Learn the Basics
Ear infections are the most common reason children are brought to my office, and they're a frequent source of concern for parents: How do I know if my child has an ear infection? What causes them? And especially, How can I prevent them? Parents have also heard about the "ear infection vaccine" or advances in treatment and want to know what's best for their child. Here's a primer on preventing and treating this notorious ailment.
Anatomy of an Ear Infection
An ear infection, also called otitis media, is specifically an infection of the middle ear, the part that contains tiny bones that transmit sound from the eardrum to the inner ear. The middle ear produces secretions, which normally drain to the back of the throat through the eustachian tubes. However, if the fluid doesn't drain and builds up in the middle ear, it creates a warm, moist environment where germs love to grow. Invading bacteria or viruses thrive and result in the pain, crankiness, and fever that signal to parents that their child has developed an ear infection.
Ear infections are not always easy for parents to diagnose, because the symptoms can be vague and mimic those of a regular cold or flu. In fact, ear infections often start as a cold with a cough and a runny nose. A cold virus causes the entrance to the eustachian tubes to swell, so it's easier for fluid to get trapped in the middle ear and infected. The next thing you know, your baby has a fever and is getting very irritable. He may also pull on his ears and seem crankier when lying down, because this position causes the fluid to push on the eardrum, resulting in more discomfort.
The only way to be sure that your child has an ear infection is to visit your pediatrician. Take a baby younger than age 2 to the doctor if a cold and apparent discomfort don't go away in two or three days, or if a fever doesn't go away in one or two days. (If your infant is younger than 4 months, notify your doctor of any fever immediately.) When your physician peeks into your child's ear to check for signs of an infection, she's looking at the eardrum to see if it is red, thick, or bulging.
Troublesome Young Ears
It's not unusual for babies and toddlers to get ear infections. Ninety percent of children have at least one by the time they're 2 years old, according to one study. Anatomy is the main reason little ones are afflicted with ear troubles. The eustachian tubes are angled less steeply in children than in adults, which makes it harder for fluid to drain from the middle ear. And kids' tubes are also shorter, which makes it easier for germs in the throat to work their way up into the middle ear. The muscles that open the tubes and allow fluid to drain (this is what you flex when swallowing to relieve ear pressure) are also not as well developed in babies and toddlers. Plus, young children have a less-mature immune system, so they can't fight off infections as well as adults can. As a result, they're more susceptible to the upper respiratory infections (colds and flus) that can lead to ear infections.
Fortunately, the rate of ear infections declines after age 3, which is when a lot of these factors start to change. However, there are some things that put your child at a greater risk for ear infections even beyond age 3. Frequent ear infections tend to run in families. In the same way that blue eyes or athletic ability is inherited, how well your ear muscles open and close is also passed on. When I have a patient who has had several ear infections, I ask his parents if they also had ear problems as children. Most moms and dads don't remember, but they're often reminded of their ear troubles after talking with their own parents. It's likely that they outgrew the problem by adulthood, and they are relieved to learn that their child probably will too.
Children with allergies are also prone to ear infections. The congestion caused by exposure to dust or pollen blocks the eustachian tubes so they can't drain. This can quickly lead to an ear infection when germs invade. Babies who are born with a cleft palate or Down syndrome are also more likely to get ear infections. The differences in their anatomy make it harder for their eustachian tubes to function properly.
Fighting the Germs
Anatomy alone doesn't cause ear infections. Germs are necessary too. There are two major germ classes that cause infections: bacteria and viruses. Bacteria are responsible for about 70 percent of ear infections, viruses cause about 8 to 25 percent, and bacteria and viruses working in concert are found in the remaining cases. Ear infections that are caused by viruses can't be treated with antibiotics, in the same way that no medicine can cure the common cold. But antibiotics can fight bacterial infections.
The only way your physician can tell if an infection is caused by a virus, bacteria, or both is to remove some of the fluid from the middle ear with a small needle. I don't often do this in my practice, because it takes 48 hours to get lab results back, and parents usually want a quicker response. When a child comes in, if he is fairly ill, I treat him with antibiotics as if he has a bacterial infection. And in children younger than 2, immediate action is critical. Untreated ear infections can spread and cause serious -- even life-threatening -- problems, such as a brain abscess or meningitis. Another rare but serious complication in young children is facial paralysis if the infection spreads to the facial nerve.
A less dangerous and more common consequence of untreated ear infections is a perforated eardrum. The fluid in the middle ear builds up until the pressure causes the eardrum to burst. Although this is frightening to parents, it results in immediate relief from the pain the child was experiencing and lets the fluid drain from the middle ear. Most of these perforations heal on their own, but some do require surgical repair.
For a child who has never had an ear infection or hasn't been on antibiotics for the past 30 days, the first drug I use to treat him is usually liquid amoxicillin -- the pink, bubble-gum-flavored kind. But if your child has recently been treated for an ear infection, it's likely that he's infected with a strain of bacteria that is resistant to amoxicillin. If that's the case, there are several stronger antibiotics your physician may try, including Augmentin, Zithromax, and Biaxin. After starting oral antibiotics, your child should begin to feel better in two or three days, but you must always finish the complete prescription.
It's also important to take him in for a follow-up visit so the doctor can ascertain that the infection has indeed cleared up. Once the infection is gone, it's common for fluid to remain in the middle ear, and that means bacteria can get into it and cause a repeat infection. In about two-thirds of children this remaining fluid will clear in one month, and in 90 percent it will clear in three months. Your doctor will monitor the situation at subsequent visits to make sure your child does not get another infection in the meantime and that the fluid doesn't remain for more than six months. That's because fluid in the middle ear for a prolonged period can result in temporary hearing loss, which is especially problematic for young children learning how to talk. Although studies have shown that there's no long-term impact on a baby's or toddler's language development, the hearing loss is a concern and may mean that your child requires ventilating or tympanostomy tubes. These small plastic or metal tubes are placed in the eardrums using a minor surgical procedure to help drain the fluid and keep it from collecting. A child's hearing returns to normal once the fluid drains. After they have tubes inserted, many of my patients get significant relief from their ear infections. The tubes stay in place until they fall out on their own. Half of the children will have to get tubes put in again, but the other half will have already outgrown ear infections by that time.
Some guidelines recommend waiting until a child has documented hearing loss before putting in tubes. I don't wait that long in my practice, but unfortunately some insurance companies deem the surgery unnecessary until there is hearing loss. If tubes are a possibility for your child, call your insurance company to learn about its policy in advance.
Fluid in the ear is not a problem only because of temporary hearing loss. It also often results in repeated bouts of ear infections, which cause children and their parents a lot of pain and anxiety. A child with recurrent ear infections is defined as one who has had three infections in the past six months or four infections in the past year. When I have patients with this problem, I recommend putting them on preventive, or prophylactic, antibiotics. This is a low-dose antibiotic taken every day for three to four months (once the latest infection has been treated with a regular round of antibiotics) to get them through the cold and flu season. This should prevent further infections and gives the middle ear a chance to reabsorb any remaining fluid. If a child continues to get ear infections despite taking prophylactic antibiotics, that also makes a case for putting tubes in his eardrums.
Fortunately, most children avoid these serious consequences. And although ear infections are troubling for both parents and kids, there's a lot that can be done to fight and treat them.
Anne Beal, MD, is coauthor of The Black Parenting Book: Caring for Our Children in the First Five Years (Broadway Books, 1998).
All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.