might just peek at the ear drum, see it looks red, and call it an ear infection, without evaluating the other properties of the ear drum.

  7. Hi Sara–Let me echo the comments of the others who have responded to your thoughts. Many “ear infections” are not truly infected, but simply normal, reddish ears (and I am sure that most pediatricians, not to mention highly-pressured ER physicians have made this mistake). And much fluid, if left alone, will resolve spontaneously, often taking as much as three months to do so. And one study, in which only one of the affected ears in each child had a tube placed, did show an immediate improvement in hearing in that ear, but no difference when studied several years later.

    All that being said, the most important thing that your pediatrician can do is remember that each child is unique, an individual, a study of one. And each child needs to be seen that way, and evaluated both for infection and for hearing, before a decision can be made. Some kids WILL definitely need tubes, and benefit from them, just as some will need antibiotics. But we, as pediatricians, are trying, with little steps, to have an impact on the use of antibiotics for conditions for which they are truly not going to make a difference.If we can reduce that usage, even a little, we will save money, save allergic reactions, and, we hope, reduce the ever-growing incidence of new bacteria resistant to the antibiotics which we do have.

  8. I came upon this article trying to do a little research. I have a 11 month old and behind her ear and down her neck is very red and warm. She is not pulling at her ear though so im not sure what it could be. Its only on the right side. She is cutting her right front tooth so Im wondering if that could have anything to do with it. No fever, no fussiness, no bowel problems. I have to be extra cautious with her because she has neutropenia. Any suggestions as to what this could be?

    • Hello Julie,

      Dr. Hackell saw your note and asked me to post this on his behalf.

      Hi Julie–this sounds like a potentially more acute problem that should be seen promptly by your pediatrician, especially since your child has neutropenia. This is not a condition that can be evaluated without examining the child, and with her age and history, I would have her seen promptly.

      It could represent anything from a sunburn to an insect bite to a more serious infection. Your pediatrician is best able to evaluate problems such as these in infants, and can be your first resource when your child shows something with which you are not familiar.

      Jesse Hackell MD FAAP

      Good luck with everything.

      Brandon

  9. Hi Julie,

    I agree with Dr. Hackell, a child with neutropenia is not your typical child. As I am sure that your Pediatrician has told you, this condition predisposes to serious bacterial infections and a red, warm area behind the ear could represent a significant infection such as cellulitis or mastoiditis that would require immediate treatment. It also could be just a sunburn or skin irritation. In your case, I would want to rule out the serious stuff and you should not be concerned if it turns out to be nothing, you should be happy. I would suggest an evaluation by your Pediatrician today.

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