otitis media in an 18 month old

My 18-month-old has had 3 bouts of otitis media. I am confused as some doctors say that antibiotics are needed to clear the infection and others don’t think they are needed. Can you tell me about this condition and how it should be treated?

Otitis media or middle ear infection (sometimes called ‘ear infection” which is wrong) is a frequent problem in early childhood although it can affect any age – I had it at 17 years of age. It is usually a complication of the common cold. The middle ear has a tube which drains mucus made in the middle ear into the nose. Swelling of the lining of the nose, caused by the cold, blocks the drainage of the mucus. Bacteria like to grow in any trapped fluid in our bodies and will grow in the mucus setting up a middle ear infection (otitis media).

It is possible for this infection to develop into an abscess, which in turn may burst through the eardrum causing pain and then discharge of pus out through the outer ear. For this antibiotics are compulsory. Such rupture of the middle ear drum is very rare in well-nourished basically healthy children but is common in poorly nourished third world children where it is a common cause of a permanent hole in the drum which causes significant hearing loss.

In the last 25 years we have come to realise that a well-nourished child will get over otitis media without the need for antibiotics just as fast as those given them. It has been estimated that one has to give antibiotics to 14 children with otitis media to help 1 – the other 13 will resolve their infection just as quickly without any medication. Thus, you are likely to see less and less prescribing of antibiotics for middle ear infections in future.

Chronically constipated 2-year-old

Our 2-year-old daughter has repeated problems with constipation. We have tried a number of medicines, which do help, but as soon as we stop them she becomes constipated again with very hard bowel actions like pebbles and sometimes there is blood on them or the toilet paper. We can see that she holds back on using her bowels because of fear that it will hurt which it often does. What is your advice?

This is a miserable problem for your daughter. The blood suggests that she has a crack in her anus (technically called a fissure-in-ano). When this is torn open by the hard bowel action it hurts so that she is reluctant to do the job.

There are two steps I would suggest:

Firstly use one of the medications that has worked again but for 3 months! Ask her to go and try to use her bowels after the 3 major meals.

If she fails to pass anything for 24 hours then increase the dose – I usually recommend doubling the dose. If that fails then she needs a suppository or enema, which your pharmacist can give you.

Secondly I recommend some anaesthetic ointment put on at least twice a day – after her bath and then about 12 hours later. This is applied to the anus and does not have to be inserted, just put it on the surface. This is to stop the passage of the bowel action from being painful. Once the process is painless you can stop the ointment.

I strongly emphasise the importance of continuing the use of medicine for 3 months even though she may seem cured much earlier. Towards the end of the 3 months you can try reducing the dose say halving it for a week. If there is any failure to use the bowels for 24 hours, double the dose again.

This is a difficult and complex matter and I would be only too happy to answer supplementary questions. Best of luck.

Repeated Cold Sores

I need your advice on cold sores. I get them but only once or twice a year and my wife does not have them at all. My son who is in his final year of High School and is studying very hard, is having multiple attacks. Do you think they may be stress related? Is there any protection we can practice? Given that we never kiss him on the lips, where are they coming from (he does not have a girlfriend)?

Cold sores are an herpes infection. We all have an initial herpes infection in our first few years of life. Then it causes mouth ulcers. After the infection is over the herpes virus remains in the nerves that supply our lips. Most of the time we suffer no harm from this carrier state. Unfortunately, for about 40% of the population, when they are stressed, the virus becomes active and the ulcers appear on and near the lips again.

The most common cause of that stress is the common cold, hence the name cold sores. However, the stress may be emotional and it seems likely that is the case for your son.

There is an anti-viral cream that is effective in herpes but as each attack is self-limiting, it should only be used in the most severe cases for fear of the virus becoming resistant to it. Babies or the very elderly can get the herpes virus in their blood stream when it is frequently fatal without this anti-viral agent. In my opinion, we should reserve this agent for these cases or particularly severe skin herpes.

Anyone with active cold sores should not go near a newborn baby (under 1 month of age). If avoidance is impossible, a mask can be worn. However, the mask must be changed and hands washed every 20 minutes if the contact with the baby is to be prolonged. I must say it is rare in my experience for the mother with cold sores to give the virus to their baby.

I am one of the 60%. Who do not have repeated cold sores, but I feel very sorry for those who do.

Childhood Illness

Why does my 3-year-old daughter have so many coughs and colds?

Coughs and colds are the commonest illnesses that children suffer. As coughs can be due to serious illnesses such as pneumonia or asthma, the parental anxiety a child’s cough can cause is quite understandable. Pre-school children have an average of about 9 upper respiratory infections (colds) per year and more if spending a lot of time with other children (being in child care for example).

The vast majority of colds are viral and do not respond to antibiotics. A very small number of children will develop a secondary bacterial infection such as bacterial tonsillitis which will require antibiotics. This secondary bacterial infection is so infrequent that the use of antibiotics to prevent it is not justified, especially when one considers the side-effects that the antibiotics may cause. 40% of patients given erythromycin develop nausea, abdominal pain vomiting or some combination. Two thirds of children when given amoxicillin under the age of 2 years will develop loose bowel actions.

So what is to be done? Medical Science has not found a way of shortening the common cold. It is important to keep up the fluids, as fever causes the child to lose water through sweating. If the child is uncomfortable they may have paracetamol (acetophenetidin or phenacetin). Regular paracetamol is not necessary; it will lower fever but fever is one of the defence mechanisms that help the body fight infection.

Aspirin is a definite no-no in young children.

If the child will not drink or looks obviously sick (listless, drowsy, struggling to breathe) then see a doctor. The person who discovers a cure for colds will become very rich and probably win the Nobel Prize

Childhood Illness

Should I have my baby boy immunized against chickenpox? I have heard that sometimes it gives them chickenpox.

The short answer is “Yes you should have him immunized for chickenpox”. Of course it means an extra needle and the very low risk of side-effects that all immunizations have.

Chickenpox (varicella) is one of the most infectious of the infectious diseases with about 90% of household contacts, who have not had chickenpox, catching it if one person in the house develops it. While more than half of cases occur in children under 10-years-of-age, 25% happen in people over 15. Ask anyone who contracted chickenpox when 15 or older and they will tell you that it is a miserable disease with intense itching.

Also 1 in 100 people (adults or children) will develop a secondary pneumonia requiring antibiotics and often hospitalization. Some children develop an involvement of the brain called encephalitis. Overall the complication rate of chickenpox is 5 to 10% and one in 400 children being hospitalized.

What are the risks to the chickenpox immunization? About 10% will develop a fever and half it will be quite high (greater than 38.degrees Celsius or 101.3 degrees Fahrenheit). One in5 children will develop slight swelling, pain or tenderness around the injection site. This clears up without any need for treatment. About a fortnight after the immunization approximately 4% will develop some chickenpox lesions around the injection site and about the same number will develop them somewhere else on the body. However, the number of these lesions is 5 or less. Compare this with more than 300 chickenpox lesions in naturally caught chickenpox and each of those 300 itches!

Both my older brother and sister had escaped chickenpox through primary school. I developed it when I was 9 years-old. Of course they both caught it from me during their summer break. My illness was relatively mild but my brother and sister itched horribly and they were not impressed with their kid brother! My last 2 children also caught it in adolescence, the older one did not sleep for 2 successive nights because of itch and this was despite excellent nursing care from his mother and generous medication from his father.