DOES YOUR CHILD HAVE AN EAR INFECTION? HOW TO TELL.
Your child has a bothersome cold for a week. Her
nasal discharge turns a little green and her cough
starts to keep you all up at night. Then one night she
is up every hour extremely fussy with a fever. You
take her into the doctor in the morning almost certain
she has another ear infection.
Ear infections are one of the most worrisome
illnesses for both parents and children to go through,
especially if they frequently recur. They also are the
most common reason for antibiotic prescriptions.
Here's a guide to help you understand why ear
infections occur, how to best treat them, and most
importantly, how you can prevent them from happening
too often.
EIGHT MAIN SYMPTOMS OF AN EAR INFECTION
Your child may have 2 or more of these symptoms:
- Cold symptoms – keep in mind that ear infections
are almost always preceded by a cold. Often a clear
runny nose will turn yellow or green before an ear
infection sets in.
- Fussiness during the day or night
- Complaining of ear pain or hearing loss
- Night-waking more frequently
- Unwillingness to lie flat
- Fever – usually low grade (101º - 102º); may not
have a fever.
- Sudden increase in fussiness during a cold
- Ear drainage – if you see blood or pus draining
out of the ear, then it is probably an infection
with a ruptured eardrum. DON'T WORRY! These almost
always heal just fine, and once the eardrum ruptures
the pain subsides.
YOUR CHILD IS UNLIKELY TO HAVE AN EAR INFECTION IF:
1. No cold symptoms – if your child has some
of the above symptoms but does not have a cold, an ear
infection is less likely, unless your child has had an
ear infection in the past without a cold.
2. Pulling at the ears or batting the ears in
infants less than 1 year of age.
Infants less than one are
unable to precisely localize their ear pain. This
means that they cannot tell that the pain is coming
from the ear or from structures near the ear. Infants
can pull on or bat at their ears for two other common
reasons:
- Teething – Baby thinks the pain from sore gums is
coming from the ears
- Because they like playing with their ears –
Infants are fascinated with these strange appendages
that are sticking out of the side of their head.
They love to explore them, play with them, and
especially to stick their finger into that strange
hole in the middle.
3. No complaints of ear pain in a child who is
old enough to tell you, usually by age two or three.
HOW CAN I TELL IF IT'S AN EAR INFECTION OR JUST
TEETHING?
Are you tired of taking your fussy baby into the
doctor just to check her ears, only to be told its
probably just teething? TO help you decide, with
teething:
- Pain usually starts at four months of age and
will come and go until the two-year molars are in.
- Tugging or digging at the ears with no cold
symptoms or fever
- Fussiness or night waking with no cold symptoms
or fever
- May have low fever less than 101
- Teething does not cause a runny nose, only drool.
HOW DO EAR INFECTIONS OCCUR
Anatomy lesson. The ear is divided into three
parts: the outer ear canal, the middle ear space where
infections occur, and the inner ear where the nerves
and balance center are. A thin, membranous eardrum
divides the outer and middle ear. The middle ear space
is also connected to the back of the nose via the
Eustachian tube.
Immature Eustachian tube. In infants and young
children this tube is much shorter and is angled. It
is therefore much easier for bacteria to migrate from
the nose and throat up into the middle ear space. As
the child grows this tube becomes more vertical, so
germs have to travel "up hill" to reach the middle
ear. This is one-reason children "outgrow" ear
infections.
Colds. When your child has a cold, the nasal
passages get swollen and mucus collects in the back of
the nose. This environment is a breeding ground for
the bacteria that normally live in the nose and throat
to begin to overgrow. Mucus is also secreted within
the middle ear space just as it is in the sinuses.
Bacterial invasion. Germs migrate up through
the Eustachian tube and into the middle ear space
where they multiply within the mucus that is stuck
there. Pus begins to form and soon the middle ear
space is filled with bacteria, pus and thick mucus.
Ear pain. This pus causes the eardrum to bulge
causing pain. It is this red, bulging pus-colored
eardrum that the doctor can see by looking into the
ear canal.
Diminished hearing. The discharge that
collects in the middle presses on the eardrum
preventing it from vibrating normally. This is what
the doctor means by "fluid in the middle ear." Also
the fluid plugs the eustachian tube and dampens the
sound like the sensation in your ears during air
travel.
