Patient information: Ear infections (otitis media) in children

EAR INFECTION OVERVIEW

Ear infection is the most frequent diagnosis for all children who visit the doctor's office; 60 to 80 percent of infants have at least one episode by their first birthday, and 80 to 90 percent of all children have an ear infection by two to three years of age.

This topic will review the definition, causes, symptoms, diagnosis, treatment, and potential complications of ear infections for infants and children.

WHAT IS AN EAR INFECTION?

Ear infection is also known as acute otitis media (otitis = ear, media = middle). Otitis media is an infection of the middle section of the ear, as compared to external otitis (also known as swimmer's ear), which is an infection of the outer ear (figure 1).

Ear infections typically develop after a viral upper respiratory tract infection, such as a cold or the flu, which cause swelling and fluid accumulation in the space behind the eardrum (the middle ear). This fluid accumulation (called an effusion) traps bacteria and viruses and increases pressure on the eardrum. The increased pressure causes the eardrum to bulge, which leads to symptoms of ear pain, pressure, and occasionally, temporarily decreased hearing (figure 2).

EAR INFECTION CAUSES AND RISK FACTORS

Ear infections are most commonly caused by bacteria and/or viruses and other microorganisms. Infants and children between six and 18 months are at the highest risk, probably because of differences in the structure of the ear and skull and because a young child's immune system is still maturing. The body's ability to fight infections improves as a child gets older.

Other factors that increase the risk of ear infection include:

• Day care — Children who attend day care are exposed to more bacteria and viruses, and have a higher incidence of ear infection.
• Tobacco smoke — Children who are exposed to tobacco smoke have a 50 percent higher risk of ear infection.
• Pacifiers — Children who use pacifiers have a slightly higher risk of ear infection.
• Family history — Children whose parents and siblings had recurrent ear infections have a higher risk of ear infection.
• Underlying medical problems — Children with underlying medical problems, including cleft palate, Down syndrome, immune deficiency, and allergic rhinitis, can have an increased risk of ear infection.
• Season of the year — Ear infections are more common during the fall and winter months.

On the other hand, children who breastfeed for at least three months have fewer episodes of ear infection, which may be related to the immune protective effects of breast milk and the position of the infant's head and facial muscles used during breastfeeding (as compared to bottle feeding). (See "Patient information: Deciding to breastfeed".)

EAR INFECTION SYMPTOMS

Symptoms of ear infection are usually sudden in onset. Adults and adolescents with ear infection may have ear aching or pain, temporary hearing loss, and vertigo (a sense of spinning).

Symptoms of an ear infection in infants and young children can be non-specific, and may include fever (temperature greater than 100.4ºF or 38ºC), ear pulling, fussiness, decreased activity, lack of appetite or difficulty eating, vomiting, and diarrhea. Table 1 describes how to take a child's temperature (table 1). (See "Patient information: Fever in children".)

These symptoms occur in illnesses other than ear infections. For this reason, parents who suspect ear infection should take their child to a healthcare provider for an examination to determine if ear infection (or another problem) is the cause of the child's symptoms.

EAR INFECTION DIAGNOSIS

The diagnosis of ear infection requires that a child have symptoms of infection as well as visible changes in the eardrum (called the tympanic membrane). Parents who suspect their child has an ear infection should contact their child's clinician to determine if and when the child should be seen.

Most infants and children do not like having their ears examined. To make the process easier, most clinicians will encourage parents to hold their child in the lap and hug the child's arms and body while the clinician uses an instrument (otoscope) to look inside the ear (picture 1).

The diagnosis of ear infection is not always straightforward. When the clinician is able to clearly see the tympanic membrane and all of the typical features of ear infection are present, the diagnosis is certain. When all of the typical features are not present, the diagnosis is less certain. In this case, the clinician will work with the parent to determine the best management plan.

EAR INFECTION TREATMENT

Treatment of an ear infection may include medications to treat pain and fever, antibiotics, observation, or a combination of the above. The treatment choice is best made by the clinician and parent together, and is based upon the child's age, history of previous infections, and any underlying medical problems.

Antibiotics — Symptoms frequently resolve quickly in children who are treated with antibiotics, although antibiotics can have side effects. In addition, the unnecessary use of antibiotics may lead to resistant bacteria (meaning that a particular antibiotic is no longer effective or that higher doses are necessary to achieve the same effect).

