You have a crying, feverish child who is waking up more frequently than usual at night. Maybe they are also tugging at one ear. You make an appointment with your pediatrician, who examines your child and confirms your suspicion: They have an ear infection.
The pediatrician prescribes an antibiotic, which you know will be a bottle of bubble-gum-flavored pink syrup that you’ll need to store in the fridge. Maybe you have memories of taking the same medication yourself as a child.
Both you and your pediatrician are eager to end your child’s suffering. In addition, you may worry about having to take days off of work to care for your child. Until their fever goes away, they won’t be able to go to school or day care. Everyone involved is invested in helping your child feel better as quickly as possible.
This scenario — an antibiotic prescription for a child’s ear infection — occurs 10 million times every year in the U.S.
Antibiotics are often considered harmless, as they generally cause few side effects (unless someone has an allergy to a specific antibiotic). It might not even occur to you that there could be any downside to filling your child’s prescription, but there are a few reasons to pause before you do.
The downsides of antibiotics
Overuse of antibiotics — primarily in farm animals, but also in humans — has led to the evolution of drug-resistant bacteria, which pose a major health threat worldwide. According to the Centers for Disease Control and Prevention, 2.8 million drug-resistant infections occur in the U.S. every year, 35,000 of them resulting in death.
The immediate side effects of antibiotics are usually mild, with diarrhea being one of the symptoms most frequently reported. As the antibiotics work to attack the bacteria causing your child’s infection, they also attack other bacteria living in and on your child’s body. This collection of microbes, which scientists estimate number in the trillions, are collectively known as the human microbiome, and a growing body of research is revealing the many ways that they impact our health.
Dr. Martin J. Blaser is the Henry Rutgers chair of the human microbiome at Rutgers University. He has studied the impact of early life events on the development of the human microbiome.
“A baby’s microbiome is acquired starting at birth, and is maturing at exactly the same time as the baby is developing,” Blaser told HuffPost.
Babies pick up bacteria in the birth canal and from breast milk, which also contains pre-biotics, or what bacteria consume in order to multiply.
“If the microbiome is perturbed early, for example by antibiotics, it may not develop normally, and there are many studies now showing increased risk of later illness,” he said.
One study that Blaser co-authored showed that one or more courses of antibiotics in the first two years of life increased a child’s risk of developing asthma, allergies, eczema, celiac disease, obesity and ADHD.
Of course, no one is proposing that we stop using antibiotics altogether. “There are important situations in which antibiotic use is absolutely necessary — lifesaving,” said Blaser.
But he believes that doctors should use caution when prescribing them to children. “We need doctors to examine children carefully and decide in whom it is necessary,” he said.
The CDC estimates that 28% of all antibiotic prescriptions in the U.S. every year are unnecessary. That’s a total of 47 million unneeded courses of antibiotics.
In the case of an ear infection, it might be viral instead of — or in addition to — bacterial, meaning antibiotics will be of limited use. One study found that viruses were involved in 70% of children’s ear infections.
When antibiotics are needed
So how can a parent know if their child’s illness truly needs antibiotic treatment?
Don’t be afraid to ask, pediatrician Jen Trachtenberg told HuffPost. It’s “perfectly acceptable for parents to ask, ‘Is an antibiotic really necessary,’ ‘Will it be able to get better without antibiotics?’ or, ‘Why exactly are you prescribing the antibiotic for my child?’”
Trachtenberg added that parents, too, need to temper their expectations about getting a prescription every time their child is sick.
“Often parents are hoping for a quick fix with a prescription medicine so a child will be better faster and return back to school,” she said. “But in fact most illnesses are viral and need supportive care and symptomatic relief like fluids, rest, fever or pain reducers.”
Yet, in a case like strep throat, where a test shows that the infection is bacterial and not treating it could lead to further problems, antibiotics are necessary.
Dr. Janine Zee-Cheng, a pediatrician practicing in Indiana, explained to HuffPost: “The reason for using antibiotics for strep throat is to prevent the progression of disease to scarlet fever and then to acute rheumatic fever. Acute rheumatic fever is a serious disease that can cause long-term heart damage, and even death.”
Other common infections that can be bacterial and responsive to antibiotics include: bacterial conjunctivitis (pinkeye), impetigo (a skin infection), bacteremia (a bacterial blood infection), and bacterial pneumonia.
Sinus infections and urinary tract infections may also require antibiotic treatment, but Zee-Cheng notes that these can be tricky to diagnose in children. Getting a “clean” urine sample from a child in diapers, for example, presents a real challenge.
For some infections, like strep throat, testing is available to determine if bacteria are present. In other cases, such as ear infections, your doctor will determine whether or not the infection is likely bacterial based on their examination and the history of your child’s symptoms.
As for treating that common ear infection? The CDC says that it can go either way — antibiotics might help. They also might not be necessary. It’s not always a black-and-white issue, so your opinion matters.
Zee-Cheng points to a study showing that 78%-85% of ear infections get better on their own, and 75% of antibiotic prescriptions for ear infections are unnecessary.
She added, however, that “infected fluid behind the eardrum can affect hearing,” which is something to consider “in young children whose speech is still developing.”
If you’d prefer to avoid antibiotics for an ear infection, there are a couple of options you can discuss with your doctor. One is “watchful waiting.” This simply means that you wait two or three days to see if your child’s symptoms improve on their own. If not, at that point your pediatrician can prescribe an antibiotic.
Similarly, you and your pediatrician could opt for “delayed prescribing,” which means that the doctor would write the prescription, but you would wait two or three days before filling it to see if the condition resolves on its own.
Note that these guidelines apply to healthy children, not those who are immunocompromised or have other health conditions. Your child’s doctor would take this into consideration.
“Antibiotics are used for so many types of infections, and in so many different scenarios,” said Zee-Cheng. Every child’s case is individual, but parents should also feel comfortable asking questions.
“It’s so important to have a conversation with your pediatrician about what the antibiotic is treating and the benefits of using it, weighed against the decision to not use it. Parents should ask these questions to have a better understanding of what the medication is treating — but also because it empowers parents to make sure that the prescriber can justify a course of therapy and isn’t writing an unnecessary prescription,” she said.