Tonsils, Toothbrushes, Ear Infections – PediaCast 153


  • New Guidelines for Tonsillectomies
  • MMR-Autism Link Found Fraudulent
  • Teenagers Claiming Abstinence Still Have STDs
  • Alcohol and Breastfeeding
  • Toddler Scared to Sleep in Bedroom
  • Toothbrushes and Colds
  • Ear Infections (In-Depth)



Announcer: Bandwidth for PediaCast is provided by Nationwide Children's Hospital for every child, for every reason.


Announcer: Welcome to PediaCast, a pediatric podcast for parents. And now direct from Birdhouse Studios, here's your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome to this week's edition of PediaCast, a pediatric podcast for moms and dads. It is Episode 153 for January 18, 2011. We're calling this one Tonsils, Toothbrushes and Ear Infections. Of course, we'll have lots more information coming your way.


But first, I want to welcome all of the new listeners. We always have an influx of new folks who are listening to the show right after the first of the year because of all the new iPhones and iTouches and iPods and MacBooks and PCs that everyone unwrapped for Christmas. So just want to welcome all of you who found us through iTunes and on the internet and other podcasting collections.

I also want to welcome any Android users that are out there. We now have an Android app that you can get at the Android store. And we have one that will be coming soon that Apple is still in the approval process so it takes a while. So we will have an iPhone and iPod app coming soon for PediaCast where you can get on the feet and we'll have special content and just make it a little bit easier to access the program from your mobile device, so that's coming up.


Also today, we have a new format. Now it's not a huge change, but we are gearing up for the big move. In fact, this is our very last show from beautiful, sunny Orlando, Florida. We're moving up north to Columbus, Ohio because PediaCast will become part of the Nationwide Children's Hospital family of media. So we're very excited about that.

So actually our next show will be coming from the campus of Nationwide Children's Hospital and that will be early next month. And the reason for the a little bit of a new format is because we're going to a weekly show again. The last show, it's been a month since we did one. And they've been kind of hit or miss and part of that is all because of the craziness that's involved with moving.

So in preparation for a weekly format, we're actually going to shorten the show a little bit, just to make it easier to do production and get things out to you. Still a meat and potatoes program, full course even in half an hour instead of an hour.


But we're going to discuss some news, we'll answer your questions and then we'll always have an in-depth topic, whether that be a research study or just a disease process or an interview with a specialist based on a question that you've asked or some topic that we're doing a theme show on.

We'll still do all still the three segments, we're just going to shorten them up a little bit. And then some of it, I'm going to have to get used to just not saying quite as much during the intro and outro because you know how worthy that can be.

Alright, so what is on the line-up today? There are new guidelines out for practitioners, so doctors and nurse practitioners who are out there, New Guidelines for Tonsillectomies. And we'll discuss those.

Also, the MMR-Autism debacle, the link between MMR and autism, you know the folks who first brought you panic and chaos in the world, a while ago they actually retracted what they had said that there was this link between MMR and autism.


And they retracted it, except for one dude, but we'll talk about him in a few minutes. But they've actually gone a little bit further than saying that we retracted. Now folks are calling it fraudulent and we'll have information on that.

Also, teenagers who claimed to be abstinent still have STDs. Yes, don't ask me how. Well, actually you may want to ask your teenager how. And this is going to be a segment that's for moms and dads but also for the practitioners out there listening.

And we're not slowly gearing this program more toward practitioners. It's just as a parent, you want to know what the current information is for the doctors so you can make sure your doctor is up to date. So teenagers who claim to be abstinent still have sexually transmitted diseases, we'll discuss that.

Also, alcohol and breastfeeding; a toddler who's scared to sleep in the bedroom, what do you do about that; toothbrushes and colds; and then in our In-Depth segment, we're going to take a look at ear infections. So we had timely topic for a condition that we see a lot of during the winter time.


Don't forget, if there's a topic that you would like us to discuss or a question or a comment you have, it's really easy to get a hold of us, just go to and click on the Contact link. You can also email

If there's little bit of an echo, it's because Birdhouse Studios is a little bare, as we're packing to move up north and I'm realizing this is the first time I've done the show in our home studio since we took some things our of this room. And there is a little bit of an echo, but once we're situated in Columbus then we should take care of that.

Alright, the information presented in PediaCast is for general educational purposes only. We do not diagnosed medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination. Also, your use of this audio program is subject to the PediaCast Terms of Use agreement which you can find at


And with that in mind, we'll be right back with News Parents Can Use right after this break.


Okay, we are back with News Parents Can Use and here's another instance where our format is just a little bit different. Our news stories really were sort of package stories so it sounded more like a news report. We're actually going to change it to a little bit more of a casual presentation, so starting with this show.

The first topic up is new guidelines for Tonsillectomies. Now when I was a kid, they would pretty much line you up to get your tonsillectomy. I mean it really was a right of passage.


In fact, it was so popular or so common, I guess I should say, that there was a popular cartoon of the day, this is going to aged me a little bit, but there was a cartoon called Fat Albert, which you may or may not recall and in Fat Albert, there was an episode, but that is so politically incorrect these days, isn't it? You would not have run a first run cartoon called Fat Albert these days. So anyway, there was a whole episode devoted in getting your tonsils out.

And I remember as soon as Fat Albert had his tonsils out, the first thing is they gave him ice cream. And so when I got my tonsils out, I thought, hey, this is going to be great. I'm going to get all these ice cream when I wake up. And my throat hurts so much that I didn't want the ice cream. So it was not true. It was bad advertising for tonsillectomies.


