Ear Infection Treatment: An Evidence Based Approach

Ear infections (otitis media) are one of the most common illnesses of childhood and the primary cause for antibiotic use in children, costing the U.S. roughly $5 billion each year. They are serious business, whether you are a parent or practitioner.

According to the CDC, approximately 75% percent of children have one by the age of three and almost half of them have 3 or more ear infections by that age. By the age of 7, 93% of children have experienced an ear infection. A total of 8.8 million ear infections in children were recorded during the year 2006, and the majority of those were in children 7 and under.

 
 

How Does This Happen?

The typical scenario involves an upper respiratory infection such as a cold or the flu. This may produce some discomfort in the ear or even more subtle signs such as tugging at an ear. A quick trip to a primary care provider prompts a peek into the ear and a diagnosis. In some cases, the child actually experiences an earache, but in many others, this “infection” is asymptomatic–it does not produce any noteworthy symptoms.

More often than not, this diagnosis results in a prescription for antibiotics, usually a broad spectrum second or third generation antibiotic (Vaz, Kleinman, Raebel, et. al., 2014). The prescription is taken and within a few days, symptoms subside.

While this scene plays out all over the country, many parents don’t realize that this standard practice is in direct conflict with evidence-based medicine, AAP guidelines, and the standard of care for ear infections across the world. Even fewer parents realize that this standard practice may be causing our children more harm than benefit.

At a Glance

Botanical: Garlic, Calendula, Basil EO
Preparation: Herbal Infusion and EO Dilution
Dose: 1-2 drops
Duration: 2-3x/day
Population: Children with routine ear infections
Effect: Improved recovery in 1-3 days

 

Antibiotic Misuse

Within the United States, five in every six children will experience an ear infection by the age of 2 years old, making ear infections the most common cause of sick-child physician visits and the most common rationale for antibiotic administration. According to the Healthy People 2020 objectives, 77.8% of pediatric visits for an ear infection resulted in a prescription for antibiotics (Healthy People, 2010). 

In spite of this frequent prescription rate, scientific studies show that antibiotics don’t have a benefit in most ear infections. The vast majority of ear infections resolve on their own without antibiotic treatment. This takes a couple of days in many cases, and can coincide with antibiotic treatments, leading many parents to believe the antibiotic is actually curing the infection. 

Because antibiotics are overused in ear infections, we’re now having to use stronger drugs than we could have used in previous generations. This means more side effects and more antibiotic resistance. According to the AAP, “Greater resistance among many of the pathogens that cause AOM has fueled an increase in the use of broader-spectrum and generally more expensive antibacterial agents.”

Ear Infection Treatments: Risks & Benefits

According to the scientific literature, initiating antibiotic use at the first visit may slightly reduce the symptoms on days 2-7 in around 5% of children who are treated.  However, antibiotics for ear infections actually cause adverse effects in 5% – 10% of children. So it harms as many children as it helps–in fact, it takes needlessly treating 20 children with antibiotics for a single child to see even a slight benefit (Venekamp, et.al., 2013). Meanwhile, for every 14 children who are treated, a child experiences an adverse event. Additionally, antibiotic treatment can cause infrequent but serious side effects and it increases the risks of antibiotic resistance. These side effects are numerous and can lead to chronic health concerns.

Perhaps most noteworthy: antibiotics don’t relieve pain or distress. They will not help little ones feel better sooner. Antibiotics target bacteria. They do not alleviate pain and if the infection is viral (or in many cases, mere inflammation and not an infection at all), antibiotics can actually worsen the symptoms. Reducing the inflammation and the accumulation of fluid will actually address the pain. And antibiotic does neither of those things. 

This knowledge is hardly emerging. The AAP has clearly recommended since 2004 that practitioners use the “wait and see” approach for most children. Given that 61% of children naturally have decreased symptoms within 24 hours, with or without antibiotics, the official recommendation is that antibiotic use be delayed for the first 48-72 hours in most children (Rosenfield and Kay, 2003). This will dramatically reduce the use of needless antibiotics, reserving them for the small percentage of children that would receive the most benefit.

 
 

An Evidence Based Approach 

The recommended approach is called the “wait-and-see” approach, meaning the provider should wait and observe the earache for 2-3 days to see if the symptoms begin to subside before writing a prescription for an antibiotic. 

