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Ear Infections in Pediatrics: Prevention, Treatment and When to Refer · Pediatrics in Practice: A CME Podcast

• 0:01
  Mike (Host): This is Pediatrics in Practice, A CME podcast.
• 0:05
  I'm Dr.
• 0:06
  Mike, and with me is Dr.
• 0:07
  Laura Neff from Children's Mercy.
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  Today we're gonna dive into pediatric ear infections, focusing on prevention
• 0:15
  treatment, and when to refer.
• 0:18
  Dr.
• 0:18
  Neff, welcome to the show.
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  I wanna get right into a big question for, I think the, the general public and even,
• 0:27
  you know, for, uh, general practitioners.
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  Why are ear infections so prevalent?
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  And what anatomical or developmental factors contribute to this?
• 0:41
  Laura Neff, MD: Yeah.
• 0:41
  Well thanks for having me.
• 0:43
  there are several reasons that young children get ear infections.
• 0:48
  The first one that I talk to parents about is that their eustachian tube And the
• 0:53
  eustachian tube is the tube that drains your ear down to the back of your nose.
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  It is shorter.
• 1:00
  And smaller and more horizontal when they're little.
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  It doesn't really get to adult size and function until you're about 10 years old.
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  so this makes it harder for little kids, especially seven and under five and under.
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  For them to get rid of fluid in their middle ear space.
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  So that's one.
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  So that fluid can trap bacteria, viruses.
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  And then on top of that, you've got little kids that are, in daycare.
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  So they're getting exposed to lots of different new pathogens.
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  and kids have immune systems that are still developing, so they're not as
• 1:36
  capable of fighting off infections.
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  So,
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  Mike (Host): So in a sense, You know, if you think about it and tell me if I'm
• 1:41
  wrong, in little kids, you know, the, the connection between the ear and your
• 1:46
  sinuses and all that fluid, it's just, it's easier for all that fluid to move.
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  From sinus to ear, ear to sinus, And then you add, add in an immune system
• 1:58
  that's still learning and growing and boom, you get a lot of infection.
• 2:03
  Laura Neff, MD: Yeah, yeah.
• 2:04
  It's everything in the back of their nose.
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  And you think about all the snot you see in little kids' noses,
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  especially in the ear, nose and throat clinic, all that can go straight
• 2:12
  into the middle ear pretty easily.
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  And then another thing is little kids have, bigger adenoids and adenoids are the
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  tissue, same tissue as your tonsils, which most people are familiar with tonsils.
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  but it's at the back of your nose and they can even obstruct those tubes as well.
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  So, it can be.
• 2:28
  Little kids have a tough go with ear infections.
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  Mike (Host): Can you walk us through the different types of ear infections?
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  you hear about middle ear, outer ear and all this kind of stuff.
• 2:37
  Like go, go through that for us.
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  Laura Neff, MD: Yeah, This is a tough thing to understand
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  because you can't see any of it.
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  So we have lots of posters in our offices that show and kind of break
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  down the different parts of the ear.
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  So what I like to tell parents is that there are really three parts.
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  So you have the outer ear, which is the ear canal, which is where like
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  ear wax lives, and that's the part that you can kind of look into.
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  And then you have the eardrum, which is a wall between.
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  The ear canal And the middle ear.
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  And the middle ear is supposed to be full of air.
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  Has your ear bones in it, and That is where ear infections, you think about like
• 3:11
  an acute ear infection that really hurts.
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  That's where that happens.
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  And then the inner ear is really all bone, and that's where then
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  the nerve goes from the inner ear to the brain for sound signals.
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  So there's always some confusion about otitis ex sternum, which is a infection
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  of the ear canal where the wax is versus.
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  Acute otitis media, which is really an infection of that space that's supposed to
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  be filled with air, and that's the space that connects to the back of the nose.
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  So when kids are swimming in a pool and have draining stuff out of their
• 3:44
  ear, That is usually otitis, externa, or an infection of the ear canal.
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  Mike (Host): Yeah, we used to, so I grew up in Southern California as a
• 3:52
  kid, And we were swimming all the time, and I remember me and, and my friends
• 3:58
  with a lot of that otitis Externa.