Well today, it's not quite where the doctors line you up like it used to be. Pediatricians use stricter guidelines for removal and in my own practice, I would say if a kid had recurrent strep, especially in the same episode.

So what do I mean by that? Well, if you had a kid who had strep throat and you treat them with an antibiotic and it didn't get any better. And you treated them with another antibiotic and they still have the strep. And you treated them a third antibiotic and they still have the strep. They were still positive and symptomatic.

Then you would say, okay, we're not able to get rid of the strep, so it's a recalcitrant-type strep and we need to have your tonsils taken out. So that would be one reason. Also if you have a bunch of strep infections in a given year and then the other was symptomatic obstructive sleep apnea which we'll talk a little bit more about that in just a couple of minutes.


But apparently, not all doctors are following the stricter approach because more than half a million tonsillectomies are still performed each year on children, making it the second most common childhood surgery after ear tubes.

These new guidelines were published earlier this month by the American Academy of Otolaryngology, so the ear, nose and throat doctors. The prior guidelines have been published in the year 2000 and at that time, they had said grounds for removal was three cases of swollen or infected tonsils in a year.

Now I mean some kids though live a whole year with swollen tonsils meaning they may have symptoms that they may not be an active infection there. But they really wanted to change the wording to something different than three cases of swollen or infected tonsils in a year.

So the new guidelines call for seven episodes of throat infection in a given year, or five episodes each year for two years or three episodes each year for three years. And they say these infections should be documented by a doctor and not just reported by parents.


The other reason for getting your tonsils out is a symptomatic obstructive sleep apnea diagnosed with a sleep study and symptoms of that of course, is going to be kids who snore and wake up frequently during the night, but a lot of kids who snore don't who have true obstructive sleep apnea which is why you want to have it diagnosed in a sleep study.

Some of the symptoms other than snoring behavioral problems from lack of sleep, school performance issues and there's also some controversial research that shows that growth may be affected by obstructive sleep apnea and again, some controversial research to show that bedwetting may also be related.

Now before you get too excited about those things, bedwetting like should we get our kid's tonsils out because they wet the bed, a December 2010 study in the Journal of Urology followed a group of 257 children undergoing tonsillectomy and found no difference in the rates of bedwetting before or after surgery.


So don't get too excited about that but I mentioned it because the article from the EE&T folks mentioned that bedwetting is one of the things that you may be able to get rid of through getting your tonsils out. But maybe not. The verdict's still have a math. I don't think the risk of surgery warrants it for bedwetting, personally.

Alright, so why do we want to decrease tonsillectomies? Well the reason is tonsillectomy is not a benign procedure. It requires general anesthesia and there's always risks involved with that. There's risk involved with introducing infection, also with bleeding and airway compromise because the tonsils are right there by some very important structures.

And also the tonsils have an important function. They're a lymphatic tissue, they're the first line of defense for intruding bacteria and viruses. So this is not something that you want to do lightly and that's the reason that the Ear, Nose & Throat folks wanted to change their criteria for getting tonsils out and making it a little bit stricter.


And I would even say that when you have those recurrent infections in the throat that you really to ought to look at if it's Group A strep or viral infections that you're dealing with because if it's recurrent viral infections, again, does the risks versus benefit warrant getting your tonsils out even for recurrent viral pharyngitis and that's something you have to discuss with your doctor and make a decision about.

Group A strep is something that we really want to avoid in kids because that can lead to rheumatic fever if it's untreated. So those are things to think about.

Alright, moving on, the study linking MMR vaccine to autism found to be fraudulent. Dr. Andrew Wakefield study created worldwide panic in 1998 because it supposedly demonstrated a link between MMR vaccine and autism. And they're saying now that this was based on doctored information and was in fact, fraudulent. That's the claim Brian Deer, a British investigative reporter in his recent article for the British Medical Journal.


Wakefield's original 1998 report was published in another British journal called The Lancet. That study claimed that 12 children, again, sample size 12, were normal until they had the MMR vaccine, after which they all developed autism.

Well 10 of the 13 authors involved in that original publication later renounced their findings and The Lancet actually retracted the article, but the damage was done. MMR vaccines plummeted and have still not reached pre-1998 levels. Measle infections has since surge with sporadic outbreaks in the U.S. and Europe and an endemic state of measles is now seen in England and Wales which has resulted in multiple childhood deaths from this once nearly eradicated disease.

A subsequent study with superior design and much larger sample sizes have found there to be no link between MMR and autism. Still, Dr. Wakefield stands by his findings with the recent lucrative book deals and a following of celebrity supporters like Jenny McCarthy.


Well now, British journalist Brian Deer calls Wakefield's 1998 study and elaborate fraud. Deer went back and interviewed the 12 children's parents and obtained medical records and he says five of these kids had documented developmental problems before they received the MMR vaccine. And he claims that all twelve cases were misrepresented when he compared the study findings to the actual medical record and the reports from their parents.

If you're interested in reading Dr. – I'm sorry, in Brian Deer's article and its entirety, hop on over to and look in the Show Notes for Episode 153 and we'll have a link so you can easily find it at the British Medical Journal's website.

Alright, a little bit of listener warning for this final story in our News Parents Can Use, it involves STDs, sexually transmitted diseases in teenagers. So if you're listening with young children and you want to skip this one, just fast forward to the music interlude and you can jump ahead to our Listener's segment and come back and listen to this one later if you feel that's appropriate.


