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All About Ear Infections

Which early-childhood illness results in more prescriptions for antibiotics than all other illnesses combined? What's responsible for 24 million doctor visits every year? What will more than 70 percent of children experience before their third birthday? Chances are you know the answer: ear infections.

Yet, as common as they are, there's still much confusion about what causes them, what risks they pose for our children, and how to prevent them.

Here, what you need to know:

Contributing editor JESSICA SNYDER SACHS is a health and science writer based in Georgia.


When do young children get their first ear infection, and why?

Ear infections usually develop between 4 and 6 months of age, on the heels of a baby's first cold or other upper-respiratory infection, like flu or strep throat. But it's not the cold germs that infect the baby's ears. Rather, the inflammation of the eustachian tube  -- the tiny air passageway to the middle ear  -- brought on by a cold causes a vacuum to build up behind the eardrum. "This creates a breeding ground for bacteria, swelling, and pain," says Benjamin White, M.D., a pediatric otolaryngologist in Atlanta.

How many ear infections can a baby have before his parent should start to worry?

Two or three a year are generally not cause for concern, as long as the fluid clears from the child's ears between infections. A pediatrician will be able to detect this at follow-up visits.

Why are certain kids more vulnerable to them?

The younger the child, the greater the likelihood of ear infections. It's not until age 4 or so that the eustachian tube attains its normal, downward sloping position that allows for better drainage. In addition, infants are more prone to infection due to their less mature immune system.

Studies also suggest that children who are regularly exposed to tobacco smoke get more ear infections, as do those who spend time in daycare, presumably because of greater exposure to common respiratory illnesses.

Are there different kinds of ear infections?

No, though there are different terms for them, which can be confusing. Otitis and otitis media mean swelling or inflammation of the ear and middle ear, respectively. Acute otitis media describes a true infection, often with obvious symptoms such as pain, fever, and a red, bulging eardrum.

Otitis media with effusion occurs when fluid collects behind the eardrum. There's usually no infection or fever, and little, if any discomfort, though the fluid can interfere with hearing and create a breeding ground for new infections.

Can an ear infection lead to hearing loss?

Some temporary hearing loss almost always accompanies fluid in the ear  -- with or without infection. "It's roughly equivalent to wearing earplugs, about the level where you'd miss out on whispers," says Michael Poole, M.D., professor of otolaryngology and pediatrics at the University of Texas Medical School, in Houston.

However, the fluid can become so thick that it interferes with a child's ability to hear conversation. If this persists for months at a time  -- especially during the first year, when he's starting to process language  -- it can result in delayed speech.

On rare occasions, a chronic, untreated infection can scar the eardrum enough to impair hearing permanently. Or it can progress to a part of the inner ear, such as the cochlea, which also results in permanent hearing loss.


How can you prevent an ear infection?

Ear infections themselves aren't contagious, but the upper-respiratory infections that cause them are. "If you can stop kids from catching colds, that's half the battle," says Dr. Poole. You won't be able to keep your child entirely cold-free, of course, but there are some preventive steps you can take:

  • Try not to let infants and toddlers share toys that they put in their mouth, and when possible, keep kids away from others with colds, flu, or sore throats.

  • Keep babies from lying down with a bottle  -- liquid can pool inside the eustachian tube, allowing bacteria to grow.

  • Teach your child to cough or sneeze into a tissue or the crook of the elbow.

  • Insist that children and caregivers wash hands often.

  • When practical, look for smaller daycare settings  -- doctors say that groups of fewer than seven kids tend to have fewer infections.

  • As always, make sure your child drinks plenty of fluids and gets adequate rest.

Several studies have confirmed that breastfeeding may help protect a baby from illness, due to the immune-boosting components of breast milk. Immunizations for flu and other upper-respiratory infections can also help, says Nancy Sculerati, M.D., director of New York University Medical Center's Division of Pediatric Otolaryngology.

How can you soothe a painful ear infection?

For immediate relief, experts recommend age-appropriate doses of acetaminophen. Also try a warm (not hot) compress against the ear. Encouraging a child to swallow or yawn will allay discomfort by temporarily opening the eustachian tube. You can also ask your pediatrician for pain-relieving eardrops, such as a benzocaine ear solution. After that, antibiotics will generally eliminate pain and fever within 48 hours.

