Should Children’s Ear Infections Be Treated With Antibiotics?
University of Washington, Tacoma
THLEAD 350: Joane Moceri

Should Children’s Ear Infections Be Treated With Antibiotics? There has been controversy about whether to treat children’s ear infections with antibiotics or just do an initial observation. Therefore, the issue to be analyzed in this paper is: Should children’s ear infections be treated with antibiotics?
Terms & Definitions
The purpose of this paper is to evaluate primary research articles by using methods of critical thinking and asking the right questions. This paper will discuss the treatment options for acute otitis media (ear infection) in children with either initial observation/watchful waiting (observing the child first before deciding to prescribe medications) or antibiotic treatment (form of medication usually prescribed to rid the body of infection). There are ten questions that I will be using from the book “Asking the Right Questions (ARQ)” by Browne and Keeley (2010), in order to do a critical analyses of six articles. For each question I will first present views from authors who are against the use of antibiotic treatment for acute otitis media (AOM). Then I will present views from authors who would rather treat acute otitis media with antibiotics.
The first and main ARQ question that will be brought up and answered throughout this paper is, “What are the issues and the conclusions?” (Brown & Keeley, 2010, p. 10). There are two types of issues, descriptive or prescriptive, that could describe an article. An issue is how an article will be discussed, what the article will be about, or the main point the author is wanting the reader to know. A descriptive issue questions the certainty of time, while a prescriptive issue questions if the issue of the article will be accepted (Brown & Keeley, p. 20). A conclusion is what the author would like the reader to take from or their main point of the article (Brown & Keeley, p. 22).
The Context AOM is one of the leading reasons for primary care physician visits. These visits are one of the causes of frequent antibiotic prescriptions in the United States among children by the age of 2 years. The typical solution is to prescribe antibiotics to cure this disease. There has been controversy regarding this way of treatment because of overuse of antibiotics. Currently, there have been guidelines set out for physicians to wait before prescribing antibiotics to children. With this new guideline, physicians have set studies to determine if antibiotic use is preferred over watchful waiting (WW).
Different Positions
There are two points of view regarding the issue of either treating AOM with WW or treating it with antibiotics. Those who are pro-antibiotic treatment are because they believe that there has been no significant change in recovery with or without antibiotics. Those who are against treating AOM with antibiotics are because of views that there is an overuse of antibiotics and believe WW would be useful. Those who are against antibiotic treatment are because parents can first treat their children with over-the-counter decongestants and wait for symptoms to subside over a period of a couple of days.
Con. McCormick et al. (2005) concludes that children with nonsevere acute otitis media may recover with initial observation (WW). Finkelstein, Stille, Rifas-Shiman, and Goldman (2005) concluded that parents and physicians who open their views to change will be more accepting of initial observation for AOM. Neumark et al. (2007) believe the recovery time of AOM would not be affected with antibiotics.
Pro. Conservative treatment with antibiotics and following up closely are vital for a better prognosis in children (Kikuta, Munetaka, Fujimaki, & Kaga, 2007). Antibiotics prescribed to children seem to protect them if prescribed within the first two weeks (Salomon et al. 2008, Park, Brooks, Chrischilles, & Bergus, 2008).
Analysis of the Points of View on the Issue
What are the Reasons?
Reasons are what the authors state or communicate in their writing for a reader to believe their conclusion and could also be from data or statistics of a study (Browne & Keeley, 2010, p. 29).
Con. McCormick et al. (2005) stated that WW has been practiced regularly in some countries and that parents are taught to wait 48 hours for symptoms to resolve before seeking treatment. Finkelstein et al. (2005) use at least three reasons to support their conclusion that prescribing antibiotics is not needed for AOM. First, support for initial observation is because of overuse and resistance of antibiotics. Second, initial observation is in demand because it has a potential to reduce antimicrobrial use for otitis media that may clear on its own. Third, guidelines from the American Academy of Pediatrics endorse initial observation of acute otitis media (AOM) in children ages 2 or younger. Neumark et al. (2007) believed there were limited differences between antibiotic-treated and non-treated groups of AOM.
