Swimmer’s Ear

Not all ear infections are created equally. Swimmer’s ear differs from a middle ear infection. It is an inflammation of the skin lining the ear canal and is most common in older children and teens. Middle ear infections (otitis media) are caused by pus behind the eardrum and are most common in infants and younger children.

What is swimmer’s ear?

Swimmer’s ear (AKA otitis externa) gets its name because it is commonly caused by water in the ear canal making a good environment for bacteria to grow, causing an infection of the skin.

Water can come from many sources, including lakes, pools, bath tubs, and even sweat, so not only swimmers get swimmer’s ear.

Increasing the risk of swimmer’s ear:

Anything that damages the skin lining the ear canal can predispose to a secondary infection, much like having a scraped knee can lead to an infection of the skin on your knee. Avoid putting anything in your ears, since it can scratch the skin of the ear canal. This includes anything solid to clean wax out of the ear.

Excess earwax can trap water, so cleaning with a safe method can help prevent infection. A little wax is good though — it actually helps prevent bacterial growth. For more on earwax, please see Ear Wax: Good and Bad.

Yes, it sometimes hurts!

Swimmer’s ear can cause intense pain. Sometimes it starts as a mild irritation or itch, but pain worsens if untreated. It typically hurts more if the ear is pulled back or if the little bump at the front of the ear canal is pushed down toward the canal.

Ear buds (for a music player) or hearing aides can be very uncomfortable (and increase the risk of getting swimmer’s ear due to canal irritation).

Other symptoms:

Sometimes there is drainage of clear fluid or pus from the canal.

If the canal swells significantly or if pus fills the canal, hearing will be affected.

More severe cases can cause redness extending to the outer ear, fever, and swollen lymph nodes (glands) in the neck.

Swimmer’s ear can lead to dizziness or ringing in the ear.

Prevention of swimmer’s ear:

Controlling wax

If your child has excessive wax buildup, talk with his doctor about how often to clean the wax. Wax does help keep your ears clean, so you don’t want to clear it too much!

Keep out!

Never put anything solid into the ear canal.

Drying ears

Dry the ear canals when water gets in.

  • Tilt the head so the ear is down and hold a towel at the edge of the canal.
  • Use a hair dryer on a cool setting several inches away from the ear to dry it.
  • If kids get frequent ear infections or are in untreated water (such as a lake), use over the counter ear drops made to help clean the canal. You can buy them at a pharmacy or make them yourself with white vinegar and rubbing alcohol in a 1 to 1 ratio. Put 3-4 drops in each ear after swimming. The acid of the vinegar and the antibacterial properties of the alcohol help to clear bacteria, and the alcohol evaporates to help dry the canal.
  • DO NOT use these drops if there are tubes or a hole in the eardrum, if pus is draining, or if the ear itches or hurts.
Avoiding swimming when needed

If your child has a scratch in the ear or a current swimmer’s ear infection, avoid swimming for 3-5 days to allow the skin to heal.

Avoid bubble baths and other irritating liquids that might get into ear canals.

If there’s tubes…

If your child has tubes placed for recurrent middle ear infections, talk with your ENT about ear protection during swimming.

The use of ear plugs for swimming with tubes has been controversial, but are generally not needed. Dr. Burton discusses this in 5 Fantastical Ear Tube Myths .

Treating swimmer’s ear:

Pain control

If you think your child has swimmer’s ear, start with pain control at home with acetaminophen or ibuprofen per package directions.

Heating pads to the outer ear often help, but do not put any heated liquids into the ear.

Visit your doctor

Most often swimmer’s ear is not an emergency, but symptoms can worsen if not treated with prescription ear drops within a few days.

Bring your child to the office for an exam, diagnosis, and treatment as indicated. Most can go to their usual physician during during normal business hours if you can get adequate pain control at home.

When to be seen immediately

If the pain is severe, redness extends onto the face or behind the ear, the ear protrudes from the head, or there are other concerning symptoms, your child should be seen immediately at their primary care office or another urgent/emergent care setting.

Ear wicks

Occasionally we will remove debris from the canal or insert a wick to help the drops get past the inflamed/swollen canal.

Never attempt this at home unless you’ve been instructed on how to do it safely!

Prescription ear drops and oral medicine

The prescription ear drops may include an antibiotic (to kill the bacteria), a steroid (to decrease inflammation and pain), an acid (to kill bacteria), an antiseptic (to kill the bacteria), or a combination of these.  They are generally used 2-3 times/day.

Have your child lie on his or her side to put the drops in the ear. He or she should remain on that side for several minutes before getting up or changing sides to allow the medicine to stay in the ear. They can use a cotton ball or tissue to collect and dripping when they get up.

Symptoms generally improve after 24 hours and the infection clears within a week.

Oral antibiotics are usually not required unless the infection extends beyond the ear canal.

If an infection causes more itch than pain or does not clear with initial treatment, we might consider a fungal infection. This requires an anti-fungal medication.

No swimming until the infection clears.

Swimming just adds insult to injury. Let the skin heal before getting it soaked in the pool again!

Special circumstances

Kids (and adults) with diabetes or other immune deficiencies are more likely to get severely sick with any infection.

Visit your doctor early if you suspect a problem.

All About Ear Infections – Prevention

Ear infections are all too common and cause a lot of distress for kids and their families. What can we do to help prevent them from happening?

