Ear Infections Otitis Media in Children

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ENT

Ear Infections (Otitis Media) in Children

WHAT ARE MIDDLE EAR INFECTIONS (OTITIS MEDIA) IN CHILDREN?

The Ear

The ear is the organ of hearing and balance and is organized into external, middle, and internal areas.

• The outer ear collects sound waves that are conducted through a canal to the tympanic membrane, commonly called the eardrum.
• The tympanic membrane is a tissue that is lined on the inside with mucus. Like a drum, it vibrates to the incoming sound waves, converting them into mechanical energy.
• This energy resonates through the middle ear, a complex structure filled with air and composed of tiny bones that vibrate to the rhythm of the eardrum and pass the sound waves on to the inner ear.
• The inner ear is filled with fluid. Here, hair-like structures stimulate nerves to convert the mechanical waves to electrochemical impulses that are carried by a network of nerve cells to the brain, which senses these impulses as sounds.
• The inner ear also contains three semi-circular canals that function as the body's gyroscope, regulating balance.
• The Eustachian tube, an important structure in the ear, runs from the middle ear to the passages behind the nose and the upper part of the throat. This tube ventilates the ear and equalizes the air pressure in the middle ear to the outside air pressure. Problems here are primary factors in most cases of ear infection.

Ear Infections (Otitis Media) in Children

Ear infections are often defined by whether they are acute (acute otitis media) or chronic (otitis media with effusion).

Acute Otitis Media (AOM). Acute otitis media (AOM) is an infection in the middle ear that causes an inflammation behind the tympanic membrane.

• Often it develops during or after a cold or a flu.
• Middle ear infections are extremely common in children but are infrequent in adults.
• In children, ear infections often recur, particularly if they first develop in early infancy.

Otitis Media with Effusion (OME) . Otitis media with effusion (OME) occurs when an effusion (fluid) builds up in one or both middle ears. When this is chronic and severe the fluid is very sticky and is commonly called "glue ear."

• It is not painful and the only clue that it is present is a feeling of stuffiness in the ears, which can feel like "being under water."
• Children who are susceptible to OME can have frequent episodes for more than half of their first three years of life.
• The episodes can last from weeks to months.

WHAT CAUSES MIDDLE EAR INFECTIONS IN CHILDREN?

Overview of the Process Leading to the Infection

Otitis media (middle ear infection) is most often the result of a combination of factors that increase susceptibility to infections by specific organisms in the middle ear. The infection typically evolves as follows:

• The primary setting for ear infections is in a child's Eustachian tube, which runs from the middle ear to the nose and upper throat. The Eustachian tubes in all children are shorter and smaller than in adults and therefore more vulnerable to obstruction.
• Changes in middle ear pressure occur in about two thirds of children with colds, which are typically the first stage in ear infections. Colds are caused by viruses, such as the rhinovirus. Viruses are increasingly viewed as important in many ear infections, although they usually only set the scene for a bacterial infection.
• Many bacteria normally thrive in the passages of the nose and throat. Most are benign and some can even block harmful bacteria from getting out of control. In addition, a defense system in the airways prevents the harmful bacteria from replicating and infecting deeper passages, such as those in the ear. Such defenses include a mucus layer that traps bacteria and cilia (hair-like structures) that move them out.
• When a cold occurs, the virus can cause the membranes along the walls of the inner passages to become inflamed, swell, and obstruct the airways. If this inflammation blocks the narrow Eustachian tube so that it cannot drain the middle ear properly, fluid builds up. The defense systems become inefficient, and the fluid becomes a reservoir and breeding ground for bacteria and subsequent infection.

Of note: respiratory viruses may also contribute directly to the infection. Allergens can also produce inflammation and blockage in the Eustachian tube, which creates an environment favorable to bacteria.

Infecting Agents and Triggers

Bacteria. Certain bacteria are the primary causes of acute otitis media (AOM) and are detected in about 60% of cases. The bacteria most commonly causing ear infections are:

• Streptococcus pneumoniae (also called S. pneumoniae or pneumococcus) is the most common bacterial cause of acute otitis media, causing about 40% to 80% of cases in the US.
• Haemophilus influenzae is the next most common culprit and is responsible for 20% to 30% of acute infections.
• Moraxella catarrhalis is also a common infectious agent, responsible for 10% to 20% of infections.
• Less common bacteria are Streptococcus pyogenes and Staphylococcus aureus.

Of note, about 15% of these bacteria are now believed to be resistant to the first-choice antibiotics.

Viruses. Rhinovirus, a cause of the common cold, is commonly the first player in the process leading to ear infection. It is not the direct infecting agent, however. However other viruses, such as respiratory syncytial virus (RSV -- a common virus in children responsible for respiratory infections) and influenza viruses ("Flu"), may be actual causes of some ear infections. Evidence is increasing that such viruses may play a greater role than previously believed for either predisposing or even causing ear infections. (Such evidence rests on the significantly lower rates of ear infections in children who have been vaccinated against influenza.)

Allergies. Allergies can cause inflammation in the airways, and contribute to ear infections.

Inborn Conditions that Predispose a Child to Middle Ear Infections

Genetic Factors. Several studies suggest that multiple genetic factors may play a role in making a child susceptible to otitis media.

• Genetic susceptibility to certain bacteria may result in development of persistent and recurrent otitis media.
• Abnormalities in genes that affect the defense systems (cilia and mucus production) and the anatomy of the skull and passages would also increase the risk for ear infections.
• Abnormalities in genes that regulate a powerful immune factor called interleukin 1 have been identified in some patients with recurrent otitis media who did not have any allergic disorders. Interleukin 1 plays a major role in producing inflammation in tissues and cells during heightened immune activity. Abnormalities in interleukin production may possibly result in a persistent inflammatory response.

Researchers are hoping that these findings may encourage primary care physicians to closely monitor children who are offspring or siblings of individuals with a history of unusually frequent or severe upper respiratory tract infections.

Medical or Physical Conditions that Affect the Middle Ear. Any medical or physical condition that reduces the ear's defense system can increase the risk for ear infections. Children with shorter-than-normal and relatively horizontal Eustachian tubes are at particular risk for both initial and recurrent infections. Other examples include inborn structural abnormalities, such as cleft palate, or genetic conditions, such as Kartagener's syndrome, in which the cilia (hair-like structures) in the ear are immobile and cause fluid build up.

Causes of Otitis Media with Effusion (OME)

Direct Causes of OME. In some cases, otitis media with effusion develops after an acute otitis media attack, although often the direct cause of OME is unknown. The role of allergies, bacteria, or other conditions may play some role in susceptible children, but their roles have not been clearly defined:

• Allergies. In one study, 89% of patients with OME also had allergic rhinitis (e.g., hay fever), suggesting a possible causal relationship in susceptible children. Some evidence suggests that allergies produce high levels of white blood cells called neutrophils in the ears of patients with OME.
• Bacteria. It is not clear what role bacteria or other infectious agents play. Standard tests do not detect bacteria in 40% to 60% of cultures taken from fluid in OME-affected ears. (In one study, a sophisticated test found genetic evidence of Haemophilus influenza bacteria in about a third of specimens in which no bacteria were detected by standard culture techniques.)
• Gastroesophageal Reflux Disorder. Gastroesophageal reflux disorder (GERD), in which acid backs up into the esophagus, is a common cause of heartburn in adults. In infants, GERD may occur when muscles in the upper part of the stomach are still immature and force acid and other compounds to back up. GERD has become associated with many upper airway problems, including ear infections and sinusitis, although some experts argue that GERD is normal in children and the association is unfounded.

Conditions that Make Children Susceptible to OME. Even when the conditions discussed above are present, however, most children do not develop OME. Susceptibility to OME is almost always due to an abnormal or malfunctioning Eustachian tube that causes a negative pressure in the middle ear, which, in turn, allows fluid to leak in through capillaries. Problems in the Eustachian tube can be due to viral infections, second-hand smoke, injury, birth defects, such as cleft palate, or genetic diseases that affect the defense systems, such as Kartagener's syndrome.

