10/23/2019
You wanted the nitty-gritty on ear infections, so here it is! 👂
Who is at risk for ear infections? Although they can occur at any age, ear infections are most common between the ages of 6 to 24 months. Potential risk factors include daycare, second-hand smoke exposure, allergies, viral illnesses, and “bottle propping.” Some babies are even genetically prone to getting ear infections. 🧬
Symptoms of an ear infection may include fever, pain, fussiness, difficulties with sleep, and poor feeding. Often times, these symptoms are mixed in with recent cold symptoms (cough, congestion, runny nose). 🤧 To make matters more confusing, a cold can cause fluid to build up in the ear – which often LOOKS and FEELS like an ear infection but has the tendency to go away all on its own. Even teething can cause your baby to pull at his or her ears!
So when is the right time to bring your child in? We all want to avoid those unnecessary visits and target the actual bacterial ear infections. I hate to say it, but it’s impossible to reliably diagnose an ear infection without taking an experienced look inside the ear itself. Symptoms of an ear infection may vary greatly, which is why we are unable to confidently give you the answer over the phone or internet.
However, I do think it’s safe to stay home when your child is otherwise doing well with only mild ear pain and low-grade fevers less than 102F. In fact, I’d feel comfortable monitoring the fevers from home for the first 3-4 days since it’s very common for a viral illness to cause several days of fever. 👶 As usual, offer Tylenol or Motrin for discomfort. I’d be a little bit more cautious with a child less than 2 years old since they are unable to verbalize their symptoms and often require treatment for a double-sided ear infection. If you think your child is teething, it is reasonable to stay home and offer cool teething rings, gum massage, a clean frozen cloth, etc. If you’re unsure of what to do, give the office a call.
Any sign of worsening illness would warrant a visit to the doctor, such as fevers lasting greater than 4 days, ear discharge, severe ear pain, unwillingness to drink, going longer than 8 hours without urinating, headache, persistent vomiting, etc. The emergency room is warranted for confusion, severe headache with neck pain, swelling of the ear/face, bulging of the ear away from the skull, concern for dehydration, difficulties breathing, or overall feeling that your child is seriously ill.
Have you ever brought your child in only to be told that he or she has a “fluid collection” rather than a true infection? 🧐 This is a huge source of confusion for families. As I mentioned above, a fluid collection (effusion) is commonly seen in a child who has the common cold (viral illness). Kids with allergies get effusions as well. The fluid collection itself does NOT require antibiotics UNLESS other ear infection criteria are met. These criteria include new ear drainage, notable bulging of the ear drum, severe pain, or temperatures of 102.2F and above (just to list the main ones). These symptoms would suggest an actual bacterial infection.
Again, a child with a simple fluid collection in the setting of a viral illness does not require antibiotics – but here’s the kicker: a simple fluid collection can turn into an actual infection. 🦠 This is why your provider will often ask you to return if symptoms get worse. They are hoping that the fluid will go away all on its own while acknowledging that it has the potential to turn into an actual infection that warrants antibiotic treatment.
So why might your doctor decide to “watch and wait” rather than just treat with antibiotics right away? Isn’t it “better safe than sorry?” As you’ve heard me preach before: We ONLY want to use antibiotics when absolutely necessary because bacteria are quickly becoming resistant to them. Plus, antibiotics have nasty side-effects like vomiting, diarrhea, and rash. Again, a cold can make the ears look a little funky, but this doesn’t necessarily mean that they’re infected with a bacteria. Even if bacteria are starting to brew, it turns out that MANY ear infections will actually clear up all on their own! 🤯
Wait… if ear infections have the ability to often clear up on their own, why don’t we just let them all run their natural course? Well, untreated infections can occasionally cause problems. Without proper treatment, some infections run the risk for complications such as mastoiditis, meningitis, brain abscess, loss of hearing, and more. However, watchful waiting has been practiced without any increased rate of complications. How is this possible? We carefully select WHICH patients qualify for watchful waiting based on prior research of presentation and outcomes.
When we suspect an ear infection, it is reasonable to try a period of watchful waiting as long as severe symptoms are not present. In other words, the child is allowed to have mild ear pain that has been present for less than 48 hours with body temperatures lower than 102.2F. The exception here is for bilateral (double-sided) ear infection in a child less than 2 years old – they should just be treated with antibiotics right off the bat. Those with new ear drainage likely need antibiotics right away as well. 💊 Otherwise, it is reasonable to give a “wait-and-see” prescription, where the caregiver is given an antibiotic script during the visit, but they are instructed to fill the prescription ONLY if the child fails to improve within 3 days or if the symptoms worsen at any time.