This is part 3 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

What can be done to prevent ear infections?

Avoid all smoke exposure.

Tobacco smoke is known to predispose children to ear infections, upper respiratory infections and wheezing.

Do not bottle prop.

Keeping a baby’s head elevated a bit while bottle feeding can help prevent ear infections.

Breastfeed.

Breast milk is protective against many types of infection, including ear infections.

General infection prevention.

Avoid taking your infant to places where there are a lot of people during sick season.

Wash hands often. Teach kids to really wash their hands. Because they don’t do a great job much of the time.

Attempt to limit sharing of toys that young children mouth, and wash them between children.

If your child attends daycare, try to find one where there are fewer children per room.

Vaccinate.

One of the biggest causes of bacterial ear infections is pneumococcus. Your child will be vaccinated against this as part of the standard vaccine schedule.

Saline.

If you know me, you know I often recommend saline to the nose.

Saline drops for babies followed by suctioning.

Nasal saline rinses for kids over 2 years of age. (Nasopure has a great library to teach proper use and even videos to get kids used to the idea.)

Saline is a great way to clear the mucus from our nose, which can help prevent cough, sinus infections, and ear infections.

Keep the pacifier in the crib.

When kids play, they often drop their pacifier, which can encourage germs to accumulate on it before they put it back in their mouth.

Xylitol.

There are several studies that suggest chewing gum with xylitol as its sweetener helps prevent ear infections in children who can chew gum. For younger infants, there are nose sprays with xylitol. Xylitol is a naturally occurring substance that is used as a sweetener is many products, many of which are reviewed here. I do not endorse any of these, but do find this a helpful resource.

Treat acid reflux.

This can include dietary changes, positional changes, or medications. Talk to your doctor to see which is right for your child.

Treat allergies.

Treating allergies can help decrease mucus production and improve drainage.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines
Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age

Share Quest for Health

All About Ear Infections – Treatments

Yesterday I wrote about what ear infections are, what they’re not, and what causes them. Many parents don’t care so much about the what’s and why’s – they want treatment. Now. Because ear infections hurt, and no one wants to watch their baby suffer. Today I’ll discuss treatments.

This is part 2 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

Treatments for Ear Infections

First manage the pain

Regardless of the cause of the earache or what the ultimate fix will be, you will want to first manage pain. It does not matter if it’s a real infection or if it’s even the ears that are causing problems, if your child is in pain, treat the pain.

Oral pain relievers

Ear pain can be managed with pain relievers, whether it’s a true infection or simply pain from the congestion that comes with a cold. You can begin pain relief at home whether or not the ear infection is confirmed with standard doses of either acetaminophen or ibuprofen.

Ear drops

Ear drops for pain work fast but the relief doesn’t last long, so I recommend also giving acetaminophen or ibuprofen per standard dosing recommendations in combination with drops. Ear drops can include both over the counter options and prescription options as long as the eardrum doesn’t have a hole or tube in it.

Do not put anything in the ear if you suspect a hole or know your child has a tube unless your doctor recommends it.

Olive oil works pretty well and most of us have that in our kitchen. Saturate a cotton ball with oil (not hot oil) and squeeze the cotton over the ear canal, putting 2-4 drops in the canal.

There are many over the counter ear drops for pain, but I find that the oil you already own is not only cheaper, but works just as well.

Prescription numbing drops are an option if your doctor thinks they are appropriate. These have been difficult to find in recent years for many factors. Be sure you’re using an approved product if you use prescription pain drops.

Positioning

If you’ve had an ear infection as an adult or watched your child refuse to sleep, you’ll know that ear infections can hurt more when lying down. Safely elevating the head can help the pain associated with the increased pressure lying down.

For young infants, elevate the head of the bed by putting risers under the legs of the bed or by wedging something under the mattress. Be sure it is stable, whichever you do. Never put an infant under 1 year of age on a pillow or other soft bedding.

For older children, propping up on several pillows is often helpful. Many toddlers and young children will not stay on pillows, so this is less effective.

Treat associated issues

When kids have ear pain, they often have a runny nose, cough, fever, and other symptoms. Each of these should be managed as discussed on previous blogs: fevergreen snotcoughgenerally sick. How long symptoms will last are discussed here.

treatment varies by age of the child and severity of the infection:

  • Pain relief for anyone with an ear infection is the first treatment. See above.
  • Monitor for the first 2-3 days without antibiotics in many instances, since most ear infections will self-resolve.
  • Antibiotics can be used if symptoms persist more than 2-3 days ~ earlier for children under 6 months of age, those with significant illness, those who had another ear infection within the past 30 days, or for those who have an increased risk of ear infection (such as immune deficiency or an atypical facial structure or chromosomal defect known to affect hearing or immune function).
  • If a child has tubes and develops an ear infection, pus will drain out of the tube. Antibiotic ear drops are the first choice for this type of infection. Antibiotics by mouth are not typically needed.
  • Prevent the next ear infection. See Part 3 tomorrow!

Why not use antibiotics for every ear infection?

Antibiotics don’t treat viruses

The large majority of ear infections are caused by a virus, for which antibiotics are ineffective. About 80% of ear infections self resolve without antibiotics.

