Obesity in Childhood

How is obesity defined?
What are the causes of childhood obesity?
Energy Stored = Energy Intake – Energy Expenditure
What are the complications of childhood obesity?
How is childhood obesity evaluated and treated?
Are there additional treatments available for childhood obesity?

Sharon H. Travers, M.D.
Assistant Professor of Pediatrics
University of Colorado Health Sciences Center
Denver, Colorado
Obesity in childhood and adolescence is one of the most serious nutritional problems facing the United States today. The prevalence of overweight children has increased by over 50% in the past two decades. The most recent data from 1990 indicates that 22% of children and adolescents are overweight. The highest percentages are among non-Hispanic Black girls and Hispanic boys at 30% and 27%, respectively.

How is obesity defined?
Obesity relates to excess body fat. In adults, body mass index (BMI) is used to define obesity. BMI is calculated by dividing one’s weight in kilograms by one’s height in meters squared (kg/m2). BMI is used because it provides a reasonable estimate of adiposity (body fatness), and it relates to adverse health outcomes. Obesity in adults is defined as a BMI greater than 30 because a BMI greater than 30 is associated with an increased risk of medical problems.
In children, the medical side effects of obesity often are not readily apparent. Consequently, deciding how to define obesity in childhood has been somewhat difficult. The International Task Force on Obesity recently suggested that BMI should be used to screen for childhood obesity. BMI in children has been shown to correlate with such complications as high blood pressure, high cholesterol, diabetes, and persistence of obesity into adulthood.
The specific BMI cutoff points have not yet been established, but it will probably approximate the 85th and the 95th percentiles. For example, children who have a BMI greater than the 95th percentile for their age and their gender are considered obese (see Figure). Children who have a BMI between the 85th and the 95th percentiles are also overweight but are not defined as obese until they are greater than the 95% percentile.

What are the causes of childhood obesity?
There are very few medical causes of obesity in childhood. Hormonal abnormalities that lead to increased weight gain in children typically are associated with short stature or poor height growth. Examples of such conditions include hypothyroidism, Cushing’s syndrome, or growth hormone deficiency. Consequently, an overweight child who has normal height growth is unlikely to have one of these hormonal abnormalities.
There are several genetic syndromes that are associated with obesity; however, these conditions generally have short stature as a coexisting finding. Additionally, developmental delays and unusual physical features commonly are part of these syndromes. A doctor can rule out the majority of syndromes and hormonal disorders by performing a careful history and a physical examination. Occasionally, blood tests or radiological examinations are performed as part of an evaluation.
The majority of obese children do not have a recognizable syndrome or a hormonal abnormality. Therefore, to understand the various proposed causes of weight gain in children, one should be familiar with the following energy balance equation:

Energy Stored = Energy Intake – Energy Expenditure
Energy stored equates to weight gain, and energy intake is calories consumed from food and beverages. Energy expenditure is composed primarily of one’s basal metabolic rate (the number of calories expended just to lie still and the major component of total energy expenditure) and energy expended for activity.
Consequently, if one’s energy intake exceeds energy expenditure, weight gain occurs. An individual gains 1 pound of weight for approximately every 3,500 excess calories. Consequently, an extra 10 ounces of juice or can of soft drink (at 150 calories each) every day would amount to a weight gain of 15 pounds per year.
Most individuals regulate their body weight so precisely that it only fluctuates by about one-half pound per year. This is because each person has his/her own “set point” for body weight, and various metabolic pathways in the body defend this set point. Changes in appetite and metabolic rate occur in response to weight gain or loss, thereby “driving” weight back to its “set point.”
For example, overweight individuals who lose weight may have lower resting metabolic rates than lean individuals, so they would need to eat less to maintain their reduced weight. This may be one reason why diets have such a high failure rate.
Children who have overweight parents are more likely to be overweight themselves. This observation suggests that individuals can inherit certain genes that make them susceptible for weight gain. Studies indicate that genetic factors determine up to 75% of our body weight. Thus, an individual who inherits a low basal metabolic rate may be susceptible to increased weight gain. Genes also may affect energy intake by determining specific feeding behaviors and food preferences.
Given that the genes in our population have not dramatically changed over the past several decades, genetic factors alone cannot explain the rise in obesity. Rather, it is the interaction between a genetic predisposition and an environment that is conducive to weight gain. Our technically advanced society-boasting energy-saving devices and convenient, high calorie foods-has led to changes in both activity and eating patterns.
People have increased their dining at restaurants, visiting of fast-food chains, and buying of prepared grocery items. Meals at restaurants tend to be very caloric because they are served in large portions, and they are high in fat and calories (see Table). We are led to believe that super sizes are a great deal because of the financial discount; however, they are not such a great deal in regard to the gain in calories.
Table. Approximate Calorie Content of Fast-Food Items
Double cheeseburger 600
Chicken nuggets (6 pieces) 290
Small french fries 250
Chicken sandwich 500
Chocolate Shake (12 oz.) 440
Pepperoni pizza (2 slices) 500
Additionally, most schools serve lunches that are high in fat and include choices from fast-food chains. Currently, there is no evidence that children are born with a preference for high fat foods. Rather, experts believe that liking certain foods is learned through repeated experiences with such foods. Observing what and how their parents eat also may shape children’s food preferences. Parents are role models; consequently, if they like to eat high fat food, their children will likely do the same.
Spontaneous, as well as intentional, physical activity has decreased in children. Participation in school physical education classes has declined significantly; a recent survey indicated that approximately 50% of high school students were not enrolled in regular physical education classes. Children also are spending their time out of school in sedentary activities, such as watching television and playing computer games.
Several cross-sectional studies report a direct association between the amount of television watched to the degree of childhood obesity. Watching television not only limits the time for exercise and vigorous activity, but also encourages snacking and consumption of high fat foods through advertisements. Parental concerns over safety also may contribute to decreased activity in children, as their neighborhoods may not be perceived safe enough to play outside.
Lastly, children of non-active parents tend to be less active themselves. Consequently, like the modeling of eating patterns, parents may be modeling sedentary activities and reliance on labor-saving devices. The positive aspect of these environmental factors is that they are, unlike genetic factors, modifiable.

What are the complications of childhood obesity?
Although the majority of weight-related problems are not seen until later on in life, an overweight child may have complications that are evident. It is important for an obese child to be evaluated for the potential consequences outlined below.
Cardiovascular Disease – Many children who are overweight have elevated blood pressures (hypertension), high cholesterol, and high triglycerides. These conditions are more likely to be seen in an overweight child whose family history is positive for cardiovascular disease, hypertension, or high cholesterol.
Endocrine – Although there is rarely an endocrine cause of obesity in childhood, there are several endocrine side effects. Overweight children often have accelerated height growth; therefore, during childhood, they are tall compared to their peers. This growth acceleration appears to be a normal result of over-nutrition, and it is actually a reassuring finding, as it eliminates the majority of pathologic causes of obesity. The timing of puberty may occur on the early side in overweight children.
Adolescent girls who are overweight may experience menstrual irregularities, including infrequent or absent periods. Many young women who have polycystic ovarian syndrome are overweight. Irregular menstrual periods, acne, and/or excess body hair characterize this disorder. Lastly, many overweight children have evidence of insulin resistance. Insulin is a hormone produced by the pancreas, permitting glucose to be transported from the blood to the cells of the body.
Insulin resistance can contribute to high cholesterol and triglyceride levels. Overweight children who have insulin resistance have an increased incidence of developing diabetes mellitus in adolescence, especially when there is a family history of diabetes. In many individuals, thickening and darkening of the skin (called acanthosis nigricans) in such areas as the neck, the underarms, and the elbows are signs of insulin resistance.
Orthopedic – Because of the extra weight that they must carry, overweight children are at an increased risk for orthopedic problems. Children may complain of leg and ankle pain that is due to stresses in the joints. In younger children, bowing of the legs may occur.
Gastrointestinal – Obesity in children can lead to fatty deposits in the liver. Although this rarely causes any health problems, there can be scarring and damage to the liver in severe cases. Gallstones also are associated with obesity; however, the incidence of this complication is much higher in obese adults.
Pulmonary – Overweight children may have obstructive sleep apnea, a condition that occurs when there is an obstruction in the upper airway, making breathing difficult during sleep. In overweight children, the obstruction may be due to fat deposits in the walls of the upper airway and by the increased work of breathing that results from fat in the abdomen and the chest. Obstructive sleep apnea may impair learning and memory function in children. It also can cause excess daytime sleepiness, which may lead to an increase in sedentary activity and further weight gain.
Psychological – The greatest costs of childhood obesity may be psychological. Young children may be teased because of their weight, and they may have difficulty making friends. Because they tend to be taller, obese children may be perceived as being older than they really are and may have unrealistic expectations placed on them. Self-concept may be low in an overweight child, especially during adolescence. How a child deals with these negative attitudes is in part related to how their parents feel about him/her. If parents accept their child regardless of his/her weight and focus on positive attributes, their child is more likely to have a positive self-concept.
Persistence – Although not an immediate consequence, the risk of childhood obesity persisting into adulthood is important, as there are serious medical complications associated with being an overweight adult. The risk persistence depends on the child’s age, gender, and degree of overweight. Studies indicate that 25% of overweight preschool children versus 80% of overweight adolescents will become obese adults. Adolescent girls, in particular, appear to have a greater risk than boys. Additionally, the more overweight a child is at any age, the likelihood of obesity persisting into adulthood is higher.

How is childhood obesity evaluated and treated?
An overweight child should be evaluated to determine if there is a pathologic cause for his/her weight gain and if there are any weight-related health problems. A primary care doctor should begin this evaluation, and he/she will decide if laboratory tests and/or a referral to a specialist are indicated. Treatment of obesity depends on the age of the child, the degree that the child is overweight, and the family’s or the child’s willingness to change. A successful treatment plan includes dietary, physical activity, and behavior modification components. It is important that all family members are involved and are willing to make necessary changes themselves.
Treatment can be implemented through a primary care doctor or a structured weight control program. Initial goals should be small, so that the family and the child are not overwhelmed or discouraged. In a moderately overweight or very young child, weight maintenance, rather than weight loss, may be the goal, as the child is growing in height and thus may “grow into” a more normal BMI.
Dietary – Diets that focus on eliminating specific nutrients have not been studied extensively in children. Consequently, it is recommended that changes be made in a step-wise manner to decrease the fat and the calorie content of the diet. A nutritionist often is helpful in evaluating a child’s eating patterns and in educating families how to make healthy low calorie choices. A child’s diet should be analyzed, with particular attention to the amount of juice and soft drink consumption, frequency of eating outside the home, school lunches, portion sizes, and snacking.
Juice and soft drinks alone can account for a significant amount of extra calories each day. For young children, it is the parents’ responsibility to determine when and how many times a child eats and what food is offered. The child’s responsibility is to decide how much he/she wants to eat (within reason). If the child does not like what is offered, the parents’ job is not to find something the child will eat. “Short order cooking” does not encourage children to learn about new foods, such as fruits and vegetables.
Activity – Exercise, in addition to dietary changes, is recommended for optimal weight management. The most important factor in choosing an activity or an exercise program is finding something that the child likes to do. Children are more likely to participate in an activity that they, rather than their parents, choose. The activity does not need to be an organized sport, but any type of activity or play that is sustained. For example, walking the dog, playing outside with friends, and riding a bike are all beneficial. Limiting sedentary activities (e.g., television and computer time) is very important, as this will increase a child’s activity level.
Behavior Modification – Various behavior modification techniques may help a child be successful in achieving weight management goals. Self-monitoring by keeping diet and activity records enables an older child to be more aware of his/her eating and activity patterns. To provide a “safe” environment, parents should limit the amount of high calorie foods in the house, discourage eating in front of the television, and serve age-appropriate portion sizes.
Having scheduled meals and snack times and eliminating between-meal eating is in everyone’s best interest. Decreasing the frequency of meals eaten outside the home and sending a bag lunch to school also are ways to make a healthier diet. Modification of eating habits may include taking smaller bites, chewing food longer, and putting the fork down between bites with the goal of increasing meal/snack duration to at least 15 minutes. Reinforcements and rewards for achieving weekly dietary and activity goals also may be helpful.

