Scott Webb: Infections in our kids' ears are very common, and depending on the severity or underlying causes or illnesses, antibiotics may be prescribed to help our kids. And I'm joined today again by Dr. Jasmine Makar. She's a great guest and she's a Pediatrician with Stanford Medicine Children's Health.

 This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb.

Dr. Makar, it's so great to have your time again. I was looking back at my calendar, realized it's been a minute, a hot minute since we've spoken, been a couple of years. How are you doing?

Jasmin Makar, MD: I am well, thank you for having me.

Host: Yeah. Today we're going to talk about ear infections, and I was saying we could maybe do a separate podcast on how to teach our kids to pop their ears on planes, but we'll get that one scheduled for another time. Today, let's just focus on ear infections. So how and why do our kids get ear infections?

Jasmin Makar, MD: Yeah, well this is certainly a hot topic. This year has been incredibly busy for us pediatricians, and for parents of young children. There have been a lot more of your, you know, standard respiratory kind of, you know, colds and viruses. And that has led to a lot of ear infections as well, because they are tied together. And for younger kids, it can be an especially kind of difficult and challenging issue, the frequent ear infections and that has a lot to do with their anatomy of their ears and just their overall kind of relative immune system immaturity.

Host: Hmm.

Jasmin Makar, MD: And the fact that they can't kind of equalize the pressure in their ears as easily as older kids and adults. And there's also the added factor of daycare settings, which, you know, just kind of lead to more frequent viral respiratory infections and then often more frequent ear infections for some kids. So that's why this winter has been especially difficult. We had a few years of masking and, and you know, kind of quiet on the illness front.

And then all these kids who didn't have any exposure before, you know, are coming down with every virus. So ear infections often follow a viral respiratory infection. So, kind of starts as a typical cold, cold symptoms and then over several days those cold symptoms instead of getting better like a typical virus, they might, you know, kind of continue and then the kids may develop fever, ear pain. And that's for the older kid who kind of can verbalize their symptoms, right? But for the younger babies and toddlers who can't verbalize their symptoms, you might notice a loss of appetite, some sleep disruption, or more obvious ear rubbing. And those can be signs that there may be an ear infection brewing.

Host: So let's talk about the signs and symptoms of ear infections. Is it always just pain? Is there any sort of discharge, is it kind of a mixed bag?

Jasmin Makar, MD: It can be a mixed bag. And again, for those infants and toddlers who can't really tell us what's going on exactly, you are sometimes just putting all these clues together. But again, fever can be one of those things where it is part of a viral syndrome. It can also be a sign of an ear infection. And so what I tell my families, is that if there was fever kind of at the start of the viral illness and then it goes away for more than a day or so, and then it comes back later in the course; that can be a sign of a secondary bacterial infection and namely, you know, an ear infection.

 Or if there wasn't fever early in the course of the viral illness and then suddenly day four, day five, day six of symptoms, they develop a fever. You know, that's something that I would definitely want to have that patient come in and take a look at their ears,

Host: Yeah, those were the worst with my kids, where they were already sick for three, four days and then the ear infection came on and, you know, it seemingly was like a two week ordeal for them, for us. So when do we know it's time to treat or when do you know, as an expert, when do you know it's time to treat? So we always see you with the little flashlight and you look in the ears, what are you looking for? And then how do you know when treatment is indicated?

Jasmin Makar, MD: Yeah, those are good questions. And that has changed. Some of that has changed a bit over the last several years. So how do we know there's an ear infection? Well, it's a bit of a continuous spectrum. There can be just be fluid in the ear, right? So fluid, which kind of just means that the eustachian tube isn't really doing its job of equalizing the pressure and there's some fluid buildup.

And then there's, you know, kind of frank puss behind the ear drum and a bulging ear drum. And that's a very acute otitis media as we would call an ear infection. And then there's like a complication of an acute otitis media, which is for perforation. So the pressure behind that ear drum is built up a lot, and then it's, you know, perforated the ear drum and then you would see some the ear discharge.

