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Should Your Child See a Doctor?

Ear Infection Questions

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Definition

  • Your child was recently examined and diagnosed as having a middle ear infection
  • You are concerned that your child's fever, earache or other symptoms are not improving fast enough
  • Your child is still taking an antibiotic for the ear infection

Ear infections (otitis media)

  • Definition: An infection of the middle ear (the space behind the eardrum)
  • Cause: Blocked eustachian tube, usually as part of a common cold. The eustachian tube connects the middle ear to the back of the nose. Blockage results in middle ear fluid (viral otitis). If the fluid becomes superinfected (bacterial otitis), the fluid turns to pus, the eardrum bulges and pain increases.
  • Ear infections peak at age 6 months to 2 years. They are a common problem until age 8.
  • The onset of ear infections peak on day 3 of a cold.
  • Prevalence: 90% of children have at least 1 ear infection. Repeated ear infections occur in 20% of children. Ear infections are the most common bacterial infection of childhood.

Symptoms

  • The main symptom is an earache.
  • Younger children will cry, act fussy or have difficulty sleeping because of the pain.
  • About 50% of children with an ear infection will have a fever.
  • Complication: In 5% to 10% of children, the pressure in the middle ear causes the eardrum to rupture and drain cloudy fluid or pus. This small hole usually heals over in 2 or 3 days.

Return to school

  • An earache or ear infection is not contagious. Your child should stay home only until any fever is resolved.

See more appropriate topic (instead of this one) if

When to Call Your Doctor

Call 911 now (your child may need an ambulance) if

 
  • Not moving or very weak
 

Call your doctor now (night or day) if

  • Your child looks or acts very sick
  • Stiff neck (can't touch chin to chest)
  • Walking is unsteady
  • Fever over 104° F (40° C) and not improved 2 hours after fever medicine
  • Earache is severe and not improved 2 hours after ibuprofen
  • Crying is inconsolable and not improved 2 hours after ibuprofen
  • New-onset pink or red swelling behind the ear
  • Crooked smile (weakness of 1 side of face)
  • New-onset of vomiting (EXCEPTION: vomiting follows hard coughing)

Call your doctor within 24 hours (between 9 a.m. and 4 p.m.) if

  • You think your child needs to be seen
  • Taking antibiotic over 48 hours and fever persists or recurs
  • Taking antibiotic over 3 days and ear pain not improved or recurs
  • Taking antibiotic over 3 days and ear discharge persists or recurs

Call your doctor during weekday office hours if

  • You have other questions or concerns

Parent care at home if

  • Ear infection with no complications and you don't think your child needs to be seen
  • Hearing loss with an ear infection
  • Prevention of ear infections
  • Ear tube surgery questions

Home Care Advice for an Ear Infection

Treatment for an ear infection

Reassurance

  • Most ear infections do not respond to the first dose of antibiotic.
  • Often, there is no improvement the first day.
  • Children gradually get better over 2-3 days.
  • Note: For mild ear infections in children over 2 years old, antibiotics may not be needed.

Continue the antibiotic

  • The antibiotic will kill the bacteria that are causing the ear infection.
  • Try not to forget any of the doses.
  • Give the antibiotic until the bottle is empty (or all pills are gone). (Reason: prevent the ear infection from flaring up again).

Pain medicine: For ear pain or fever above 102° F (39° C), give acetaminophen (e.g., Tylenol) OR ibuprofen as needed. (See dosage table).

Local cold: Apply a cold pack or a cold wet washcloth to outer ear for 20 minutes to reduce pain while medicine takes effect (Note: Some children prefer local heat for 20 minutes) (Caution: Hot or cold pack applied too long could cause burn or frostbite.)

Eardrops: 3 drops of prescription eardrops or olive oil drops will usually relieve pain not helped by pain medicine. If your child has ear tubes or a hole in the eardrum, don't use them.

Restrictions

  • Your child can go outside and does not need to cover the ears.
  • Swimming is fine as long as there is no perforation (tear) in the eardrum or drainage from the ear.
  • Children with ear infections can travel safely by aircraft if they are taking antibiotics. Most will not have any increase in their ear pain while flying.
  • Give your child a dose of ibuprofen 1 hour before take-off to deal with any discomfort they might have. Also, during descent (prior to landing) have your child swallow fluids, suck on a pacifier, or chew gum.

Contagiousness: Your child can return to school or child care when feeling better and any fever is gone. Ear infections are not contagious.

Expected course: If you give your child the antibiotic as directed, the fever should be gone by 2 days (48 hours). The earache should be improved by 2 days and gone by 3 days (72 hours).