Causes of Increase in Incidence of Ear Infections and Other Airway Infections and Disorders

Increased diagnosis of other disorders and infections of the upper and lower airways, such as asthma, allergies, and sinusitis, have paralleled the rise in ear infections. For example, the same bacteria are often responsible for both ear infections and sinusitis. In one study, 38% of children with ear infections also had sinusitis, and other studies have reported that nearly half of children with OME have concurrent sinusitis. These studies may have overestimated the extent of clinically important sinus disease, but nonetheless, the association is significant but causal relationships are unclear. Researchers are looking for common risk factors:

• Increase in Day Care Center Attendance. Although ear infections themselves are not contagious, the respiratory infections that precipitate them can pose a risk for children with close and frequent exposure to other children. Some experts believe, then, that the increase in ear and other infections may be due to the higher attendance of very small children, including infants, in day care centers beginning in the 1970s. For children who had the condition for a long time, however, neither day care attendance nor any other risk factor, including a history of upper respiratory tract infections or family history of OME, appeared to be relevant. Attendance in day care centers, then, may explain part, but not all, of the current increase in ear infections and other upper airway disorders.
• Increase in Allergies. Some experts believe that the increase in allergies is also partially responsible for the higher number of ear infections, which is unlikely to be related to day care attendance. Studies indicate that 40% to 50% of children over three years old who have chronic otitis media also have allergic rhinitis (hay fever). Allergies are also associated with asthma and sinusitis.

The rise in the rate of otitis media, then, is probably due to a combination of factors that are also responsible for the increase in these other airway problems.

WHO GETS EAR INFECTIONS?

Acute ear infections account for 15 to 30 million visits to the doctor each year in the US. In fact, ear infections are the most common reason why an American child sees the doctor. Furthermore, the incidence of AOM has been rising over the past decades.

Gender and Age

Acute Otitis Media. About two thirds of children will have a least one attack of acute otitis media (AOM) by age three, and a third of these children will have at least three episodes. Boys are more apt to have infections than girls are.

It generally affects children between the ages of six and 18 months. The earlier a child has a first ear infection the more susceptible he or she is to recurrent episodes (i.e., three or more episodes within a six-month period).

As children grow, however, the structures in their ears enlarge and their immune systems become stronger. By 16 months the risk for recurrent infections is rapidly declining. After age five, most children have outgrown their susceptibility to any ear infections.

Otitis Media with Effusion. About 10% of children with AOM (who are usually between two and four years old) develop persistent otitis media with effusion (OME). (Because OME has fewer symptoms than acute otitis media, however, it is difficult to give an accurate estimate.)

Specific Risk Factors in Children

Ear infections are more likely to occur in the fall and winter. Some conditions, including the following, also put children at higher risk for ear infection:

• Allergies.
• Enrollment in day care.
• Exposure to second-had cigarette smoke.
• Being bottle-fed as infants.
• Having siblings with recurrent ear infections.
• Being in lower socioeconomic groups.
• Being Native American.
• Possibly having a higher number of cavities. (The study suggesting this was small. More research is needed.)
• Obesity. One 2001 study found a link between ear infections and childhood obesity. Eardrum abnormalities increased the more the child weighed, which might explain the association. The researchers also suggested that parents may be confusing their children's fussiness due to the ear infection with hunger and, therefore, overfeeding them.
• Certain medical disorders, including Down's syndrome, cleft palate, Kartagener's syndrome, and immunosuppressive disorders, such as HIV, increase the risk for ear infections.

Parental Behavior

The behavior of parents can increase a child's risk for otitis media.

• Parents who smoke pose a significant risk for both otitis media with effusion (OME) and recurrent acute otitis media (AOM) in their children. (Passive smoking does not appear to be a cause of initial ear infections, however.)
• Pregnant women who drink alcohol put their babies at risk for birth defects that can cause a number of problems, among them hearing loss and OME.
• Babies who are bottle-fed may have a higher risk for otitis media than do breastfed babies.
• Several studies have found that the use of pacifiers place children at even higher risk for ear infections. Sucking increases production of saliva, which is a vehicle for bacteria that can travel up the Eustachian tubes to the middle ear.

WHAT ARE THE SYMPTOMS OF EAR INFECTIONS IN CHILDREN?

