By Cindy L. Jones
Issue 104, January/February 2001
Antibiotics probably are used more often for the treatment of otitis media, or middle ear inflammation, than for any other purpose in the US. Is this use justified? Several recent reviews in medical journals have suggested that antibiotics provide little if any benefit for otitis media,1 but until now the lack of a good controlled clinical study has made it difficult to evaluate the information. Finally, however, that study is available. Dr. Roger Damoiseaux and colleagues at the University Medical Centre in Utrecht, Netherlands, have published the first controlled clinical trial evaluating the use of antibiotics for otitis media in the British Medical Journal. The study concludes that antibiotics provide no benefit over placebo, or what the researchers refer to as "watchful waiting."2
The study looked at 240 children between the ages of six months and two years from 53 general practices in the Netherlands who were diagnosed with otitis media. Half the children were randomly assigned to receive the antibiotic amoxicillin; the other half received no treatment but were watched carefully in case the condition worsened. Patients were evaluated at days four and 11 and again at six weeks. No significant differences were found between the groups in terms of reported symptoms or a physical examination with an otoscope.
The Problem of Bacterial Resistance
The study's findings are particularly significant because the overprescribing of antibiotics is not without side effects. Although penicillin drugs such as amoxicillin, which is typically prescribed for otitis media, are less toxic than many other antibiotics, they can cause severe allergic reactions and gastrointestinal upset, including nausea, vomiting, and diarrhea. Also, any antibiotic can cause the overgrowth of bacteria or other organisms that are not susceptible to that particular antibiotic. This can lead to yeast infections or "superinfections" of staphylococci.3
More ominously, the increased use of antibiotics has resulted in the development of resistant bacteria. Bacteria that once were killed by a particular antibiotic, in other words, are no longer susceptible to that antibiotic. This makes infectious diseases caused by those organisms more difficult to treat.
For instance, the leading bacteria that cause infections of the middle ear, Streptococcus pneumonia, can also cause pneumonia, sinusitis, bronchitis, and meningitis. S. pneumonia was originally easy to treat with penicillin, but by the late 1980s a penicillin-resistant strain had emerged. In the past 15 years, the number of cases of penicillin-resistant S. pneumonia in the US has more than doubled. In Asia, cases of antibiotic-resistant S. pneumonia amount to 70 percent of total pneumonia infections; in the US such cases are as high as 25 percent. In US daycare centers, antibiotic-resistant S. pneumoniae can be as high as 61 percent.4 These resistant bacteria are passed from one person to another and are particularly high in children with otitis media.
Another study compared the number of antibiotic-resistant isolates of S. pneumonia found in 120 pediatric patients before and after antibiotic treatment for otitis media. After three to four days of antibiotic treatment, there was a significant increase in the number of antibiotic-resistant bacteria found in the nasal passages.5 This suggests that patients previously treated with antibiotics have not only an increased risk of becoming infected themselves with antibiotic-resistant Streptococci but also of passing those bacteria on to other individuals. These antibiotic-resistant strains, moreover, can be fatal because of the difficulty of treating them. In fact, there has been at least one report of death from meningitis caused by antibiotic-resistant bacteria in a child previously treated with antibiotics for uncomplicated acute otitis media.6
Why Do Children Get Otitis Media?
Otitis media (the term actually means inflammation of the inner ear rather than a bacterial infection) is most common in infants and children because of the design of the eustachian tubes, also called the auditory canals. These tubes, which connect the inner ear to the nose and throat, are not fully formed in children. As a result, fluid in the ear cannot drain properly into the nose as it does in adults. When the fluid builds up, it can cause pressure and pain on the eardrum and lead to inflammation, and can provide a good environment for bacteria to grow, resulting in an infection. Typically, by age six or seven, the auditory canal becomes large enough to allow good drainage, and most children stop having chronic ear inflammation at that age.
Other factors affect a child's susceptibility to ear infections. There seems to be a hereditary influence: If you had frequent ear infections as a child, your child may be more susceptible. Children at large care centers tend to get more ear infections than other children, presumably because they are exposed to more bacteria. Children exposed to cigarette smoke also are at an increased risk for both ear infections and respiratory problems. Breastfed babies are less prone to ear infections, probably because of immunological components that are passed through breastmilk.
Decreasing Your Child's Exposure to Antibiotics
Many physicians prescribe antibiotics simply because of patient expectations. Let your physician know that you want to use antibiotics only if absolutely necessary. Make sure the antibiotic you are receiving is the right one. Amoxicillin is the recommended antibiotic for treating ear infections, even for a second incidence.7 Some physicians prescribe broad-spectrum antibiotics, such as cefprozil or cefixime, which are aimed at a wide variety of microorganisms rather than just the bacteria likely to be responsible for ear infections; this practice increases the risk of bacteria developing resistance.