ARE EAR INFECTIONS CONTAGIOUS?
No, the bacteria inside the ear causing the infection
are not contagious. The cold virus that can lead to an
ear infection is contagious. Oftentimes, if the ear
infection occurs a week after the cold begins, the child
is no longer contagious.
HOW ARE EAR INFECTIONS TREATED?
Ear pain – Getting through the night:
- Acetaminophen or ibuprofen are
effective pain relievers for ear pain. You can
safely use both medications together if one alone
is not enough. Click on each medication for
dosage.
- Warm compress – apply a warm washcloth
to the ear.
- Warm olive oil, vegetable oil, or garlic
oil – put several drops of one of these into
the ear. MAKE SURE THE OIL ISN’T TOO HOT.
- Anesthetic eardrops – if the above
remedies aren’t enough, these are available by
prescription and can numb the eardrum to minimize
the pain for an hour or two.
- WARNING
– if you see any liquid or pus draining out of the
ear, DO NOT PUT ANY OF THE ABOVE DROPS
INTO THE EAR. See below under ear
drainage.
Antibiotics – a seven-day course is the
current recommendation, unless your doctor feels a
longer course is indicated. The whole issue of
antibiotics can be confusing to parents. Here are some
general guidelines to help you:
- Amoxicillin – "the pink stuff" – this
is the standard first-line treatment used by most
doctors, and rightly so. It works well most of the
time, is inexpensive, tastes pretty good, and is
easy on the stomach and intestines.
- Azithromycin, Augmentin
(amoxicillin/clavulinate mix), double dose
amoxicillin, cefuroxime – this are all common
second and third line choices.
- A new combination of Augmentin plus extra
amoxicillin called Augmentin ES has been
shown to be very effective in treating resistant
ear infections. Your doctor may prescribe both.
- Finish the prescribed course – even if
you child is feeling better after two or three
days, it is best to complete at least seven days
of treatment to help ensure the infection doesn't
come back.
Ruptured eardrum – if this occurs, your
doctor will probably also prescribe an eardrop that is
a mix of antibiotic and hydrocortisone. This helps the
ear canal heal.
Avoid antibiotic resistance - But doctor,
amoxicillin doesn't work for my child, and it's so
hard to give it to her three times a day! Can I
please have the once a day for only five days stuff?
Be careful about doing this. Always taking a
stronger, more convenient antibiotic can make the
bacteria that dwell in your child more resistant to
the stronger antibiotics, and can make future
infections more difficult to treat. Even if
amoxicillin hasn't worked once or twice in the past,
chances are that this new infection is a different
bacteria that is sensitive to amoxicillin,
especially if more than two months have passed since
the last antibiotic. The good news is amoxicillin
now comes in a twice-a-day form, and treatment is
usually only seven days, not ten.
When to use a stronger antibiotic – it is
usually best to start out with the simple amoxicillin.
Here are some reasons to go with something stronger:
- If the fever and fussiness are not improving
after 48 – 72 hours of an antibiotic, your child may
need a stronger one.
- If amoxicillin has not worked two or three times
in the past, then it's ok to start with a stronger
antibiotic for future infections.
- If your child has taken amoxicillin in the past
six weeks, and then develops another ear infection,
chances are that this infection is resistant and
needs a stronger antibiotic.
- If your child is allergic to amoxicillin
- If the infection is still present after one
course of amoxicillin
- Important note – the antibiotics only take care
of the bacteria causing the ear infection. They
don't treat the virus that is causing the underlying
cold symptoms. So don't expect the runny nose and
cough to improve for 3 to 14 days.
ARE ANTIBIOTICS ABSOLUTELY NECESSARY TO TREAT EAR
INFECTIONS?
No, they are not absolutely necessary, but they are
very helpful for several reasons:
- Antibiotics will help your child feel better
faster by eliminating the bacteria, which in turn
reduces the fever and ear pain more quickly.
Children generally feel better after one or two days
of antibiotics.
- Allowing an ear infection to heal on its own
usually subjects a child to four to seven days of
fever and ear pain.
- Antibiotics help prevent the very rare, but
possible, complications of an ear infection
spreading into the brain or bone surrounding the
ear.