Antibiotics can cause problems

Not only are antibiotics not needed, but they also carry risks. About 15% of kids who take antibiotics develop diarrhea or vomiting. Nearly 5% of children have an allergic reaction to antibiotics — this can be life threatening. So when you look at the benefits vs risks, you can see that most of the time antibiotics should not be used as a first treatment.

Superbugs

When bacteria are exposed to an antibiotic but don’t get completely killed, they learn to avoid not being killed the next time they see that same antibiotic. This is called bacterial resistance, also known as “superbugs”.

Superbugs can be shared from one child to another, which explains why some children who have never had antibiotics before have an infection that is not easily taken care of with the first (or second) round of antibiotics and why if a child needed several different antibiotics to clear an ear infection might get better with generic amoxicillin with the next.

It’s the bacteria in the ear that become resistant, not the child. The more we use antibiotics, the more resistance builds up and the less likely antibiotics will work for serious infections.

What are tubes and how do they work?

Tympanostomy tubes are small plastic tubes that are placed in a surgically made hole in the eardrum (tympanic membrane). They keep the hole in the eardrum open so that if pus develops in the middle ear it can drain out through the tube. This helps prevent the pain caused by the pus filling the middle ear area and pushing out on the eardrum. It also helps prevent the hearing loss that happens when the eardrum can’t move due to pus behind it.

photo from USAToday (Rosenfeld RM. A Parent’s Guide to Ear Tubes. Hamilton: BC Decker Inc., 2005)

Pus behind the eardrum causes many symptoms, which may include balance problems, poor school performance, hearing difficulties, behavioral problems, ear discomfort, sleep disturbance, and/or decreased appetite with poor weight gain. The benefits of tube placement for these children must be compared to the cost and risks of anesthesia and having an opening in the eardrum.

The majority of ear infections resolve completely without complication. The longer the pus remains behind the eardrum the less likely it will go away. If the pus is there longer than 3 months, it’s less likely to resolve without treatment.


When are tubes recommended?

Since placing tubes does involve risks, they are not recommended for everyone.
Guidelines recommend the following evaluation for tubes:
  • If pus or fluid has been in the middle ear for over 3 months (OME or OM that never clears), a hearing test should be done.
  • If the hearing test is failed, tubes should be considered.
  • If fluid has been there longer than 3 months but hearing is normal, recheck the hearing every 3-6 months until the fluid clears. If the hearing test is failed on rechecks, then tubes are warranted. (I know plenty of families who opt for tubes despite normal hearing due to quality of life despite this recommendation.)
  • Children with higher risk of speech issues or hearing loss may be considered for tubes earlier. This would include children with abnormal facial structures, such as cleft palate, or certain genetic conditions that predispose to developmental delays, hearing concerns, or immune problems.
 Dr. Deborah Burton is an Ear, Nose, and Throat (ENT) surgeon who answers common ear tube questions and discusses common tube complications in just a couple of her fantastic collection of blogs. She also gives tips on how to avoid ear infections to prevent the need for surgery!

What about recurrent ear infections?

I know parents get frustrated with recurrent ear infections, and I’ve seen many families who are happy that they got tubes for their child after recurrent ear infections, but studies show they aren’t really necessary. If each ear infection clears, that shows that the eustachian tube (the tube that drains the middle ear into the throat) can do its job. As long as the pus is there less than 3 months with each infection, the risk of tubes does not usually outweigh the benefits according to studies.
Again, quality of life can factor in here and I think that’s hard to measure in a study. If kids are missing out on sleep and not eating well due to ear pain, tubes might really help. Discuss this with your child’s doctor.

Are there kids who should be considered tube candidates earlier?

Some kids are more sensitive to the problems associated with OME. These kids might have sensory, physical, cognitive, or behavioral issues that increase his or her risk of speech, language, or learning problems from pus in the middle ear. Children with known craniofacial abnormalities or chromosomal abnormalities who are at higher risk for speech and hearing impairment will also be considered for tubes more liberally. These kids might benefit from tubes even if they don’t have pus for 3 months in the middle ear or hearing loss.

What are complications and risks of tubes?

Tube placement requires anesthesia, which is overall safe, but not without risk.
Tubes keep a hole in the eardrum, which can allow water and bacteria to get into the middle ear, leading to infection. This leads to pus draining out of the ear canal, called otorrhea. This pus can be treated with antibiotic ear drops initially, and oral antibiotics if it last more than a month.

Some ENTs recommend earplugs when kids with tubes swim, but studies do not show that they are needed in most cases. If kids get recurrent otorrhea, they might be candidates for earplugs when swimming. Kids who swim in lake water or do deep water diving might also benefit from earplugs.

NEXT UP: Prevention

So now that you know what ear infections are and how to treat them, check in tomorrow for Part 3: how to prevent them.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines

Share Quest for Health

All About Ear Infections – What they are and why they happen

When babies and children have ear infections everyone in the house suffers because they cry all night and no one sleeps. They hurt. Especially at night. Parents don’t want to see their children in pain and they don’t want to see it happen again and again, so they often wonder if tubes are the answer.

This is part 1 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

What causes ear infections and what does not?

A middle ear infection usually happens because of swelling in one or both of the eustachian tubes (which connect the middle ear to the back of the throat as pictured above). The tubes let mucus drain from the middle ear into the throat. If they are blocked, the mucus builds up in the middle ear.

