Patient Presentation
A 3-year-old female came to clinic with a 1 day history of ear pain and pulling on her left ear. She also had some yellowish discharge on her pillowcase that morning.
She had no upper respiratory tract symptoms or fever, and had been playing in a lake.
The past medical history, and review of systems was negative.
The pertinent physical exam showed a happy female who was afebrile with normal growth parameters.
Her left external auditory canal had watery, yellow discharge and the canal was red and swollen with whitish debris. The tympanic membrane was not visualized due to the debris.
The pain was reproducible when pushing on the tragus.
The right external auditory canal had some mild erythema but no obvious discharge and the tympanic membrane was normal.
The rest of her examination was normal.
The diagnosis of left otitis external was made. Ciprofloxacin otic drops were prescribed along with information about the natural history and ways to prevent the recurrence.
The father then asked about what type of life jacket he should buy as they were invited to a boating party.
The pediatrician spoke with the father about general water safety including all persons wearing life jackets while on the water and needing to use a U.S. Coast Guard approved life jacket that was based on the weight of the child.
He also emphasized that boating operators should not be drinking alcoholic beverages, and that he recommended designating another adult in the boat to help monitor the water for other boats and people who may be around.
Discussion
Otitis externa, also known as swimmer’s ear, is a common infection, especially in school age children.
Moisture in the ear causes edema, skin breakdown and bacteria to grow. Swelling and debris may obstruct the external canal exacerbating the problem.
Common predisposing factors include swimming (especially in water with high bacterial counts), foreign body (including hearing aids, retained cerumen, insects, etc.), dermatitis, viral infections and local trauma (i.e. finger nails, cotton-tipped applicators, etc.).
Otitis externa is most commonly caused by Pseudomonas aeruginosa and Staphylococcus aureus, which often co-exist. Treatment with topical antibiotics such as ciprofloxacin and ofloxacin and pain treatment with acetaminophen or ibuprofen usually is all that is needed.
Learning Point
Drowning is the second leading cause of death for children between the ages of 1 to 14 years. In 2002, 832 children died from drowning in the U.S..
Personal flotation devices (PFD, or often called life jackets) are based on the child’s weight.
On the PFD label there should be a user weight such as less than 30 pounds, 30 to 50 pounds, and 50-90 pounds.
Persons over 90 pounds usually can wear PFDs for adults.
There also should be an approval statement such as “Approved for use on recreational boats and uninspected commercial vessels not carrying passengers for hire, by persons weighing __ lbs”.
States have different regulations regarding PFD use.
Generally one appropriately-sized PFD should be available for every person in a boat, and any boat 16 feet or longer must also carry a throwable device (PFD Type IV) such as a cushion or buoy.
A PFD should be worn at all times if at all possible while using a boat, kayak, canoe, personal watercraft (also known as a jetski) or in any towed activities such as waterskiing or inner tubing.
The labels of PFDs for personal watercraft and towed activities will be marked for these activities.
If PFDs are not worn in the boat, they should be stored on the boat so they can be retrieved and put on immediately (i.e. not in locked containers or with gear stored on top of the PFDs).
The throwable PFD must be immediately available for use.
Individuals negaged in activities where a person is in the water such as personal watercraft or towed activities should wear a PFD at all times.
PFDs come in different types:
- Type I – designed for all types of water (calm or rough) and especially remote waters where rescue may be delayed. Designed to turn a person face up.
- Type II – designed for calm, inland water or where there is a good chance of quick rescue. May turn a person face up. One of the most common and least expensive types.
- Type III – designed for calm, inland water, or where there is a good chance of quick rescue. Designed so the person can put themselves in a face-up position. The person may have to tilt their head back to avoid turning face down.
- Type IV – throwable device such as cushion, life ring, or buoy
- Type V – special use – such as working on sailing boars, or offer hypothermia protection.
Examples of these products can be found from the Wisconsin Department of Natural Resources at: http://www.dnr.state.wi.us/org/es/enforcement/safety/pfd.htm
Many PFDs are made of foam and generally not compressible. These can be bulky to wear for some people.
Some PFDs are inflatable and may be more comfortable to use. Inflatable PFDs should only be used by persons 16 years and older.
There are also hybrid PFDs with foam and inflation which are available for adults and children.
Overall, the best PFD is one that is rated for the weight of the child and can be worn comfortably at all times.
Parents should be reminded that PFDs must fit snugly on a child. To check for a good fit, pick the child up by the shoulders of the PFD. If the PFD fits right, the child’s chin and ears will not slip through.
PFDs are also not babysitters and a responsible adult should also be closely monitoring the children.
PFDs are not toys and toys are not PFDs. PFDs should be used for their intended purpose and not played with as they can be damaged. Inflatable toys and rafts should not be used instead of a proper PFD.
Questions for Further Discussion
1. At what age can a person operate or be a passenger on a personal watercraft (i.e. jetski)?
2. At what age can a child truly learn to swim?
3. Where can a person take a boating safety course in the local community?
Related Cases
- Disease
- Otitis Externa
Ear Infections
Water Safety (Recreational)
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for these topics: Water Safety and Ear Infections.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
United States Coast Guard. Teach Your Children Well.
Available from the Internet at http://www.uscg.mil/hq/g-m/mse4/pfdchild.htm (rev. 5/23/02, cited 1/10/08).
United States Coast Guard. Federal Requirements and Safety Tips for Recreational Boats.
Available from the Internet at http://uscgboating.org/safety/fedreqs/equ_pfd.htm (rev. 2005, cited 1/10/08).
Yuma P, Carroll J, Morgan M. A guide to personal flotation devices and basic open water safety for pediatric health care practitioners. J Pediatr Health Care. 2006;20(3):214-8.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Date
February 11, 2008
Pediatric Education 