Why They Happen
During one of my daughter's recent play dates with some neighborhood friends, a mother lamented to me that her 14-month-old son had just been diagnosed with his fourth ear infection in the past three months. "He's been on one antibiotic after another and I hate the idea of having to give him more medicine. What's worse, last month the antibiotic didn't work and they had to give him three shots to clear it up. Now he's not sleeping, not eating, and I'm at the end of my rope! What am I doing wrong? Will he ever be well?"
As a parent, you can most likely spell amoxicillin without batting an eye. You've probably become so adept at picking up on your child's symptoms that you can make the diagnosis yourself before ever darkening your pediatrician's door. Ah, yes, the badges of parenthood should be worn proudly. As a pediatrician and a mother, I've faced this issue from both sides. While ear infections are frustrating to us as parents, they can be equally troubling to physicians. Fortunately, understanding why ear infections develop and how they should be treated can help ease the pain associated with this condition for both you and your kids.
Here Comes Ear Trouble
Fluid accumulates within the middle ear space (located behind the eardrum) when the eustachian tube, which leads from the middle ear to the back of the throat, becomes blocked. This is usually due to the swelling and congestion of the nasal lining that occurs during a cold or with seasonal allergies. Your child might also be at risk if she has a family history of ear infections, or if she attends childcare, which increases exposure to infection-causing bacteria and viruses.
When the eustachian tube can't drain adequately (this is often the case with young children; their eustachian tubes are smaller and angled less steeply than those of adults), fluid inside the middle ear stagnates, making it the perfect breeding ground for germs. Add to that the fact that their immature immune systems make them more vulnerable to the colds that cause congestion and blockage, and suddenly you're up all night with a fussy child who even the best episode of The Wiggles won't entertain! As a child grows, his eustachian tubes lengthen and become better at draining, allowing him to outgrow the tendency toward ear infections by 2 years of age.
There are steps that parents can take to prevent ear infections from occurring in the first place.
- Breastfeed your baby. Nursing offers infants valuable immune protection, which translates into fewer colds, fewer allergies, and therefore, fewer ear infections. A study published in 2003 found that exclusive breastfeeding, especially during the first three to four months of life, decreases a child's risk of developing ear infections almost by half.
- Don't smoke. There is clear evidence that exposure to secondhand smoke increases a child's susceptibility to ear infections. Tobacco smoke contains small particles that can clog the eustachian tube, putting a child at risk for repeated infections.
- Ditch the nighttime bottle. Laying your baby down in her crib with a bottle at bedtime can increase her risk for ear infections. The constant suck-swallow motion opens the eustachian tube, and when this happens often in a supine position, it allows breast milk or formula to enter the middle ear space, which can lead to an infection. Pacifier use at bedtime only slightly raises your baby's chance of getting an ear infection, because she already has to be sick for germs to enter the middle ear.
- Vaccinate! Prevnar, a vaccine that protects against pneumococcus bacteria, which causes meningitis, pneumonia, and most ear infections, is offered in a series of four injections from 2 months of age. Since it became available in 2000, we've seen a small but apparent decline in the number of ear infections. We've also seen a decrease in the number of prescriptions written for antibiotics, and the rate of surgical ear-tube placement has dropped by about 25 percent. Also make sure your child also gets an annual flu shot (not for infants under 6 months). Viruses cause a minority of ear infections, but antibiotics are powerless against these types of infections.
Beyond the Bubble-Gum Cure
For most children, the mainstay of treatment is still antibiotics. Amoxicillin, the pink, bubble-gum-flavored medicine, is still the first-line antibiotic recommended for typical ear infections, even for infants. Due to a large number of resistant bacterial strains causing ear infections, we now routinely use higher doses of amoxicillin than we previously did. If, on the other hand, your kid has had an ear infection treated with an antibiotic within the past 30 days, or has had a pattern of recurrent infections, your child's doctor may prescribe a broader-spectrum oral antibiotic, such as Omnicef and Cedax. Sometimes the bacteria causing the ear infection is so resistant that it will only respond to injectable antibiotics.