Ear infections are usually caused by viruses that cause typical cough and colds. The mucus made during the infection gets into the middle ear, causing pain. Bacteria can also get into the middle ear and cause infections.

Things that increase the likelihood of an ear infection include anything that increases mucus or decreases drainage:
  • Young age
  • Swollen tonsils or adenoids
  • Acid reflux
  • Secondhand smoke
  • Allergies
Things that DO NOT increase the risk of middle ear infections:
  • Taking a bath when it’s cold
  • Getting water in the ear
  • Getting wind in the ear
  • Going outside in cold weather

Why do babies get so many ear infections?

The eustachian tube helps to equalize pressure in the middle ear. If it is swollen or blocked it does not allow the pus in the middle ear to drain (think of how the tissues in your nose swell with a cold or allergies). Infants and young children are more prone to ear infections than adults because their eustachian tube is flatter, which inhibits drainage (see picture below).

photo source: MedlinePlus

 

what an ear infection is and what it’s not

A healthy ear drum is grey and shiny and we can see the small ear bones behind it. (See eardrum on the right.)

photo source: Medscape
Otitis media

Correctly diagnosing an acute ear infection (otitis media, OM) can be more difficult than it seems.

The child must have significant pus behind a red eardrum, as in the left image above, or pus draining out of the ear canal from pressure causing a hole in the eardrum allowing pus to drain (perforated eardrum) or ear tubes.

Even with this pus and redness, it is not possible to tell if a bacteria or virus is causing the infection.

Otitis media with effusion

If there is pus behind the eardrum without redness or other symptoms, it is not an acute ear infection but rather otitis media with effusion (OME).

This fluid can range from clear to white or yellow and may accumulate in the middle ear as a result of an upper respiratory infection or a resolving acute ear infection.

Many kids have no symptoms of pain with this ear fluid but it can affect hearing. OME is often found at “well” visits during the winter months or at school hearing evaluations.

OME typically self resolves within a month or two. If it persists beyond 3 months and causes hearing loss, tubes will drain the fluid (see below). Sometimes removing the tonsils or adenoids are recommended, since removal might help the eustachian tube drain the middle ear.

Decongestants and other medicines have not been found to help OME. OME can get mistaken for an ear infection if the child is crying during an exam, which reddens the eardrum.

Red ears

Many kids cry when being examined, and the eardrum can turn red just from crying (just like their face and ears turn red when they’re mad).

We often see this when kids are in the office for upper respiratory tract infections. School nurses will sometimes send kids in to check on red ears.

This is not an ear infection unless there’s also pus.

It’s just a crying kid. Or a child with a fever and red ears.

Many less experienced (or just busy) clinicians call it an ear infection even if there’s no pus so they can quickly write a prescription and move on to the next patient. Parents are happy “knowing” that there’s an ear infection (that’s not real) and that they can do something about it. This is incorrect on several levels. There must be pus involved. It’s easy to over diagnose an ear infection if you’re just looking at the color of the eardrum.

Swimmer’s Ear

Swimmer’s ear is a different type of infection entirely because it involves the skin of the ear canal, not the middle ear, and is covered in-depth in Swimmer’s Ear.

Ears and eyes

When babies have pink eye I always want to look at their ears before treating the eyes. This is why I don’t recommend getting antibiotic eye drops by phone for young kids. Ears and eyes often become infected together and the ears should be treated in addition to the eyes, and the eye drops do nothing for the ears. I’ve seen plenty of kids over the years who have no ear symptoms with their ear infections – they just get red matted eyes, with or without fever.

Are ear infections that rupture the eardrum more serious?

I’ve had several parents worry that their child had a hole in the eardrum allowing pus to drain out. They automatically think this child is at higher risk of ear problems and should get tubes. This isn’t exactly the case.

Many factors can lead to ear drum perforation (or rupture). In general, when the eardrum perforates, a hole allows the pus to drain (much like tubes), which allows for faster healing of the infection and pain. This does not necessarily mean the child is prone to ear infections or needs tubes.

In days before antibiotics, a treatment for ear infections was to put a needle into the eardrum to draw the pus out. This helped relieve pain and was very effective to clear the infection.

I find that many kids who have eardrum ruptures feel better faster than those who don’t. Occasionally the hole lasts for years and it becomes recommended to patch it closed, but typically the hole closes up very quickly — sometimes too quickly before the infection is cleared and pus re-accumulates behind the eardrum.

Next up: Treatments

So now that you know what ear infections are, check in tomorrow for Part 2: how to treat ear infections.

Until then, you can check out these 7 Ear Infection Facts Every Mother Should Know from Dr. Deborah Burton, an ENT with a fantastic blog.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines

Share Quest for Health

Ear Wax: Good and Bad

We make ear wax, also known as cerumen. Many people are annoyed by wax buildup, but it has a purpose! Wax grabs all the dust, dirt, and other debris that gets into our ears. It also moisturizes the ear canal ~ without it our ears become itchy. It even has special properties that prevent infection. That’s all good stuff, so don’t be too frustrated with a little wax!

Why do we have ear wax?

Most often the wax moves from the inner part of the ear canal to the outer edge of the canal on its own.

It’s amazing to me how our bodies are put together so perfectly: it is designed so the wax is made deep in the canal, then skin cells and wax migrate to the outer edge of the canal, taking with them debris!