So more than 10% of teenagers who claimed abstinence actually test positive for STDs. That's according to the study published in this month's Journal Pediatrics. Study author, Dr. Jessica McDermott Sales in the Department of Behavioral Sciences and Health Education at Emory University, says STD screening should happen regardless of what teenagers say about their sexual history. She goes on to say these infections can have some pretty major consequences for young people so it's worth the simple urine test.

Yes, it used to be you have to had to have a pelvic exam to get those test done, but now it can be actually be done on a urinalysis. So a study based on data from the National Longitudinal Study of Adolescent Health and this has tracked thousands of teens and young adults for more than a decade, in fact, there are more than 14,000 youth involved with this study and 14,000 kids agreed to provide urine specimens to check for three STDs: gonorrhea, chlamydia and Trichomonas.


11,000 of these youth, so 79% claimed that they had sexual intercourse in the previous 12 months. Let me just pause there. I know the study is talking about kids who claimed to be abstinent but then have STDs. Well first of all, 79% of the youth said no, we're not abstinent and that we have had sexual intercourse in the previous 12 months. So just ruminate on that, moms and dads.

The remaining 3,000 youth are reported to be abstinent. Well, urine STD tests came back positive for 964 of the youth total. Now the vast majority of positive tests came back for youth who did report sexual activity, but 118 teenager with positive results denied having sexual intercourse in the past 12 months, and 60 of these teens denied ever having sexual intercourse in their lives.


Dr. Sales says it is very important, this is a very important finding that self-reported abstinent youth can still test positive for an STD. And the bottom line for doctors is if you suspect an STD based on symptoms, order the urine test even if the teenager denies sexual activity. And the bottom line for parents, don't assume your teen will give the doctor or you an accurate sexual history report.

And don't get upset at your doctor for ordering these tests even if your child's saying no, I'm not sexually active, your doctor orders the test and they come back negative. Don't get upset at your doctor, they're just doing it because so many kids say they're not sexually active but do come back with an STD. So you get burn on that a couple of times and you're more likely to start ordering it on a more widespread basis.


Alright, and incidentally, if your teenager is saying no, I'm not sexually active, just remember, 79% of teenagers are and so you really need take a look at that if your child's saying that they're not. And take a little grain of salt and don't be absolutely sure unless your with your child 24/7.

Alright, we are going to take a quick break and we will be back with our Listener segment right after this.


Alright, we are back and our first question comes from Melissa in Merrimack, New Hampshire. And Melissa says, “Hi, Dr. Mike. I just had my second chid and I'm breastfeeding. I'm pursuing the internet, I'm perusing, sorry. And with your perusing you're probably perusing it as well.


I was perusing the internet and looking for information on what foods breastfeeding mothers can eat. I specifically was looking for information on alcohol and breastfeeding.

There seems to be some contradictory information. The lactation consultant I was asking for advice says absolutely not, but my obstetrician says alcohol in moderation, one or two drinks per week is okay and I don't have to pump and dump as long as the alcohol is out of my system by the time I pump or feed the baby. What is the correct information? Thanks, Melissa.”

Alright well, the biggest concern with alcohol and breastfeeding is that alcohol is a CNS, central nervous system depressant. And it causes drowsiness which is not always a bad thing in babies especially if and when colic kids. But in addition to causing drowsiness, it can also cause respiratory depression which can make babies stop breathing which leads to death.


So you don't want to use alcohol to make your baby drowsy to help them sleep because it can affect their breathing. So this is an important question, how much alcohol gets in the breastmilk, how long does it stay and what's a safe exposure for your baby. Let's tackle these questions one at a time.

First, ethanol which is the type of alcohol we're talking about in social drinks, it easily enters breastmilk but it also leaves breastmilk just as easily. And as it turns out, ethanol remains in equilibrium with ethanol in the blood. So ethanol in breastmilk remains in equilibrium with ethanol in the blood.

So as the ethanol is cleared from the blood, it's also cleared from the breastmilk at the same rate. So there's no reason to pump and discard after drinking. So the question then becomes how long does it take to clear alcohol from the blood and from the breastmilk?


Well, the rule of thumb is two hours for a single alcoholic beverage and a single serving is defined as 12 ounces of beer, 5 ounces of wine or 1.5 ounces of ED proof liquor. Although, if you're breastfeeding, lay off the liquor.

Each additional serving then requires an additional two hours. However, breastfeeding mothers really should limit themselves to one serving per day and why is that? Well, you want to avoid excessive time constraints on your infant's feeding schedule. And also too much alcohol decreases breastmilk production and results another maternal health risk like poor nutrition and liver damage.

And the last of our questions, how much alcohol exposure in breastmilk is too much for a baby, and I would say any amount in the breastmilk is too much, which is why you should wait the full two hours after single serving and limit yourself to one serving per day.

It's not okay to judge how the alcohol is making you feel because it'll take much less of the ethanol to cause respiratory depressions in your baby. So you may feel fine immediately after a single drink, but it doesn't mean your baby will be fine with that same concentration of alcohol in his or her blood and brain. I mean you may be fine but it could still be enough to cause your baby to stop breathing.


Alcohol exposure also has the potential to cause long-term developmental issues, how much does it take? Well, we really don't know and I don't think you want your baby to be the case study that helps us find out, right?

So to sum up, breastfeeding moms should limit themselves to one drink per day and should wait two hours after that single drink to breastfeed again. There's no need to pump and discard between the drink and your baby's next feeding. And one more time, the definition of a single drink is 12 ounces of beer, 5 ounces of wine and 1.5 ounces of ED proof liquor but lay off that stuff. Hope that helps, Melissa.

