Ear infections

Key points to remember about ear infections

• ear infections are very common in young children
• they can cause pain, and often fever
• antibiotics are not always needed
• pain relief is important
• there may be some fluid in the space behind the ear drum (middle ear) for several weeks or months after the infection - this is normal, and usually clears up on its own
• most children outgrow ear infections and have perfect and undamaged ears and normal hearing
• if you think your child has an ear infection, take them to your family doctor

What does the inside of the ear look like?

Diagram of the inside of the ear. Artwork copyright © Dr Peter Allen and printed with permission from the book 'Understanding ear infections'.

What is an ear infection and how does it develop?

Ear pain and concerns about hearing are one of the most common reasons parents take their young children to the doctor. The medical name for an ear infection is 'otitis media'.

There are 2 common types of middle ear problems:

• an ear infection (acute otitis media) – discussed on this page
• glue ear (otitis media with effusion or secretory otitis media)

Ear infections often happen either during or just after a cold, in the following way:

• germs (bacteria and viruses) from a cold (or other upper respiratory infection) travel up the Eustachian tube which connects the space behind the ear drum (middle ear) to the back of the nose
• the germs infect the space behind the ear drum
• the swelling and inflammation of the Eustachian tube, as a result of the infection, can cause the tube to become blocked
• as a result, air cannot reach the space behind the ear drum
• fluid and pus collects in the space behind the ear drum (see diagram below left)
• the ear drum bulges out and becomes red and painful (see diagram below right)
• the rapid stretching of the ear drum causes your child pain, and the infective process can cause fever

Artwork copyright © Dr Peter Allen and printed with permission from the book 'Understanding ear infections'.

Who gets ear infections?

Ear infections are very common in babies and young children who are more likely to develop them than older children and adults. This is because their Eustachian tubes (connecting the middle ear to the back of the nose) don't function as well as in older children and adults. In a young child the tubes are smaller, shorter and flatter (more horizontal) than in adults. This makes it easier for them to become blocked during head colds, which are very common in small children.

As children grow older, their Eustachian tubes work better. They also get fewer colds, and so they often outgrow the tendency to have frequent ear infections. This tends to happen from around 7 years of age, although there are some children who may have problems beyond this age.

What puts my child at risk of getting ear infections?

We know some important risk factors, but not all the reasons why some children develop more ear infections than others. The most important risk factors include:

• a family history of ear infections
• your child being exposed to cigarette smoke
• early child care where young babies and children are exposed to more colds/flu viruses; having an older brother or sister in child care or early primary school also increases the risk
• season of the year – ear infections are more common during the autumn and winter months

There is no clear evidence that allergy causes ear infections.

Can I do anything to prevent ear infections in my child?

It is not easy to prevent ear infections, but the following may help reduce the risk:

• keeping your child smoke-free
• breastfeeding your baby for 3 to 6 months is thought to be protective against the early development of ear infections. This may be because breast feeding boosts the immune system (the body's defence against potentially harmful germs)

What are the signs and symptoms of an ear infection?

Older children will complain of significant ear pain and may have a fever. They may also feel unwell and complain of reduced hearing in the affected ear.

In babies and younger children, sometimes the only sign of an ear infection is a fever.

Younger children may also:

• cry and become very upset, distressed, irritable and hard to deal with
• have very disturbed sleep at the beginning of the infection
• be harder to settle to sleep
• vomit, lose interest in eating, seem to have no energy
• become 'clingy' and 'grizzly'

Sometimes pus will burst through the eardrum (see the diagram at right). The pus looks like snot coming out of the ear. When the ear drum bursts, children often feel better as the pressure causing the pain is suddenly released. The burst eardrum usually heals without treatment or future problems. See 'When should I seek help?' below.

Artwork above copyright © Dr Peter Allen and printed with permission from the book 'Understanding ear infections'.

Can you catch middle ear infections?

Ear infections can't be passed on from one person to another, but the cold or other infection which caused them can.

How are middle ear infections diagnosed?

