Should You Prescribe Antibiotics for Ear Infections?

Ear infections are common in young children and infants. Seeing a miserable child with an anxious parent makes us want to DO something to help—such as prescribing antibiotics. But is that the best course of action? Read on to find out why antibiotics shouldn’t be used for the majority of ear infections, and what to do instead.

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Most Ear Infections Are Still Treated with Antibiotics

Ear infections, or acute otitis media, affect a majority of children by age three (1).  Research has shown that without treatment, 80 percent of ear infections clear on their own (2). Despite this, 95 percent of ear infections were treated with antibiotics in the United States in 2001 (3).

By almost any definition, this is a gross misuse. New guidelines by the American Academy of Pediatrics (AAP) reject immediately prescribing antibiotics for ear infections in favor of a “wait-and-see” approach in most cases (4). However, because this reversal occurred recently, and because of pressure from parents for immediate treatment, many pediatricians and family doctors still jump to prescribing antibiotics.

Antibiotics absolutely have a place in medicine and should be prescribed in severe cases, but over-prescription has contributed to widespread antibiotic resistance and gut microbiome destruction. As I have covered numerous times, including here, here, and here, a properly developed gut microbiome is vital to good health. Wiping out gut bacteria with antibiotics should only be done when truly necessary, since damage to gut bacteria populations is not easily reversed (5).

Antibiotics Are No Longer the Go-To Solution

Why did the AAP recently change its own guidelines for prescribing antibiotics for ear infections? Numerous trials demonstrate that most children (up to 80 percent) don’t need antibiotics to clear up an ear infection. A recent review analyzed a large collection of trials about antibiotics and ear infections (6). Two main types of studies were looked at: those that compared antibiotic treatment to placebo treatment and those that compared immediate antibiotic treatment to an expectant watchfulness, or wait-and-see, approach.

In comparing antibiotic treatment to placebo, antibiotic prescription did slightly reduce pain at various follow-up times up to two weeks following the start of treatment. Instances of ruptured eardrums and infection of the originally unaffected ear were also decreased mildly in the antibiotic group compared to placebo. However, 20 percent fewer children had recurrent ear infections in the placebo group. Perhaps the placebo-group children had superior gut flora due to fewer antibiotic doses, making them less susceptible to subsequent infections! These studies indicate that a wait-and-see approach would have probably been more prudent—those in the placebo group who had severe infections eventually requiring antibiotics would have been identified within a few days and properly treated. And those from the antibiotic group would mostly NOT have been given antibiotics unless otherwise indicated, thereby preserving gut microbiomes.

In comparing immediate antibiotic treatment to a wait-and-see approach, where antibiotics are only given if symptoms and pain persist or get worse after three to seven days, the results speak for themselves. The immediate antibiotic treatment groups showed no advantage over the wait-and-see approach in pain reduction, eardrum rupture instances, subsequent infection of the opposite ear, or long-term effects.

The bottom line seems clear: wait out the ear infection a few days before considering antibiotics because most ear infections will pass on their own without much added discomfort.

The latest research on ear infections and antibiotics

Patient Relief during the Wait-And-See Period

A child with an ear infection can be miserable, from general fussiness to trouble eating and sleeping. During the wait-and-see period, garlic mullein oil is a good option for treating discomfort as long as the eardrum is not ruptured. This more natural treatment has been shown to alleviate ear infection pain as well as an anesthetic drop (7). In addition, garlic has some antibacterial, antiviral, and antifungal properties to help fight the infection itself.

When fighting any infection, small doses of vitamin C, echinacea, and elderberry can also be beneficial (with caution for children under two), as all of these support the immune system. One of my favorite superfoods, cod liver oil, is full of vitamins A and D and long-chain omega-3 fats, which are extra important when the immune system is hard at work.

Tubes for Recurrent Ear Infections?

For patients with chronic ear infections, inserting grommets, or ear tubes, into both ears is common practice. The tubes are meant to help fluid drain from the ears before an infection occurs. But the community is split on how effective they are at preventing future ear infections, especially beyond six months after insertion (8, 9, 10). Furthermore, even though ear tubes did decrease overall time with ear infections compared to watchful waiting in one study, it increased instances of infection in the opposite ear, ear discharge, and eardrum scarring. These are some pretty severe and uncomfortable side effects (11).

If you have a patient who is experiencing ear infection after ear infection, a bigger underlying health or gut issue is probably present and should be addressed. Chronic illnesses indicate that something else is going on. I would advise first trying some of the health-boosting recommendations below before resorting to ear tubes because the research on their effectiveness is mixed, side effects are possible, and any surgery requiring general anesthesia carries its own separate risks. However, some patients who already have severe, chronic ear infections may benefit from having tubes inserted while they also work on any underlying health issues.

Preventing Recurring Ear Infections

To help prevent any infection, a healthy body including a healthy gut is optimal. If breastfeeding is possible, it is one of the best preventative options, since it helps line the gut with beneficial bacteria. Introducing formula in the first six months of life is associated with more ear infections in early childhood (12). For kids of all ages, feeding them other prebiotics and probiotics, first in very small doses, will also improve gut health over time.

Another way to boost health is removing toxins from the child’s diet, including processed foods, refined grains and sugars, industrial seed oils, and pesticide residues. If these recommendations sound familiar, it is because they are some of the first steps toward a Paleo diet and lifestyle, which can have a profound impact on overall well-being. Often children with food allergies are more susceptible to ear infections (13), perhaps because the immune system is already overly activated and cannot properly fight additional infections. Removing common allergens such as gluten, soy, dairy, and peanuts from the child’s diet (and the mother’s diet during breastfeeding) also may help.

Xylitol, a sugar alcohol, in a nasal spray can help ward off infections of the ear, nose, and throat (14, 15). This compound acts to break down the tough buildup of bacteria, called biofilm, that can stagnate in the nasal passageways. If you have a patient prone to chronic ear infections, a regimen of xylitol nasal spray, such as Xlear Nasal Spray, is worth exploring (16).

Conclusion: Antibiotics Are Usually Not Necessary for Ear Infections

If a child with an ear infection is brought into your office, research dictates that it is best to first wait and closely monitor the child. Have the parent keep an eye on the illness progression and schedule a follow-up in a day or two. Most infections will usually clear up without antibiotics in a few days. In the meantime, some garlic mullein oil and extra immune-boosting supplements and foods are the way to go. Over several days, if the symptoms and pain do not subside, antibiotics may be warranted. To avoid future illness, encourage your patient to build and maintain a healthy gut while following a Paleo lifestyle.