Pro. Next are reasons why authors are in favor of antibiotic treatment for acute otitis media. AOM represents most common reasons for prescribing antibiotics and AOM have responded fairly well to antibiotics (Kikuta et al., 2007, Salomon et al., 2008). Park et al. (2008) believe several reasons why children responded well to antibiotic-treatment. First, positive benefits were found in randomized controlled trials. Last, there was few treatment failures with children first treated with antibiotics than WW.

Which words or phrases are Ambiguous?
Words or phrases to be ambiguous are to have more than one meaning for what the author is communicating (Browne & Keeley, 2010, p. 39).
Con. The authors used ambiguous phrases like: describing potential advantages of initial observation, acceptable options by encouraging careful diagnosis, and demonstrated reasonable acceptability and outcomes, (Finkelstein et al., 2005). Ambiguous phrases that McCormick et al. (2005) state are not of good quality and strict diagnostic criteria for AOM. Neumark et al. (2007) used ambiguous phrases like: significant differences, asymptotically reached a plateau, separate statistically, and masterly inactivity.
Pro. Kikuta et al. (2007) and Park et al. (2008) used ambiguous phrases such as: responded favorably, minimal inhibitory, forced entry multiple logistic regression analyses, and significant factor without expressing exactly what they meant. Salomon et al. (2008) used phrases like: pertinently, and significantly twice in the same sentence.
What are the Value and Descriptive Assumptions? Browne and Keeley (2010) state that an assumption is taking something unstated for granted (p. 55). A value assumption is a reader’s first choice of thought over another (Browne & Keeley, 2010, p. 57).
Con. The value assumption in the article by Finkelstein et al. (2005) would be that parents with more education or knowledge of antibiotics would be open to the idea of WW. Children who experience otitis media with effusion would not benefit from antibiotic treatment (McCormick et al., 2005). Major risk factors for the spread of antimicrobial resistance are due to the overuse of antibiotics (Neumark et al., 2007).
Pro. Value conflicts that Kikuta et al. (2007) used are the Declaration of Helsinki principles and that recurrent AOM recur more than twice in the past 6 months. Parents expect their children’s physician to prescribe them antibiotics for the onset of an infection and will see a different physician if they do not receive one (Salomon et al., 2008). Park et al. (2008) believes it is inappropriate to assume children with AOM will not benefit from antibiotics.
Are there any Fallacies in the reasoning? A fallacy is a trick used by the author to convince a reader to believe in their conclusion (Browne & Keeley, 2010, p. 71). One type of fallacy used in an article is called a red herring, which means a topic that is not pertinent is stated to change the outcome of the original issue (Browne & Keeley, p. 82).
Con. McCormick et al. (2005) mentions that there have been no clinical trials using standardized methods for determining the severity of AOM. Finkelstein et al. (2005) mentioned an intervention was done on the education of AOM and how antibiotics were not a benefit for colds or flu-like symptoms. Another fallacy could not be found in the article by Neumark et al. (2007). Pro. A fallacy, according to Kikuta et al. (2007), would be that patients with increased infection are often subjected to repeated antibiotic medications which further increase the development of drug-resistant bacteria. Office based visits decreased when AOM was treated with antibiotics within 14 days of diagnosis (Salomon et al., 2008). Lowering antibiotic use in patients in Iowa Medicaid resulted in no lost cures (Park et al., 2008).

How good is the Evidence?
Evidence is factual information given by the author to explain the decision of a claim and usually given through data from studies, statistics, and sample sizes (Brown & Keeley, 2010, p. 92).
Con. McCormick et al. (2005) conducted about a two year study comparing 112 children signing up for immediate antibiotic treatment and 111 to WW with results showing no significant difference. Evidence given by Finkelstein et al., (2005) comes from a study in 16 Massachusetts communities that participated in an intervention on antibiotic use with the response from 2054 parents (34% satisfied with WW, 26% are neutral, and 40% dissatisfied) and 160 physicians (38% never used WW, 39% occasionally used WW, 17% sometimes used WW, and 6% used WW most of the time). Neumark et al. (2007) had 32 health centers and 72 general practitioners conducted trial on children ages 2-16, of which 179 completed the trial. Pro. Kikuta et al’s. (2007) study was conducted at the Fujimaki Ear, Nose and Throat Clinic in Chiba, Japan and consisted of 170 patients (98 boys, 72 girls) with AOM with 106 chosen for multivariate analyses. Evidence produced by Salomon et al., 2008 states that an analyses of 2456 3-6 year old children was done and monitored for five months but there was no clinical trial done, just a pharmaco-epidemiological study. Park et al., (2008) had a higher cure rate with 28,298 patients treated with antibiotics than those under WW. Are there Rival Causes? “A rival cause is a plausible alternative explanation that can explain why a certain outcome occurred” (Brown & Keeley, 2010, p. 123).
