An ear infection is one of the most common reasons to visit a pediatrician. By the time you've read this today, I've probably seen at least one ear infection in my office. But there is more to an ear infection than you might think.
What is an ear infection?
The medical term for an ear infection is acute otitis media, meaning inflammation (-itis) of the middle ear space. When a child gets a cold (a viral infection of the ears, nose, and throat), the Eustachian tubes may become swollen and blocked. The Eustachian tubes drain the middle ear space behind the ear drums into the nasal passages. Fluid builds up in the middle ear, which is called a middle ear effusion. When bacteria grow in that fluid, we call it an ear infection. If an ear infection is going to happen, it usually does between days 3 and 7 of a cold. Ear infections have nothing to do with earwax, teething, or swimming. (An infection of the ear canal is called otitis externa or swimmer's ear, and it is a totally different thing.)
Why do babies get ear infections?
There are a few reasons. First, babies tend to get a lot of colds. (It is normal for a toddler to get 6-8 colds a year — more if she is in daycare.) Each cold has the potential to set up the conditions that lead to an ear infection. Second, babies' Eustachian tubes are oriented more horizontally than adults' tubes, so fluid builds up more easily.
How can I tell if baby has an ear infection?
This is trickier than it seems. Tugging on the ears might appear to be an obvious sign, but it turns out that little kids mess with their ears for all sorts of reasons — they have earwax, they're tired, they're teething, or their ears are kind of fun to play with. Ear tugging is not strongly associated with ear infections. Kids with ear infections tend to cry, fuss (especially when lying down), sleep poorly, spike a fever (temperature over 100.4 degrees F), or have clear or cloudy fluid draining from the ear (but not waxy drainage). These signs are not specific, however. The only way to really diagnose an ear infection is to look at the eardrum.
How is an ear infection diagnosed?
This is much trickier than it seems. Trust me, I look in little ears all day long. The ear canal is tiny, the eardrum is often blocked by wax, and the ear is attached to a kid who is usually not terribly pleased to have someone looking in there. To accurately diagnose an ear infection, a clinician has has to see thick pus behind the eardrum, so much that it causes the eardrum to bulge outward. The clinician can also diagnose an ear infection if the eardrum is intensely red (think fire-engine red), and the child has severe pain. Redness alone is not enough to call it an infection. A crying child's eardrums turn red, just like her face turns red. Just seeing fluid behind the eardrum isn't enough either. Many children with a cold will have fluid behind their ear drums. Often, the fluid does not cause any symptoms and goes away on its own, usually in a few weeks. If the fluid sticks around for three months or more, and causes problems with hearing, pediatricians typically recommend a visit to an Ear, Nose and Throat (ENT) specialist to discuss ear tubes. Ear tubes can also be placed in kids with recurrent ear infections. (Ear tubes create a hole in the eardrum to let pus drain out instead of building up and causing an infection.)
Treating an ear infection
How do you treat an ear infection? First, ear infections hurt, so treating the pain is important. The go-to pain meds for kids are acetaminophen and ibuprofen. There isn't much benefit in alternating between the two, so I recommend picking one and sticking with it. (However, do not use ibuprofen in babies younger than six months.) Second, it is an ear infection so it is treated with antibiotics . . . right? Well, even the decision of how to treat an ear infection is a little more nuanced that you might think. The truth is that many ear infections get better on their own. In fact, a review in 2013 showed that up to 60% of ear infections improve after 24 hours, regardless of whether they are treated with antibiotics or not. Expert guidelines released in 2013 recommend an optional watch-and-wait approach for certain ear infections. In particular, if the fever is less than 102.2 degrees F, the pain is not severe, the symptoms have been present for less than 48 hours, and only one ear is affected, it is reasonable to give pain meds but hold off on antibiotics. If this approach is taken, it is important to have access to follow up with the pediatrician over the next two or three days to make sure the ear can be checked again if symptoms worsen.
Why watch and wait?
Why is this a big deal? If your child is sick, giving antibiotics for an ear infection without an accurate diagnosis could mask a more serious infection, like pneumonia or a urinary tract infection. More often, however, a child with a cough, fever, and runny nose has a viral illness that will get better on its own. Antibiotics only treat bacterial infections, so they won't help a viral illness. Antibiotics have side effects (most commonly diarrhea) and can cause allergic reactions, some of which can be serious. Antibiotic overuse can lead to bacteria that are resistant to antibiotics. (I'll point out that it's the bacteria that become resistant to antibiotics, not the kid.) Doctors are now dealing with more and more difficult-to-treat infections due to resistant bacteria.
How can I reduce the risk of an ear infection?
Ear infections are almost universal, but here are some tips to reduce the risk: breastfeeding, eliminating bottle use after 12 months, avoiding secondhand tobacco smoke exposure, and making sure your child is up-to-date on vaccines are all good ways to reduce the risk of ear infections. It does not appear that medications for allergies or acid reflux prevent ear infections.
Some last points to keep in mind about ear infections:
First, they are not emergencies. A night of bad sleep with a crying toddler is awful, but if you think it is an ear infection, you can wait to call your pediatrician in the morning. The infection will not spread overnight, or probably ever, to areas outside of the middle ear space.
Chronic fluid in the middle ear can impair hearing, but this is not a situation that occurs overnight either; the infection will not damage the bones of the middle ear. Even an eardrum rupture is not super serious. Sometimes, the pressure of the infected fluid builds up and punches a hole through the eardrum. This usually relieves the pain of an infected ear. The eardrum can be treated with antibiotic drops as well as antibiotics by mouth, and it will almost always heal and work perfectly fine after a few days to weeks. So, it is not necessary to go to the emergency department in the middle of the night for an ear infection. (However, if you are concerned that your child has something more serious, call your pediatrician, as there may be a need for a prompt medical evaluation.)
This article does not necessarily pertain to children with certain anatomic abnormalities of the head and neck, immune deficiencies, hearing impairments, conditions like Down syndrome, and other chronic conditions. And as always, this is general information. If you have any questions about your child, you can always call your friendly neighborhood pediatrician.
Sources Cited:
The Diagnosis and Management of Acute Otitis Media. http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488 Accessed 03/20/16
Dr. Ben Kleifgen is a pediatrician with First Steps Pediatrics and Adolescent Medicine in western Pennsylvania and surrounding areas of West Virginia and Ohio. He graduated from Temple University School of Medicine and completed his pediatric residency at the University of Arizona in Tucson.