Alright, Nicole in Simi Valley, California says, “Hi, Dr. Mike, I'm a long-time listener and it's great to have you back. My question is about three and a half year old daughter. Her twin brother and her share a room and they've always fallen asleep fairly easily by themselves. We sleep-trained them to this by at a young age.


I should also mention that we have a bedtime routine that we never waive from, it includes pyjamas, brushing teeth, reading a book and singing songs before saying good night. All of a sudden about six weeks ago, my daughter decided she didn't want me to leave the room at bedtime. She said she was scared but I couldn't get it out of her what she was scared of. She started hysterically crying to the point of hyperventilation so I stayed until she fell asleep.

Well since that night I have stayed with her until she fell asleep. And every night, I console her telling her there's nothing to be afraid of. On the nights, I put my foot down and insist she fall asleep without me or try to leave the room before she's asleep. She screams and calls at me to stay or bolts out of her room and runs away from me when I try to put her back in bed.

I was literally chasing her around the house one night and had to catch her. She was so distraught and her eyes glazed over with fear. I knew that putting her in bed with her 13-year old sister just to get her to go to sleep. Well not only is this nightly event a disruption to both mine and her bedtime routines, but it's also a disturbance to the rest of the family.


Her twin brother gets upset and cries when she cries and now he is used to me staying in the room until he's asleep too. My teen daughter gets awakened by the screaming and crying and my husband is sick and tired of me falling asleep in her bed. I still have not been able to nail down what exactly she's afraid of, where this came from or why this started out of nowhere.

Please help, Dr. Mike, I know I probably messed up by reinforcing this behavior by creating this new routine of staying with her, but I would love any insight you have or any tips on how to help her fall asleep peacefully again without me there. Thanks for your time and I'm looking forward to more podcast, Nicole.”

Alright, Nicole, well thanks for you question. We've talked about this before and the answer is still the same but rather than make you wait through listen kind of go through briefly how you deal with this, first of all, first, let me say I don't think your daughter's scared of anything.


I think she wants you there, it's the bottom line. And I mean, obviously you want to limit her exposure to scary things. A kid who's having this issue, Scooby-Doo might not be the best cartoon for him to see.

So you want to really watch what kinds of books and stories you're reading to him as you want to limit exposure to things that they can kind of grasp on at bedtime. But I think this has been going on long enough that if there was something in particular that she was scared of, you would probably know what it is.

Little kids at this age aren't afraid to tell you what's on their mind. And so if she's not able to identify what she's afraid of over this period of time, it's most likely that it's really nothing and that really, ultimately she knows of this behavior.

And not necessarily on a conscious level, but deep in her brain she knows if she acts this way, you'd stay with her and that's what she wants. So what you have to do is stop staying with her. Now this is easier said than done, I realize. And she is going to continue to throw a fit and things are going to get worse before they get better.


But you have to remember that when you give in, she got what she wants. And if in the deep recesses of her brain, she knows hey, if I'm loud enough and do it long enough, she does stay. So you have to get to the point where no, you don't stay. And that's going to take some really bad nights. But that'll get you where you want to be.

You can also do a little more gently by having a behavioral modification routine. And I've described what we did for my daughter several times on this show. In a nutshell, you can – you don't follow this to the letter, you can modify it for how it works best with your child and it may actually take a trial run on a behavior other than bedtime so that she can make the connection of what's going on here in her brain.

But what we did is back then, Polly Pockets were a big toy which I had to think about, they had tiny little pieces that were chokable. So they've sort of changed what Polly Pockets looked like.


But back in the day, these were little things with magnets. This is great, really not safe. But again, don't follow this exactly. We bought a package of Polly Pocket. It was a huge packet. They have little houses and the little dolls and little accessories. It had a ton of stuff in it.

And we basically let her see the whole package and said okay, here's what we're going to do: if you go to sleep and you'll only call us – if you call us because you need something less than three times, then in the morning you'll get a star on the little chart. And we even had a three strikes, you're out kind of thing. So if she called, if she went – came out of the room or we went in the room, we'd say okay, here's one strike and make a little X on the paper. The second time we'd make a little X. The third time is you strike out. [Phone rings] And there is the phone. See here's the issue with the home studio, and not only home studio but with the phone in here.


We were not set up for this, so I apologize for that. We took care of that. So in any case, if you strike out, then it's a done deal for the night. And you want to get to the point though where you're not striking out too many nights. And that's why seeing the connection ahead of time may help you out, and you got to stick with that strike out.

Now in the morning if they didn't strike out, then they get to put a star. And if they get so many stars, they get to pick a part of that toy out to play with it. Only one part though. So you'd start out with okay, you only have to do this one night and you get a toy. So if you only call us twice, in the morning you'll get this toy. You'll get to pick which part of it that you want to play with and keep out.

So then the next night, now we're going to say okay, now you've got to earn two stars. And so you have to not strike out two nights in a row, and then you bump it up to three to five stars right around there. So you get a new part of the toy every three to five days.


But let me just say that each of these toys, it was just a package deal that we got a really good price on. But each one is a full little house and we'd let her pick out one of the dolls too. So it wasn't like okay, you get one piece of the puzzle every three to five nights. So it was a substantial deal and she really loved playing with these. I mean, you got to hit the right button, you got to know what your child likes to be able to have the right motivation.

