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.
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.
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.
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.
Treating allergies can help decrease mucus production and improve drainage.
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.
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 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.
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: fever, green snot, cough, generally 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.
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.
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.
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.
All About Ear Infections – What they are and why they happen
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:
Swollen tonsils or adenoids
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).
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.
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 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.
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:
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 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.
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:
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!
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.
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: