White Coat Notes

Antibiotics for child ear infections have modest benefits, some risks

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November 22, 2010

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Prescribing antibiotics right away for children with middle ear infections does only a little good and can cause some nasty side effects, a new review of the medical studies concludes.

Middle ear infections are the most common childhood infection treated with antibiotics, but there is surprisingly little scientific consensus on how to diagnose and treat them. Dr. Tumaini Coker and colleagues from Mattel Children’s Hospital UCLA and the RAND Corporation were asked to update guidelines issued by the American Academy of Pediatrics. They pooled the results of 135 scientifically rigorous clinical trials before coming to their conclusions, which appeared in last week’s Journal of the American Medical Association.

They estimate that for every 100 children with ear infections, about 80 would get better in about three days without antibiotics. If all 100 children received antibiotics as soon as they were diagnosed, 12 more children would improve, but three to 10 children would also get a rash and 5 to 10 would develop diarrhea. These rates apply to otherwise healthy children over the age of 1 who don’t have immune system problems or other conditions that would place them at higher risk.

“Not every ear infection needs to be treated with antibiotics,’’ said Dr. Mark Vecchiotti, chief of pediatric otolaryngology at Floating Hospital for Children at Tufts Medical Center. He was not involved in the study. “It’s not easy and we have to resist temptation in sick children to treat them with an antibiotic when we’re not actually sure.’’

Diagnosing an ear infection isn’t as simple as seeing a child tugging an ear, despite what parents may think. Even when a doctor peers through an otoscope and sees a red eardrum, that’s not enough. There needs to be fluid behind the eardrum and some indication that it’s infected, Vecchiotti said. If the child has rapidly become sick — having a fever, not eating or sleeping normally — that also points toward a diagnosis. But ordering antibiotics isn’t necessarily the next step.

Doctors and parents are more aware of the dangers of overprescribing antibiotics thanks to educational campaigns warning that using the drugs inappropriately or too often can make them ineffective. Side effects can add to the problem. If a child on antibiotics develops a rash or diarrhea and parents stop giving the antibiotic before its full course is done, that’s the worst of both worlds, Vecchiotti said. Stopping early can foster the growth of bacteria that are resistant to common antibiotics.

Parents may not like being advised to watch and wait a few days to see if their child’s symptoms go away, especially if a prescription for antibiotics is their child’s ticket back into day care. They should watch for worsening symptoms, such as fever and worsening ear pain. Untreated ear infections can lead to a perforated eardrum or mastoiditis, which is an infection of the bone behind the ear.

If children need antibiotics to get better, first-line antibiotics such as amoxicillin work as well as newer, more costly drugs, the study authors said.

Vecchiotti said there are two things parents can do to prevent further infections, based on other research about risk factors.

“Don’t smoke around your kids, and don’t give your child a bottle to go to bed,’’ he said.


Racial gaps in heart care persist

One of the cornerstones of the 2006 Massachusetts health care law was the belief that improving access to care would narrow health gaps among racial, ethnic, and socioeconomic groups. A new report from Harvard says disparities in the heart treatments provided to black and white patients persisted two years after enactment of the landmark law requiring near-universal insurance coverage.

Dr. Michelle Albert, a cardiologist at Brigham and Women’s Hospital, led a group that analyzed the billing records for more than 62,000 heart patients two years before the law was enacted and more than 61,000 patients two years after. The researchers tracked which patients with blocked blood flow to their hearts received bypass surgery, angioplasty, or stenting.

Before the law was passed, black patients were 43 percent less likely to get these procedures than white patients; Hispanic patients were 17 percent less likely to get them than whites. After the law, those differences did not budge. There was a change among Asian patients. But Albert said that should be interpreted with caution because there were only 1,265 Asian patients in the study. E.C.

Seriously ill say health hurt by economy

Up to a third of Americans with serious illnesses say the economic downturn has hurt their health, according to a new Harvard survey.

The survey also found that 4 in 10 patients said they believe they will be worse off under the new national health care law. Roughly a third said the law won’t make much difference. Only 14 percent of heart and diabetes patients and 11 percent of cancer patients think they will benefit from the law.

“Although experts suggest the health care reform law has provisions that could help people with illnesses like heart disease, diabetes, or cancer, many people who have such diseases do not believe it,’’ Robert J. Blendon, director of the Harvard Opinion Research Program, said in a statement.

The poll was conducted in the last week of October. A nationally representative group of more than 1,500 people were recruited by telephone and interviewed online. The margin of error is plus or minus 6 percentage points. E.C.

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