Amoxicillin usually is preferred for children with ear infection, although another antibiotic may be used in some situations (such as in children who have recently received amoxicillin or have an allergy to it). Antibiotics usually are given for 10 days in children younger than 24 months, while older children may be given treatment for five to seven days.

Infants who have symptoms of an ear infection and are younger than 24 months are usually treated with an antibiotic.

Pain management — Pain-relieving medications, including ibuprofen (Motrin®), acetaminophen (Tylenol®), or ear drops such as Auralgan®, which contain a local anesthetic (numbing medicine), may be used to reduce discomfort. A dosing chart for acetaminophen (table 2) and ibuprofen (table 3) are provided here.

Observation — In some cases, a provider will recommend that the parent watch the child at home, before starting antibiotics, to see if symptoms progress over 24 hours; this is called observation. Observation can help to determine if antibiotics are required.

Observation may be a reasonable approach when the diagnosis is uncertain, provided that the clinician and parents agree. This strategy may be recommended for a child who is older than 24 months if ear pain and fever are not severe and the child is otherwise healthy. This management strategy was developed after clinical studies determined that many older children with ear infection improved without using antibiotics.

When the decision is made to observe the child without antibiotics, pain-relieving medication can be used to reduce discomfort. (See 'Pain management' above.)

Parents should call or return to the clinician's office after 24 hours to determine if antibiotics are needed. Antibiotics may be started if a child's pain or fever continues or worsens; observation may continue if the child is improving.

Complementary and alternative medical treatments — There are a wide variety of complementary and alternative medical (CAM) therapies marketed to treat children's ear infections. These may include homeopathic, naturopathic, chiropractic, and acupuncture treatments.

However, there are few scientific studies of CAM treatments for ear infection, and even fewer studies that show CAM treatments to be effective. As a result, complementary and alternative treatments are not currently recommended for ear infections in children.

Decongestants and antihistamines — Decongestant and antihistamine medications have not been proven to improve healing or reduce complications of ear infections in children. In addition, these treatments have side effects that can be bothersome and potentially dangerous. Neither decongestants nor antihistamines are recommended for children with an ear infection.

Follow up — Symptoms of an ear infection should improve within 24 to 48 hours. A child who does not improve after 48 hours should be seen again by a clinician to confirm the diagnosis, evaluate other potential causes, and determine the need to start or change antibiotic therapy. Although fever and discomfort may continue in a child taking antibiotics, they should improve daily. Parents of a child who seems worse should contact their child's healthcare provider.

Follow-up ear examination after treatment is important for children who are younger than two years or who have language or learning problems. This follow up helps to ensure that the fluid collection in the middle ear has resolved. Follow up also is important if the parent or child is concerned about hearing loss. (See 'Ear infection complications' below.)

EAR INFECTION COMPLICATIONS

Hearing loss — The fluid that collects behind the eardrum (called an effusion) can persist for weeks to months after the pain of an ear infection resolves. An effusion causes hearing loss that usually is temporary but, when left untreated, can interfere in the normal development of speech and language. Middle ear effusion (MEE) usually resolves without any treatment. However, children with MEE that persists for longer than three months may need treatment.

The decision to treat the middle ear fluid is based upon the amount of hearing loss and the child's risk of speech problems. Children who fall into one or more of the following groups may need treatment sooner:

• A large degree of hearing loss
• Hearing loss prior to effusion
• Previous diagnosis with a speech or language delay
• Autism spectrum disorder, craniofacial disorders, developmental delay, or visual impairment

Children with MEE who have mild to moderate hearing loss but no other risk factors are most often monitored with examination and hearing testing every three to six months. Effusion often resolves without treatment, and there is a low risk of long-term harm to speech and language development.

Treatment — The best treatment for MEE that does not resolve is a surgical procedure. During the procedure, fluid is drained from the middle ear by making a small opening in the tympanic membrane (called myringotomy) and placing a tube to maintain the opening (called a tympanostomy tube) (figure 3). This procedure usually is performed by an ear, nose, and throat surgeon (otolaryngologist) in a hospital while the child is under general anesthesia.

The benefit of surgery is improved hearing. The risks of surgery include a small chance of damage to the tympanic membrane. Children who are most likely to benefit from surgery include those with chronic or prolonged MEE, described above, as well as some children with recurrent infections. (See 'Ear infection prevention' below.)