Suggest adopting a watchful approach to the condition. This means that you will watch for any worsening of the condition and seek further treatment if complications appear. Complications from ear infections include mastoiditis (infections in the skull behind the ear) and meningitis. Ask your physician what signs you should look for. Mastoiditis can occur if an ear infection does not clear up after several weeks. Symptoms include pain, redness, swelling, and tenderness behind the ear; a creamy discharge from the ear may also occur. Deafness or meningitis may result if not treated. Meningitis is an inflammation in the lining of the brain or spinal cord and can be deadly if not treated. Its symptoms include a high fever, headache, a stiff neck, and confusion.
Ask your physician about a shorter course of antibiotic treatment. Antibiotic treatments traditionally run for ten days, but few studies support a ten-day course, and European physicians in particular have been investigating a shorter course for ear infections. A recent review of the literature supports the use of a five-day antibiotic treatment for uncomplicated acute otitis media in children.8 Most of these studies, however, used the antibiotic azithromycin rather than the preferred amoxicillin.
Try delaying treatment for a day. In most cases, pain from otitis media resolves in just 24 hours, making antibiotics unnecessary. If pain and inflammation are still present after 24 hours, you can have the prescription filled if you are still concerned. This postponement of treatment is also gaining popularity in Europe. Many physicians believe that it gives the body's immune system time to become activated.9
What about Pain?
The pain of otitis media results from pressure on the eardrum and typically lasts about 24 hours without treatment--a seeming eternity if you are the one caring for the two year old! There are other ways to alleviate pain. The American Academy of Pediatrics suggests applying a warm compress to an older child's ear.10 Use a hot-water bottle, or warm a sock filled with grain or flaxseed heated to a comfortably warm temperature in the microwave or oven. (If you use the oven, take care that the sock does not burst into flame.)
If the child is old enough to chew gum without swallowing it (probably over age three), this will help to relieve the pressure. Gum sweetened with xylitol in particular may be beneficial and reduce the risk of ear infections.11 The American Academy of Pediatrics also suggests using an extra pillow at night to hold a child's head more upright and thus facilitate drainage. If your child is too young to use a pillow, use a wood block or books to prop up the head end of the mattress.
Herbs for Ear Pain
Mullein (Verbascum thapsus) has long been used as a demulcent to relieve congestion and inflammation. Components of mullein have also been found to have antibacterial, antiseptic, and pain-relieving properties.12 A few drops of oil infused with mullein can provide great relief for a child feeling the pain of ear inflammation. Use commercial ear drops containing mullein, or prepare your own ahead of time (making infused oil can take two weeks). To make the oil, cover a handful of dried mullein flowers with a carrier oil such as olive or almond oil. Let the oil set for two weeks, shaking it daily. If you are pressed for time, speed the process by heating the oil and mullein flowers gently on the stove for 30 minutes. Strain and use it when it reaches body temperature, testing it just as you would a baby's formula, by dropping it on your wrist. The oil should be warm but not hot. Cold oil can be warmed gently by setting the bottle in a bowl of hot water for a few minutes. Use a few drops in the ear canal up to three times a day if necessary.
Garlic (Allium sativum) has both antibacterial and antiviral properties13 and is often used in combination with mullein in oil to treat ear infections. Again, either buy this commercially or prepare it yourself. To make it yourself, crush a garlic clove in a few tablespoons of olive oil and gently warm it over the stove for 30 minutes. Strain before use and put a few drops of body-temperature oil in the ear canal.
St. John's wort (Hypericum perforatum) is another herb that may be beneficial for its antiviral, antibacterial, and soothing qualities.14 St. John's wort can be purchased commercially, or you can make infused oil from the tips of the branches, including the flowers and leaves. Put a few drops of oil into the ear canal.
Essential oil of lavender (Lavandula officinalis) has antiseptic and soothing qualities.15 Dilute lavender oil in an equal amount of vegetable oil, such as almond oil. Use a few drops of this warmed oil in the ear canal. Lavender oil, either in the ear or rubbed behind the ear, can also soothe nerves and may help an anxious toddler to sleep.
Drinking peppermint (Mentha piperita) tea can be soothing to a child. Peppermint also has antiseptic and decongestant qualities that can help relieve the pain of ear inflammation.16 You can mix peppermint with chamomile tea, which also is anti-inflammatory and has slight sedative qualities that may help relax a child in pain.