Con. A rival cause would be that if parents’ options were explained to them by their provider, they may accept the option of watchful waiting (Finkelstein et al., 2005). A possible rival cause would be that antibiotics are prescribed as a backup prescription for AOM with the request to not fill it unless symptoms do not improve within three days (McCormick et al., 2005, Neumark et al. 2007). Pro. A rival cause for the use of antibiotics can cause retention of middle ear fluid due to the presence of multiple bacteria (Kikuta et al., 2007). Kikuta et al., 2007 believed the detection of drug-resistant bacteria happened less in the children in their study. The risks of AOM are lowered with antibiotic treatment after nasopharyngitis and antibiotics are effective in rhinitis symptom reduction (Salomon et al., 2008, Park et al., 2008).
Are the Statistics Deceptive? Deceptive statistics are when dishonest data is given or is lacking significant numbers to make a statistic factual (Brown & Keeley, 2010, p. 137).
Con. The statistics given by McCormick et al. (2005) are deceptive because there were 223 participants out of 689 subjects and that some groups were unblended. Neumark et al. (2007) conducted open trials that altered the way parents saw symptoms in their children. The authors also stated that 179 participants gave a substantially lower result than intended. Pro. Kikuta et al. (2007) show deceptive statistics because only 106 out of 170 patients were chosen to test for the presence of multiple bacteria and the study was conducted in private clinics (upper class patients only) and not in public hospitals. Salomon et al. (2008) did not conduct clinical trials and based study with risk factors of AOM. Park et al. (2008) statistics are deceptive because they conducted a trial with three times more patients in the antibiotic treatment than in the WW treatment.
What Significant Information is Omitted? Omitted significant information can result in the reader being influenced by the author’s reasoning (Brown & Keeley, 2010, p. 147).
Con. McCormick et al. (2005) fails to note who performed the studies and that this was a 2-year study but only talked about 30 days. The article by Finkelstein et al. (2005) fails to mention how long their study was conducted or if only doctors performed the study. The article mentions existence of “early adopters” but the data is from patients’ perceived desires (Finkelstein et al., 2005). Neumark et al. (2007) acknowledges assistance from practitioners and care centers, and financial backers of their studies. Pro. Kikuta et al. (2007) omitted information pertaining to the number of all patients and if they conducted other exams after the initial exam. Salomon et al. (2008) state that France is the world leader of antibiotics but fails to state if there is an alternative cure to AOM or how other illnesses would affect AOM. Park et al. (2008) seem to have all their information in order.
What Reasonable Conclusions are possible? The possibility of other reasonable conclusions is defined as having a different outcome from the authors’ conclusions (Brown & Keeley, 2010, p. 157).
Con. An alternative for nonsevere AOM is WW because over-the-counter decongestants used at first signs of cold symptoms seems to help (McCormick et al., 2005). A possible conclusion could be that some parents and physicians believe there is an unnecessary use for antibiotics for acute otitis media after reading the guidelines from the American Academy of Pediatrics (Finkelstein et al., 2005, Neumark et al., 2007). Pro. Another reasonable conclusion is that antibiotic use may not be a cure for AOM because a cure could occur when the drug-resistant bacteria leave the body (Kikuta et al., 2007). Limiting the use of antibiotics may be an alternative cure but further research is needed (Salomon et al., 2008, Park et al., 2008).
Strengths & Weaknesses of Each Position Con. Strengths: The authors presented reasons why they believe antibiotics should not be used to treat acute otitis media in children because of over usage and the body building drug-resistant bacteria. Their studies showed no significant difference in antibiotic treatment versus watchful waiting. Some authors would say that treating the onset of the common cold would prevent the build-up of bacteria from causing acute otitis media. Weaknesses: Along with the treatment of watchful waiting, some physicians will give parents a prescription (with the instructions of not to fill it) for antibiotics if their child’s symptoms get worse after a 72 hour window. Pro. Strengths: The authors have strong beliefs that the use of antibiotics is the best treatment for acute otitis media. They believe if antibiotics were taken right away that would cause children to experience less pain. Weaknesses: The authors had biased studies to show the results of antibiotic treatment to be better than watchful waiting. They would also state that it is not always necessary to treat acute otitis media with antibiotics and perhaps watchful waiting would be a good idea.