Some people naturally make dry ear wax, others make wet wax. This can be due to genetics and other factors. The important thing to remember with this is how your wax tends to build up and how to best keep it from building up.

When is ear wax a problem?

If wax builds up it can cause pain, itching, ringing in the ear, dizziness, decreased hearing, and infection.

Inappropriate cleaning with hard and/or sharp objects (such as cotton swabs or paperclips) can increase the risk of infection or even perforation of the ear drum.

Even special cotton swabs made “safe for ears” can push wax deeper and cause a solid collection of wax plugging up the canal.

How can parents help babies and kids keep their ears clean?

Routine bathing with clean warm water allowed to run into the ear followed by a gentle wiping with a cloth is all that is needed most of the time.

No, water in the ear doesn’t cause ear infections. It can contribute to swimmer’s ear, but ear wax buildup also can contribute to that.

If you’ve been told your child makes excessive Ear wax:

wax removal drops
Ear wax removal drops and a bulb syringe are a safer way to remove wax when needed.

Ear drops made for wax removal with carbamide peroxide can be put in the ear as long as there is no hole in the ear drum or tubes.  The oily peroxide acts to grab the wax and bubble it up. Then rinse with clean warm water and a soft cloth (see syringe tips below). If there is excessive buildup, daily use of drops for 3-5 days followed by weekly use of the drops to prevent more buildup is recommended. (For particularly stubborn wax, using drops 2-3 times/day for 3-5 days initially can help.)

Make your own solution of 1:1 warm water:vinegar and gently irrigate the ear with a clean bulb syringe.

Mineral oil or glycerin drops can be put in the ear. Let a few drops soak for a few minutes and then rinse with warm water and a soft cloth.

Occasional use of a syringe to gently irrigate the ear can help.

How to use a bulb syringe:
  • First, be sure it’s clean!

Fungi and bacteria can grow within the bulb ~ you don’t want to irrigate the ear with those!  While they can be boiled, they are also relatively inexpensive and easily available, so frequent replacement is not a bad idea.

  • Use only warm fluids

Warm the fluid to body temperature or just above body temperature.

Cold fluids may make the person dizzy and possibly nauseous!

If using drops first, put the bottle in warm water or rub it between your hands a few minutes (as if rubbing hands together to warm them, but with the bottle between the hands).

Don’t overheat the fluid and risk burning the canal!

  • Have the child stand in the tub or shower.

This just helps decrease the mess!

  • Pull up and back gently on the outer ear to straighten out the canal.
  • Aim

Aim the tip slightly up and back so the water will run along the roof of the canal and back along the floor.

Do NOT aim straight back or the water will hit the eardrum directly and can impact hearing.

  • Go slow

Don’t push the water too fast ~ a slow gentle irrigation will be better tolerated.

If they complain, recheck the angle and push slower.

If complaining continues, bring them to their doctor’s office to let us do it to be sure there isn’t more to the story. Sometimes there’s an infection that makes the canal exquisitely tender and needs to be treated. And beads, rocks, and other objects have been known to sneak into ears…

  • Refill the syringe and repeat as needed until the wax is removed.
  • Clean and dry

Use a soft cloth to grab any wax you can see and dry the ear when done.

Some people like to use a hair dryer set on low to dry the canal. Just be sure to not burn the skin!

What if you can’t get it out?

If wax continues to be a problem, we can remove it in the office with one of two methods:

Curette Method

First we inspect the ear canal carefully with an otoscope (or as I call it ~ my magic flashlight).

If wax is identified and deemed in need of removal, we can use a curette to remove the wax. A curette looks like a spoon or a loop depending on provider’s preference and wax type. We place the curette behind the wax and pull it out.

This is often the fastest method in the office, but is not always possible if the wax is too flaky or impacted into the canal leaving no room for the curette to pass behind the wax.

It should only be done by trained professionals… don’t attempt this at home!

Irrigation Method

If the ear wax is plugging up too much of the canal, the canal is very tender, or if the wax is particularly flaky and breaks on contact with the loop, we will let the ear soak first, then irrigate with warm water.

This process takes longer but is better tolerated by many kids and they think it is fun to “shower their ear”.

We often must follow this with the curette to get the softened wax completely out.

ENT.

Sometimes I recommend having an Ear Nose and Throat specialist remove the wax.

Very narrow ear canals might require special equipment an ENT has available.

If a child has tubes in the ears, I do not attempt to remove wax. In this situation I send them to their ENT to clean them out if they think it’s necessary.

My biggest tips:

 

  • Never use cotton tipped swabs, pipe cleaners, pencils, fingernails, or anything else that is solid to clean the ear!

Note: I still don’t recommend them if the package says “safe.” They aren’t!

  • Don’t put liquid in the ear canal if there is a hole in the ear drum (tubes are included in this).

Pus draining from the ear is a sign that there might be a hole.

  • Ear candles are not a safe solution.

Burns are too big of a risk!

  • Don’t do things that cause increased pain or bleeding.

Many parents attempt to clean ears with Q-tips, ear buds, pipe cleaners, or other unsafe objects. Remember to never use anything smaller than your finger in your ear.

The ear canal is very sensitive, especially if wax buildup has been there a while and has caused an infection of the skin in the canal. Anything put into the ear can increase any pre-existing pain.

