The pediatrician's office that Katie Young takes her three children to has five doctors. She dreads those mornings when one of her children wakes up feverish and fussy and she calls in only to discover that the only pediatrician available is Dr. X.

"This doctor won't give antibiotics even if I can tell that my kid needs them," says Young, of Austin, Texas. "After three kids, I think I know a little bit about what's up with my own kids' health. I'm not the only parent that feels that way, either. We don't really understand why she has to drag everything out; it just takes longer for the kids to get better."

It's parents like Young that are going to be the tough sell now that the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) have released their long-awaited new guidelines for ear infections.

Wait and See
These guidelines have been in the works for some time, and they are controversial simply because they suggest using pain relief rather than antibiotics in some cases – even if there is evidence of infection. As the chart below shows, these guidelines will be based upon both age and symptoms.

This is not a new idea. The medical community has been becoming increasingly worried about American's over-reliance on antibiotics for a number of years. The impetus behind this movement is that the number of antibiotic-resistant illnesses is growing. And it's ear infections in children that account for a huge number of the antibiotics currently prescribed.

Dr. Richard Rosenfeld is a New York-based pediatrician and co-chair of the Otitis Media With Effusion subcommittee for the AAP, as well as a consultant for the guidelines on acute otitis media. "The main reason we're doing this is because there are terrible problems with antibiotic resistant diseases," says Dr. Rosenfeld. "People die more and more from infections that are resistant to antibiotics and this happens from a liberal use of antibiotics. They create hardier bacteria that are just waiting to spring into action."

Dr. Rosenfeld says that the New York State Department of Health published a set of guidelines back in 2002 that advocates observation first, antibiotic treatment later. Called the "Observation Option Toolkit for Otitis Media," it is a forerunner of the new national guidelines.

A Difficult Diagnosis
Currently, the problem with prescribing antibiotics for ear infections, according to Dr. Rosenfeld, is that diagnosing an ear infection often isn't cut and dried. "To make a diagnosis of what is called an ear infection, the first thing you have to have is a space behind the ear filled with fluid, mucus, pus, bacteria, etc.," he says. "Second, there must be signs and symptoms that are consistent with infection such as fever, ear pain, rubbing, poking or pulling. With those two components there's no doubt that an ear infection is the problem and treatment can proceed from there."

However, he says, sometimes, while the signs and symptoms are there, the doctor never actually sees physical evidence of true otitis media. This is not because of incompetence or a lack of knowledge, but merely because it's not always easy to see behind the eardrum, and when a small child is in distress, it's often easier to just assume an ear infection and prescribe the antibiotic.

Dr. Rosenfeld also acknowledges that it's going to be difficult to convince some parents, like Young, that there is a better way to treat her child's discomfort. Doing so, he says, requires education therapy to replace the antibiotic therapy. "One thing doctors need to be able to do is to provide parents with some sort of education and materials to show this isn't just some crazy thing they thought up," he says. "It's important for them to understand that the main reason this is being done is because there are terrible problems associated with the overuse of antibiotics."

An Ounce of Prevention
Other issues that are addressed in the new ear infection guidelines are some of the environmental factors that contribute to ear infections. These include the prevalence of ear infections in children in daycare situations, in lower income households and in bottle-fed babies. Again, it may be tough to convince some parents that their baby may just be healthier at home.

Dr. Ari Brown, a pediatrician in Austin, Texas, and the author of Baby 411:Clear Answers and Smart Advice for Your Baby's First Year (Windsor Peak Press, 2004), says she knows it's tough to ask a working parent to change their lifestyle based upon ear infection rates, but, like anything else, sometimes a cost-benefit analysis shows that staying at home is more cost-effective when you factor in lost work days.

Aside from daycare, other environmental factors that contribute to ear infections are secondhand smoke, not feeding baby in an upright position, pacifiers and poor infection control.

Dr. Brown is familiar with the new guidelines. She has coined the phrase "The Denmark Plan," because this monitoring approach is a common one in the Dutch community. "This is a reasonable approach to ear infections, but I understand why it will be a hard sell," says Dr. Brown. "A lot of parents work outside the home and if you tell them to just watch their child's symptoms and come back in a couple of days, they have to miss another day of work, as well as pay for another office visit. Also, if you have a child who's really not getting better you may not be sleeping. But those are the downsides we have to face for the long-term health of our children."

What Dr. Brown recommends, and Dr. Rosenfeld heartily agrees with, is to treat the pain with analgesics, such as ibuprofen or acetaminophen. It's also important to be consistent about giving the pain medication on a regular time schedule to help control the symptoms. She also suggests that perhaps a warm compress on the ear or elevating the head of the bed may help as well.

"The fact is that without antibiotics about 80 percent of patients with ear infections get better on their own," says Dr. Rosenfeld. "With the antibiotics it goes up to about 90 percent, which is better but not so much better that it makes it worth the possible consequences of over prescribing."

While the AAP is still grappling with the issue of how to make these guidelines understood by busy parents across America, a good guideline for now is to take your child to the pediatrician if he's sick, but be more active in questioning that ear infection diagnosis.

Want to see more?

• A Pain in the Ear: Ear Infections in Young Children
• The Ins and Outs of Ear Tube Surgery
• Ear Infections Are a Pain! How to Spot and Treat a Common Infant Ailment
• Talk about it!