Ear Infection in Children

An ear infection is an inflammation of the middle ear, usually caused by bacteria, that occurs when fluid builds up behind the eardrum. Anyone can get an ear infection, but children get them more often than adults. Three out of four children will have at least one ear infection by their third birthday. In fact, ear infections are the most common reason parents bring their child to a doctor.


There are three main types of ear infections; each has a different combination of symptoms.


  • Acute otitis media is the most common ear infection. Parts of the middle ear are infected and swollen and fluid is trapped behind the eardrum. This causes pain in the ear—commonly called an earache. Your child might also have a fever.
  • Otitis media with effusion sometimes happens after an ear infection has run its course and fluid stays trapped behind the eardrum. A child with otitis media with effusion may have no symptoms, but a doctor will be able to see the fluid behind the eardrum with a special instrument.
  • Chronic otitis media with effusion happens when fluid remains in the middle ear for a long time or returns over and over again, even though there is no infection. This condition makes it harder for children to fight new infections and also can affect their hearing.


Most ear infections happen to children before they’ve learned how to talk.


If your child isn’t old enough to say “My ear hurts,” here are a few things to look for:


  • Fussiness and crying
  • Trouble sleeping and poor feeding
  • Fever (especially in infants and younger children)
  • Fluid draining from the ear
  • Tugging or pulling at the ear(s)
  • Clumsiness or problems with balance
  • Trouble hearing or responding to quiet sounds


What are the signs of acute otitis media?


The most common predisposing event to the development of acute otitis media in infants and children is a preceding viral upper respiratory tract infection. Accordingly, children with acute otitis media, particularly infants, may present with nonspecific signs and symptoms associated with a cold, and that may happen with or without a fever. In addition to the rhinorrhea and cough, the infants may also be irritable. Fevers occur in about half of the children with acute otitis media.


There are several reasons why children are more likely than adults to get ear infections:


  • Eustachian tubes are smaller and more level in children than they are in adults. This makes it difficult for fluid to drain out of the ear, even under normal conditions. If the eustachian tubes are swollen or blocked with mucus due to a cold or other respiratory illness, fluid may not be able to drain.
  • A child’s immune system isn’t as effective as an adult’s because it’s still developing. This makes it harder for children to fight infections. As part of the immune system, the adenoids respond to bacteria passing through the nose and mouth.
  • Sometimes bacteria get trapped in the adenoids, causing a chronic infection that can then pass on to the Eustachian tubes and the middle ear.


What should you expect from the doctor?


The first thing a doctor will do is ask you about your child’s health history.


  • If an ear infection seems likely, the simplest way for a doctor to tell is to use a lighted instrument, called an otoscope, to look at the eardrum. A red, bulging eardrum indicates an infection.
  • A doctor also may use a pneumatic otoscope, which blows a puff of air into the ear canal, to check for fluid behind the eardrum. A normal eardrum will move back and forth more easily than an eardrum with fluid behind it.
  • Tympanometry, which uses sound tones and air pressure, is a diagnostic test a doctor might use if the diagnosis still isn’t clear. It measures how flexible the eardrum is at different pressures.


Treatment of Otitis Media:


The backbone of treating a child with acute otitis media is the use of medications to control the pain, if pain is present, and antibiotics to treat the infection. The 3 bacterial agents that cause acute otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The antibiotic of choice is amoxicillin with or without clavulanic acid.


In recent years, there has been discussion and controversy regarding whether there is a need to treat all children who have acute ear infections with antibiotics immediately after the diagnosis is known. In the approach that is referred to as watchful waiting, the parent is given a prescription for the antibiotics and is advised to fill it only if the child does not improve over the next few days. This strategy is considered because some cases of acute otitis media resolve spontaneously -- that is, without the use of antibiotics. However, for children under 2 years of age who have signs and symptoms of acute otitis media, there is no controversy. All of these children should be treated with an antibiotic. In my opinion, when the diagnosis of acute otitis media is certain, in any age group, antibiotic treatment is favored. Children in whom observation or watchful waiting can be considered are children older than 5 years of age who have unilateral disease that is very mild.