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  Laura Neff, MD: Yeah, it's really painful.
• 4:02
  Mike (Host): Yeah.
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  That, And that was the big thing, Dr.
• 4:04
  Neff, I remember that.
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  It, it wasn't, you could hear Okay.
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  The ear didn't feel really full.
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  It was just, it hurt.
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  And that's a difference between otitis media, which which is more
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  like a fullness almost, right?
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  Laura Neff, MD: Right.
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  And that's something that we always talk to families about is the
• 4:21
  treatment is so different, right?
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  So the treatment for otitis externa or swimmer's ear is
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  drops through the ear canal.
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  And another important factor is to really clean out all the debris
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  that's in the canal because.
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  If you can't get the drops to the ear canal And the skin that's
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  hurting, then it won't get better.
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  So one of the key treatments for a swimmer's ear is making sure the ear
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  canal is cleared of debris, which is very different than an ear infection
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  in the middle ear, where if you don't have ear tubes, you need to treat
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  with potentially with antibiotics.
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  Mike (Host): when I was young, again, going back to those days, there were a
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  lot of home remedies for otitis externa.
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  different solutions and stuff that people swore about.
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  Not necessarily true, right.
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  Laura Neff, MD: You know, there are some kids who maybe have more narrow
• 5:12
  ear canals or maybe are more prone to having more wax that can trap water
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  and bacteria in their ear canal.
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  So for those kids who are maybe.
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  They're getting swimmer's ear once a month in the summer.
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  we do have some preventative things that we'll have them do.
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  One is keep the ear canal clean as much as possible.
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  And There are actually rinses that you can do with like a white vinegar,
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  solution to kind of help dry out the ear.
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  Some kids who are like competitive club swimmers and they swim year round,
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  I'll actually have them hold a hair dryer at arm's length and kind of
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  just try to dry out that ear canal,
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  Mike (Host): Yeah,
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  I remember that.
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  Laura Neff, MD: Yeah, so there are certain things you can do to try
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  to decrease the incidence if it's you have a kid That is prone to it
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  Mike (Host): Now when you going from externa to media or otitis
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  media, you mentioned antibiotics.
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  how often do you have to use antibiotics versus watchful waiting?
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  Laura Neff, MD: for the otitis cerna or the otitis media.
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  Oh yeah.
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  So media, I follow the recommendations of the American Academy of
• 6:18
  Pediatrics or the a a p, and they support watchful waiting for 48 to
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  72 hours for mild ear infections.
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  And that's in kids over two.
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  'cause a lot of times it resolves on their own, especially if it's like a viral.
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  And so you can support them with pain control, with Ibuprofen or Tylenol.
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  they do recommend antibiotics.
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  For severe cases, which is high fever, severe pain, or kids that are
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  under two with bilateral infections.
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  And so since this change, it, it's kind of decreased unnecessary antibiotic use.
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  And then also, you know, a lot of those kids have pretty bad side effects type of
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  rash and everything else from amoxicillin.
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  so I really follow the a EP guidelines on that.
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  Mike (Host): Well, what are the red flags though that are gonna tell you, okay,
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  I need to write a prescription here.
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  Laura Neff, MD: So immediate antibiotics are recommended for kids that are
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  less than six months old, And then kids who are six months to two years
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  that have severe symptoms, which is considered high fever or severe pain.
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  And then also kids who have bilateral infections.
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  Mike (Host): And that right there.
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  So Those are your red flags.
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  You're gonna be getting them on antibiotics.
• 7:25
  Laura Neff, MD: Yeah.
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  Yeah.
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  in the ENT clinic we usually see kids that, are being referred from
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  all the primary care physicians who have been treating these
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  acute otitis media episodes.
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  And we also see the complications of where, acute otitis media can go with
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  mastitis and other complications.
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  So, if you certainly need to treat, then treat.
• 7:42
  Mike (Host): What about prevention?
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  Are there any preventative strategies that have proven to be effective?
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  Laura Neff, MD: they've done studies, you know, kids who ha who
• 7:51
  breastfeed generally do better.
