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How Do I Know If My Child Needs Ear Tubes?

Written by Jesse Hackell MD., FAAP.

imageEar tubes, or more properly known by their medical name, tympanostomy tubes, represent the most common surgical procedure performed on children in the United States.

Over 600,000 children undergo ear tube placement every year, in a simple procedure under general anesthesia, with the attendant risks of surgery and anesthesia as well as the costs associated with these procedures having a significant impact on these children and their families.

The arguments for and against tube placement have been debated for years, and various guidelines have been proposed in order to develop some degree  of a rational approach to the medical issues which lead to ear tube surgery.

The American Academy of Otolaryngology–Head and Neck Surgery has recently convened a panel of experts in several fields of medical care, as well as experts in hearing and audiology and consumer protection, in order to develop a set of clinical practice guidelines on tympanostomy tubes in children.

This panel, of which I was a member, met several times over the course of a year, and was charged with reaching a consensus opinion on how best to apply the scientific evidence in the literature to the decision-making process regarding the placement of ear tubes in children.

The panel’s research and deliberation has resulted in a comprehensive article on this topic, which includes a thorough discussion of the nature of middle ear disease, as well as specific recommendations regarding the decision to place ear tubes in children who fall into a number of distinct categories. The complete article has been published in the journal Otolaryngology–Head and Neck Surgery (Otolaryngol Head Neck Surg July 2013 vol. 149 no. 1 suppl S1-S35) and can be accessed online here: http://oto.sagepub.com/content/149/1_suppl/S1.long .

Some of the recommendations made by the panel relate directly to acute otitis media (ear infections) and otitis media with effusion (ear fluid), which as we all know are very common complaints and findings in children.

For example, one recommendation is that ear tubes NOT be placed when the ear fluid has been present for less than three months.

However, this is complemented by the recommendations that hearing testing should be performed if the fluid lasts three months or longer, and that tubes should be offered if the fluid has persisted for more than three months and hearing loss is found to be present.

The guidelines further recommend that children with fluid but without hearing loss should be re-evaluated on a regular basis, watching either for resolution of the fluid or development of a hearing loss.

Another guideline recommends NOT placing tubes in children with repeated episodes of acute ear infections, unless persistent fluid is seen between episodes of acute infection.

Of particular note in these guidelines is the attention paid to children with special needs, such as cranio-facial abnormalities and chromosome abnormalities such as Down’s Syndrome. In these children, the guidelines recommend a much more liberal use of tubes, since they have a greater incidence of hearing loss and are at greater risk of secondary problems developing as a result of even brief periods of ear fluid and hearing loss.

Two additional recommendations of particular interest to parents whose children have already had tubes placed are, first:

that acute drainage of fluid from an ear with a tube in place should be treated only with antibiotic ear drops, and not with oral antibiotics, unless the child appears systemically ill with a complicated course of the infection, and, second, that water protection, such as ear plugs, is NOT recommended when children go swimming after they have had ear tubes placed.

Because these evidence-based principles are guidelines, of course, they serve as a starting point for dealing with the question of tympanostomy tube placement, and should not be taken as the absolute and final word on the subject.

Children and their illnesses are unique, and each and every case may not fit clearly into one of the guideline categories. For this reason, each of the recommendations emphasizes the role of shared decision making between the clinician and the parents.

As a panel member and an author of the report, I would suggest that if your child’s physician is suggesting that ear tubes be placed in your child, it would make sense to at least make sure that the physician is familiar with these new guidelines, and is willing to discuss how your child fits in with these new recommendations.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.

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My Child Has A Fever, Should I Be Afraid?

Written By Jennifer Shaer MD, FAAP, FABM, IBCL

Everyone gets nervous when their child has a fever. However, fever is not dangerous. There are many myths surrounding fever. Here are some facts about fevers:

Fever helps the body fight infection. Fever helps slow growth of bacteria and viruses. It also enhances the immune fighting cells in the blood.

A high fever does not necessarily mean that there is a serious disease. Many viral illnesses can cause very high fevers. While these fevers might be high, they will go away without any help in three to five days.

Fevers do not cause brain damage.

Again, fever is a normal physiologic response. The only time that fever is dangerous is when it is from heat stroke or hyperthermia. Symptoms of heat stroke are red hot dry skin with no sweating and confusion.

Infections and illnesses that cause fever do not cause heat stroke and are not dangerous. It is true that a small percent of children who get a fever will have a febrile seizure. Febrile seizures occur in about 4% of kids. They can be very scary to watch but they do not cause brain damage.

Medicines to lower fever are not expected to bring the temperature down to normal.