Many doctors will prescribe an antibiotic, such as amoxicillin, to be taken over 7 to 10 days. Your doctor also may recommend over-the-counter pain relievers such as acetaminophen or ibuprofen, or eardrops, to help with fever and pain. (Because aspirin is considered a major preventable risk factor for Reye’s syndrome, a child who has a fever or other flu-like symptoms should not be given aspirin unless instructed to by your doctor.)


Serious complications of acute otitis media are relatively rare. Less serious complications include perforation of the eardrum and temporary hearing loss. More serious complications, such as mastoiditis or local spread of infection, are relatively uncommon. The least common are suppurative intracranial complications, such as meningitis, epidural abscess, or brain abscess.


Your child should start feeling better within a few days after visiting the doctor. If it’s been several days and your child still seems sick, call your doctor. Your child might need a different antibiotic. Once the infection clears, fluid may still remain in the middle ear but usually disappears within three to six weeks.


To keep a middle ear infection from coming back, it helps to limit some of the factors that might put your child at risk:


  • Wash hands frequently. Washing hands prevents the spread of germs and can help keep your child from catching a cold or the flu.
  • Avoid exposing your baby to cigarette smoke. Studies have shown that babies who are around smokers have more ear infections.
  • Never put your baby down for a nap, or for the night, with a bottle.
  • Don’t allow sick children to spend time together. As much as possible, limit your child’s exposure to other children when your child or your child’s playmates are sick.


In spite of these precautions, some children may continue to have middle ear infections, sometimes as many as five or six a year.


On follow up:


Otitis media with effusion, often referred to as OME, is defined as the presence of middle ear effusion in the absence of acute signs of infection. Otitis media with effusion most often arises following either a recognized or an unrecognized episode of acute otitis media. In many cases, the uninfected middle ear effusion may precede the episode of acute otitis media and may also follow the episode after the antibiotics have sterilized the middle ear effusion.


In some cases, otitis media with effusion occurs with a simple cold. Because of the frequency of episodes of viral upper respiratory tract infections and acute otitis media during the first 2 years of life, a young child may spend a significant proportion of those years with middle ear effusion.


Clinical signs of acute illness are by definition absent in patients with otitis media with effusion. However, whenever fluid fills the middle ear there is a conductive hearing impairment. The median hearing loss is 25 decibels, which is the equivalent of putting plugs in your ears. The infant may not be able to express the hearing loss, but the parent is usually aware that the child is not hearing well. Older children and adults usually recognize the hearing impairment.


Otitis media with effusion is transient in most children and may never be recognized. The gold standard to make the diagnosis is pneumatic otoscopy. In general, the approach to the management of otitis media with effusion is watchful waiting. The fluid in the middle ear in these cases is sterile, and antibiotics are not beneficial at all. In most cases, the fluid will disappear spontaneously over the next several months.


Sometimes, because children have frequent colds, they will have fluid in their middle ear for a substantial period of time during the first 2 years of life. Unquestionably, while the fluid is in the middle ear, the child will experience some hearing loss, a damping or muffling of sounds.


The following recommendations have been made for the use of tympanostomy tubes:


First, they are recommended in children who have a hearing loss of at least 40 decibels. They are also recommended for children who have had otitis media with effusion for at least 4 months with persistent hearing loss of at least 21 decibels, or other signs or symptoms. The last category is children with recurrent or persistent otitis media with effusion who are at risk for speech and language problems or learning problems for other reasons, such as children who have cognitive impairments.


Currently, the best way to prevent ear infections is to reduce the risk factors associated with them. Here are some things you might want to do to lower your child’s risk for ear infections:


  • Vaccinate your child against the flu. Make sure your child gets the influenza or flu, vaccine every year.
  • It is recommended that you vaccinate your child with the pneumococcal vaccine (PCV13). The PCV13 protects against more types of infection-causing bacteria than the previous vaccine, the PCV7. If your child already has begun PCV7 vaccination, consult your physician about how to transition to PCV13.


Studies have shown that vaccinated children get far fewer ear infections than children who aren’t vaccinated. The vaccine is strongly recommended for children in daycare.



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