| What is a middle ear infection? |
Most parents don't have to be told that middle ear infections — also known as otitis media — are one of the most common illnesses affecting infants and young children. Most children have at least one ear infection by age 3. By age 7, almost all children have had an ear infection.
Ear infections usually start with a cold, which can cause fluid to build up behind a child's eardrum. The fluid itself isn't necessarily a problem. But it's an ideal breeding ground for bacteria or viruses that cause infection.
An acutely infected ear is very painful. But interpreting pain in a child who may be too young to communicate verbally can be a challenge. Signs other than pain may be more apparent. A child with an ear infection may also have a fever and be irritable or listless. Difficulty sleeping is common.
Although ear infections can be extremely worrisome for parents and painful for children, the news is encouraging. Most children stop having multiple ear infections by the time they reach school age. In fact, the ear infection age range is 4 months to 4 years for the vast majority of children.
Some ear infections require the use of antibiotics, but many ear infections may clear without using antibiotics. Together, you and your doctor can decide on the best approach for your child. A few simple measures can greatly reduce your child's risk of ear infection.
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| Signs and symptoms |
Ear infections often affect children who are too young to describe how they feel. In addition, some of the signs of an ear infection, such as fever and sleeplessness, can be the result of many other medical conditions. That's why ear infections are sometimes hard to spot. Knowing what to look for can help. Keep in mind that ear infections often develop shortly after a cold and that your child will likely have the most discomfort in the first 24 hours after an infection develops.
Infants who are in pain are listless, and their crying is different from crying associated with hunger or tiredness. As a parent, you're probably familiar with your baby's different cries.
Young children may rub or pull on their ears and may not respond to sounds. Even though this may be a sign of fluid buildup in the middle ear, it's not necessarily a sign of an ear infection. Acute ear infections typically produce a lot of pain and are usually accompanied by a fever. Other signs and symptoms may include a loss of appetite or a feeling of dizziness or loss of balance. An older child may complain of an earache or a feeling of fullness or pressure in the ear.
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| Causes |
Your middle ear is a pea-sized chamber behind your eardrum (tympanic membrane) — a small circle of tissue that vibrates in response to sounds. It contains three tiny bones (ossicles) that send vibrations from your eardrum to your inner ear, where they're converted into the nerve impulses for sound. These impulses are what allow you to hear.
Your middle ear is connected to the back of your nose and your throat by a narrow passageway called the eustachian tube. Normally, this tube helps equalize the pressure inside and outside your ear. It also helps drain fluids from your middle ear.
Most ear infections begin with an upper respiratory infection such as a cold, which can cause swelling and inflammation in the eustachian tubes. A child's eustachian tubes are usually narrower and shorter than those of an adult. This increases the likelihood that inflammation will block the tubes completely, trapping fluid in the middle ear.
Fluid buildup will temporarily affect your child's hearing to a slight degree. That's because it's harder for the eardrum and the tiny bones in the middle ear to send sound vibrations in fluid. Yet the fluid itself isn't necessarily cause for concern. Usually this fluid disappears on its own in a few weeks. But sometimes it may remain in the middle ear for months. Then it may impair your child's hearing to such an extent that his or her speech development is affected.
Middle ear fluid also is an ideal environment for bacteria and viruses that cause infection. Inflamed fluid may cause inflammation and a buildup of pus that presses against the ear. This can be very painful for your child. Rarely, the pressure may rupture the eardrum.
| Risk factors |
All children are susceptible to ear infections, but some children are more likely to get them than others. Those most at risk include:
- Boys
- Children attending child-care centers
- Children whose siblings have a history of recurrent ear infection
- Children with a family history of asthma, allergies or eczema
- Children who are exposed to secondhand smoke
- American Indian, Alaskan-Eskimo or Canadian-Eskimo children. The shape of their eustachian tubes may make these children more susceptible.
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| When to seek medical advice |
If your child complains of an earache or pressure in the ear that lasts longer than a day or is associated with a fever, call your doctor. Also, see your doctor as soon as possible if you see a discharge of blood and pus. This may be a sign that your child's eardrum has ruptured.
