Next to colds, ear infections are the most common infection in children. They are usually complications of a cold or the flu (or sometimes allergies). Children, particularly those under the age of two, are much more prone to develop ear infections than older children and adults. Ear infections are bacterial infections of the middle ear space. Antibiotics are of some benefit, particularly in younger children. In older children and adults, the infection often resolves without antibiotics. Most children will have at least one ear infection by the time they are two years old. They are common until about 6-8 years of age.
What are the symptoms?
- Ear pain, which usually starts suddenly. Younger children may just pull at their ears. The ear pain is usually worse at night.
- Poor sleeping, usually due to ear pain.
- Infants and toddlers are usually very fussy.
- Fever (remember that fever won’t hurt your child).
- Usually preceded by several days of cold symptoms (runny nose, nasal congestion, cough, sore throat).
- Ears may feel full or “pop” and hearing may be decreased.
- Occasionally, the eardrum may rupture and pus will drain from the ear. (This is not uncommon and is not an emergency, but your child will need to be seen again).
What causes ear infections?
The middle ear is an open space filled with air, which allows the eardrum to move in response to sound waves. There is a tube (the eustachian tube) which connects the middle ear space with the throat so that the space can stay filled with air and the pressure can stay equal. When a person has an infection or other condition (such as allergies or exposure to tobacco smoke) causing swelling in the nose and throat, the tube becomes blocked or does not function properly and air cannot get into the middle ear space. This leads to a negative pressure behind the ear drum. The space then begins to fill with fluid instead of air and this fluid is the perfect broth for bacteria to grow in. The bacteria that are already present in a person’s nose and throat begin to grow in this fluid, causing pressure to build resulting in pain and inflammation. Viruses may also sometimes directly infect the eardrum and middle ear space causing inflammation and pain.
Ear infections are more common in younger children for several reasons. One is that they get more colds and colds are the main factor leading to ear infections. The other reason is that the tube connecting the middle ear to the throat is shaped differently in children less than 2 years old and does not function as well, leading to a greater chance of developing ear infections.
What should I expect?
- Ear infections are usually complications of a cold, so the child usually has runny nose and other cold symptoms for several days.
- Then there is the sudden onset of fever, ear pain, not sleeping well at night, and fussiness in infants and toddlers.
- Ear infections in older children and adults will often go away without any specific treatment. Pain should be treated with analgesic ear drops and oral pain medication such as acetaminophen or ibuprofen. If the pain is getting worse, then antibiotics are probably needed. In younger children, there is a higher risk of complications such as the spread of the infection to tissues around the ear, meningitis, rupture of the eardrum, or failure for the infection to go away on its own. Antibiotics are usually used in children less than 2 years old, along with pain medication, because of the higher risk of complications or of failure to resolve on its own.
- Serious complications are rare. Permanent damage to the ear or hearing problems are extremely uncommon. Ruptured ear drums usually heal quickly.
- Sometimes the germ causing the ear infection is resistant to some antibiotics and requires multiple treatments to cure the infection. Sometimes ear tubes are necessary to fully cure the infection in very resistant cases.
- Recurrent ear infections, with 4-6 infections in a year, are also sometimes treated with ear tubes to prevent further infections.
What is the treatment?
- Pain medication such as acetaminophen or ibuprofen.
- Ear drops for pain may also be used. These are prescription drops.
- Sometimes a heating pad or an ice pack over the ear can make your child feel better.
- Antibiotics when necessary (such as children under 2, or failure to control pain or worsening symptoms in older children). Be sure to take the antibiotic for all the days it is prescribed.
- If the ear is not better in 48 hours after starting the antibiotic, then your child may need a different antibiotic and should be re-evaluated.
- If your child’s ear drum has ruptured, ear drops are also usually used.
- Children should follow-up in 2-3 weeks to be sure the infection has resolved and that fluid does not persist.
- Swimming and air travel are safe when your child has an ear infection. There is no need to cover the ears when outside.
How can ear infections be prevented?
- Breastfeeding
- Not drinking a bottle while lying down.
- Avoiding exposure to tobacco smoke.
- Avoiding daycare and other causes of numerous colds during the first 2 years of life.
- In older children who still get ear infections, allergies or enlarged adenoids may be the cause and your child should be evaluated, especially if allergy symptoms, snoring or mouth breathing are common.
When can my child return to school or daycare?
Ear infections are not contagious. As long as your child is drinking well, does not have a fever and is not having pain that interferes with activities, she can return to school or daycare. Fever usually indicates that your child should stay home for extra fluids and rest. If your child also has a cold, then that is contagious for the first few days, though this is not usually considered a reason to stay out of school or daycare.
Other causes of ear pain
- Swimmer’s ear (an infection if the skin in the ear canal)
- Sore throat
- Teething
- Colds or allergies causing ears to be stopped up, pop and crackle
When should I seek further care?
Seek medical care immediately if:
- If your child develops a severe headache or stiff neck
- Your child suddenly acts a lot sicker
Call your doctor during regular hours if:
- If the ear pain is not better after 48 hours on the antibiotic
- Your child seems to be getting worse not better. (Please remember that the antibiotic for the ear infection will not help the symptoms of a cold such as congestion and cough).
References
Lieberthal, A.S., Carroll, A.E., Chonmaitree, T., et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics 131, e964–e999. doi:10.1542/peds.2012-3488
Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD000219. doi: 10.1002/14651858.CD000219.pub4
Chonmaitree, T., Trujillo, R., Jennings, K., Alvarez-Fernandez, P., Patel, J.A., Loeffelholz, M.J., Nokso-Koivisto, J., Matalon, R., Pyles, R.B., Miller, A.L., McCormick, D.P., 2016. Acute Otitis Media and Other Complications of Viral Respiratory Infection. Pediatrics 137, e20153555. doi:10.1542/peds.2015-3555
Tähtinen, P.A., Laine, M.K., Huovinen, P., Jalava, J., Ruuskanen, O., Ruohola, A., 2011. A Placebo-Controlled Trial of Antimicrobial Treatment for Acute Otitis Media. New England Journal of Medicine 364, 116–126. doi:10.1056/NEJMoa1007174
Hoberman, A., Paradise, J.L., Rockette, H.E., Shaikh, N., Wald, E.R., Kearney, D.H., Colborn, D.K., Kurs-Lasky, M., Bhatnagar, S., Haralam, M.A., Zoffel, L.M., Jenkins, C., Pope, M.A., Balentine, T.L., Barbadora, K.A., 2011. Treatment of Acute Otitis Media in Children under 2 Years of Age. New England Journal of Medicine 364, 105–115. doi:10.1056/NEJMoa0912254
Klein, J.O., 2011. Is Acute Otitis Media a Treatable Disease? New England Journal of Medicine 364, 168–169. doi:10.1056/NEJMe1009121