• 7:53
  Of course, we promote vaccination.
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  Environmental changes can be helpful too, although sometimes they're not realistic.
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  secondhand smoke is a known risk factor for ear infections, so we always
• 8:03
  encourage parents if they do smoke to.
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  be outside of the house And then change clothes if they're gonna
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  come in and hold the child.
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  daycare is something That is a constant source of infections and pathogens.
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  but that's not an option for a lot of families to take their kid out of daycare.
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  sometimes you can have a smaller family-based daycare.
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  It might make a difference.
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  And then not having bottles in bed, so laying flat on their back.
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  Holding a bottle can also be bad for ear infections.
• 8:30
  Mike (Host): going back to the breastfeeding that you mentioned,
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  is that really just related to better immune system for the child?
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  Laura Neff, MD: Yeah, it's really just providing some immune protection for
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  the first four to six months of life.
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  Mike (Host): so that's a recommendation.
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  Now you mentioned vaccination as well.
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  is there any specific vaccinations you're talking about or is the vaccinations
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  that these kids are getting just also helping to train their immune system?
• 8:56
  Laura Neff, MD: The Pneumococcal vaccine And the influenza vaccine
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  can be helpful for ear infections.
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  Mike (Host): that's interesting.
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  I
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  didn't know that.
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  Laura Neff, MD: yep.
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  Mike (Host): so breastfeeding, vaccination, and if you can, environmental
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  changes, which is gonna be the hard one, I think for a lot of people.
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  Laura Neff, MD: Yeah.
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  I think the main thing is really avoid secondhand smoke at all costs for these
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  kids.
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  Mike (Host): that's good for all of us.
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  Right.
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  Laura Neff, MD: Yes.
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  Yeah,
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  Mike (Host): let's talk about kids with recurrent ear infections.
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  When should pediatricians consider referring them to an
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  ENT specialist like yourself?
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  for ear tubes or, you know, other in interventions.
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  Laura Neff, MD: Yeah, I think about in indications for ear tubes, uh,
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  involving kind of two, two reasons.
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  One is the recurrent ear infections.
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  If a kid has had three or four ear infections within six
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  months, it's probably time to think about sending them over.
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  The guidelines mention that if kids are having lots of ear infections, they
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  should have fluid on exam when we see them in ENT clinic to get ear tubes.
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  That being said, there are some other reasons or indications to go ahead and do
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  ear tubes in kids who have ear infections.
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  One is they're on to like getting ception shots, right?
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  So these are kids who have had amoxicillin, they've had Augmentin,
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  they've had cine ear, and now they're getting cept shots.
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  And I think about it, okay, we are putting a kid through that
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  versus a five minute anesthetic for ear tubes and all the antibiotic
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  exposure that their gut is getting.
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  sometimes.
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  Some point it makes more sense to get ear tubes.
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  other kids that have had like a febrile seizure, when they have ear infections,
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  that's kind of another loose indication.
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  kids who have eardrum ruptures multiple times, then we think about, okay,
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  maybe we should get a tube in for that.
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  And then the other reason is fluid.
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  That's been there for a long time And so chronic otitis media can affect
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  hearing, it can affect balance.
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  The indications to put tubes in for chronic fluid.
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  Is to have fluid for three months or more and have evidence of hearing
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  loss on, an audiogram or hearing test.
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  Mike (Host): How often do you, you know, in your practice, how
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  often are you placing, the tubes?
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  Is this something that's common or not common?
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  Laura Neff, MD: Oh, very common.
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  Mike (Host): Yeah.
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  Laura Neff, MD: Yeah.
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  I'm actually gonna do a set right after
• 11:13
  our podcast,
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  Mike (Host): there you go.
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  Yeah.
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  So This is common.
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  And what kind of, like when you're talking to parents about this, what
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  do you tell them about the ear tubes?
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  Laura Neff, MD: the main thing I try to stress is that the benefit
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  of ear tubes, if it's for a kid who has recurrent ear infections, I feel
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  like one of the best benefits of the ear tube for a child is to decrease
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  systemic antibiotic exposure because when you have ear tubes, you can treat.