Are there additional treatments available for childhood obesity?
There are many medications that have been used successfully in adults to aid with weight loss; however, the Food and Drug Administration has not approved these medications for use in children. At this time, medications for childhood obesity are limited to clinical studies and for some extraordinary medical situations. Gastric surgery also has been performed with successful results in adults, but there have not been enough studies in children to recommend this procedure.
Figure reprinted with permission from the American Journal of Clinical Nutrition.

Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. Pediatrics 1998;102:E29.
Himes JH, Dietz WH. Guidelines for overweight in adolescent preventive services: recommendations from an expert committee. Am J Clin Nutr 1994;59:307-16.
Strauss R. Childhood obesity. Curr Probl Pediatr 1999;29:5-29.
Troiana R, Flegal KM, Kuczmarski RJ, Campbell SM, Johnson CL. Overweight prevalence and trends for children and adolescents. The National Health and Nutrition Examination Surveys 1963-1991. Arch Pediatr Adolesc Med 1995;149:1085-91.
About the Author
Dr. Travers is an assistant professor of pediatrics at the University of Colorado Health Sciences Center in Denver, Colorado. She is board certified in both pediatrics and pediatric endocrinology.
As a clinician at The Children’s Hospital of Denver, she provides care to those children with various endocrine disorders. Her clinical and research interests include Turner syndrome and childhood obesity.
Copyright 2012 Sharon H. Travers, M.D., All Rights Reserved

Otitis Media, Acute

What is acute otitis media?
What causes acute otitis media?
How does it cause disease?
How common is acute otitis media?
Who gets an ear infection?
Is an ear infection contagious?
How do you know if your child has an ear infection?
What does the eardrum look like when it is infected?
How is an ear infection treated?
What are the complications?
How can an ear infection be prevented?
What research is being done?

by Stan L. Block, M.D.
Associate Clinical Professor of Pediatrics
University of Louisville and University of Kentucky
What is acute otitis media?
Acute otitis media is an infection of the middle ear, generally caused by bacteria. In acute otitis media (i.e., an ear infection or an infection of the middle ear), pus and infected fluid accumulate in the middle ear space.
The tympanic membrane (eardrum) appears inflamed, reddened, and often protrudes outward. Usually, an ear infection begins after the eustachian tube (a small tube connecting the back of the nose to the middle ear space) has become swollen, congested, and closed, most commonly resulting from an ongoing viral respiratory infection.

Acute otitis media should not be confused with: 1) external otitis (“swimmer’s ear”)-a painful bacterial infection of the superficial skin of the ear canal, or 2) otitis media with effusion (secretory otitis or “fluid ears”)-an accumulation of non-inflamed fluid behind the eardrum. Otitis media with effusion is not considered infected, and most doctors do not treat it with antibiotics. This uninfected fluid in the middle ear is a remnant in 50% to 60% of resolved ear infections. It is frequently a mild complication of colds, respiratory illnesses, or nasal allergies.