Your family doctor will ask questions about your child's recent and past health and examine your child's ears. To do this they will use an instrument called an otoscope to look at your child's ear canal and ear drum. An otoscope contains both a small powerful light and a low power magnifying lens.

Most infants and children do not like having their ears examined. To make it easier, your doctor will probably encourage you to hold your child on your lap and hug their arms and body while your doctor looks inside your child's ear. This should not be painful. It is important to hold your child securely while having their ears examined. If your child moves during this examination it can be painful for them and make it more difficult to examine their ears both now and in the future.

How long does an ear infection last?

The pain from an ear infection comes on rapidly and doesn't last long. It usually wears off within 24 hours.

After an ear infection, your child may have fluid behind their ear drum (effusion) which can last several weeks to months. This may cause your child to have an ongoing feeling of discomfort in their ears. It is more a dull, abnormal feeling than a nasty, sharp pain. The fluid also causes a short term decrease in hearing in that ear. See the glue ear page.

What is the treatment for an ear infection?

Pain relief

Regular pain relief is important to help your child feel more comfortable. Paracetamol or ibuprofen can help reduce pain, and also lower fever which can make your child feel better. You must follow the dosage instructions on the bottle. It is dangerous to give more than the recommended dose. Your family doctor or pharmacist can advise you on the right dose of pain relief medicine for your child.

Antibiotics

Your doctor may either:

• wait to see whether the infection will clear up by itself, or
• recommend treatment with antibiotics, if your child is unwell and feverish

Your child's doctor will be happy to discuss your child's treatment with you so that you can be involved in the treatment decisions. The decision about whether or not to use antibiotics may depend on some of the following factors:

• how severe the infection is
• how old your child is
• how often your child has had middle ear infections before
• how long your child has had this infection
• whether your child has ever had complications from ear infections before
• whether your child has any other medical conditions
• your views on how to manage your child's ear problems

How can I care for my child at home?

• pain relief is important 
• your child may need rest and lots of comforting and cuddles
• keep your child home from child care or school while they are unwell or have a fever

There is no evidence that decongestant medicines (including nose sprays) and antihistamines are of any benefit in the treatment of acute ear infections and they can have unwanted side-effects so they should not be used.

Are there any complications from ear infections?

Hearing loss is the main complication of ear infections. The fluid that collects behind the eardrum (called an effusion) can last for weeks to months after the pain of an ear infection is over. The fluid is usually gone in 80 percent of children within 12 weeks. See the following pages:

• glue ear
• hearing problems in children
• hearing and communication

A hole in the ear drum (ear drum perforation) can result from the build-up of pus. In most cases this is a small hole that heals quickly (in hours to days). In a small number of children, the perforation can become long lasting (chronic) with fluid leaking from the ear. Sometimes an operation to repair the perforation may be necessary but usually not before the age of 8.

There are some very rare complications which can occur. See 'When should I seek help?' below.

When should I seek help?

The symptoms of ear infections also occur in other illnesses; for this reason, if you suspect your child has an ear infection, take them to your family doctor. Your doctor will examine your child to see if an ear infection (or another problem) is the cause of your child's symptoms.

Once an ear infection is diagnosed, your child should start to improve within 24 to 48 hours. If the symptoms are no better or are getting worse, or you are worried about your child, take them back to your family doctor.

You should always take your child to your family doctor to have their ears reviewed after any ear infection, to make sure the ear fluid has gone. This recheck usually happens around 4 to 6 weeks after the infection.

You should also take your child to your family doctor if:

• your child's ear starts to discharge
• your child has a fever which doesn't go away after 24 – 48 hours
• you are worried about the continuing unwellness of your child

You need to take your child to a doctor immediately if your child:

• has any swelling, redness or tenderness in or around the ear
• is feeding poorly
• has any change in consciousness
• has a stiff neck
• has sensitivity to light

If your child keeps getting frequent ear infections, they may need to see an ENT (ear, nose and throat) specialist to consider grommets (tympanostomy or ventilation tubes). See 'Grommets (tympanostomy or ventilation tubes)'.