If your child has reoccurring ear infections, consider boosting his or her immune system. This can be done with echinacea (Echinacea) spp. extracts as well as vitamin C.17, 18 With echinacea, use a formula made especially for children, or one-fourth the adult dose for children from two to ten, one-half the adult dose for children over ten. For vitamin C, approximately 500 milligrams per day is a good dose for children. If diarrhea develops, cut back on the dose.
1. S. F. Dowell et al., "Otitis Media: Principles of Judicious Use of Antimicrobial Agents," Pediatrics 101 (1998): 165-172.
2. R. A. Damoiseaux et al., "Primary Care Based Randomised, Double Blind Trial of Amoxicillin Versus Placebo for Acute Otitis Media in Children Aged under 2 Years," British Medical Journal 320 (February 5, 2000): 350-354.
3. E. Jawetz, "Penicillins and Cephalosporins," in Basic and Clinical Pharmacology, B. G. Katzung, ed. (Norwalk, CT: Appleton & Lange, 1995), 680-692.
4. M. R. Jacobs, "Antibiotic-resistant Streptococcus pneumoniae in Acute Otitis Media: Overview and Update," Pediatric Infectious Disease Journal 17 (1998): 947-952.
5. R. Dagan et al., "Dynamics of Pneumococcal Nasopharyngeal Colonization During the First Days of Antibiotic Treatment in Pediatric Patients," Pediatric Infectious Disease Journal 17 (1998): 880-885.
6. M. M. Sloas et al., "Cephalosporin Treatment Failure in Penicillin and Cepaholsporin-resistant Streptococcus Pneumoniae Meningitis," Pediatric Infectious Disease Journal 11 (1992): 662-666.
7. W. J. Hueston et al., "Treatment of Recurrent Otitis Media after a Previous Treatment Failure: Which Antibiotics Work Best?" Journal of Family Practice 48 (1999): 43-46.
8. A. L. Kozyrskyj et al., "Treatment of Acute Otitis Media with a Shortened Course of Antibiotics: A Meta-analysis," Journal of the American Medical Association 279 (1998): 1736-1742.
9. See Note 1, 165-171.
10. The American Academy of Pediatrics, www.aap.org
11. M. Uhari et al., "Xylitol Chewing Gum in Prevention of Acute Otitis Media: Double Blind Randomised Trial," British Medical Journal 313 (1996): 1180-1184.
12. Dr. Duke's Phytochemical and Ethnobotanical Databases, www.ars-grin.gov/duke/plants.html
13. C. A. Newall, L. A. Anderson, and J. D. Phillipson, Herbal Medicines: A Guide for Health-Care Professionals (London: Pharmaceutical Press, 1996), 129-133.
14. See Note 13, 250-252.
15. J. Valnet, The Practice of Aromatherapy (Rochester, VT: Healing Arts Press, 1990), 144-148.
16. M. A. Weiner and J. A. Weiner, Herbs that Heal (Mill Valley, CA: Quantum Books, 1994), 260-261.
17. J. Pepping, "Alternative Therapies: Echinacea," American Journal of Health System Pharmacy 56 (1999): 121-122.
18. H. Hemila, "Vitamin C Supplementation and Common Cold Symptoms: Factors Affecting the Magnitude of the Benefit," Medical Hypothesis 52 (1999): 171-178.
FOR MORE INFORMATION
Jones, Cindy L. A. The Antibiotic Alternative: The Natural Guide to Fighting Infection and Maintaining a Healthy Immune System. Healing Arts Press, 2000.
Reichenberg-Ullman, Judyth, and Robert Ullman. Homeopathic Self-Care: The Quick & Easy Guide for the Whole Family. Prima Publishing, 1997.
Schmidt, Michael A. Childhood Ear Infections: What Every Parent and Physician Should Know about Prevention, Home Care, and Alternative Treatment. North Atlantic Books, 1990.
Schmidt, Michael A., Lendon H. Smith, and Keith W. Sehnert. Beyond Antibiotics: Healthier Options for Families. North Atlantic Books, 1994.
Zand, Janet, Rachel Walton, and Bob Rountree. Smart Medicine for a Healthier Child. Avery Publishing Group, 1994.
For more information about antibiotics and ear infections, see the following articles in past issues of Mothering: "Ear Infections in Children," no. 81; "Natural Remedies for Winter Illnesses," no. 69; and "When Your Child Needs Antibiotics," no. 65.
Cindy L. Jones has a doctorate in biochemistry and molecular biology and is a freelance writer and educator. She lives in Colorado with her husband and two sons, 9 and 4. Her book The Antibiotic Alternative was published by Healing Arts Press in 2000