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  Ear infections through the ear canal, through the ear tube
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  into the middle ear space.
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  So you should be able to treat it at home.
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  So, it saves you a, a visit to a pediatrician.
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  It saves you oral antibiotics.
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  And also comfort.
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  I mean, I don't know if you've had an ear infection recently, but they hurt.
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  They're really uncomfortable.
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  And so, that takes away that pressure 'cause the ear can
• 11:59
  drain through the ear tube.
• 12:00
  So Those are kind of the three benefits I think about.
• 12:03
  Mike (Host): it's been a long time since I've had an, ear
• 12:06
  infection, but I have had them and I remember just, yeah, very painful.
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  And it's hard to like sleep.
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  Laura Neff, MD: Yes.
• 12:13
  Yes.
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  Mike (Host): to get comfortable,
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  Laura Neff, MD: Yep.
• 12:16
  Mike (Host): you know, so I do, I do remember all of that.
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  Now when it comes to kids with frequent infections, what about
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  speech and language development?
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  Do you see issues there?
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  Laura Neff, MD: You can, it is normal for.
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  Patient's who have ear infections, even though the infection goes away And the
• 12:35
  pain gets better, you can actually have fluid in your middle ear space for up
• 12:40
  to two months after an ear infection.
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  So then you think about, okay, if they're getting an ear
• 12:44
  infection every three months.
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  You know, they're only having a little bit of time where they have a clear
• 12:48
  ear to hear well, and if you have fluid, you can have anywhere from
• 12:52
  a mild to a moderate hearing loss.
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  And so it's kind of like they're hearing underwater, so you might
• 12:56
  be talking to them and they might hear you, but it's muffled.
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  And so kids, of course, learn by imitating what they're hearing in
• 13:02
  their environment and So, it makes it hard for them to, pronunciate
• 13:06
  and, and hear what they need to hear.
• 13:09
  Mike (Host): You're listening to Dr.
• 13:10
  Laura Neff from Children's Mercy.
• 13:12
  just to kind of wrap this all up, as a specialist in, in all of this
• 13:17
  that we're talking about are there any emerging treatments, technologies
• 13:22
  that you're really excited about?
• 13:24
  Laura Neff, MD: Yeah, so one thing that's kind of coming down the pipeline
• 13:28
  is, there is a, it's called Optical coherence tomography that I'm been
• 13:32
  interested in is it's a light that helps you see through the eardrums, you can
• 13:36
  actually see the middle ear space better.
• 13:38
  and that's something, I guess, that's used more in the eye world, than ENT.
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  Now, the other cool thing is they've had.
• 13:44
  Smartphone apps where you can see into the ear.
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  You can even get 'em on Amazon for like 20 bucks, and I've gotten
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  some, but now they're starting to have AI technology also help.
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  Determine whether or not there's fluid.
• 13:57
  So for people who aren't used to looking at an eardrum, you could
• 14:00
  just, diagnose it at home almost.
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  And so that's kind of an interesting tool that's kind of coming down
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  the, the pipeline, just adding the AI element to the otoscopes, the
• 14:10
  smartphone otoscopes that already exist.
• 14:12
  and there is some technology that people are working on and some people
• 14:16
  are doing it in office, but doing ear tubes and young children in office.
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  There's a special technique that, peruses the ear canal with a numbing medicine
• 14:25
  And then it has like a little gun that shoots in the ear tube really quickly.
• 14:28
  it hasn't been adapted nationwide that much yet just because in general, ear
• 14:34
  tubes are so quick and easy in the or.
• 14:37
  but it is kind of an interesting concept because it is los anesthesia.
• 14:40
  Mike (Host): That is very fascinating.
• 14:41
  Dr.
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  Neff, I want to thank you for coming on the show today.
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  This has been a lot of great information and I really appreciate it.
• 14:49
  For more information, you can visit CM KC link slash CME podcast.
• 14:56
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  Of interest to you.
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  This is Pediatrics in Practice, A CME podcast.
• 15:06
  I'm Dr.
• 15:07
  Mike.
• 15:08
  Thanks for listening.