Tympanic membrane perforation — Perforation (rupture) of the tympanic membrane occurs when pressure created by the middle ear effusion reduces blood flow, causing the tissue to weaken and eventually rupture. After perforation, fluid from the middle ear drains into the ear canal, releasing the pressure (and relieving ear pain). Rupture of the tympanic membrane is more common in young infants; it occurs in 5 to 10 percent of children with MEE.

If the tympanic membrane ruptures as a result of a new ear infection, the child should be treated with antibiotics. The tympanic membrane typically heals quickly, usually within hours to days. However, a small fraction of perforations persist, resulting in chronic drainage and infection of the middle ear or mastoid (a bone behind the ear). Treatment usually requires repeated or long-term antibiotics.

EAR INFECTION PREVENTION

Several approaches are available to prevent recurrent ear infections, depending upon the child's age and history of infections and infection complications. Recurrent infection is defined as three or more infections in three months, or four or more infections within 12 months. Preventive treatments include continuous antibiotics and surgical placement of tubes in the ears.

Some of the vaccines included in the routine childhood immunization schedule (such as the pneumococcal conjugate vaccine [PCV7] and influenza vaccine) may help to reduce the frequency of ear infections. (See "Patient information: Immunizations for infants and children age 0 to 6 years".)

Preventive antibiotics — Children who have recurrent ear infections may be given a small dose of antibiotic on a daily basis during the fall, winter, and early spring months. The antibiotic helps to prevent new ear infections, although studies show the benefit is small. In addition, there is concern that long-term use of antibiotics can lead to bacteria that are resistant to standard antibiotics. A parent or clinician who is considering preventive antibiotics must weigh the potential benefit of fewer infections against this risk.

Surgery — Surgical placement of tympanostomy tubes may be considered for some children with recurrent ear infections (graph 1). Tubes may help to prevent recurrence and shorten the duration of middle ear effusion.

Some studies show that tubes are effective while others do not [1]. Parents and healthcare providers must consider both the risks and benefits of surgery for their individual child.

Future preventive treatments — There are two treatments that may be recommended in the future for prevention of recurrent ear infections, including chewing gum that contains xylitol, and probiotic (healthy bacteria) nasal sprays. However, there is not currently enough information to conclude that these treatments are safe and effective.

SUMMARY

• Ear infections usually develop after a cold or the flu. (See 'What is an ear infection?' above.)

• Symptoms of ear infections in children include fever (temperature greater than 100.4º F or 38º C), ear pulling, fussiness, being less active, lack of appetite or difficulty eating, vomiting, or diarrhea. These symptoms can also be caused by other illnesses. (See 'Ear infection symptoms' above.)

• Parents who think their child has an ear infection should contact their child's doctor or nurse. (See 'Ear infection diagnosis' above.)

• Treatment of an ear infection may include medicines to treat pain and fever, antibiotics, or a combination of the above. Not all children require antibiotics. (See 'Ear infection treatment' above.)

• Some children temporarily have trouble hearing after an ear infection. Hearing problems usually go away without treatment. However, children who have trouble hearing for longer than three months may need treatment to prevent difficulty with learning to speak. (See 'Ear infection complications' above.)

• Several treatments are available to prevent ear infections from coming back. The best type of prevention depends upon the child's age and number of previous ear infections. A child may have surgery to place tubes in the ears (graph 1).
• Vaccines are recommended for all children. Some vaccines (such as the pneumococcal conjugate vaccine [PCV7] and influenza vaccine) help to prevent frequent ear infections (see 'Ear infection prevention' above.

WHERE TO GET MORE INFORMATION

Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Deciding to breastfeed
Patient information: Fever in children
Patient information: Immunizations for infants and children age 0 to 6 years

Professional Level Information:
Acute otitis media in children: Diagnosis
Acute otitis media in children: Epidemiology, pathogenesis, clinical manifestations, and complications
Acute otitis media in children: Prevention of recurrence
Acute otitis media in children: Treatment
Etiology of hearing impairment in children
Otitis media with effusion (serous otitis media) in children
Prevention and management of tympanostomy tube otorrhea in children

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• The Cochrane Collaboration

      (www.cochrane.org, search for "acute otitis media")

• The American Academy of Pediatrics

      (www.aap.org/advocacy/releases/aomqa.htm)

• The Nemours Foundation

      (www.kidshealth.org/parent, search for "ear infection")

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