Ear Infections and Antibiotics

February 12th, 2013 posted by Gwenn Schurgin O'Keeffe, MD, FAAP

Do you remember the good old days when we were given an antibiotic for just about everything and often over the phone?? Those days are clearly gone and there’s current evidence that they are likely not to return any time soon. This is great news to our kids’ bodies and the growing problem of antibiotic resistance. Recent medical advances have taught us so much more than we knew in the past and we have confirmation after confirmation that most childhood illnesses are viral and viruses get better with time. But there are always exceptions and treating acute ear infections in children is one of them. While most ear infections are viral, some are not. So, current guidelines are aimed at using antibiotics very judiciously and are becoming more widely accepted and practiced. // From a public health perspective, focusing on ear infections so vigorously makes sound sense as they place a huge burden on our medical system with more than 10 million yearly antibiotic prescriptions and 30 million doctor’s office visits per year. Family life also takes a toll with missed school and work days.

Current guidelines are based on multiple studies in the United States and Europe which have taught us some important lessons:

  • for kids toddler age and older, most ear infections are caused by viruses so antibiotics are not needed;
  • infant ear infections are usually bacterial and require antibiotics;
  • the ear infections needing an antibiotic will declare themselves with persistent symptoms, especially ear pain.

So, if your infant has an ear infection, you will be given a prescription that day. But if your toddler or older child has an ear infection, controlling pain and fever for 2-3 days is the rule of thumb with Tylenol or Motrin, and numbing ear drops. If your child still has symptoms 2-3 days later, an antibiotic will be prescribed. Sometimes you will be given the prescription at the initial visit but advised to not fill it for 2-3 days. What about ER visits? A recent Journal of the American Medical Association study demonstrated that this approaches works well even if used in the emergency room with a doctor who doesn’t know the family well. In that study, 60% of parents given an antibiotic prescription did not need to fill the prescription. There is a big between the lines message here as well. It is perfectly safe and appropriate to wait at home for 2-3 days if your child has ear pain then see your doctor. This also means you don’t need to schlep your child to the emergency room at 3am if he or she awakens in pain. You have some time to let the situation evolve. So, next time your child wakes you up at 2am with ear pain, take a deep breath, give your child some Tylenol or Motrin, and see what happens. Your pediatrician is only a phone call away in 2-3 days if the discomfort persists, but there’s a good chance by then the ear pain will be a distant memory and your lives will be back to normal.


The following feedback was received from an FC visitor. Dr. Gwenn’s reply follows: Dear Dr. Gwenn: I am replying to your ear infection protocol. While I truly agree with you that doctors are too quick to prescribe antibiotics, I disagree with the wait at home and see point of view! I have 5 children and we have had our share of ear infections over the years. By the time my children wake up in pain or tell me about their ear pain, their ear drums are bulging! Just 3 weeks ago I had three of my children at the doctor for their ear pain. I took them all to the doctor the same day that they told me about the pain…all three of them had an ear drum burst! I didn’t read any caution about that in your story! Please let parents know that if they wait and see that this is a possible outcome. Also, this may cause hearing loss as happened to my 10 year old. I appreciate your great articles; but, I wanted to make sure that all possible problems are discussed. Thank you, KG

Dear KG:

Thank you for your comment. Let me clarify a few points that may help you understand this better. First, it is the bulging, painful ear drum (tympanic membrane is the technical term) that is diagnostic of acute ear infections so all children with ear infections have to have that. Pain is also part of the picture. Rupture happens rarely but it does happen. The cause is pressure build up from fluid and is a way for the ear to release the pressure, and for the pain to subside. Antibiotics don’t prevent this; it is a fluid accumulation issue and will occur if it is going to occur with or without antibiotics. That said, an ear infection that causes a ruptured tympanic membrane should always be evaluated by a pediatrician and antibiotics are usually used in this situation. This is a unique situation and would not fit into the wait and see category. Finally, hearing loss does occur in some children due to frequent ear infections. Many kids have a temporary reduction in hearing after an ear infection because fluid can persist in the middle ear up to 3 months after an infection. But, antibiotics do not prevent this from occurring. For children who have more significant hearing loss, consultation with an Ear/Nose/Throat doctor is usually considered. The bottom line is most ear infections in kids 2 years of age and older are thought to be viral and self-limited. Studies really do prove that over 80% of children get better without antibiotics. But, that still leaves 20% who may need antibiotics. The wait and see plan allows for kids who need the antibiotics to get them and the kids who don’t to not. Best,

Dr. Gwenn

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Gwenn Schurgin O'Keeffe, MD, FAAP (36 Posts)

Pediatrician, Dr. Gwenn Schurgin O'Keeffe, MD, is a board-certified pediatrician and Fellow of the American Academy of Pediatrics. Dr. Gwenn is an experienced columnist, educator, and practicing pediatrician. Dr. Gwenn strives to write as if she were talking to a parent. As a parent herself, she knows how important it is to obtain information but also understand how precious little time parents have to find that information on the internet. Pediatrics Now was developed to fill that gap and provide a bridge between the parenting and pediatrics worlds.


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