Various over-the-counter products  -- nasal decongestants, antihistamines, and sugarless gum  -- have been cited as being helpful in relieving ear infections. But experts say there's no conclusive evidence on these remedies.

Why not let an infection run its course without antibiotics?

At least half of all ear infections clear up on their own. "The problem," says Dr. White, "is the other half of ear infections that don't clear up." When your child has an ear infection, your doctor may recommend waiting to see what happens. This makes sense as long as the baby's symptoms (fever, pain) don't progress and you're in touch with your pediatrician.

Grave complications can arise if an ear infection is left untreated. These include a ruptured eardrum, felt as a sharp pain or popping sensation, followed by fluid draining out of the ear. "Typically, the rupture heals within 24 hours," says Dr. Poole, "but occasionally it won't heal on its own, and may require surgical repair."

In rare cases, the untreated infection can spread to the mastoid bone (behind the ear), and on to the lining of the brain (causing meningitis), the brain itself, or into the child's bloodstream.

Is it okay to discontinue antibiotics once a child feels better?

No! Though antibiotics, which relieve pain and fever, usually wipe out the most vulnerable bacteria within 48 hours, a full course of antibiotics is typically required to kill the tougher bacteria. If you fail to complete the full course of medication, those strains may stay intact and repopulate.


Why does a child sometimes develop an ear infection only a few days after finishing a round of antibiotics?

"It might be a new infection, but it's more likely the persistence of an old one that the first round of antibiotics failed to eradicate completely," says Dr. Poole.

According to some studies, up to half of all strains of Streptococcus pneumoniae, the most prevalent cause of acute otitis media, now shrug off standard doses of amoxicillin, the first-line treatment.

The good news, according to Dr. Poole, is that doubling the child's dose of amoxicillin  -- which the Centers for Disease Control and Prevention recommends  -- takes care of most infections with minimal side effects (minor stomach upset or diarrhea in some children). When this fails, broader-spectrum antibiotics, such as amoxicillin-clavulanate (Augmentin) or cefuroxime axetil (Ceftin), may be required.

Do low-dose antibiotics, given continuously, help to prevent recurrent ear infections?

It's not uncommon, though still controversial, to place ear-infection-prone children on a daily regimen of low-dose amoxicillin for 6 to 12 months. Maintenance antibiotic therapy, as this course of treatment is called, has its place, says Dr. Sculerati, when treating recurrent infections in children whose ears remain clear of fluid between bouts. "It can mean less antibiotics  -- not more," she says.

Dr. White doesn't agree with this at all. "It contributes to the development of resistant strains of germs," he says, "which puts the child at risk for getting more severe infections later on."


When is a referral to an ear-nose-and-throat doctor in order?

Generally, when chronic ear infections make life miserable despite antibiotics, or when fluid remains in a child's ears for more than three months, it's time to see a specialist.

Long-term hearing loss from lingering ear fluid is the greatest concern, which is why experts urge parents to pay attention to their child's hearing and speech development.

"If a child is yakking away and easily picking up on conversation, I wouldn't worry," says Dr. Sculerati. "But if she seems to miss sounds, asks you to repeat things, or lags behind peers in speech, I'd say she needs attention now."

A child with a suspected hearing loss should be seen by an audiologist experienced in testing babies, toddlers, and preschoolers for subtle hearing problems. Many pediatric otolaryngologists have such audiologists on staff.

What are ear tubes, and when are they needed?

Tympanostomy tubes, as they're called, are tiny, usually plastic tubes inserted in the eardrum that allow air and fluid to flow from the middle ear. Implanting them usually requires brief general anesthesia, as the doctor needs to make a small incision in the eardrum.

"Ear tubes are needed when a child has prolonged fluid buildup in the middle ear, resulting in hearing loss and speech delay," says Dr. Sculerati. "Improvement in hearing is nearly immediate. Tubes require surgery, though, so they shouldn't be taken lightly."

One new treatment, laser myringotomy, may offer an alternative for some ear tube candidates. Using a hand-held laser, the doctor creates a tiny hole in the eardrum, allowing it to drain. The hole usually closes up within a few weeks.

If your child is susceptible to ear infections, it may seem as though they'll never end. But most kids outgrow them by age 4, so be patient, take your child for regular checkups, and know that relief  -- for both of you  -- is in sight.