And again in order for them to see the connection, you may want to start with okay, if you're good during dinner, or some other thing other than the bedtime issues, start with that so they see the connection between the stars and receiving the toys.

So again this is just a behavior modification routine, you may have to make it so that it – something that your child will be motivated to do, maybe an activity, it may be a toy, it may be just something that pushes their buttons that hey, I want this, it's worth not bothering mom and dad about. Falling asleep with the light on is fine and the door open.


Again, it's just you want the distractions to a minimum. If they're going to scream and cry, you run up – you can go up and say okay, you get one strike. And if we hit – see three X's on here, you don't get your star in the morning and then you're not going to get the toy. Again, you just have to modify that to your needs in the call, but hopefully that will help you out.

But I will warn you, yes, you did mess it up by sleeping with her. And now she's gotten to the point where she knows how long and how loud she needs to be to get you to stay and she has to learn that that's not going to work. So you may have some loud sleepless nights on your hand but probably not too many of them. And by doing this the behavior modification-type routine that may help but get better a little bit faster for you.

Okay, we are running out of time here. So we're going to move on to Emmanuelle in Paris, France. Emmanuelle says “Hi, Dr. Mike. I love your podcast. I have a couple of questions about one thing I often hear laymen and health professionals say. Perhaps I've even heard you say it on your podcast.


Why is it necessary to throw out your toothbrush after a cold? Isn't it impossible to re-infect oneself due to the antibodies that have been developed? I realize this doesn't apply specifically to pediatrics. Maybe you can still find time to answer it on the program. Thanks for all the time you put into the show, I appreciate it so much.”

Thanks for your question, Emmanuelle in Paris. I do want to say that this is more of a concern for bacteria and especially Group A strep than it is for viruses. A virus is really pretty fragile on surfaces, and they're best spread by respiratory droplets which is why you sneeze on your hand, touch a door knob, someone touches a door knob, pretty soon after and then rubs their face or nose, you can spread it that way.

But through a toothbrush that's setting idle all day and then is rinsed with water, viruses are probably really not going to be spread back to yourself that way. But bacterial infections – and you're right, by the way, about the antibodies, you do make the antibodies against viruses which make a bad infection from that virus less likely down the road.


So reinfecting yourself with a cold virus is unlikely with a toothbrush. However, bacterial infections are a little bit different in that you can reinfect yourself afterward. And Group A strep are actually fairly hardy bacteria that can live in the bristles of a toothbrush for several days.

So we do talk about changing the toothbrush when you have strep throat because sometimes kids do reinfect themselves that way after their course of antibiotics. So yes, something to think about. It's probably a good idea to change the toothbrush while you're in the midst of being treated for strep throat. But for viruses, it's really not necessary.

Alright, well thanks to our listeners for asking their questions. Don't forget, if you have a question you'd like us to talk about, just go to the website,, click on the Contact link. You can also email

Alright, we are going to take a quick break here and then we are going to come back and talk about a book ten minutes or so on ear infections, and then we'll wrap up the show. So come on back right after this.



Okay, we are back and we are going to talk about otitis media which is middle ear infections and it's the right time of the year for it. It's a common problem and there's lots of misconceptions about ear infections.

Let's start with just a little anatomy lesson. Very briefly, if you're looking at the ear, the outside parts of the ear canal which is the skin that leads inside where the eardrum is, and when that skin gets infected, that's an otitis externa or an external ear infection. Sometimes we call it a swimmer's ear.


And then you hit the eardrum, this is where sound waves are converted to mechanical vibrations. And then behind the eardrum is the middle ear space, so this is the space that gets infection when you have a middle ear infection or an otitis media, which is what we're going to talk about.

In the middle ear space, there are three little bones and they transmit the vibrations from the eardrum to the inner ear, and again, this is the area that gets infected with otitis media. Now in the inner ear, vibrations are converted to electrical impulses and that's where the auditory nerve then takes as electrical impulses to the brain and then your brain interprets those as sound.

There's also semi-circular canals in the inner ear and those have a role to play in balance. Inner ear infections can also happen, those are usually caused by viruses and result in dizziness because of the semi-circular canals become inflamed.


And then there's one other structure that we need to talk about here and that is the eustachian tube. Now the eustachian tube connects the back of the throat to the middle ear space. And it actually has a job, but it's also oftentimes the culprit in development of middle ear infection.

So what does the eustachian tube do? Well it equalizes the pressure on both sides of the eardrum. So if you think about air is coming the ear canal and pushing on the outside part of the eardrum, the middle ear space also has air and you want the air pressure to be the same on both sides of the eardrum, otherwise, the eardrum will bulge in one direction or the other. So you want air that's in the room to come in through the mouth through the eustachian tube and basically, push on the inside part of the eardrum so you have an equal pressure on both sides.


And this is the reason why there's is an issue when you go up and down in the mountains or you go up and down in an airplane. It's because the pressure where your body is, the air pressure is coming in through the ear canal and pushing on the outside part of the eardrum and the air pressure of where you were, that air pressure is still in the middle ear space pushing on the inside.

So just as an example, when you are going down in an airplane, when you're equilibrated with cabin pressure, you have cabin pressure which has a lower air pressure, right? Because there's less of column, they're pushing down on you from above so you have lower air pressure pushing on both sides of the eardrum, from the outside and from the inside because it's cabin pressure air that's went to the eustachian tube.