What causes acute otitis media?
Acute otitis media usually is caused by one of four bacteria:
. Streptococcus pneumoniae (pneumococcus) in 30% to 45% of cases.
. Haemophilus influenzae (Haemophilus-but not the Haemophilus strain in the HIB or meningitis vaccine) in 20% to 30% of cases.
. Moraxella catarrhalis (Moraxella; sometimes called Branhamella catarrhalis) in approximately 10% of cases.
. Group A Streptococcus (like the strep bacteria of strep throat) in 5% of thecases.
The pneumococcus bacteria is now the most difficult to treat. Some strains have become very resistant to antibiotics by using their unique ability to transform their genes and cell wall into a bacterial form, which is resistant to most of the antibiotics that commonly are used to treat ear infections. These resistant strains frequently are cultured from children who do not respond to several courses of antibiotics. When a child has an ear infection that does not respond to antibiotics, resistant pneumococcus bacteria may cause it.
Pneumococcus has 90 different types, which are all genetically related; however, 7 types account for the majority of ear infections in childhood and nearly all of the antibiotic resistant strains. In addition, pneumococcus is the leading cause of meningitis, bloodstream infections, and serious pneumonia in children, sometimes as a result of a preceding ear infection.
Up to half of Haemophilus and nearly all Moraxella bacteria produce an enzyme (beta-lactamase), which makes these bacteria resistant to some of the commonly used antibiotics. This enzyme may destroy many antibiotics when they come in contact with the bacteria. Nonetheless, several available antibiotics are still quite effective against these strains.
Viruses play a critical role in the development of acute otitis media by enabling the bacteria to travel into the middle ear (see below). By themselves, though, viruses account for only 6% to 10% of ear infections.

How does it cause disease?
As long as air entering from the back of the nose is able to reach the middle ear space via the eustachian tube, the middle ear rarely becomes infected. The eustachian tube in younger children is flimsy and easily collapses. As the child grows, the cartilage tissue surrounding the eustachian tube becomes stiffer, longer, and more angulated inside the skull.
Pneumococcus, Haemophilus, and Moraxella commonly reside in the back of the nose, and do not infect the child. Once a child becomes infected with a respiratory virus, it not only causes congestion of the nose and the lungs, but also of the eustachian tube. When this tube becomes clogged, the cells in the middle ear space produce a fluid-like substance, which allows bacteria to grow and infect the middle ear space. A virus infection precedes up to 90% of cases of acute otitis media.
Respiratory virus infections also trigger ear infections by upsetting the body’s normal defenses in the nose and the eustachian tube, and allowing certain normal bacteria that reside in the nose to “stick” better to the lining of the nose and the eustachian tube. Certain viruses, such as the flu (influenza) and RSV (a respiratory syncytial virus, or the “bronchiolitis bug”), are more frequently associated with ear infections. Occasionally, the child’s nose becomes colonized by a new aggressive strain of bacteria, which rapidly invades the middle ear. Unfortunately, more exposures (e.g., via daycare attendance) to viruses and new strains of bacteria increase the likelihood of ear infections.

How common is acute otitis media?
Acute otitis media is predominantly an infection of young children, primarily occurring in the first three years of life. Children in the 1990s experience 30% more episodes of acute otitis media as compared with children in the 1970s, probably as a consequence of high rates of day care. Currently, acute otitis media accounts for one-fourth of all pediatric office visits in the first three years.
Nearly 94% of children will experience at least one ear infection in the first three years of life, with an average of about three episodes in the first and second years, and one and one-half episodes in the third year. As many as 5% to 8% of children will undergo the placement of ventilating tubes in their first 24 months of life. Much of this is related to the high rate of daycare attendance in the United States, with increased exposure to infectious agents.

Who gets an ear infection?
At the highest risk for ear infections include those children who:
are male;
are of the white, American Indian, or Eskimo races;
attend daycare;
have Downs syndrome;
are immunocompromised;
have a strong family history of otitis media;
were not breastfed during the first 12 months of life; and/or
reside in a smoking household.
Children with a cleft palate or HIV have particularly severe problems with recurrent ear infections.
Age affects the rate of acute otitis media, with a dramatic decline in frequency in children older than three years. However, some children with a history of ventilating tubes or frequent recurrent otitis media, severe allergies, or large adenoids may still be plagued with ear problems.

