Ears, Noses and Throats By Lisa Glickstein, Ph.D, Triplet Mom Originally printed in July, 2005 By far, one of the most dreaded of childhood ailments are ear infections. An ear infection guarantees at least one and maybe many sleepless nights with a miserable, wailing child, as well as at least one unplanned trip to the pediatrician with all that entails. Parents usually want whatever will give quickest relief and are heavily biased in favor of antibiotics, particularly if they have worked in the past. Doctors are inundated with research studies warning against overuse of antibiotics and risks of generating antibiotic-resistant bacteria. What about ear tubes? No one really wants to put in ear tubes, with all of their complications, even though everyone knows they work. When does a sore throat need antibiotics? At last, the years of nearly universal tonsillectomy have passed, but some families have to endure adenoidectomy in every child. Here is a rundown on the latest information for these common complaints. My child has an earache – what should I do? Most earaches begin as viral infections of the nose and throat that back up into the ears. The blocked-up fluid becomes a breeding ground for bacteria, and a viral earache can turn into a bacterial one. Try to catch and treat a mild earache before it becomes severe, with some over-the-counter remedies (if you child is younger than nine months, call you doctor first). We used a decongestant (like Sudafedtm) to help shrink swollen tissues so fluid can drain, in combination with ibuprofen (Adviltm or Motrintm) to reduce inflammation. Remember that acetaminophen does not reduce inflammation. If the decongestant makes your child too agitated or restless, you can substitute an antihistamine (like Benadryltm) that will dry up the secretions and make him or her drowsy and more likely to sleep. There are non-medical options as well, including propping up the head end of the crib or bed, or having an infant sleep in a carseat to help drainage. Convincing an older child to sleep with his or her head propped up can help. Apply a warm, dry compress to the affected side (warm a wet washcloth very briefly in the microwave and seal in a Ziploc – not too hot! This works for stomachaches too!), or the old remedy of hot salt (heat on the stove in a dry skillet) in an old, thick sock. Please do not burn your child! For an infant, lying on mom or dad’s chest or stomach, skin-to-skin, may be enough warmth to give relief. Using a suction bulb to remove secretions from the nose can help with breathing and drainage. As with all sick children, keep up the fluids, which will thin secretions. If you have a child who is prone to earaches, try these remedies at the first sign of a cold. Certain signs should send you immediately to the pediatrician, including fever over 100oF (perhaps a bit higher in older children or those prone to higher-than-average fevers with viral infection), strange-colored discharge from the nose (bright green or yellow, or bloody), or any discharge from the ear itself. Any earache that lasts longer than three days, or a severe earache, is due to be seen by the pediatrician. Should I insist on antibiotics? It usually takes one to three days for an earache to go away. Antibiotics will not make a viral earache go away any faster. Many pediatricians will give a prescription for antibiotics at the first visit, with instructions to wait two days to fill it if needed. This avoids a second pediatrician visit. For children having a first earache, or who only get an earache once a year, this is excellent advice and may avoid future problems. Go over the over-the-counter regimen with the doctor and ask for any other advice they have for relief measures. Children who have frequent bacterial earaches, or who have had a recent (within a month) documented bacterial earache, can probably press the pediatrician a bit if they receive this recommendation. It is possible that the prior infection has not been cleared fully. However, remember that children who have had multiple or even a single recent earache will be more sensitive to swelling (both physically and likely emotionally), therefore, the level of pain alone is not a good indicator if the earache is viral or bacterial. Good pain relief is important whether antibiotics are used or not. If your child does begin an antibiotic prescription, finish it completely according to the doctor’s instructions, even if your child is feeling better, or the antibiotic has given him or her mild gastrointestinal upset. Call the pediatrician if you feel the need to stop the prescription, as he or she may suggest an alternative antibiotic or a relief measure for the side effect. What about ear tubes? Ear tubes are a hearing-saving measure for many children who have had frequent earaches or fluid-filled ears. Tympanotomy tubes allow fluid to drain out of the middle ear (by changing air pressure in the