Whilst as you descend, the air pressure in the cabin becomes greater because you have a greater, larger column of air pushing down on you. So now the pressure coming in through your ear is greater. So it's pushing the eardrum inward, but the pressure that's in your middle ear space is still that high-altitude pressure which is less.


So what you have to do is chew gum or kind of crank on your jaw and when that does is it opens the eustachian tube so that new, that higher pressure air can get in and equalize the pressure. So the eustachian tube was all about equalizing the pressure on both sides of the eardrum.

Well the problem with the eustachian tube is that in little kids, and there's a bit of a genetic component to this. So some kids are born this way because of their family history and that's why frequent ear infection oftentimes run in families.

So some kids have a short, wide, floppy eustachian tube. And then as they grow and mature and their head grows, the tube becomes thinner, stiffer and longer. So why does this matter?

Now we got to go back to mouth bacteria. I mean normally, everyone has a mouth bacteria. If you don't have mouth bacteria, then you're going to have yeast and trush and fungal infections in the mouth.


So you want mouth bacteria but you want good bacteria. Now because the mouth is full of bacteria, you don't want that bacteria to go up the eustachian tube into the middle ear. So the eustachian tube is aligned with little cells that have hairs in them called cilia. And those cilia are kind of there to push the bacteria back down to the mouth and not let them get up into the middle ear space.

Well, when you have a viral infection, a cold virus, the cold actually infects those cilia hair cells so that they don't work right. So now it's easier for bacteria to get up the eustachian tube into the middle ear space and if you have a little kid who has a wide eustachian tube that is short and the cilia aren't working, it's really easy for mouth bacteria to get up into the middle ear space.


Now combine that with all the mucus that you're making with the cold and the mucus now clogs that eustachian tube and if you're also born as little kid with a floppy eustachian tube, now it can flop close and that mucus sticks it all together.

So basically, early on in the cold, any mouth bacteria that didn't make its way up the eustachian tube now becomes trapped in the middle ear space and can't get back down to the mouth because it's closed now and there's mucus blocking the way.

So the bacteria stay in the middle ear space, they start to reproduce, you get bacterial overgrowth in that space, the body sense and white blood cells do invade and that creates a pus and you get fluid and pressure and inflammation which equals pain.

Now that is how a bacterial ear infection gets going. The virus itself that infected the cilia can also get up into the middle ear space and especially if you already have a little bit of fluid in there from a previous bacterial infection, the virus can infect the lining of the middle ear space itself and cause inflammation and more fluids.


So there's a fair number of middle ear infections that are actually caused by viruses and not caused by bacteria. So how do you tell the difference between a viral ear infection and a bacterial ear infection?

Well, the gold standard way which we're not saying you should do would be to puncture the eardrum, collect the fluid and grow it out and see if bacteria grows. If bacteria grows, you know it's bacterial. If not, it's viral, and probably a combination of the two.

But one way that you can tell is by looking at the history. And so if you have a kid who the ear hurts or it looks kind of red in the first day or two of symptoms, it's probably viral because you haven't really had enough time for the bacteria to migrate up there, reproduce, the white blood cells come in. So the more typical scenario for a viral middle ear infection is that you have the ear pain right off the bat, right when the virus, the runny nose and congestion sort of that same time that, that's all started.


Now in a younger kid, especially under the age of two, I wouldn't make that assumption and I'd still treat with antibiotic. But if you have an older kid who has a little bit of ear pain and is early on in the process, that's where we get this idea of kind of watch and wait. Don't the antibiotic right away because it's probably a viral middle ear infection and even if it is kind of an early bacterial one, your body, just give it a chance to go away on its own before you get crazy with the antibiotics. In younger kids, that's not necessarily the case.

But now that you know the anatomy and how this whole thing gets set up, you can see that if you have a kid who's had a viral infection for a week, five to seven days and they maybe even seem like they were starting to feel a little bit better. And now all of a sudden, they have ear pain and the high fever and you look in the ear, the doctor does and it's red and the eardrums bulging and it looks like there's pus behind the eardrum, well now it's more likely to be a bacterial infection because when you look at sort of the sequence of events, you've had the right timing for all that to happen.


So that's how ear infections get started. It's not water in the ear. It's not cold weather, it's not wind or any of those things. Symptoms of ear infections, fever, pain, the pain can lead to the nausea and vomiting, in little kids they won't eat as well because of the pain and when they swallow, it pulls down on the eustachian tube and that can create a sharp pain sensation in the ear. So a lot of little kids won't eat as well. And again, they had oftentimes runny nose and congestion for a few days before the ear infection gets going.

A differential diagnosis on ear infections, you know again, we talked about viral infections causing the middle ear, also if you have an older kid with ear pain, just the mucus itself clogging the tube can create that pressure differential. So that kid's ears might feel like they're kind of popping and crackling like you're going up and down in an airplane or in the mountains. And that may be the real issue. It's not really an ear infection at all, there's just the pressure sensation, that can happen.


Swimmer's ear can cause ear pain, a foreign body in the ear can cause ear pain so as the doctor, that's sort of the other things you're thinking about when the kid comes in especially in the older one who's saying their ear hurts.

So what do you do, how do you do to sort of work this up, is it from the doctor point of view? You're looking at your history, do they have precursor upper respiratory infection or were they swimming a lot or did they put a foreign body in their ears or history for that. So sort of when you're collecting the information on the history, there's things you're thinking about.

Also the patient's history of the head, ear infections before, how many, how often, what antibiotics have been used and family history, is this frequent ear infections run in the family? Again, because of this genetic component because of the structural thing to short, floppy, wide open eustachian tube run in the family.

