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INTRODUCTION — Ear infections, also called acute otitis media, are a common problem in children. Approximately one-fourth of infants in resource-abundant countries have at least one ear infection by their first birthday. Ear infections can cause pain in the ear, fever, and temporary hearing loss, and general signs such as loss of appetite and irritability. Some children get better without specific antibiotic treatment, but use of an antimicrobial agent often shortens the duration of fever and earache. Some children who develop ear infections early in life are more likely to go on to have recurrent ear infections and persistent middle ear fluid. They may be at increased risk for complications from their infections.
This topic will review the definition, causes, symptoms, diagnosis, treatment, and potential complications of ear infections in infants and children.
More detailed information about ear infections is available by subscription. (See "Acute otitis media in children: Treatment".)
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 ear. Most of the time, it is caused by bacteria that nearly all children have in their nose and throat at one time or another.
Ear infections most often develop after a viral respiratory tract infection, such as a cold or the flu. These infections can cause swelling of the mucous membranes of the nose and throat and diminish normal host defenses such as clearance of bacteria from the nose, increasing the amount of bacteria in the nose. Viral respiratory tract infections also can impair Eustachian tube function. Normal Eustachian tube function is important for maintaining normal pressure in the ear. Impaired Eustachian tube function changes the pressure in the middle ear (like when you are flying in an airplane). Fluid (called an effusion) may form in the middle ear and bacteria and viruses follow, resulting in inflammation in the middle ear (figure 1). The increased pressure causes the eardrum to bulge, leading to the typical symptoms of pain and fussiness in young children or even rupture resulting in draining fluid in the ear canal. (See 'Ear infection symptoms' below.)
EAR INFECTION SYMPTOMS — Symptoms of an ear infection in adolescents and older children usually include earache or pain and temporary decrease in hearing. These symptoms usually come on suddenly.
In infants and young children, symptoms of an ear infection are more often nonspecific. Many of the symptoms of an ear infection may be caused by a simultaneous viral respiratory tract infection. The symptoms of an ear infection can include:
●Fever (temperature higher than 100.4°F or 38°C, see the table for how to measure a child's temperature) (table 1)
●Pulling on the ear
●Fussiness, irritability, or restless sleep
●Decreased activity
●Lack of appetite or difficulty eating
●Vomiting or diarrhea
●Draining fluid from the outer ear (called otorrhea)
EAR INFECTION DIAGNOSIS — If you suspect that your child has an ear infection, call your doctor or nurse to see if and when the child should be examined.
Although the examination is not painful, most infants and children do not like having their ears examined. To make the process easier, hold your child in your lap and hug your child's arms and body while the doctor or nurse uses an instrument (otoscope) to look inside the child's ear. Often cerumen (ear wax) will need to be removed so your doctor or nurse can get a good view of the ear drum.
The doctor or nurse can tell if your child has an ear infection by looking at the ear drum (tympanic membrane) for the typical features of an ear infection.
EAR INFECTION TREATMENT — Treatment of an ear infection may include:
●Antibiotics
●Medicines to treat pain and fever
●Observation, often called watchful waiting
●A combination of the above
Treatment should be individualized based on your child's age, history of previous infections, severity of illness, recent antibiotic use, and any underlying medical problems.
Antibiotics — Antibiotics are routinely given to infants who are younger than 24 months or who have high fever or infection in both ears because children with these characteristics get better more quickly with antibiotic treatment. Children who are older than 24 months and have mild symptoms may be treated with an antibiotic or often are observed to see if they improve quickly without antibiotics. (See 'Observation' below.)
Antibiotics can have side effects such as diarrhea and rash, and overusing antibiotics can lead to more difficult to treat (resistant) bacteria. Resistance means that a particular antibiotic no longer works or that higher doses are needed next time.
Observation — In some cases, your child's doctor or nurse will recommend that you watch your child at home before starting antibiotics; this is called observation. Observation can help to determine whether antibiotics are needed.
Observation may be recommended in these situations:
●If the child is older than 24 months
●If ear pain and fever are not severe
●If the child is otherwise healthy
Pain-relieving medicines should be given to ease pain whether your child is receiving antibiotics or being observed. (See 'Pain management' below.)
If your child is being observed rather than treated with antibiotics, you may need to call or go back to the doctor or nurse's office after 24 hours for follow-up. If your child's pain or fever continues or worsens, repeat evaluation may be necessary and antibiotics are usually recommended; observation may continue to be appropriate if the child is improving even if not completely back to baseline.
Pain management — Pain-relieving medicines, including ibuprofen (sample brand name: Motrin) and acetaminophen (sample brand name: Tylenol), may be used to reduce discomfort.
Complementary and alternative medical treatments — There are a wide variety of complementary and alternative medical (CAM) treatments advertised to treat ear infections. These may include homeopathic, naturopathic, chiropractic, and acupuncture treatments.