So it's spectrum and the decision to treat is really based on a child's age, how certain we are about the diagnosis and you know, how severe the illness is. So, a younger child who has both ears infected and there is fever, we're going to be more likely to want to go ahead and start antibiotics, at the time of the visit. Right. For an older child, you know, and I'm talking, over age two, who doesn't have a fever, who might only have fluid behind, you know, one ear; we may take like a watch and wait type of approach where we say, let's see how this plays out, because many of those ear infections, those would likely resolve on their own within about three days without any kind of treatment.

So we are, in the past few years taking more of a watch and wait approach for a lot of kids. And this is because, you know, we are much more aware of antibiotic stewardship. We're much more aware that antibiotics have their own potential kind of side effects and unnecessary treatment kind of can lead to unnecessary risks. So, we've kind developed this plan, and it's different than, you know, maybe what we were used to when we were kids.

Host: For sure.

Jasmin Makar, MD: So really we're utilizing a lot of shared decision making with our families, right? We're talking about how long has this been going on already? How much is this impacting the child and the family. There's a quality of life component I think there too. And many times when we are doing a watch and wait approach for the older kids with non-severe disease, you know, we're going to also offer a safety script.

So we'll say, Hey listen, I wouldn't start antibiotics today. Right. You know, this is day one of ear pain and it's very likely that this is going to resolve within a few days. And so, for now, just do some pain medicine. Right. You know,

Host: OTC type stuff, yeah.

Jasmin Makar, MD: That would be acetaminophen or ibuprofen. And then if the symptoms don't get better, or certainly if they get worse and the child develops a fever or both ears are hurting, we'll go ahead and send a prescription in and you can go ahead and start that prescription at that point. But we often have them wait, you know, about 48 or 72 hours before they do that.

That's been, I think a very successful way of treating where we're working together with families to kind of create a good plan that works for them, and also utilizes good antibiotic stewardship.

Host: Yeah. So, when we think about treatment and antibiotics are indicated, is it a, you know, a range there as well, depending on how severe or is it pretty much a standard antibiotic, you know, will do the trick for ear infections.

Jasmin Makar, MD: Well, there's been a lot of studies about the typical bacteria that cause most of the ear infections. And so there is a protocol and, you know, some treatment guidelines that we all tend to utilize. And so the mainstay of treatment for most kind of first ear infections, is your, you know, amoxicillin. And I think we're all used to that one that. The pink one. And it's because it's well tolerated. It's a twice a day medicine typically, and with a low side effect profile. And also it covers most of those typical, you know, bacteria that cause ear infections. So that's usually our first line of treatment and we use what we call like a high dose version of that.

 And that's to penetrate the ear and to get that antibiotic where it's needed, which is in the ear. And if we use the kind of standard dosing for amoxicillin, we have a lot of treatment failure. So we've discovered that over the years. So, definitely seems to be more effective when we use the higher dose of amoxicillin.

And so often I have that discussion with families about even when we don't treat these, they often get better on their own. And we, so we just try to use some analgesia until the body can start fighting this off itself. You know, a lot of parents are really kind of understanding once you educate them on those points. Then they're very willing to kind of wait and see, and appreciate that we're not overtreating things. So we've found it to be very successful.

Host: Yeah, I'm sure that it's a balance. You don't want to undertreat, you don't want to overtreat, getting it just right. It's been really great. It's always nice to speak with you and just get the 411 on all this type of stuff. Questions, I'm sure parents have, maybe some kids they might be listening. As we wrap up here, Doctor, are ear infections contagious? I feel like they're not, but maybe, you know, I didn't go to medical school, so you would know for sure.

Jasmin Makar, MD: Yeah, it's a question we get a lot. I definitely wanted to cover that. So the ear infection itself is not contagious. You are right. It's the viruses that kind of start off the whole thing that are contagious. But the ear infection itself is contained typically within the middle ear. And so it is not contagious. So, I just wanted to make that very clear for parents.

Host: I understand completely because, you know, we know that our kids especially when they're younger, seemingly my daughter, son and daughter went to Montessori school and then kindergarten, and it was like every kid seemed like they were always sick you know, you just don't know. Right. Like, we know that some things are contagious, some things aren't so good to know that ear infections are not. Good information and always great information from you. So thanks so much for your time. You stay well.

Jasmin Makar, MD: Thanks for having me. You too.

Host: And for more information, go to stanfordchildrens.org. And we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.