And then physical exam standpoint, you need a clear view of the tympanic membrane. Wax can be an issue. So you got to pull that, the doctor's got to pull the wax out to really get a good look what the eardrum's looking like.


Also redness of the eardrum can fool doctors because when babies are crying or have a fever, blood flow to the eardrum increases so even when kids don't have a true ear infection, their ear drum can look red because of increased blood flow from fever and from crying. So you really want to do more than just look for red eardrums, you got to look, does it look like there's pus behind it, is it bulging, we can put a little puff of air in and see if the eardrum wiggles to tell if there's fluid or air on the other side of the eardrum.

So all things that your doctor thinks about when they're trying to decide, is this really an ear infection or not? OK, so let's say your doctors decided that yes, you do have ear infection, what do you do?

Well again, if it's an older kid and it's sort of the beginning of the illness and you think well, this may be viral or the body may have the chance to knock this off, the watch and wait scenario is something to think about. In young kids, you treat if it's bacterial and in any toxic-looking kid with a really high fever and just looks sick, bad ear pain, you want to treat them and not assume that it's viral.


So you decide, OK, we're going to treat it. What antibiotic do we use? Well again, if it's viral, antibiotics aren't going to work, keep that in mind. And the antibiotic is not going to help the runny nose and congestion that goes along with it. And if the fever is from the viral component, the antibiotic's not going to help the fever go away either. That's to keep in mind.

So what antibiotic do you do? Well, that choice depends on if a bacteria, if you think the bacteria is going to be resistant to amoxicillin. Amoxicillin is a penicillin antibiotic, first choice for ear infection unless a kid has been on that recently.

And then, the worry there is if a kid's been on a penicillin antibiotic like amoxicillin recently, just keep in mind our anatomy and sort of how this all get started. If you kill off all the easy-to-kill bacteria with amoxicillin, you're left with the bacteria in the mouth that the amoxicillin won't kill. And those reproduce and fill them out up with the resistant bacteria.


So you have the thing processed that happens, but now rather than it being an easy-to-kill bacteria that migrated up into the middle ear, now it's more likely that a resistant bacteria has done it. So a kid who's been on amoxicillin in the last six to eight weeks, the last month or two, probably ought to get a “stronger”, you could see my hands right now you know I'm doing the air quotes, stronger antibiotics. It's not really stronger, it just works by different mechanism.

And amoxicillin works by a chemical called beta-lactam and if a bacteria produces a beta-lactamase, it makes it so that protein doesn't work right so the antibiotic becomes ineffective. So the bacteria is making a chemical that makes the amoxicillin not work. So you have to use something – in terms of a medicine like augmentin, you put another chemical in that makes that thing not work.


So you've got amoxicillin there, you've also got clavulanic acid and if the bacteria is making a chemical that makes the amoxicillin not work, well now the clavulanic acid, it's an augmentin, makes it so that the chemical that the bacteria is making doesn't work.

And there's the doorbell. So again, we're at home but we're moving to the Nationwide Children's Campus here soon. We won't have telephones and doorbells. So anyway, and then in the medicine like Keflex or Omnicef, it just works by different mechanisms so that it doesn't really matter that the bacteria is making this substance that makes the amoxicillin not work. So things again, things to think about in determining what treatment that you're going to use.

And again, this is for the residents and doctors in the audience, but parents need to know this too, so you'll understand why different antibiotics are chosen.


Okay so what kind of complications can you get from an ear infection? Well, you can get perforation of the tympanic membrane so there's so much fluid, so much pressure that little hole opens up and fluid leaks out through and you see pus basically coming out of the ear. If that happens recurrently, you can get scarring of the tympanic membrane.

And then the bacteria can spread to the surrounding structures, this is less common but possible. You can get mastoiditis which is a bone infection by the ear, meningitis is also a possibility that you have to worry about.

You can also then get a residual fluid that just hangs out for a while after the infection. Sometimes for many months and we call that a serous otitis media. It's not really an active infection, it's just left over fluid. And it may affect hearing temporarily.

The thing is with that is even if their hearing is affected by it, there's several studies that show that having the fluid there and having some hearing deficit from the fluid does not affect language development and it will resolve on its own even though it may take several months to do that.


Antihistamines won't help get rid of that fluid and ear tubes are not indicated to drain off that fluid because the risk of the surgery really outweighs any benefit because that fluid isn't really causing a problem anyway other than a little hearing loss, which is temporary, not permanent and does not affect language development.

Prognosis for ear infection, well, kids tend to outgrow the yeast as the eustachian tube elongates, narrows and becomes more rigid. And then also these kids are more and more expose to viruses, they make antibodies, remember it's the virus that gets the whole ball rolling and so if you have fewer viral infections, you're going to have fewer complicating ear infections.

So as you develop viral immunity, as you get sick often with viruses as kids do in daycare and when they first starts school, as they get older, they get more immunity against these viruses so you're going to have ear infection. So the prognosis is good as kids get older.


OK, so how do you prevent ear infections? Well, it's not by putting hat on, although you do want to avoid hypothermia and you want your kids to be comfortable, so hats are good but they won't prevent ear infection.

Well, to do, you'd want prevent an upper respiratory infection since that's what gets everything started, but that's difficult to do in young kids especially in day cares and schools, pre-schools and kindergarten.

Ear tubes, what do ear tubes do? Kids who get recurrent bacterial ear infection, not the fluid that hangs out for a while but they're really getting several antibiotics in a rows not working. How do your tubes help?