My Point of View I believe that parents need to be educated on what antibiotic use could entail, the side effects, and that antibiotics are not always needed for an illness. Parents should participate in shared decision-making with providers of their own children. Based on the evidence given, the authors against antibiotic treatment provided enough information for me to believe the option of watchful waiting in children with acute otitis media because symptoms tend to dissipate in mild conditions. Careful watch over children and treating the onset of symptoms of the common cold could prevent from further spread of the bacteria. There are a couple of personal reasons why I stand by this decision. First, my stepson used to get ear infections every few months at an early age. His doctor would prescribe antibiotics and send him home. His current doctor believes that he had been prescribed too many antibiotics at an early age and those just masked his real condition. The antibiotics provided temporary relief of the pain but did not treat the issue. The infection in my stepson’s ear caused him to go deaf for at least a year before his doctor was able to notice what his real condition was and treat it. This disability kept him from learning valuable communication skills that you would as a toddler. He was a slow learner because of this and still has trouble communicating at the level he should be at (a 12 year old communicating at a 7 year old level). The other reason why I stand by this decision is because I too saw the over usage of antibiotics given for infections when I worked in the dental field. Patients would have infections and were given antibiotics for a temporary cure in hopes for them to come in to do actual treatment that would clear the infection. These patients felt like their infection was cured by taking the antibiotics but did not realize that the infection is still present but just lay dormant because of the antibiotics. They would not come back to finish their treatment and finally come back in when the infection returned.
Further research is needed to come to a final conclusion for both the pro and con side. However, there are different levels of acute otitis media that need to be treated. Physicians still need to treat children and determine their treatment on a case by case basis.
Conclusion
In this paper, the ARQ process is the way of analyzing research articles by critically thinking and asking the right questions from the book “Asking the Right Questions” by Browne and Keeley (2010). This paper discussed the treatment options for acute otitis media in children with either initial observation or antibiotic treatment. This paper gave views from authors that are for and against the use of antibiotics in the treatment of acute otitis media. Further information was given to support the authors’ findings and results of how they came to their conclusions.

References

Browne, M.N., & Keeley, S.M. (2010). Asking the right questions: A guide to critical thinking. (9th ed.) Upper Saddle River, NJ: Prentice Hall.
Finkelstein, J. A., Stille, C. J., Rifas-Shiman, S. L., & Goldmann, D. (2005). Watchful waiting for acute otitis media: Are parents and physicians ready? Pediatrics, 115, 1466-1473.
Kikuta, S., Munetaka, U., Fujimaki, Y., & Kaga, K. (2007). Factors associated with the presence of drug-resistant bacteria and recurrent acute otitis media in children – a study in a private clinic. Acta Oto-Laryngologica, 127. 5-8. doi: 10.1080/03655230701595220
McCormick, D. P., Chonmaitree, T., Pittman, C., Saeed, K., Friedman, N. R., Uchida, T., & Baldwin, C. (2005). Nonsevere acute otitis media: A clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment. Pediatrics, 115. 1455-1465.
Neumark, T., Mölstad, S., Rosén, C., Persson, L., Törngren, A., Brudin, L., & Eliasson, I., (2007). Evaluation of phenoxylmethylpenicillin treatment of acute otitis media in children aged 2-16. Scandinavian Journal of Primary Health Care, 25. 166-171. doi:10.1080/02813430701267405
Park, T., Brooks, J. M., Chrischilles, E. A. & Bergus, G. (2008). Estimating the effect of treatment rate changes when treatment benefits are heterogeneous: Antibiotics and otitis media. Value in Health, 11. 304-314. doi: 10.1111/j.1524-4733.2007.00234.x
Salomon, J., Sommet, A., Bernède, C., Tonéatti, Carbon, C., & Guillemot, D. (2008). Antibiotics for nasopharyngitis are associated with a lower risk of office-based physician visit for acute otitis media within 14 days for 3- to 6-year-old children. Journal of Evaluation in Clinical Practice, 14. 595-599.