ear, they may also help the drainage tubes down into the throat work better). When the fluid is removed, hearing is restored, and also the breeding ground for bacteria is gone as well so infections are reduced. However, ear tubes require a surgical procedure that entails some risks, and care afterwards to prevent the ears from getting wet (affecting bathing and swimming). For these reasons, many pediatricians and parents try to avoid placing ear tubes. This is appropriate caution, but it is good to remember that ear tubes work, are usually placed without complications, and that there are special earplugs that can be worn to allow swimming. Ear tubes are sometimes placed for children who don’t have earaches, but present with hearing loss and are found to have fluid in the middle ear. Why does my child get so many earaches compared with other children? This is an important question to ask. For some children, genetics that control the shape of the drainage tubes from the ear (Eustachian tubes) are to blame. They may have a parent who had frequent earaches as a child. However, there are many other conditions that predispose a child to earaches, including tonsillitis or adenoiditis, allergies and reflux (gastroesophogeal reflux disease – GERD). Children with frequent earache should be referred to a good ENT (ear, nose, throat specialist) for a full evaluation. Particularly, GERD may need to be evaluated separately. This condition is newly recognized to complicate many throat and ear problems, as the acid reflux leads to inflammation of the throat and can help block the Eustachian tubes or set up a fertile environment for bacterial growth. Treating the underlying GERD, or allergies, can prevent or reduce the number of earaches. What about having the tonsils or adenoids removed? A referral to an ENT is required to assess the tonsils and adenoids. Tonsils rarely need to be removed. Tonsillectomy was frequently performed during my childhood and earlier in order to prevent future complications of tonsillitis. However, it is now recognized that the tonsils and adenoids are important immune organs, especially in young children. It is also known that most children will improve with antibiotic treatment, and that tonsillectomy rarely gives enough improvement to warrant the surgery and its risks. In some cases, where the tonsils have formed an abscess, or are involved in extensive infection of the head and neck (lymph nodes or sinuses), the surgery is performed. Adenoidectomy is performed if the adenoids are so swollen that they impede breathing, or if ear tubes have been placed and earaches are still occurring. It is not uncommon for many children in the same family to require this surgery. However, as allergies and GERD are recognized earlier and treated appropriately, it is hoped that this will prevent adenoid infection and surgery will no longer be required. What about sore throat? Sore throats are usually viral, occur before other symptoms (like runny nose), and go away in two to three days, just as the runny nose begins. These type may be accompanied by a mild fever or headache, but usually do not prevent normal activity or eating and drinking. A sore throat that is accompanied by a high fever, severe headache, and particularly vomiting in younger children may be caused by streptococcus, commonly called strep throat. Strep throat requires treatment with antibiotics and untreated strep throat can lead to more severe complications. There is an in-office rapid test for one of the types of streptococcus that can cause strep throat and a swab is also taken to be sent out for culture. These tests are usually only positive after at least 24-hours of infection. Furthermore, newer recommendations are that children only be treated with antibiotics for strep throat after two to three days of illness, so that they have time to build up some immunity to the strep germs. The hope is that this will reduce their chance of getting reinfected in the future. So, if you suspect your child has strep throat, you should wait at least a full day before going into the pediatrician, unless your child is severely ill, or you will likely have to make another visit. In the meantime, treat with acetaminophen or ibuprofen for symptomatic relief. Strep germs can live for several days on a toothbrush, so it is important to throw away your toothbrush after several days but before you finish your antibiotics so you don’t reinfect yourself! Strep throat is contagious, but not as much so as a cold virus. Children can go back to school if their fever is gone and they have been on antibiotics for at least 24 hours. If there are many cases in a classroom or a family over an extended period of time, it is possible that someone in the family or class is a healthy carrier of the streptococcus. If the family member or classmate can be identified (by testing at their family doctor) and treated, the cases may stop.