Well ear tubes of course, once the fluid's there, it drains it off, but it also helps to prevent ear infections with the next viral illness. And the way that, that works is that you're putting a little plastic tube to the eardrum that has a hole in the middle of it.

So if you think about our scenario, bacteria migrate up the eustachian tube, collect in the middle ear space, well now they have an exit route. They can get through a hole in the middle of the tube and basically become external skin bacteria. So it basically ventilates that space so that the bacteria don't collect in there.


So that sounds great, kids who have had two or three infections, put the ear tubes in. Well, you have to remember, there is risk with ear tubes. Again, it's surgery, there's the risk of anesthesia. You also have the risk of bacteria getting in from the outside now, so now water in the ear can be a factor, especially if it's water that's not sterile and it gets through the tube. Although some ear, nose and throat doctors would argue that it takes water under good deal of pressure to get through the hole in that tube but others would say no, it doesn't. So something to think about, you may need earplugs depending on what your doctor's opinion on that is.

So also, you worry about scar tissue, it's possible with the tube itself. So you're making a bigger hole in the ear and especially with a kid who's never had a perforated eardrum, I mean you're creating a new hole in the ear to put this plastic tube in, that can scar over and can cause issues down the road.


So I mean, there's issues to think about. There's risk versus benefit to think about with ear tubes so you really wanted to be a kid who needs it based on your doctor's opinion and ear, nose and throat doctor's opinion.

Alright, so hope that helps you understand a little bit more about ear infections. I'm looking at the time and we're about 15 minutes or so in. So I mean I even – it's like, OK, I've less material here so I thought it would be a shorter show. But you know give me less material and I'll just adlib more and so we have still have a 15-minute show. I don't know.

We're shooting for half hour ones, but it looks like I might be able in so we may end up somewhere between 45 minutes to an hour show with this new format. It really is a new format you know, we did three news stories instead of five. We did three listener questions instead of five but I'm getting hoarse and that, Chris, I'm getting over viral infection myself.

So anyway, really appreciate all of your support. Let's take a quick break and we'll come back and wrap up the show right after this.



Alright, thanks go out to the Nationwide Children's Hospital for helping us out with the bandwidth for this program. Also, as most of you know now, we are moving the production to Nationwide Children's Hospital in Columbus, Ohio next month. Here very soon, in fact, we're pulling out a dodge a week from today and we'll be setting up shop in Columbus.

I know, Orlando, Florida, we're going to miss you. And we really, really are going to miss Orlando. We have lots of friends here, great church, really great co-workers where I work at after I was at pediatrics in Orlando, great group of people and we're going to miss you. We really are.


But this opportunity to move up closer to lots of our family and to move the production to Children's and to be able to do this show as a part of my day job instead of at home where I'm taking up family time and you get ringing telephones and doorbells. So we're excited about the move but at the same time, it's bittersweet because we have so many good friends in Orlando and I mean, who can't not love living literally five minutes behind the Magic Kingdom and watching fireworks from your balcony every night?

It's a sacrifice moving back up north but one, I'm willing to make it for you, the valued listener. So we thank you for being a part of the show. You really do make the program what it is.

I would like to mention, a lot of people out there, we mentioned iTunes reviews. And reviews on iTunes are definitely helpful. If you have not done a review on iTunes, please do so because when listeners are perusing the iTunes library, looking for a show to listen to, they look at that ratings and how many people like it and subscribed and such and so iTunes reviews are very helpful.


But you know what, Facebook and blogs are also helpful. So if you're on Facebook, mention us. Put a link in as your status to PediaCast and say, hey there's a new PediaCast 153 out. Check it out, you know with the link. Also, if you do write a blog and wanted to mention PediaCast, that would be so helpful.

Again, not to toot our own horn here. I mean the idea here is not prestige and to have the biggest audience possible. The idea here really is to empower moms and dads to understand more about their children's health, to understand why their doctors make the decisions they do.

And I will say, a lot of doctors out there get into bad habits. And they get into bad habits because of parent expectations. The parent wants an antibiotic, the parent wants this, they want the ear tubes. And so by understanding why your doctor wants to do what he wants to do, it helps parents not put unnecessary pressure on their doctor to make bad decision.


So we just want to put power in the hands of moms and dads so that they understand their child's health better. And so by you helping spread that word, we can empower more moms and dads to understand about their child's health.

So I hope everyone likes the new format. At least the show doesn't go over an hour this way. Our next show again will be early February from the campus of Nationwide Children's Hospital and again, if there is a topic that you would like us to discuss, we're going to have an entire range. Nationwide Children;s Hospital is one of the top five largest, most research-producing academic, grant-funded university-associated children's hospitals in the country.


So I mean this literally, it's not a little mom and pop children's hospital down the road. I mean this is a large children's hospital. One of the largest in the country. And I'm just so excited to be able to bring PediaCast to that place and really for you, when we have discussion on otitis media, we'll get a pediatric ear, nose and throat doctor in the studio. You have a question about Von Willebrand disease, we'll get a hematologist, oncologist in the studio.

So we have a full collection of every pediatric sub-specialty that exists, there's the phone again. We have every pediatric sub-specialty that exist we'll be able to get in touch with and bring into the studio and just make this an incredible program. So please send your questions, now is the time as we're gearing up for our new location. Contact link or


Alright, I have basically made a half-hour program into an hour and I got to do something about that. Anyway, until next time which will be soon, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long, everybody.


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