Should we treat the ear PAIN in the meantime? Yes. Ear infections can be very painful. The discomfort can last for 3-7 days even after starting an appropriate antibiotic, especially in young children. Tylenol or Motrin are the mainstays of pain treatment for ear infections. They can be used regardless of whether or not antibiotics have been started.
Does every child treated for ear infection need a follow-up visit? Not necessarily. Your pediatrician may decide to reassess their at-risk patients, such as young children with severe symptoms or recurrent infections. It is important to note, however, that a fluid collection can still be present in up to 70% of children even 2 weeks after successful antibiotic treatment.
Having a persistent fluid collection without the symptoms of an actual infection (pain, fevers, fussiness) is called otitis media with effusion (OME). OME does not require more antibiotics, but it does need to be followed because it poses a risk for hearing loss, speech delay, and permanent ear damage. Surgery for tube placement should be considered if the OME persists for more than 3-6 months, especially among developmentally at-risk children such as children with Down syndrome, autism, blindness, or global developmental delay.
Who else should potentially get ear tubes? Tubes may be considered when your child has had 3 infections in the past 6 months OR 4 episodes within a 1-year period (with at least 1 of those episodes falling within the past 6 months). The final decision to place tubes should be made with an Ear/Nose/Throat (ENT) doctor, as every individual circumstance has different pros and cons. Plus, the newest recommendations for tube placement certainly evolve over time. 💪
How can we prevent ear infections altogether? Try to breastfeed for at least 4-6 months if you can. Vaccinate your child with the pneumococcal vaccine. Avoid to***co exposure. If your pediatrician feels that allergies are a contributing factor, consider the treatment recommendations (such as nasal sprays and oral antihistamines). Avoid “bottle propping” and avoid feeding your baby completely flat on their back (keep them at a slight angle to prevent fluid from entering the Eustachian tubes). Try to eliminate pacifier use after the first 6 months of life. Switch from the bottle to a sippy cup by 1 year of age. Lastly, try to avoid getting sick as much as possible by frequently washing your hands and steering clear of sick family and friends. 🧽
Are there any alternative remedies for prevention and treatment of ear infections? I’d like to think that some of the alternative methods out there are actually safe and effective (things like homeopathy, herbal medicine, chiropractics, xylitol, vitamin D supplementation, probiotics, etc). However, the scientific evidence is lacking. To my knowledge, the studies that have been done are of poor scientific quality, and therefore I am unable to make any strong recommendations regarding their use. This is a noteworthy area of future research, especially given the era of antibiotic resistance.
What about home otoscopes? That is a tricky one. You know that I LOVE empowering you guys to make safe, educated decisions from home while avoiding unnecessary office visits.👍 However, even experienced physicians admit that checking ears can be difficult for a variety of reasons: squirmy child, small/curvy ear canals, wax build-up, new versus resolving effusions, temporary redness secondary to crying, etc. The path to diagnosing a viral-related fluid collection versus a true infection is a bit tortuous. I’m not saying that you can’t use an otoscope at home or that you need to ditch the one that you already have. I just feel that using them isn’t as straight-forward as we would like it to be. I wish a better tool was available. Thankfully, the development of inexpensive, easy-to-use video pneumatic otoscope is on the horizon!
Let me also take this opportunity to kindly remind everyone that a typical ear infection is not an emergency. 🚑 Unless your child is otherwise acting very sick (with confusion, severe headache, stiff neck, dehydration, or bulging of the ear away from the skull, etc), ear pain and fever in an otherwise healthy child over the age of 3 months does not require a costly visit to the emergency room!
Please note that this information does not replace clinical judgment nor is it meant to serve as a protocol for ALL children with ear-related conditions. Individual providers may vary in their practice. The doctor that knows your child best is the most equipped to address your child’s individual needs.
If you’ve made it this far and feel like you’ve learned something useful and new, feel free to share! 🥰
Primary Sources:
https://pediatrics.aappublications.org/content/131/3/e964
https://www.ncbi.nlm.nih.gov/pubmed/31592792
https://www.aafp.org/afp/2017/0115/p109.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753897/
