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The term "watchful waiting" usually describes a treatment for prostate cancer.
Increasingly, it also describes an option for treating ear infections in children.
Pediatricians and family-practice doctors say they often delay before prescribing an antibiotic for children with ear pain. They treat the pain and monitor the symptoms before offering an antibiotic.
This approach is inspired by the notion that antibiotics don't help if the infection is caused by a virus. Also, the frequent use of antibiotics can lead to another problem--antibiotic resistance.
"We're watching closely while we wait just a couple of days," said Dr. Kathy Smyth, a pediatric hospitalist at Mary Washington Hospital.
Recent studies support this approach, including one published this month in the Journal of the American Medical Association. That study concluded that antibiotics make little difference in curing ear pain in children.
But doctors also know that the scientific ideal sometimes conflicts with the realities of practice.
Ear pain can be tricky to diagnose, especially when the patient is a crying infant, said Dr. Pamela Mancini, a Fredericksburg pediatrician.
Sore throat, runny nose or teething may be the cause of the pain. And even if the child is pulling on the ears, the ears may not be infected.
In addition, parents sometimes expect an antibiotic in hopes of a speedier recovery.
"We are so geared to getting the kids back to school, getting them back to day care," Mancini said.
Ear infection, or otitis media, is one of the most common of childhood ailments. Three out of four children experience it by the time they are 3 years old, according to the National Institutes of Health.
The problem begins when parts of the ear become swollen, often from a cold. Fluid becomes trapped inside the middle ear, and viruses or bacteria grow in the fluid. The result is an infection and a sick, uncomfortable child.
To make the diagnosis, doctors usually rely on their examination of the child and the testimony of the parents.
Mancini said she wants to know "how long has it been going on, how severe are the symptoms and how disabling are the symptoms." She also asks about the child's prior history with ear infections and the age of the child.
As a part of her exam, Mancini puffs air into the eardrum to see if it moves the way it's supposed to. She also checks for fever and looks for a "red, bulging, opaque eardrum" with pus behind it.
"I probably err on the side of prescribing antibiotics if I'm not absolutely certain and the child looks sick to me," she said.
She added that she's also comfortable withholding an antibiotic if the child doesn't look "terribly ill and we can make him comfortable with pain medication."
Ear infections are the most common reason for prescribing an antibiotic for children, according to this month's JAMA study.
Each year, U.S. doctors treat ear infection in children with 15 million prescriptions for antibiotics.
When parents take their children to the doctor for treatment of ear infection, they walk out with a prescription for antibiotics more than 80 percent of the time, according to the American Academy of Pediatrics.
The downside of this, doctors say, is that antibiotics don't relieve the immediate pain that the child is experiencing, and may not touch the underlying infection if it's not caused by a bacteria.
There's also the reality of antibiotic resistance. Doctors report seeing more infections that do not respond to treatment with antibiotics.
"If you always take antibiotics, eventually the bacteria learn how to handle it," said Dr. John Eanes, head of the pediatric hospitalists program at Mary Washington Hospital. "It may not be long before antibiotics are not going to be effective against anything."
One option for doctors is a technique popular in Europe and used in the U.S. for about 10 years. Called "watchful waiting" or "wait-and-see prescription," the approach calls for the doctor to suggest a Motrin or Tylenol-type drug for the child's fever and discomfort.
"I always try to make clear to parents that an antibiotic does not relieve pain. It's not a pain reliever; it's a sterilizer," Mancini said.
The doctor delays for 48 to 72 hours before prescribing an antibiotic. Parents are sometimes given a prescription and told to fill it only if the child does not get better. Or, they are asked to return to the doctor's office if the child does not improve.
"If you give it a chance, the majority of the time, the body takes care of it on its own," Eanes said.
This month's JAMA study reached a similar conclusion.
The study looked at two groups of children with ear infections, ages 6 months to 12 years, who were treated during a one-year period in a hospital emergency room in New Haven, Conn.
One group had 138 children and the other had 145 children. Both groups received ibuprofen and ear drops for pain relief.
One group received a prescription for an antibiotic, with instructions not to fill it unless the child was worse or not better after 48 hours. The other group received a prescription for an antibiotic with instructions to fill it right away.
Research assistants phoned the parents three times over the next month. They found no difference in the two groups in subsequent fever, earache or unscheduled visits to the hospital.
The study concluded that the "wait-and-see" approach reduces the use of antibiotics and "may be an alternative to the routine treatment" of ear infection with antibiotics.
The study also acknowledged that "wait-and-see" has been controversial. Many pediatricians have been trained to routinely prescribe antibiotics for ear infection, it said, and "many parents expect a prescription."
Dr. Matthew Hengy, a family-practice doctor in Spotsylvania County, said he's seen a gradual shift in parents' expectation over the last several years.
"The majority of people, if you spend time explaining why you're not giving an antibiotic, they are accepting of that," Hengy said.
But some parents are more insistent, he added. They want an antibiotic.
"They're really more accepting of it if it's someone else's child," Hengy said.
Pam Ernandes of Spotsylvania said recently that her pediatrician is often cautious about prescribing antibiotics.
Recently she took one of her two sons to the doctor with a possible ear infection. The pediatrician wanted to wait 24 hours, and the problem resolved during that time.
"I was glad she waited," Ernandes said.
To reach JIM HALL:
Email: jhall@freelancestar.com