If the skin is friable from prolonged wax and/or infection there is often bleeding with cleaning. If you notice this at home, your child should have the ears evaluated in our office. We will look for holes in the ear drum, scratches on the skin in the canal, and signs of infection needing antibiotic.

  • Stop cleaning regularly.

Most of the time ear wax does not cause problems, so it doesn’t need to be removed.

Some people who suffer from itchy ears can help themselves by NOT cleaning their ears so much!

  • Earwax usually can be left alone.

Only try to clean it out if there are signs of problems with it (ear pain, ringing in the ears, decreased hearing, etc).

If kids don’t tolerate removal with the methods above, bring them in for us to take a good look. There might be more to the story that needs to be addressed.

  • Bring your child in to the office to have us assess and treat if:
  1. Significant ear pain persists
  2. Pus or bleeding from the ear is noticed
  3. You suspect something is in the ear

UPDATE:

In January of 2017, the American Academy of Otolaryngology-Head and Neck Surgery Foundation issued updated AAP-endorsed guidelines regarding wax buildup. Check out this list of Do’s and Don’ts from the guidelines.

Hearing Loss in Kids

Most of us associate hearing loss with old age, but it is increasingly common for children and teens to suffer from mild to moderate hearing loss. Nearly 15% of kids have hearing loss according to the CDC. Hearing loss can be due to many things that are difficult to control, such as heredity, infection, and medications. In kids and teens it is oven due to a preventable cause: noise.

Where does the excessive noise come from?

Even young children are exposed to more loud noises through toys, television, and gaming devices than children of years past.

Widespread use of ear buds for prolonged periods can take its toll on hearing. Unlike the bulky headphones used when I was a child, ear buds deliver sound directly into the ear canal without any sound buffering in between. Most often the ear buds are used with iPods and other mp3 players are low to mediocre quality, so they are unable to transit the bass as effectively. Many kids turn the music up to hear the bass. If others can hear the music coming from ear buds, they are too loud!

Loud concerts or sporting events can also expose our ears to excessive volumes for a prolonged period of time.

Not all excessive noise is from kids being undisciplined – some kids are helping out the family or trying to earn extra cash by mowing lawns or using power tools, which puts them at increased risk.

How much is too much?

According to the Centers for Disease Control and Prevention (CDC), being exposed to more than 85 decibels (dB) of sound for eight hours can damage your hearing. At 105 dB, hearing loss is possible after a mere 5 minutes.

If you’re like me, that means nothing because how much is 85 dB? There is a great chart of common sounds and how loud they are on this page from the CDC. There are also several free apps available for download on smartphones and tablets – search “sound meter” or “decibel” and read reviews before downloading. Take advantage of these — and because it’s in the phone, kids might actually have fun playing around with them and learning about their environmental risks at the same time!

Signs of hearing loss

One early sign of excessive noise is ringing in the ears, but most people with hearing loss never realize it’s happening because it’s slowly progressive. If you notice your child asking “what” more often or complaining that the television is too quiet when others hear it well, it is a good idea to have their hearing tested.

Consequences of hearing loss

There are many potential consequences to hearing loss:

  • Learning – you have to be able to hear the lecture.
  • Behaviors – if directions and instructions are missed, a child might incorrectly be seen as misbehaving.
  • Friendships and social skills – if a child can’t follow a conversation they aren’t easy to talk to or play with.
  • Job availability – many jobs require hearing at a certain level.

Prevention

Talk to your kids about the risks of their habits that involve loud sounds.

Unfortunately kids won’t always take parental advice to heart because they have a feeling of invincibility, but studies show if they learn about hearing loss they are more likely to use protection.

Even more so, what their friends are doing alters their behavior. Teach not only your kids, but also their friends. If they’re all going to a loud event, consider giving them all ear plugs.

Once hearing is damaged they can’t gain the hearing back, so prevention is key.
Ways to protect include:
  • Wear hearing protection (earplugs) when mowing the grass and attending loud events, such as concerts or sporting events.
  • Turn down your music! Some music players have alerts when the volume goes too loud, but those can be ignored if the child doesn’t understand why it’s important to lower the volume. If others can hear the music you’re listening to through ear buds, turn it down.
  • Lower the maximum volume setting on your iPod or mp3 player. To do this, go to “Settings” and select “Volume Limit” under Music. Set it at about 60% of the full volume, that way you can’t accidentally turn your music too high.
  • Use big headphones instead of ear buds. They offer more external noise cancelling, which allows the music to be heard better at lower volumes. They are also physically further from your eardrum, which helps.
  • If you must use ear buds, use high quality buds that transmit bass if you are tempted to turn music up to hear the bass.
  • Follow the 60/60 rule: No more than 60 minutes of listening at a time, and no higher than 60 percent of maximum volume. If you go under “settings,” you can actually set your iPod for maximum volume setting of 60 percent, so you can’t accidentally turn your music up too loud.
  • Higher pitched sounds have greater potential to damage your ears than lower pitched sounds. Turn down the volume when a high-pitched song comes on.
  • Try not to fall asleep with ear buds or headphones on. The time of exposure matters and why waste sleep time damaging your ears?
  • If you need “white noise” to fall to sleep, put together a playlist of soft songs or sounds and have it play at a low volume from a speaker on your bedside table. Use your clock’s “sleep” function, which will automatically turn off your music after a set amount of time to ensure the music doesn’t end up playing all night long, which saves energy in addition to your hearing.
As always:

Model these behaviors for your children.