- New research is suggesting that 80% of
uncomplicated ear infections will resolve within 4
to 7 days without antibiotics. Parents who choose
not to use antibiotics can treat the pain and fever
with Auralgan anesthetic ear drops and ibuprofen or
acetominophen.
MINIMIZING THE SIDE EFFECTS OF ANTIBIOTICS
Side effects can include:
- Diarrhea
- Fungal diaper rash
- Oral thrush
- Vomiting
- Rash
HOW EAR INFECTIONS RESOLVE
There are two components of ear infections that need
to resolve:
- Infection – the antibiotics usually take care of
the bacteria, which in turn resolves the fever and
pain with a few days.
- Middle ear fluid – it takes much longer for this
to resolve, anywhere from a few days up to 3 months!
The fluid slowly drains out through the Eustachian
tube down into the nose. Taking repeated courses of
antibiotics does not speed up this process, since
the fluid is usually no longer infected with
bacteria. Chronic nasal congestion or allergies can
block the Eustachian tube and therefore prevent the
ears from draining. Your child's hearing may be
muffled until the fluid drains out. This is not
permanent. See below on preventing ear infections
for tips on how to improve ear drainage.
- Remember, since the runny nose and cough are
usually caused by a cold virus and not bacteria, it
may be 3 – 14 days before these symptoms resolve.
FOLLOW UP WITH THE DOCTOR
Most doctors will have you follow up anywhere from
one to four weeks after an ear infection. There are
several reasons for this:
- To make sure the infection is clearing up
- To make sure the middle ear fluid is draining
out. If the fluid stays around continuously for more
than three months, your doctor needs to know.
- To help determine if the next ear infection is a
new one or a continuation of an old infection. This
helps determine which antibiotic to use.Your doctor
may perform a tympanogram
– a rubber probe that
painlessly fits into your baby's ear canal and
measures how the eardrum vibrates. This helps
determine if there is any fluid left.
IMPORTANT NOTE: Try to avoid over-treating
with unnecessary repeated courses of antibiotics. At
your follow-up visit with your doctor, there may still
be fluid in the middle ear. If the ear is not red or
bulging, and your child is acting fine, you may not
need another course of antibiotics. Doctors will vary
in how aggressive they like to treat ear fluid. You
may be able to spare your child from an unnecessary
course of antibiotics.
CHRONIC EAR FLUID
As stated above, sometimes it can take several months
for the fluid to drain out of the middle ear space.
During this period the hearing can be muffled. This
isn't dangerous and does not cause permanent hearing
loss. Thankfully, the fluid often drains out within
two or three weeks. There are several situations,
however, when you do need to worry about this fluid in
the ear:
- Eustachian tube dysfunction – this is a condition
where the Eustachian tube can't do its job correctly
and the middle ear doesn't drain. Causes include
chronic sinus infections, nasal allergies and
frequent colds.
- Fluid that stays in the ear for more than three
to four months can become thick and gooey, a term
called "glue ear". This type of fluid often needs to
be drained surgically by an ear specialist.
- If this long period of muffled hearing occurs
during the first two years of life when language
development is crucial, it can cause speech delay.
This is usually only temporary, however, but the
longer it goes on, the longer the speech and hearing
can be delayed.
- If your child has several ear infections over a
three to four month period, and the fluid never
really has time to drain in between infections, this
can cause a prolonged period of muffled
hearing.Again, don't worry if it takes one or two
months for the fluid to drain out of your child's
ear. This is common. We would like to stress,
however, the importance of proper follow-up with
your doctor to make sure it eventually resolves.
NINE STEPS TO PREVENTING EAR INFECTIONS
If your child has had several ear infections already,
or you simple wish to lower her risk of getting them
in the first place, here are some ways to prevent or
at least lessen the frequency and severity of ear
infections:
1. Breastfeeding. There is no doubt whatsoever
in the medical literature that prolonged breastfeeding
lowers your child's chances of getting ear infections.
2. Daycare setting. Continuous exposure to
other children increases the risk that your child will
catch more colds, and consequently more ear
infections. Crowded daycare settings are a set up for
germ sharing. If possible, switch your child to a
small, home daycare setting. This will lower the risk.
3. Control allergies.
4. Feed baby upright. Lying down while
bottle-feeding can cause the milk to irritate the
Eustachian tube which can contribute to ear
infections.