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, we do not recommend these treatments for ear infections in children.
Decongestants and antihistamines — Cough and cold medicines (which usually include a decongestant or antihistamine) have not been proven to speed healing or reduce complications of ear infections in children. In addition, these treatments have side effects that can be dangerous. Neither decongestants nor antihistamines are recommended for children with ear infections.
Follow-up — Your child's symptoms should improve within 24 to 48 hours whether or not antibiotics were prescribed. If your child does not improve after 48 hours or gets worse at any time point, call your doctor or nurse for advice. Although fever and discomfort may continue even after starting antibiotics, the child should improve every day. If your child appears more ill than when seen by their health care provider, contact the provider as soon as possible.
Children who are younger than two years and those who have language or learning problems should have a follow-up ear examination two to three months after being treated for an ear infection. These children are at risk for delays in learning to speak. This follow-up helps to ensure that the fluid collection (which can affect hearing) has resolved. (See 'Ear infection complications' below.)
EAR INFECTION COMPLICATIONS
Tympanic membrane rupture — One of the common complications of an ear infection is rupture (perforation) of the ear drum, also known as the tympanic membrane. The tympanic membrane can rupture when fluid presses on the membrane, reducing blood flow and causing the tissue to weaken. It does not hurt when the membrane ruptures, and many children actually feel better because pressure is relieved. Fortunately, the tympanic membrane usually heals quickly after rupturing, within hours to days. Rupture of the ear drum is an indication for antibiotic treatment of an ear infection.
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 trouble hearing, which is usually mild to moderate and temporary. If the fluid persists, however, it may interfere with learning and/or speech. (See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis" and "Otitis media with effusion (serous otitis media) in children: Management".)
Effusions usually resolve over time without any treatment. However, if the effusion persists for more than three months, the child may need treatment with a surgical procedure. The decision to treat is based upon how much the effusion affects the child's hearing and the child's risk of learning or speech problems.
Children with underlying speech, hearing, or developmental problems may have worse outcomes related to the fluid and conductive hearing loss. They should be evaluated before the three month time period recommended for children without these problems because they may need earlier intervention.
Children who are not treated for an effusion should be monitored over time. This includes an ear examination and hearing testing every three to six months until the effusion goes away.
EAR INFECTION PREVENTION — Some children develop ear infections frequently. Recurrent ear infections are defined as three or more infections in six months, or four or more infections within 12 months. In addition to receiving the pneumococcal conjugate and influenza vaccines, as recommended by the American Academy of Pediatrics and American Academy of Family Practice for all children, several interventions can help reduce the risk of recurrent infections. These include avoidance of tobacco smoke, breastfeeding, continuous low dose antibiotics (called prophylaxis), and/or surgical placement of tubes in the ears. (See "Acute otitis media in children: Prevention of recurrence" and "Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)".)
Preventive antibiotics — Children who have recurrent ear infections are sometimes treated with a preventive regimen of a daily antibiotic during the fall, winter, and early spring months. Although preventive antibiotics might help reduce the number of ear infections, it is still possible for the child to get an infection. There is also a risk that taking antibiotics for a long period of time can lead to bacteria that are resistant to standard antibiotics. Talk to your child's doctor or nurse about the potential benefits and risks of this approach.
Surgery — Some studies show that having surgery to place tympanostomy tubes in the ears helps to prevent recurrent ear infections. Tympanostomy tubes let fluid to drain from the middle ear (figure 2), let air into the middle ear, and keep the pressure in the middle ear and the ear canal the same. Other studies show no benefit of tympanostomy tubes for prevention of recurrences. Talk to your child's doctor about the risks and benefits of surgery.
WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients and caregivers, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Ear infections (otitis media) in children (The Basics)
Patient education: Outer ear infection (The Basics)
Patient education: Eustachian tube problems (The Basics)
Patient education: Ear wax impaction (The Basics)
Patient education: Ruptured eardrum (The Basics)
Patient education: Ear tubes (The Basics)
Patient education: Secondhand smoke: Risks to children (The Basics)
Patient education: Tonsillectomy and adenoidectomy in children (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Acute otitis media in children: Clinical manifestations and diagnosis
Acute otitis media in children: Epidemiology, microbiology, and complications
Acute otitis media in children: Prevention of recurrence
Acute otitis media in children: Treatment
Hearing loss in children: Etiology
Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis
Tympanostomy tube otorrhea in children: Causes, prevention, and management
Otitis media with effusion (serous otitis media) in children: Management
The following organizations also provide reliable health information.
●National Library of Medicine
(www.medlineplus.gov/earinfections.html)
●The Nemours Foundation
(https://www.kidshealth.org/en/parents/otitis-media.html)
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ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Jerome O Klein, MD, who contributed to an earlier version of this topic review.