Is an ear infection contagious?
To some degree, the bacteria that cause ear infections are contagious because they may colonize, or set up residence, in the nose of children or close contacts. However, only a small proportion of children colonized with a new strain of bacteria will develop an ear infection. For example, in the case of pneumococcus, only about 15% of children colonized in the nose with a new strain of it will develop an ear infection, and usually only within the first month. Also, some bacterial strains appear more aggressive than others and will directly invade the middle ear.
What may be even more important than new bacterial colonization is the spread of respiratory viruses, particularly among children in daycare and pre-schools. Respiratory viruses are very contagious in close quarters. They frequently make a child more susceptible to an ear infection by upsetting the normal balance between the child’s local nose immunity and the co-inhabitant bacteria. When the child’s defenses are down, or the eustachian tube becomes clogged, the bacteria tend to infect the middle ear.

How do you know if your child has an ear infection?
Children with an ear infection display a wide range of symptoms, from none at all, to a high fever, to a screaming earache. Many infants and toddlers with an ear infection show less obvious symptoms, such as sleeplessness, irritability, decreased feeding, or a fever. Ear pain and ear tugging are helpful clues, but are fairly unreliable. Even in older children with a respiratory illness, mild to moderate ear complaints and earaches frequently occur in children with normal ears. In these children, a sore throat often causes the ear complaints. Fever occurs in only one-fourth of ear infections, and it does not signify an ear infection.
One of the more reliable indicators of an ear infection in younger children is when a child, who has had a cold and a runny nose for three to seven days, suddenly develops sleeplessness and inconsolability during the night, along with increasing fussiness throughout the day. Children with a persistent ear infection who have recently received antibiotics often show few symptoms.
Antibiotics should not be prescribed over the phone for a presumed ear infection, without an examination by a physician. Only a careful examination of the eardrum by a doctor can determine whether the ear is truly infected. Often, when the child is brought into the office in the early phase of a cold or a mild respiratory infection, the eardrum will be normal, only to become infected several days after the office visit. If the child has only a mild cough and a runny nose, it is best to wait at least five to seven days into the illness before making an office visit.
The new EarCheckTM (acoustic reflectometry instrument) may help parents to determine whether a young child is getting an ear infection. If a previously healthy child, who now has an illness, develops an abnormal reading on the instrument, parents can assume a 70% chance of fluid behind the eardrum. It will not distinguish between infected or uninfected fluid. More importantly, if the readings are normal and the child’s symptoms are mild, parents can assume that it is very unlikely that the child has an ear infection, and an office visit may be avoided.

What does the eardrum look like when it is infected?
When a doctor examines the eardrum through the otoscope instrument, the eardrum normally appears as a thin gray, translucent membrane (like wax paper). When infected, it will look opacified (cloudy), very reddened, and yellowish. Sometimes, it shows a small layer of pus-like material. During an infection, the eardrum usually becomes rigid because of the accumulation of fluid, and it will not wiggle when the doctor puffs a small amount of air against the eardrum with an otoscope. Use of tympanometry or acoustic reflectometry (i.e., the EarCheck instrument) may help to determine if there is fluid behind the eardrum. Neither instrument distinguishes between infected or uninfected fluid.
From the appearance of the eardrum, the doctor cannot determine the type of bacteria, or whether bacteria or viruses are causing the infection. The eardrum in children with otitis media with effusion appears as an orangish or dull, straw-colored fluid, and it also does not move when air is applied to it.

