Ear infections in babies and children

What is an ear infection?

Also called otitis media, an ear infection refers to inflammation or infection of the middle ear (the little air-filled pocket behind the eardrum).

There are a few different types of middle ear infections, but the one most commonly experienced by babies and children is called acute otitis media (AOM). In this type of ear infection, fluid is trapped behind the eardrum, and parts of the middle ear become infected and swollen. This causes pain in the affected ear and your child may also develop a fever.

What causes ear infections?

A middle ear infection can be caused by bacteria or a virus. After an illness such as a cold or flu, fluid can build up in the middle ear, allowing bacteria or viruses that have traveled to the area to multiply and cause an infection.

Normally any fluid that enters this area drains quickly through the eustachian tubes, which connect the middle ear to the back of the nose and throat. But if a eustachian tube is blocked – as often happens during colds, sinus infections, and even allergies – the fluid gets trapped in the middle ear.

Germs like to grow in dark, warm, wet places, so a fluid-filled middle ear is the perfect breeding ground. As the infection gets worse, the inflammation in and behind the eardrum also tends to worsen, making the condition more painful. Your child may also develop a fever as his body fights the infection.

Using a pacifier may increase the risk of middle ear infections. In one study, the incidence of ear infections was 33 percent lower in babies who didn't use pacifiers.

Babies are more prone to ear infections because they have short (about 1/2 inch) horizontal eustachian tubes. As children grow to adulthood, their tubes triple in length and become more vertical, allowing fluid to drain more easily.

Signs of an ear infection in babies and children

The easiest way to tell if your baby might have an ear infection (or any other illness, for that matter) is by observing a change in her mood.

If your baby gets fussy or starts crying more than usual, be on the lookout for a problem. If she develops a fever (whether slight or high), you have another big clue. Ear infections tend to follow a common cold or sinus infection, so keep that in mind too.

You may also notice the following symptoms:

• Pulling, grabbing, or tugging at the ear. This could be a sign that she's in pain. (Babies do pull on their ears for many other reasons, so if your baby seems otherwise fine, she probably doesn't have an ear infection.)
• Diarrhea or vomiting. The bug that causes the ear infection can also affect the gastrointestinal tract.
• Reduced appetite. Ear infections can cause gastrointestinal upset. They can also make it painful for your baby to swallow and chew. If your baby has an ear infection, she may pull away from the breast or bottle after the first few sips.
• Yellow or whitish fluid draining from the ear. This doesn't happen to most babies, but it's a sure sign of infection. It also signals that a small hole has developed in the eardrum. (Don't worry – this will heal once the infection is treated.)
• Unpleasant smell. You may smell a foul odor coming from your child's ear.
• Difficulty sleeping. Lying down can make an ear infection more painful.
• Fever. Your child may have a rectal temperature of 100.4 degrees F or higher.

If you have a toddler or an older child, an earache is often the first noticeable symptom. Your toddler may seem cranky or might tug at her ear. Or your child may tell you that her ear hurts.

In addition to the symptoms above, you may notice these symptoms in your toddler or older child:

• Headache. Pain from the ear can radiate to the head.
• Trouble hearing sounds. Fluid buildup in the middle ear can block sound.
• Difficulty with balance. The ear helps with equilibrium, so you may notice that your child seems a bit unsteady.

How common are ear infections in children?

Ear infections are one of the most commonly diagnosed illnesses in children in the United States. A large study found that 23 percent of babies had at least one ear infection by their first birthday, and more than half had at least one ear infection by age 3.

Ear infection treatment in babies and children

Treatment depends on the severity of the infection and the age of your child. Babies who are 6 months and younger, and children with severe cases, may need to be treated with antibiotics. For most other children, doctors recommend a wait-and-see approach for two to three days, because ear infections usually clear up on their own. (About 80 percent of kids with AOM get better without antibiotics.)

For years, antibiotics were the first line of defense against ear infections, but now doctors are prescribing them more judiciously. Taking antibiotics too often is a concern because it can set children up to be vulnerable to antibiotic-resistant infections (see below for more information).

Ask your child's doctor whether she suggests watchful waiting or prescription medicine. The doctor may suggest an approach like this:

• If your child is between 6 and 24 months old and has mild symptoms in only one ear, or if he's at least 2 and has mild symptoms affecting one or both ears, keep an eye on his condition first. Your child's doctor may also suggest an over-the-counter pain reliever to help him feel better.
• If your child doesn't improve in 48 to 72 hours, follow up with your child's doctor, who may consider starting an antibiotic.

The American Academy of Pediatrics (AAP) recommends treating AOM with antibiotics for:

• Babies 6 months or younger; infants don't yet have a strong immune system and are especially vulnerable to complications from AOM
• Children 6 months or older with severe symptoms, such as a fever higher than 102 degrees F or moderate to severe ear pain that lasts at least 48 hours
• Children between 6 and 24 months old who have AOM affecting both ears (even without severe symptoms)

If your child does need an antibiotic, give him the entire course, even after he seems to feel better. Then have his ear rechecked a few weeks later so the doctor can make sure the medication worked.

If your child doesn't improve after 48 to 72 hours on the antibiotics, let the doctor know. She may want to switch medications.

Why are doctors concerned about prescribing antibiotics for ear infections?

Doctors are generally cautious about prescribing antibiotics because more and more bacteria are becoming resistant to them. And besides contributing to antibiotic resistance, giving a child antibiotic medication kills good bacteria, which are essential for keeping the digestive tract healthy.

Also, an ear infection can be caused by either bacteria or a virus. Since antibiotics don't work against viral infections, doctors are more cautious about prescribing them.

Drug companies used to stay one step ahead by continually introducing new medications, but bacteria have been mutating rapidly in response, making the drugs less effective. (Doctors say that parents can help combat this problem by not requesting antibiotics for every ear infection or bout with the common cold.)