The wait and see approach merely allows the ear infection to go away on its own–as studies reveal will happen if nothing is done. However, while antibiotics offer more risk than benefit, there are many botanical solutions that do offer benefit and enable parents to take actions rather than simply waiting to see what will happen. These interventions have been shown in the scientific literature to reduce the total duration of an ear infection and to help make a child more comfortable.

 
 

Botanical Solutions

Perhaps the most commonly utilized at-home treatment is garlic oil. This is based on the understanding that garlic is antimicrobial and the oil will act as a natural alternative to antibiotics. However, this approach is faulty as it still focuses on microbes, rather than comfort. Scientific research on garlic oil includes anti-inflammatory botanicals so that the infused oil can both bring about pain relief and address any microbes that may be present. 

A study published in Pediatrics outlines a double blind trail using a garlic, mullein, calendula, St. John’s Wort, and lavender infused olive oil, as compared to amoxicillin. The researchers found that, after 3 days, the group with the herbal ear drops had better improvement than those with the antibiotics. The herbal drops were less expensive, well absorbed, and better tolerated thanks to the avoidance of those previously mentioned adverse effects. 

Sweet basil essential oil also holds potential as a valuable ingredient in a natural ear preparation. A 2005 study looked at the potential for sweet basil (linalool ct) to reduce overall healing time for ear infections (Kristinsson, 2005). This study found that a sweet basil oil led to significant improvement after just 1 day for most children with full recovery for most children after 3 days. While most ear infections are viral, these results were found in children who had bacterial ear infections–both gram positive and gram negative.

Note: Natural ear oils should not be applied to eardrums which have ruptured. If in doubt, confirm the diagnosis to ensure that the diagnosis is an actual infection and not simply redness or swelling.

 

 
 

Comfort Measures & Advanced Care

Because scientific evidence shows that most of ear infections subside on their own within a couple of days–or a week at the most–increasing comfort is by far the most important approach. Treatments should include other measures to reduce the pain, including OTC pain relievers, if appropriate. 

Additional natural options include warm compresses, gentle osteopathic manipulation techniques, and massage. Orange essential oil can also be diffused in the area for 15-30 minutes as studies reveal that the inhalation of orange oil reduces overall pain perception. 

While the vast majority of ear infections resolve on their own, a very small percentage of infections may require more advanced interventions. If the symptoms do not begin to subside after 2-3 days or persist longer than 7 days, it is possible that the ear infection needs advanced care–or that the ear infection has actually progressed to something more serious.

Additionally, infants under the age of 6 months should always be seen by a care provider right away. When working with any health condition at home, a well educated team of professionals is always the best resource to have on your side.

 
 

REFERENCES:

  1. Coker TR, Chan LS, Newberry SJ, et al. Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in Children: A Systematic Review. JAMA. 2010;304(19):2161-2169.
  2. Del Mar, C. B., Paul, P. G., & Hayem, M. (1997). Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ314(7093), 1526.
  3. Gates, G. A. (1996). Cost-effectiveness considerations in otitis media treatment. Otolaryngology–Head and Neck Surgery114(4), 525-530.
  4. Healthy People 2020. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.
  5. Kristinsson, K., Magnusdottir, A., Petersen, H., & Hermansson, A., (2005). Effective treatment of experimental acute otitis media by application of volatile fluids into ear canal. The Journal of Infectious Disease. 191:1876-1880.
  6. Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., … & Schwartz, R. H. (2013). The diagnosis and management of acute otitis media. Pediatrics131(3), e964-e999.
  7. Rosenfeld, R. M., & Kay, D. (2003). Natural history of untreated otitis media. The Laryngoscope113(10), 1645-1657.
  8. Rosenfeld, R. M., Vertrees, J. E., Carr, J., Cipolle, R. J., Uden, D. L., Giebink, G. S., & Canafax, D. M. (1994). Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. The Journal of Pediatrics124(3), 355-367.
  9. Soni, A. (2008).Ear Infections (Otitis Media) in Children (0-17): Use and Expenditures, 2006. Statistical Brief #228. Agency for Healthcare Research and Quality, Rockville, MD.
  10. Vaz LE, Kleinman KP, Raebel MA, Nordin JD, Lakoma MD, Dutta-Linn MM, Finkelstein JA. Recent trends in outpatient antibiotic use in children. Pediatrics. 2014;133(3):375-85.
  11. Venekamp, R. P., Sanders, S., Glasziou, P. P., Del Mar, C. B., & Rovers, M. M. (2013). Antibiotics for acute otitis media in children.
 
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