5. Keep the nose clear. When a runny nose and
cold start, do your best to keep the nose clear by
using steam, saline nose drops, and suctioning. See
colds for more info on this.
6. Cigarette smoke. There is strong evidence
that smoking irritates baby's nasal passage, which
leads to Eustachian tube dysfunction.
8. Eat more raw fruits and vegetables - these
can greatly boost your child's immune system and help
fight off infections.
MEDICAL PREVENTION FOR CHRONIC OR FREQUENT EAR
INFECTIONS
If your child is having frequent ear infections, more
aggressive prevention may be indicated. There are
different opinions as to the definition of chronic ear
infections. How many is too many?
- More aggressive doctors may choose to begin
medical prevention if you child has more than three
ear infections in six months, or more than four in
one year.
- Less aggressive doctors may allow your child to
have more infections before recommending medical
prevention. We lean more in this direction.
- Other factors such as hearing loss and speech
delay may warrant more aggressive treatment.
There are three forms of medical prevention:
- Prophylactic antibiotics. This consists
of a once-a-day dose of amoxicillin or similar
antibiotic. There are two ways to do this:
- Daily treatment for several months
continuously, such as through the winter season.
- Start the daily treatment at the first sign
of any cold symptoms, and then continue the
antibiotic for 7 – 10 days.
- Advantage to taking prophylactic antibiotics
is that you avoid full dose courses of possibly
stronger antibiotics.
- Disadvantage is that your child gets and
antibiotic possibly more often and this could
contribute to antibiotic resistance.
- OUR PREFERENCE is to start the daily
amoxicillin at the first sign of cold symptoms.
- Immunization. There is a new vaccine
called Prevnar that came out in 2000. Four doses are
given during the first two years of life. For
children 15 months and older, one dose is enough.
This vaccine helps prevent infections from a
bacterium called pneumococcus. This bug causes
pneumonia, blood infections, meningitis and ear
infections. The main purpose of this vaccine is to
prevent the more serious infections. It also can
prevent ear infections in two ways:
- Decreased number of ear infections – this
effect is minimal. Studies have shown that this
shot only decreases ear infections by 10 – 20%.
- Decreased ear infections from resistant
pneumococcus – this is considered a much more
valuable benefit from the shot. The vaccine has
been shown to significantly decrease the number
of ear infections caused by pneumococcus that
are resistant to standard antibiotics.
- Ear tubes.
These are tiny tubes that an
ENT specialist inserts into the eardrum under
general anesthesia. They usually stay in place for 6
months to over a year. There are several purposes
achieved by tubes:
- To drain chronic ear fluid that may turn into
"glue ear".
- To provide an outlet for middle ear fluid to
drain out as it begins to collect during a cold.
This may help prevent a full ear infection from
occurring.
- To preserve hearing and timely speech
development by avoiding long months of muffled
hearing caused by middle ear fluid.
- To help prevent the rare complication of
chronic hearing loss caused by recurrent ear
infections.
THE EAR TUBE CONTROVERSY
While ear tubes do have their place in treating
recurrent ear infections, there does exist some
controversy over their use. The advantages are listed
above. Some common concerns about tubes are:
- Some doctors may be too quick to recommend ear
tubes before exhausting all other preventative
measures or before allowing enough time to allow the
ears to clear up without surgery.
- As with any surgery, there are risks (though
minimal) to general anesthesia.
- The tubes often leave a little scar covering
approximately one sixth of the eardrum. This scar is
often permanent. There does not seem to be any
long-term consequence of this scarring, but we're
not completely sure. Please note that recurrent ear
infections with or without eardrum rupture can also
lead to scarring.
- Please note that ear tubes don't always prevent
ear infections. Some children will still get as many
infections even with the tubes in, but the fluid
drains out right away.
OVERALL EAR TUBES DO HAVE A PROPER PLACE IN TREATING
RECURRENT EAR INFECTIONS WHEN USED APPROPRIATELY.
- Many children benefit from ear tubes. Parents
declare their child is a new person. The ear
infections are gone. The hearing is improved. No
more sleepless nights with a crying child. No more
endless courses of antibiotics.
- General indication for tubes are chronic ear
fluid for more than four to six months; or more than
three ear infections in six months or more than five
in one year. You and your doctor should decide
together when it is the right time for ear tubes for
your child.