When to call the doctor

Call at the first sign of an ear infection. If the doctor asks you to come in, she'll probably look in your child's ear with an otoscope. An eardrum that's red, bulging, and possibly draining is probably infected.

The doctor may also check whether the eardrum moves in response to a device called a pneumatic otoscope, which releases a brief puff of air into the ear. If it's not moving, that's another indication that fluid is collecting in the middle ear and may be infected.

Whether the treatment is watchful waiting or antibiotics, your child's condition should improve each day. If your child isn't doing better after 48 to 72 hours, let the doctor know. She may want to have you come back for a follow-up exam and start antibiotics, or to change antibiotics if your child was already taking them.

Home remedies and other ways to treat pain and discomfort

Here are a few ways to help your child feel better:

• Pain reliever. The correct dose of infant acetaminophen or ibuprofen (only give ibuprofen if your child is 6 months or older) can relieve pain. If your child is younger than 3 months, ask her doctor before giving her any medication.
• Warm compress. Hold it gently to your child's ear to help relieve pain.
• Lots of fluids. Encourage your child to drink more fluids, because swallowing helps to drain the middle ear and relieve painful pressure. If you have an infant, offer the breast or bottle more frequently. Encourage your toddler or older child to sip on water throughout the day.

Here's what NOT to do:

• If your child is 3 years or younger, do NOT give your child over-the-counter (OTC) cough and cold medications such as decongestants or antihistamines. These not only won't help her get better, they can also cause dangerous side effects in young children. (The AAP does not recommend OTC cough and cold medications for children under the age of 6, though some doctors may suggest it for 4- and 5-year-olds. Be sure to follow your doctor's advice.)
• Never give your child aspirin because it makes her more susceptible to Reye's syndrome, a rare but potentially fatal disease.

How to prevent ear infections in babies and children

The following are steps you can take to lower your child's risk of recurring ear infections. (The first few are specifically intended for babies.)

• Breastfeed your baby for at least six months. Breast milk provides antibodies against ear infections. A major study published in the journal Pediatrics showed that children who are breastfed for the first 6 months of life are less likely to develop ear infections.
• Hold your baby upright when feeding him. Hold him so his head is higher than the rest of his body. Babies fed while they're lying down are more likely to develop AOM.
• Wean your baby off the pacifier if your baby is prone to ear infections. Babies who are 6 months of age or older are slightly more likely to develop ear infections if they use pacifiers. But since using pacifiers in the first year may help protect against SIDS, ask your baby's doctor about the best time to wean.
• Wash your hands often. Although ear infections aren't contagious, the respiratory infections that lead to them are. Keep your child's hands clean, and stay away from people with respiratory infections whenever possible.

• Make sure your child's vaccinations are up to date.Immunizations help prevent certain illnesses that can lead to an ear infection. For example, the pneumococcal conjugate vaccine has dramatically reduced the number of ear infections in children. Research shows that since the pneumococcal conjugate vaccine has been on the immunization schedule, the number of 3-year-olds who have had at least one ear infection dropped by 20 percent.

  If your child has repeated ear infections, especially after bouts of the flu, talk to your doctor about giving your child an annual flu vaccine. (Only children who are at least 6 months old can get a flu shot.)

• Avoid secondhand smoke. Researchers have concluded that kids whose parents smoke are more likely to get ear infections and have hearing problems.

  Children living with a smoker have a 37 percent higher risk of middle ear infections and hearing problems, and a 62 percent higher risk if the mother is the household smoker. Kids are also 86 percent more likely to receive surgery for their middle ear problems when their mothers smoke, compared with children who have no smokers in their household.

  Even a weekend spent in a house with a smoker can significantly harm a child and raise his chances of getting an ear infection. Tobacco smoke seems to suppress the immune system, making it more difficult for your child to fight off infection. Don't let people smoke in your house, and keep your child out of smoky environments.

Can ear tubes help with repeated ear infections?

Possibly. Doctors vary on whether ear tubes should be used for recurrent ear infections because there isn't much research on their effectiveness, and the available data is inconclusive. According to the AAP, "More and better controlled studies of [ear] tube placement would help determine its benefit versus harm."

If your child's doctor suggests ear tube surgery, you'll have a conversation about the procedure's pros and cons. The doctor may suggest this treatment if your child:

• Is at least 6 months old
• Has recurring hearing problems or speech delays due to multiple ear infections
• Has persistent fluid behind the eardrum
• No longer responds to antibiotic treatment

The AAP says ear tubes can be offered to babies (who are at least 6 months old) and children who have had three episodes of recurrent AOM in six months, or four episodes in one year with the most recent episode occurring within the last six months.

Here's how ear tube surgery works:

• Your child is taken to the operating room and given general anesthesia.
• An otolaryngologist (ear, nose, and throat doctor) makes a tiny incision in the eardrum and removes fluid using suction.
• The doctor inserts a small tube into the slit.
• The tube releases pressure and acts as a vent, letting air in and fluid out, so bacteria can't flourish.
• Your child will wake up in the recovery room.

As with any surgery, there are risks, which can include the following:

• Complications from the anesthesia
• Bleeding
• Infection
• The tubes can sometimes come out by themselves
• Increased risk of damage to the eardrum

Are ear infections in babies and children ever serious?

They can be. A severe or untreated infection can rupture your child's eardrum. Ruptures don't happen very often and generally heal quickly, but it's important to follow up with your child's doctor to make sure the infection has cleared up and the eardrum is healing well.

Repeated ear infections can sometimes cause hearing loss and scarring. And in very rare cases, untreated ear infections lead to mastoiditis (a skull infection behind the ear) or meningitis.

Learn more:

How to give medicine to your child safely and effectively