Ear infections often affect children who are too young to tell you what's wrong. In children who are between 4 months and 24 months of age, be alert for sleeplessness, irritability and poor appetite following an upper respiratory infection such as a cold. Your child may or may not have a low fever. Young children may also pull on their ears and may not respond normally to sounds. If these signs and symptoms last longer than a day, call your doctor. Although an ear infection isn't an emergency, it may make your child very uncomfortable.
If an ear infection has been diagnosed in your child, see your doctor if the signs and symptoms don't improve with time or treatment or if they seem to become worse. In some cases, your doctor may schedule follow-up visits.
| Screening and diagnosis |
Middle ear infections are sometimes hard to diagnose. Your doctor can usually detect fluid in your child's middle ear. But there's no way to be sure the fluid is infected or if an infection is caused by a virus or a bacterium. Still, your child's doctor will try to make the best diagnosis possible based on your feelings about your child's pain, additional medical history and a physical exam.
During the exam, your doctor will likely check your child's head and neck for conditions that may make your child more susceptible to ear infections. Your doctor will also use a lighted instrument (otoscope) to look inside the ear for redness of the eardrum and for evidence of fluid behind the eardrum. The combination of these two findings may suggest middle ear infection.
In addition, he or she may check the eardrum to see whether it vibrates in response to air pressure. If the eardrum doesn't move freely, it's a sign that there may be fluid in the middle ear. A bulging eardrum or one that has changed color may indicate infection. Your child's doctor also may look for strep throat or enlarged, swollen tonsils.
In some cases your doctor may recommend a tympanogram or an audiogram test, especially if your child has had fluid in the middle ear for some time. A tympanogram test measures how well the eardrum moves. An audiogram test uses tones of varying frequencies to check for signs of temporary hearing loss.
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| Complications |
Many untreated ear infections clear on their own with no complications. But long-lasting or recurrent infections can damage the eardrum, ear bones and middle ear structure and may cause permanent hearing loss. In young children, even short-term hearing loss can cause delayed speech development.
In rare cases the pressure of an infected ear may cause your child's eardrum to rupture. You'll likely see a discharge of pus and blood that may be quite alarming. But the rupture actually relieves your child's pain, and in most cases the eardrum will heal on its own. If the eardrum continues to rupture repeatedly and doesn't heal, your child may require a surgical procedure to repair the eardrum and ensure that any infection is treated appropriately. It's also possible that your child's tonsils or adenoids may be enlarged and blocking the eustachian tubes. Any scar tissue that develops usually won't affect your child's hearing. Call your child's doctor as soon as possible if you suspect a ruptured eardrum.
| Treatment |
Doctors treat ear infections in a number of ways. What's best for your child depends on many factors, including:
- The diagnosis
- Any additional medical concerns
- How often your child has ear infections
- How long your child has had this ear infection
- Your child's age
- Whether the infection affects your child's hearing
- Wait-and-see approach. It's difficult for parents to see their children in pain. And most
parents would do anything to help their child feel better. But it may be in your child's best interest
to focus first on pain relief and to reserve antibiotics for persistent infections. That's because
most ear infections clear on their own in just a few days.
In addition, antibiotics won't help an infection caused by a virus. They also won't eliminate middle ear fluid. Furthermore, antibiotics may cause side effects such as nausea, diarrhea, rashes and allergic reactions. And frequent use of antibiotics can create strains of antibiotic-resistant bacteria. This can make it much more difficult to treat serious infections in the future.
If you do decide to hold off on antibiotics, watch your child for any sign of increased pain or hearing loss and ask your doctor for advice on pain relief. - Antibiotic therapy. If your doctor is concerned that your child's ear is infected, he or
she may recommend using an antibiotic. When the medication is effective, your child should start
feeling better in a few days. But even if your child's symptoms improve, continue giving the medicine
for the full length of the prescription, which can vary from 5 to 10 days depending on the regimen.
Stopping medication too soon could allow the infection to come back. It also contributes to the
development of antibiotic-resistant strains of bacteria.