Ibuprophen and acetaminophen are often used to bring down fever in children. However, these medicines will only help the child feel better for a short time.

When the medicine wears off, the fever will return. Your child will continue to have fever for as long as the illness lasts (usually 3-5 days). Also, these medicines will lower the fever but they are not expected to bring the temperature back to normal.

It is expected and helpful to have some fever while your child is sick.

Of course you want your child to be comfortable and you do not want your child to get dehydrated from a high fever but remember that the fever is helping your body fight infection.

Also when your child is sick, he or she should be resting. If you bring the temperature back down to normal with medicine than he will want to run around a play. The goal in using medicine for fever control is to keep your child comfortable while his body is fighting the illness.

Fevers will not continue to rise without treatment. The brain has a “set point” temperature that it will reach and then start to come down, even without medicine.

Medicines to bring down fever will not prevent a febrile seizure.

One in twenty five children will have a febrile seizure. It is impossible to predict and it is impossible to prevent. Remember that while they are scary, they are not dangerous.

Do not use medicine to try and prevent a seizure. Medicine for fever should only be used to keep your child comfortable.

It is most important to determine the cause of your child’s fever.

Fever is just a symptom.

If the fever is from strep throat or an ear infection then he might need antibiotics. If the fever is from a virus, then it will need to “run its course”.

You should bring your child to the doctor to help determine the cause of the fever. Once you know the cause, you can relax.

Medicines come in many shapes and sizes and they are dosed based on your child’s weight. To determine how much medicine your child should take, visit Allied Pediatrics – Med Dosage Resource

Dr. Shaer is a pediatrician and a board certified lactation consultant (IBCLC). She is director of the Breastfeeding Medicine Center of Allied Pediatrics of New York.

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In Defense of Cough

Written by Nelson Branco MD

 

There are always coughing kids, but this time of year the number of visits to pediatricians for “cough” begin to outnumber almost everything else. Once the kids have been back in school for a few weeks, and they’ve had a chance to cough and sneeze all over each other, the cough season has begun.

Most parents worry that their child might have asthma, pneumonia or some other infection causing the cough. Your doctor will be running through a much longer list of possible reasons for cough – pneumonia, wheezing, croup, asthma, bronchitis, congestive heart failure, viral upper respiratory illness, bronchiolitis, reflux, post nasal drip due to allergies or sinus infection, habit cough, aspirated foreign body and a few others. It usually takes only a few questions to narrow down the possibilities, but sometimes it takes a bit more work, especially if the cough has been going on for some time or has not responded to treatment.

Obviously, many of these causes will have a specific treatment – antibiotics for pneumonia or sinusitis, steroids and albuterol for asthma, antihistamines or nasal steroids for allergies, antacids for acid reflux. But how about if your child has a viral illness? These illnesses – upper respiratory infections (the common cold), tracheitis, bronchitis, and bronchiolitis, are usually self-limited and don’t need any specific treatment.

Cough is a protective reflex that keeps the lungs clear of mucous, irritants and infection. Cough is usually involuntary, and it’s difficult to suppress a cough when your brain says it’s necessary. Cough can interrupt sleep, be disruptive at school or irritating to your child, and cough is a very efficient way to pass infections to others (Cover That Cough!). So, given all this, why don’t we generally prescribe cough suppressants? The first reason is that most don’t work. Even codeine, when studied in large groups of children, doesn’t work well at suppressing cough. Over-the-counter medications don’t work too well either, though there are many available and lots of people use them.

Another reason not to suppress all coughing is to prevent pneumonia or lung infection. Cough is a helpful reflex – it keeps mucus from the throat and upper airway out of the lung, and helps move mucus up and out of the lung. Most of this mucus is swallowed; this is fine. The lungs are lined with cells that have tiny hair-like projections called cilia. These cilia all beat in one direction to help move mucus and debris out of the lungs, like an escalator. The cough helps move things along even faster.

One of the biggest problem with cough is that it can interrupt sleep. Because sleep and rest is important to help fight off any virus or other infection, we often recommend treatments that will help with sleep. A teaspoon of honey given at bedtime has been proven to be just as effective as an over the counter cough syrup. You can also use herbal tea with lemon and honey, and vaporizers/humidifiers, steamy bathrooms, and saline nose drops can help to thin the mucous so that it’s easier to cough up.

Remember – not all cough is bad. Sometimes cough is a sign that there is a problem that you need to talk to your doctor about. Most of the time, though, cough is just doing its job to keep the lungs clean. Teach your kids to wash their hands frequently, cough into their elbow instead of onto surfaces or their hand, make sure to get a flu shot and, as much as possible, avoid people who are obviously sick.

 

Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP.

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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.