Ear discharge

  • If pus or cloudy fluid is draining from the ear canal, it means the eardrum has a small tear in it caused by the pressure from the ear infection. It also normally occurs if your child has ear tubes.
  • The pus may be blood-tinged.
  • This usually heals nicely after the ear infection is treated.
  • Wipe the discharge away as it appears.
  • Avoid plugging the ear canal with cotton. (Reason: retained pus can cause infection of the lining of the ear canal)

Call your doctor if

  • Fever lasts over 2 days on antibiotics
  • Ear pain becomes severe or crying becomes inconsolable
  • Ear pain lasts over 3 days on antibiotics
  • Ear discharge is not improved after 3 days on antibiotics
  • Your child becomes worse

Treatment for hearing loss with an ear infection

Temporary hearing loss

  • During an ear infection, fluid builds up in the middle ear space instead of draining out normally to the back of the nose.
  • The fluid can cause a temporary mild hearing loss.
  • It will gradually improve and should resolve with the antibiotic treatment.
  • In some children, it may take longer for the fluid to go away, even though the fluid is no longer infected. In 90% of children, it clears up by itself over 1 to 2 months.
  • Permanent damage to the hearing from ear infections is very rare.

Talking with your child

  • Get close to your child and get eye contact.
  • Speak in a louder voice than you normally use.
  • Reduce any background noise from radio or TV while talking with your child.

Call your doctor if

  • Hearing loss not improved after the antibiotic course is finished.

Prevention of recurrent ear infections

Reassurance: Some children have recurrent ear infections. If your child has lots of ear infections, here are some ways to prevent future ones.

Avoid tobacco smoke: Protect your child from tobacco smoke because it increases the frequency and severity of ear infections. Be sure no one smokes in your home or at child care.

Avoid excessive colds

  • Most ear infections start with a cold. Reduce your child's exposure to children with colds during the first year of life.
  • Try to delay the use of large child care centers during the first year by using a sitter in your home or a small home-based child care.

Breast-feed

  • Breast-feed your baby during the first 6 to 12 months of life.
  • Antibodies in breast milk reduce the rate of ear infections.
  • If you are breast-feeding, continue.
  • If you are not, consider it with your next child.

Avoid bottle-propping

  •  During feedings, hold your baby with the head higher than the stomach.
  • Feeding in the horizontal position can cause formula to flow back into the eustachian tube.
  • Allowing an infant to hold his own bottle also can cause milk to drain into the middle ear.

Get all recommended immunizations: The pneumococcal vaccine and the flu vaccine will protect your child from serious diseases and some ear infections.

Control allergies: If your infant has a continuously runny nose, consider allergy as a contributing factor to the ear infections. If your child has other allergies such as eczema, your child's doctor can check for a milk protein or soy protein allergy.

Check the adenoids: If your toddler snores every night or breathes through his mouth, he may have large adenoids. Large adenoids can contribute to ear infections. Talk to your child's doctor about this.

Ear Tube Surgery Questions

Ventilation tubes

  • Ventilation tubes are tiny plastic tubes that are inserted through the eardrum by an ENT surgeon.
  • The tubes allow fluid to drain out of the middle ear space and allow air to re-enter.
  • This reduces the risk of recurrent ear infections and returns the hearing to normal.

Indications for ventilation tubes

  • Fluid has been present in the middle ear continuously for over 4 months and both ears have fluid.
  • In addition, the fluid has caused a documented hearing loss greater than 20 decibels. The reason to test the hearing first is that some children with fluid in their ears have nearly normal hearing and tubes are not needed.
  • A separate indication is for frequent ear infections (3 or more within a 6 month period) or ear infections that do not clear up after trying multiple antibiotics.
  • Prevention techniques should be attempted before turning to surgery.

Expected course

  • Normally the tubes come out and fall into the ear canal after about a year. Then they come out of the ear canal with the normal movement of earwax.
  • If the tubes remain in the eardrum for over 2 years, the surgeon may need to remove them.

Risks of ventilation tubes

  • After the tubes come out, they may leave scars on the eardrum or a small hole that doesn't heal. Both of these problems can cause a small hearing loss.
  • Because of these possible complications and the need to give anesthesia to young children before the operation, physicians recommend ventilation tubes only for children who really need them.

And remember, contact your doctor if your child develops any of the "Call Your Doctor" symptoms.

Disclaimer

This information is not intended be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D. Clinical content review provided by Senior Reviewer and Healthpoint Medical Network.

Last Review Date: 9/22/2010
Last Revised: 10/20/2010 9:45:59 AM

Content Set: Pediatric HouseCalls Symptom Checker
Version Year: 2011

Copyright 1994-2011 Barton D. Schmitt, M.D.

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