Dear Lisa,
My child has had an ear infection for six weeks now she is four years old. She has been on four different medications. That is a concern but what I have also noticed is that her hair is thinning out and she wakes up complaining about a pain in her leg. Can all this be related somehow?
“Granny”
Dear “Granny”,
Otitis Media is the infection of the middle ear cavity and is commonly referred to as a Middle ear infection. It is a common childhood ailment and accounts for 20% of all visits to the doctor during the first five years of life. (1) The symptoms include earache, sensation of “blockage” of ears, rubbing or pulling ears, hearing loss, fever, irritability, upper respiratory symptoms, vomiting or diarrhea. (1)
Risk factors for developing Otitis Media include daycare attendance, exposure to secondhand cigarette smoke, pacifier use, formula feeding as opposed to breastfeeding, bottle propping practices, having more than one sibling, Native American ancestry, and a family history of Acute Otitis Media. (1) Eighty percent of cases of Acute Otitis Media resolve without antibiotics. When antibiotics are used there is an earlier resolution of pain, reduced risk of developing a middle ear infection in the opposite ear and the reduced risk of developing complications. (1) On the other hand, Antibiotic use may contribute to bacterial resistance. (1)
There are two treatment options for children with Otitis Media; antibiotics or a wait and see approach. The American Academy of Pediatrics recommends antibiotic treatment for children less than 6 months old, children with serious illness, children who cannot be followed up, children with chronic medical conditions, children with a recurrence of Otitis Media in the previous 30 days and children with chronic Otitis media with effusion. (1,2), Children not belonging to these categories can be watched and reassessed in 48-72 hours. If at that point the child is still symptomatic and has Otitis Media upon physical examination, antibiotics are recommended.
Research has shown that children under two years old diagnosed with Otitis Media and treated with an antibiotic have a higher rate of recovering and a decreased rate of recurrence. (3) In addition children in daycare and children with a history of several cases of Otitis Media were found to have higher failure and recurrence rates. (3)
When an antibiotic is prescribed there should be a response to therapy within 48-72 hours. If no improvement is noted after this time the antibiotic typically is changed to a different type. Research studies show that microorganisms that cause refractory cases or severe cases of Otitis Media can be eradicated in 96% of children when high dose amoxicillin-clavulanate is used. (4) Once an inner ear infection is treated, fluid can remain in the ear for 90 days after the acute infection has resolved.(5) This fluid many times resolves on its own and is not considered an infection.
I can see why you are concerned about your child’s ear infections. An ear infection that lasts six weeks and does not respond to 4 different types of antibiotics is not normal. Children who experience an ear infection that does not resolve with repeated antibiotic treatment or those with a high rate of recurrence should be referred to an Otolaryngologist or Ear Nose and Throat Specialist.(6)
Complicating factors such as Eustachian-tube blockage or dysfunction, allergic rhinitis, enlarged or chronically infected adenoids and inefficiency of palatal muscles need to be ruled out.(1,6) Careful evaluation of risk factors should also be evaluated. Depending on your social situation, whatever measures that you can take to eliminate risk factors such as stopping the use of a pacifier or switching to a smaller day care setting may be helpful. (5)
In regards to your question about your child’s hair, hair thinning in a child may reflect normal developmental changes. In some cases the thinning of hair can be due to an underlying problem or condition. Most of the time, normal hair growth patterns are responsible for what appears to be hair thinning.
Hair replacement occurs according to a cyclic pattern alternating between growing and resting phases. Hair on the scalp grows steadily and continuously for 2 to 6 years. Then the hair enters a resting phase in which the hair stops growing. After three months of no hair growth the hair starts to fall out. Following this hair shedding period, the hair rests for an additional 3 months and then new hair growth resumes.
Both this rate of growth and the replacement cycle may be altered by many factors. These factors include; illness, diet, high fever, major illness, surgery, blood loss, drugs, radiation or severe emotional stress. (7) Your child has had an illness and this could be an explanation for the hair thinning that you are seeing. If she had high fevers with her ear infections this could be another explanation.
Diffuse hair loss or hair loss throughout the head can be due to thyroid disease, systemic disease, anorexia nervosa, low ferritin levels and drugs. (8) therefore, if your daughter’s hair thinning is dramatic or doesn’t improve, it would be a good idea to have her checked by her Primary Care Physician. Your doctor will be able to determine if your daughter’s hair changes are due to thinning or from patches of hair that are missing and guide you accordingly.
Children complain or muscle aches for a multitude of reasons. Muscle aches many times accompany an illness or can be a sign of injury or overuse. A child with persistent leg pain associated with fevers presents a particular concern. Children are susceptible to developing Osteomyelitis or a bone infection.(9) Osteomyelitis occurs when germs or microorganisms from the blood deposit into the bone.(9) Children with leg pain and fevers need to be evaluated and Osteomyelitis should be ruled out. Other concerning signs include leg pain that involves a joint, limping, increase in pain intensity and persistence of pain despite palliative treatment. Children with these symptoms should also be evaluated by their Physician.
References:
(1)Alper B, Fox G. Acute Otitis Media. The Clinical Advisor. 2005. April:78-86.
(2)American Academy of Pediatrics/American Academy of Family Physicians Subcommittee on Management of Acute Otitis Media. Clinical practice guideline. Diagnosis and management of acute Otitis media. Pediatrics. 2004;113:1451-1456.
(3)McCormick DP. Watchful waiting in non-severe AOM: How to select cases, and does it work in young children. Session 2600 Update on treatment options for acute Otitis media. Presented at: pediatric Academic societies’ 2006 annual Meeting; April 29- May 2. San Francisco.
(4)Bell E. Acute Otitis media treatment guidelines: Are prescribers using them? Infectious Diseases in Children. 2006. August:14.
(5)Carlson L. What’s New in the Guideline? Therapeutic Spotlight. 2004. June:11-13.
(6)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:489-492.
(7) Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984: 112-113.
(8)Stephenson M. Effective Treatments available for alopecia areata, vitiligo. Infectious Diseases in Children. 2006. May:20.
(9) Bautista S, Gholve P, Pediatric Musculoskeletal Infections: Advances in Diagnosis and Management. Consultant for Pediatricians. 2006.Aug:481-494.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice For Sick Children
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