If they see you mowing the grass with loud music blaring in your ears, they will grow up to do the same.

If you wear ear buds many hours of the day, they will see that as a normal and acceptable behavior.

What happens that hurts our hearing?

Don’t let your kids and teens ruin their hearing!

Below it the music soundtrack and volume levels are shown.

The video then breaks to showing what happens to the hair cells in our ear with these volumes, which makes the damage more understandable because you can see it happening.

Resources:

CDC’s Hearing Loss main page

Traveling with Kids

Many families travel when school’s out of session, which over the winter holiday season and spring break means traveling when illness is abound. I get a lot of questions this time of year about how to safely travel with kids. Traveling with kids can increase the level of difficulty, but it can be done safely and still be enjoyable!

Sleep disturbances

Sleep deprivation can make everyone miserable, especially kids (and their parents). Make sure your kids are well rested prior to travel and try to keep them on a healthy sleep schedule during your trip.
  • Bring favorite comfort items, such as a stuffed animal or blankie, to help kids relax for sleep. If possible, travel with your own pillows.
  • If you’re staying at a hotel, ask for a quiet room, such as one away from the pool and the elevator.
  • Be sure to verify that there will be safe sleeping areas for every child, especially infants, before you travel.
  • Try to keep kids on their regular sleep schedule. It’s tempting to stay up late to enjoy the most of the vacation, but in reality that will only serve to make little monsters of your children if they’re sleep deprived.
  • If your kids nap well in the car, plan on doing long stretches on the road during nap time. If kids don’t sleep well in the car, be sure to plan to be at your hotel (or wherever you’re staying) at sleep times so they can stay in their usual routine.
  • Some families leave on long trips at the child’s bedtime to let them sleep through the drive. Just be sure the driver is well rested to make it a safe trip!
  • If you’re changing time zones significantly, plan ahead. Jet lag can be worse when traveling east than when going west. Jet lag is more than just being tired from a change in sleep routine, it also involves changes to the eating schedule. Kids will often wake when they’re used to eating because the body is hungry at that time. Try to feed everyone right before they go to sleep to try to prevent this. Breastfed infants might have a harder time adjusting because mother’s milk production is also off schedule.
  • Tired, sick, and hungry all make for bad moods, so try to stay on track on all accounts. Sunlight helps regulate our circadian rhythm, so try to get everyone up and outside in the morning to help reset their inner clocks. Keep everyone active during the day so they are tired at the new night-time.

Keeping track of littles

  • Toddlers and young kids love to run and roam. Be sure that they are always within sight. Use strollers if they’ll stay in them.
  • Consider toddler leashes. I know they seem awful at first thought, but they work and kids often love them! I never needed one for my first – he was attached to parents at the hip and never wandered. My second was fast. And fearless. She would run between people in crowds and it was impossible to keep up with her without pushing people out of the way. She hated holding hands. She always figured out ways to climb out of strollers – and once had a nasty bruise on her forehead when she fell face down climbing out as I pushed the stroller. She loved the leash. It had a cute monkey backpack. She loved the freedom of being able to wander around and I loved that she couldn’t get too far.
  • Parents have a number of ways to put phone numbers on their kids in case they get separated. Some simply put in on a piece of paper and trust that it will stay in a pocket until it’s needed. Others write it in sharpie inside a piece of clothing or even on a child’s arm. You can have jewelry engraved with name and phone number, much like a medical alert bracelet. Just look at Etsy or Pinterest and you’ll come up with ideas!
  • It’s a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.
  • If you want more, I wrote a whole blog on keeping kids from wandering.

Airplane issues

  • The great news is that air travel is much safer from an infection standpoint than it used to be. Newer airplanes have HEPA filters that make a complete air change approximately 15 to 30 times per hour, or once every 2-4 minutes. The filters are said to remove 99.9% of bacteria, fungi and larger viruses. These germs can live on surfaces though, so I still recommend using common sense and bringing along a small hand sanitizer bottle and disinfectant wipes to use as needed. Wipe down arm rests, tray tables, seat pockets, windows, and other surfaces your kids will touch. After they touch unclean items sanitize their hands. Interestingly, sitting in an aisle seat is considered more dangerous, since people touch those seats during boarding and when going to the restroom, so if you’re seated in the aisle pay attention to when surfaces need to be re-sanitized. Sitting next to a sick person increases your risk, so if there is an option to move if the person seated next to you is ill appearing, ask to be moved.
  • Most adults who have flown have experienced ear pain due to pressure changes when flying. Anyone with a cold, ear infection or congestion from allergies is more at risk of ear pain, so pre-medicating with a pain reliever (such as acetaminophen) might help. If you have allergies be sure to get control of them before air travel. The best allergy treatment is usually a nasal corticosteroid.
  • It has often been recommended to offer infants something to suck on (bottle, breast or a pacifier) during take off and landing to help with ear pressure. Start early in the landing – the higher you are, the more the pressure will change. Older toddlers and kids can be offered a drink since swallowing can help. Ask them to hold their nose closed and try to blow air out through the closed nostrils followed by a big yawn. If your kids can safely chew gum (usually only recommended for those over 4 years of age) you can allow them to chew during take off and landing.
  • Airplane cabin noise levels can range anywhere from 60 – 100 dB and tend to be louder during takeoff. (I’ve written about Hearing Loss from noise previously to help you understand what that means.) Use cotton balls or small earplugs to help decrease the exposure, especially if your kids are sensitive to loud noises.
  • The Car Seat Lady has a great page on knowing your rights when flying with kids.