How is an ear infection treated?
The intense ear pain of acute otitis media can be partially relieved by adequate doses of ibuprofen or acetaminophen. For more severe earaches, some doctors may prescribe codeine. Numbing eardrops provide minimal relief, and only for a short time. A warm washcloth or sweet oil (olive oil) directly instilled in the ear canal may temporarily distract from the child’s ear pain.
Nearly all doctors in the United States believe that acute otitis media should be treated with antibiotics by mouth, particularly if the child has symptoms. Antibiotics generally provide prompt and dramatic relief of the ear pain. Oral antibiotics for acute otitis media are safe and effective, with exceedingly rare serious side effects.
In a few European countries, ear infections are not treated in children older than two years, unless symptoms persist for more than 48 hours. A few U.S. physicians recommend this same tactic.
Most experts in the United States are concerned about the tendency for pneumococcus in an ear infection to cause more serious infections. When pneumococcus causes an ear infection, if left untreated, it will persist in the ear of 80% of children for up to a week. However, most episodes of acute otitis media will resolve on their own from 3 to 10 days. Yet, non-treatment may be dangerous, not only because of the risk of serious pneumococcus infections, but also because of the possibility of other serious complications. Furthermore, few parents are willing to watch a child suffer with an earache, a fever, and crying for several days.
Amoxicillin (the “pink ink”) is the drug of choice for initial ear infections, except in the penicillin allergic child. In an attempt to enhance the effectiveness of this inexpensive and safe antibiotic, many doctors are now prescribing amoxicillin twice a day and in double the daily standard dose. Effectiveness for initial therapy with most antibiotics approaches 70% to 80%. There are other antibiotics to treat children who do not respond to amoxicillin or who never seem to respond to initial amoxicillin therapy.
Children who do not respond after two or more standard courses of antibiotics can be expected to respond to another antibiotic only about 50% to 60% of the time. Most children who fail antibiotic therapy are younger than 24 months, have poor eustachian tube function, and tend to be infected with more resistant bacteria. At this point, the easy-to-treat bacteria usually have been eliminated. The persistent bacteria are the most resistant strains of the three most common ear bacteria. The emergence of more resistant strains is outpacing the development of new effective drugs. A child’s doctor should be relied upon to select the most effective second-line antibiotic choices.
The new “one-shot” (ceftriaxone) for acute otitis media also is effective for simple cases of acute otitis media. However, “the shot” should only be used in select children, such as those with vomiting and diarrhea, very cantankerous toddlers, or children with an associated moderately serious illness. Three daily doses of ceftriaxone also may be very effective in children who have failed three to four consecutive courses of antibiotics, and are destined for tube placement.
The Centers for Disease Control (CDC) has convincingly pointed out that antibiotic overuse is one of the major culprits for the increasing antibiotic resistance problem. Parents should not insist on an antibiotic prescription for fevers, minor colds, and respiratory illnesses.
Physicians almost never know which bacteria they are treating. Thus, the CDC and other otitis experts advocate the use of tympanocentesis (lancing the ear or ear tap) for children who have failed antibiotic therapy.
relieves instantly the pain of the child with a crying earache; enables the physician to culture the bacteria and to select the best antibiotic for the infection; and allows the ear infection (like an abscess) to drain, which may improve the healing process.
The procedure can be performed nearly pain free. Only physicians who have been trained in the procedure perform it.
No medication is currently available to treat viruses that precipitate ear infections, either before or during the illness. An exception is the flu virus. Anti-flu medications and the flu vaccine could help prevent some wintertime ear infections, but only for the small number of children with ear infections related to the flu.