Most children may have fluid in their ears for as long as 2 months after an infection has cleared up. This shouldn't be a problem unless it affects hearing. - Preventive antibiotics. If your child has recurrent ear infections — three or more ear
infections in a 6-month period, or four a year — your doctor might suggest a low-dose antibiotic for a
few weeks or months as a preventive measure. Antibiotics won't clear fluid from the middle ear, but
they may help prevent bacteria from growing. Antibiotics won't prevent viral infections. On the other
hand, because many bacteria are resistant to antibiotics, your child could develop an infection even
while taking medication. In addition, the longer your child takes antibiotics, the greater is his or
her chance of having side effects such as diarrhea, rashes and allergic reactions. Giving children
antibiotics as a preventive measure is an increasingly controversial decision. Be sure you discuss the
risks and benefits to your child with your child's doctor.
- Drainage tubes. If middle ear fluid is affecting your child's hearing, or recurrent ear
infections don't respond to antibiotics, your doctor may suggest insertion of a small drainage tube
through your child's eardrum. This helps drain the fluid and equalize the pressure between the middle
ear and outer ear. Your child's hearing should improve immediately. As your child's eardrum grows, the
tube is eventually pushed out and the drainage hole heals.
This surgical procedure (myringotomy) requires general anesthesia. About 25 percent of children continue to have problems and need surgery to insert a second set of tubes. A few children require even a third set.
If your child has drainage tubes, your doctor may caution against swimming, which can increase the risk of ear infections.
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| Prevention |
You can't protect your child completely from ear infections. But you can reduce your child's risk by taking the following steps:
- Choose a small child-care setting, if possible. Children in child care are more likely to
have ear infections than children who are cared for at home. And the more young children there are in
a child-care setting, the greater are the chances that your child will catch a cold that leads to an
infection. To reduce your child's chances of exposure, select a child-care center that has few
children of similar age.
- Protect your child from secondhand smoke. Children who breathe secondhand smoke are far
more likely to develop ear infections. If they do get sick, they will also take longer to recover. The
best way to keep your child safe is to make sure that no one smokes in your home and car. Preferably,
no one should smoke in your child's presence at all, such as in restaurants or at other gatherings.
Also, in most states, child-care centers are supposed to be smoke-free. Check to make sure yours meets
this requirement.
- Breast-feed your baby for at least 4 months. Infants who are bottle-fed are more likely to
develop ear infections than are babies who are breast-fed. Breast-feeding helps by passing along
immunity that protects against middle ear infections. It also helps keep your baby's eustachian tubes
from becoming blocked. If you do bottle-feed, hold your baby in an upright position. Avoid having your
child feed from a bottle while lying in bed.
- Ask your doctor about the pneumococcal 7-valent conjugate vaccine (Prevnar). This vaccine prevents the seven most common subtypes of the pneumococcal bacterium found among children. It's given as a series of four shots at 2, 4, 6 and 15 months of age. Although Prevnar is intended to prevent serious, life-threatening infections such as pneumonia and meningitis and has been shown to slightly reduce the incidence of some ear infections, it won’t prevent all ear infections.
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| Self-care |
Though an ear infection isn't an emergency, it can lead to intense pain during the first 24 hours. Home treatments can help relieve your child's discomfort. You may want to try one or more of the following:
- Pain relief. Ask your doctor about using an over-the-counter (OTC) pain reliever such as
acetaminophen (Tylenol, others) or ibuprofen (Motrin, Advil, others). Use the correct dosage for your
child's age and weight. If given for long periods of time or in large doses, either of these
medications can have serious side effects. Don't give aspirin to children under age 16. It may cause
Reye's syndrome, a potentially life-threatening condition.
- Warmth. Apply warmth to the ear. Using a warm, moist cloth may help relieve pain and
comfort your child.
- Eardrops. Consider asking your doctor to prescribe eardrops containing a local anesthetic. These won't cure the infection, but they may help relieve pain. Don't use drops if your child has drainage from the ear. Before administering the drops, warm them slightly by placing the bottle containing the drops in warm water. Then, gently lay your child on a flat surface with his or her infected ear facing up. Don't try to insert the drops with your child in your arms or on your lap.
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| Coping skills |
If your child has an ear infection, remember that time is usually on your side. As children mature, their eustachian tubes become wider and more angled. These developments help protect against ear infections. Although ear infections may still occur, they probably won't develop as often when your child reaches school age.
When caring for your child, plan some low-key activities that your child will find comforting and distracting. These can be simple things you don't normally have time to do, such as reading an extra book out loud. To make your child more comfortable, don't underestimate the benefits of extra cuddling.
— December 2, 2002 —
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