Cruise ship issues

  • Learn about cruise-specific opportunities for kids of various ages. Many will offer age-specific child care, “clubs” or areas to allow safe opportunities for everyone to hang out with people of their own age group. Cruises offer the opportunity for adventurous kids to be independent and separate from parents at times, allowing each to have a separate-yet-together vacation. Travel with another family with kids the same ages as yours so your child knows a friendly face, especially if siblings are in a different age group for the cruises “clubs”.
  • Talk to kids about safety issues on the ship and make sure they follow your rules. They should always stay where they are supposed to be and not wander around. There’s safety in numbers, so have them use a buddy system and stick with their buddy. Find out how you can get a hold of them and they can get a hold of you during the cruise.
  • Of course sunscreen is a must. Reapply often!
  • Be sure kids are properly supervised near water. That means an adult who is responsible for watching the kids should not be under the influence of alcohol, shouldn’t read a book, or have other distractions.

Car seats (for planes, trains and automobiles)

  • I know it’s tempting to save money and not get a seat for your child under 2 years of age on a plane, but it is recommended that all children are seated in a proper child safety restraint system (CRS). It must be approved for flight, but then you can then use the seat for land travel.
  • I always recommend age and size appropriate car seats or boosters when traveling, even if you’re in a country that does not require them. Allowing kids to ride without a proper seat will probably lead to problems getting them back in their safe seat when they get back home. Besides, we use car seats and booster seats to protect our kids, not just to satisfy the law.
  • So… my section header was meant to be cute. Trains don’t have seatbelts, so car seats won’t work. But they are a safe way to travel. Car Seat for the Littles has a great explanation on Travel by Train.

Motion sickness

When should pregnant women and new babies avoid travel by air?

  • A surprising number of families either must travel (due to a job transfer, death in the family, out of state adoption, or other important occasion) or choose to travel during pregnancy or with young infants.
  • Newborns need constant attention, which can be difficult if the seatbelt sign is on and needed items are in the overhead bin. New parents are already sleep deprived and sleeping on planes isn’t easy. New moms might still have swollen feet and need to keep their feet up, which is difficult in flight. Newborns are at high risk of infection and the close contact with other travelers can be a concern. And traveling is hard on everyone. But the good news is that overall young infants tend to travel well.
  • It is advisable to not travel after 36 weeks of pregnancy because of concerns of preterm labor. Pregnant women should talk with their OB about travel plans.
  • Some airlines allow term babies as young as 48 hours of age to fly, but others require infants to be two weeks – so check with your airline if you’ll be traveling in the first days of your newborn’s life. There is no standard guideline, but my preference would be to wait until term babies are over 2 weeks of age due to heart circulation changes that occur the first two weeks. Waiting until after 6 weeks allows for newborns to get the first set of vaccines (other than the Hepatitis B vaccine) prior to flight would be even better. Infants ideally have their own seat so they can be placed in a car seat that is FAA approved.
  • Babies born before 36 weeks and those with special health issues should get clearance from their physicians before traveling.
  • Overall traveling with an infant is not as difficult as many parents fear. Toddlers are another story… they don’t like to sit still for any amount of time and flights make that difficult. They also touch everything and put fingers in their mouth, so they are more likely to get exposed to germs.

Illness prevention

Who wants to be sick on vacation? No one. It’s easy to get exposed anywhere during the cold and flu season, so protect yourself and your family.
  • Teach kids (and remind yourself) to not touch faces – your own or others. Our eyes, nose, and mouth are the portals of entry and exit for germs.
  • Wash hands before and after eating, after blowing your nose, before and after touching eyes/nose/mouth, before and after putting in contacts, after toileting or changing a diaper, and when they’re obviously soiled.
  • Cover sneezes and coughs with your elbow unless you’re cradling an infant in your arms. Infants have their head and face in your elbow, so you should use your hands to cover, then wash your hands well.

 

Make sure all family members are up to date on vaccines.

 

Keep records

Take pictures of your passport, vaccine record, medicines, insurance cards, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.

  • your name, address, and phone number
  • emergency contact name(s) and phone number(s)
  • immunization record
  • your doctor’s name, address, and office and emergency phone numbers
  • the name, address, and phone number of your health insurance carrier, including your policy number
  • a list of any known health problems or recent illnesses
  • a list of current medications and supplements you are taking and pharmacy name and phone number
  • a list of allergies to medications, food, insects, and animals
  • a prescription for glasses or contact lenses

Enjoy!

Last, but not least: Enjoy your vacation!
Be flexible.

Don’t overschedule. Your kids will remember the experience, so make moments count – don’t worry if you don’t accomplish all there is to do!

Take a look at some of the Holiday Health Hazards that come up at vacation times from Dr Christina at PMPediatrics so you can prevent accidents along the way.

Take pictures, but don’t make the vacation about the pictures. Try to stay off your phone and enjoy the moments!