What are the complications?
The most serious complications secondary to ear infections are mastoiditis (infection of the skull bone behind the ear) and meningitis (infection of the lining of the brain). Both are extremely rare.
Chronic draining ears and chronic perforations (holes in the eardrum) are uncommon, but occur more frequently as a result of resistant pneumococcus. However, these complications are commonly seen in developing countries where antibiotics are not readily available. Permanent hearing loss from very severe recurrent infections is a major concern, but is still rarely observed with effective antibiotic therapy. Children with an ear infection (even ones that rupture and drain) suffer only some temporary, low grade hearing loss. As the fluid resolves, which may take months, the hearing returns to baseline levels.
Your child’s doctor may work with an ear-nose-and-throat doctor to help treat the more severely afflicted child, or one who has suspected chronic hearing loss. Children with chronic fluid persisting for more than four months, or with more than five or six ear infections in a year, may require the insertion of “tubes.” This is most important during the first two years of life when hearing is critical for speech and language development. Chronic ear infections may aggravate learning and later school problems, but cause and effect on this issue remains speculative.
Severe complications from ear infections nearly have been eliminated, and there is an array of antibiotics to treat them; however, the rate of highly resistant bacteria infecting children has increased. Physicians cannot continue to wastefully prescribe antibiotics, and parents should not demand them to treat everyday colds and viral infections. Although the new Prevnar vaccine may prevent many strains of highly resistant pneumococcus, with continual antibiotic misuse, microbiologic history will repeat itself in other pneumococcal strains or in other bacteria.

How can an ear infection be prevented?
The simplest preventive measures include the following:
Breastfeed an infant during the first 12 months of life
For bottle-fed infants, never prop the bottle and wean off the bottle by 12 months
Do not smoke around the baby, particularly in the household or the car
Do not smoke during pregnancy
Consider a private sitter or a smaller daycare, instead of a high volume daycare
Avoid the introduction of solid foods in the first four months of life
Administer the flu vaccine annually after six months of age
Consider allergen avoidance and allergy shots in older children (over three years) with chronic fluid
Administer Prevnar vaccine to infants less than 24 months of age
More controversial preventive measures include the following:
Avoid the pacifier
Give the pneumococcal vaccine (Prevnar) to infants and children older than 24 months who are unvaccinated with Prevnar and still getting recurrent ear infections
Ineffective measures include the following:
Covering a child’s head with a hat during the winter
Using decongestants and antihistamines to “prevent” ear infections
Chiropractic manipulation
Herbal remedies

What research is being done?
The most important recent development to potentially reduce the frequency of ear infections is a new pneumococcal conjugate vaccine. A study from Northern California suggests that this vaccine could prevent about 7% of overall episodes of ear infections, and up to 23% of recurrent ear infections.
The new pneumococcal vaccine contains 7 of 90 types of pneumococcus, which are the most common and the most resistant bacteria. Elimination of these resistant types could have an impact on the number of antibiotic failures in children. This also could mean a reduction in the placement of tubes, possibly by one-fourth, as observed in the California study.
This vaccine is administered to infants at 2, 4, 6, and 12 months of age. Side effects have been minimal, and it has been a very safe vaccine. It uses the same technology as the universally administered HIB vaccine.
ome new antibiotics are about to undergo testing in children with acute otitis media. In preliminary testing, these drugs appear to work against the resistant pneumococcus.
In the future, there may be alternate ways of treating or preventing ear infections. A new antibiotic may be able to penetrate the eardrum directly by instilling eardrops. A nasal spray squirted in the nose of infants a few times a day may prevent the common bacteria of acute otitis media from gaining access to the nose. Some Scandinavian investigators have shown slight reduction in the number of ear infections in children who regularly used an experimental sugar called xylitol.

About the Author

Dr. Block is a full-time practicing pediatrician in rural Bardstown, Kentucky who serves on the clinical faculties at both the University of Kentucky and the University of Louisville as an Associate Clinical Professor of Pediatrics.
His pediatric practice is one of the leading pediatric research groups in the United States and, in fact, Dr. Block was awarded the American Academy of Pediatrics 1998 Practitioner Research Award.
He has authored and published over 20 articles and 40 abstracts on pediatric infectious diseases. He has also lectured on Otitis Media extensively to pediatricians and other physicians throughout the U.S. and Canada.
Copyright 2012 Stan L. Block, M.D., All Rights Reserved