Not All Antibiotics are Created Equal
Keep in mind that what worked for your neighbor's kid, or even your child's older sibling, may not be right for your kid. In fact, just because one antibiotic may not have been effective for a prior episode with your child does not mean that it should never be used again.
Because the majority of ear infections go away on their own, the latest recommendations from the American Academy of Pediatrics give physicians the option of not using antibiotics to treat mild to moderate cases in children over 2 years old. I usually tell parents that their kids should give them some indication that they're feeling a little better within 48 hours, for example, their fever breaks, their appetite improves, or they sleep more soundly. If parents don't see any of these signs, then that particular infection may fall into the 25 to 30 percent of cases that don't get better without antibiotics.
Watch, Wait -- and Medicate?
When physicians use this watchful-waiting approach, they often give parents a safety-net prescription, telling them to fill it only if a child isn't feeling better after two days. This saves them a trip back to the office, and in my experience, many parents don't end up at the pharmacy anyway.
In light of this, you may wonder why doctors ever prescribe medication to treat ear infections from the start. First, kids younger than 2 years can't voice the severity of their discomfort. Plus, antibiotics appear to shorten the duration of symptoms by about a day or two, and in some instances, may prevent rare complications of ear infections.
Even when the pediatrician chooses to utilize the watch-and-wait option, she'll usually suggest that parents administer pain relievers at home. If your child is over 2 years old, your pediatrician might recommend using acetaminophen or ibuprofen to help manage the earache while you wait the infection out. There are many herbal and pain-reliever eardrops available, but only use them with your pediatrician's approval. If the eardrum is perforated as a result of the infection, certain eardrops can cause permanent damage to the hearing bones in the middle ear. The observation-only option has been used in Europe for decades, with great success, no higher incidence of hearing or language deficits in children, and with lower rates of antibiotic-resistant bacteria.
Try these at-home techniques in addition to the course of treatment your pediatrician prescribes.
- Heat: The application of moist heat to the outer ear can be very soothing. The best way to accomplish this is by placing a warm washcloth over the ear and leaving it there until it cools. This can be done several times per day. Heating pads and water bottles are not recommended, due to the risk of skin burns.
- Sit upright: Children with ear infections often seem fine during the day when they are up and playing, but at night they are miserable due to increased middle ear pressure from lying flat. Placing your child in a more upright position for sleeping can make the nights much more bearable during an infection.
Knowing when to worry is another key aspect of ear infection management. By far, the most common complication associated with ear infections is temporary hearing loss. We know that most, if not all, children suffer from mild hearing disturbance during an ear infection, but the question that many parents want answered is whether one or two or 10 ear infections will permanently affect their child's hearing.
Fluid persists in the middle ear space even after the germs are cleared away, and it is this fluid that decreases the ability of the middle ear bones to conduct sound. The fluid usually drains within three weeks after an ear infection. Sometimes it can take up to three months for the fluid to go away. Occasionally it can take even longer, which is why your child should have her ears examined again around this three-month mark. If fluid is found, a hearing test may be performed.
Going to an ENT
Your child's pediatrician might refer you to an ear, nose, and throat specialist in the following instances: when the hearing test demonstrates a significant hearing loss, or when a child has suffered three infections within 6 months, or four or more infections over the course of 12 months. At the appointment, the specialist will probably discuss the possible need for ventilation tubes, which are surgically placed in eardrums to prevent fluid from building in the middle ear space.
All these possibilities may seem overwhelming, but there is reassuring news: Comparison studies reveal no major differences in ultimate language development between children who suffered from recurrent ear infections as infants and those who didn't. Ear infections will continue to be a common problem -- or yet another requirement before entering kindergarten! But arming yourself with knowledge about this almost inevitable condition is as important as any treatment pediatricians can toss at you.
Sara DuMond, MD, is a pediatrician in Mooresville, North Carolina, and the mother of two young children.
Originally published in American Baby magazine, December 2005.
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.