Symptoms of Acute Otitis Media

Symptoms of acute otitis media usually develop suddenly and can include:

• Pain or discomfort in the ear. (It is difficult to determine if a preverbal child or infant has an ear infection. Some children may indicate pain if they have trouble swallowing food and rejecting it. Some parents believe that tugging on the ear indicates an infection, but this gesture is more likely to indicate pain from teething.)
• Coughing.
• Nasal congestion.
• Fever.
• Irritability.
• Loss of appetite.
• Vomiting.
• Pus in the ear may cause hearing loss in some children.
• If the ear infection is severe, the tympanic membrane may rupture causing the parent to notice pus draining from the ear. (This usually brings relief from pain.)

Fevers and colds often make children irritable and fussy, so it is difficult to determine if otitis media is present as well. In about a third of children with acute middle ear infection, symptoms are not apparent.

Symptoms of Otitis Media with Effusion

Otitis media with effusion (OME) often has no symptoms at all. Some hearing loss may occur, but it is often fluctuating and hard to detect even by observant parents. The only signal to a parent that the condition exists may be when a child complains of "plugged up" hearing. Other symptoms can include not responding to verbal commands, talking louder, and turning up the television or radio.

Older children with OME may have difficulty targeting specific sounds in a noisy room. (In such cases, some parents or teachers may attribute their behavior to lack of attention or even to an attention deficit disorder.) OME is often diagnosed, however, only during a regular pediatric visit.

HOW SERIOUS ARE EAR INFECTIONS IN CHILDREN?

Acute Otitis Media in Infancy

There has been some concern that ear infections in infants less than three months old may indicate more serious infections, such as meningitis. A reassuring 2002 study reported, however, that only 4% of infants with ear infections had any bacterial infections. Still, any indication of infection in a baby warrants prompt medical attention.

Hearing Loss and Its Consequences

Evidence strongly suggests that severe cases of recurrent acute otitis media and persistent otitis media with effusion (OME) impair hearing. The effect of long-term hearing problems may have the following effects:

• Learning Delays. Hearing loss in children slows down language development and reading skills. Children with even mild hearing loss may miss spoken words and have trouble making sense out of a conversation or a lesson in school. It is not clear, however, even after years of research, if OME and its attendant reduced hearing have any significant and long-term effects on learning. Some research suggests that these effects may last into the teens. Other studies, however, indicate that any effect on learning is temporary and that children catch up later on. And some evidence suggests that lower learning scores reported in children with OME may actually be due to the fact that such children tend to be in lower socioeconomic groups and so have less home attention.
• Behavioral and Social Problems. Children with impaired hearing may appear to be distracted, inattentive, and unintelligent. Some have even been inaccurately diagnosed as having attention deficit hyperactivity disorder. As with learning, however, studies have been mixed on the significance of long-term effects of OME on behavior. Considering the increased usage of medications for attention deficit disorder and the social burdens carried by children diagnosed with emotional and learning disabilities, more research is essential for clarifying this relationship.
• Speech Problems. A few small studies have found speech problems in some young children with OME.

Physical and Structural Injuries in the Face and Ears

Serious complications or permanent physical injuries from ear infections are very uncommon, but may include the following:

• In severe or recurrent otitis media, certain children may be at risk for structural damage in the ear.
• Cysts in the ear known as cholesteatomas are an uncommon complication of recurrent or severe ear infections.
• In rare cases, even after a mild infection, certain children, possibly because of immune abnormalities, develop calcification and hardening in the middle and, occasionally, in the inner ear.

Mastoiditis

Before the introduction of antibiotics, mastoiditis, an infection in the bones located in the skull, was a major and serious complication of otitis media. This condition is difficult to treat and requires intravenous antibiotics and drainage procedures. Surgery may be required. If pain and fever persist in spite of antibiotic treatment of otitis media, the physician should check for mastoiditis. Even without antibiotics this is a rare complication. At present, cases of mastoiditis are generally not associated with ear infections.

 

Other Possible Complications

Impaired Balance. Some studies have indicated that children with chronic OME have problems with motor development and balance.

Facial Paralysis. Very rarely, a child may develop facial paralysis, which is temporary and relieved by drainage surgery.

HOW ARE EAR INFECTIONS IN CHILDREN DIAGNOSED?

Medical History

The physician should be sure to ask the parent for a history of any recent cold, flu, or other respiratory infections. If the child complains of pain or has other symptoms of otitis media, such as redness and inflammation, the physician should be sure to rule out any other causes of such symptoms. They may include, but are not limited to the following:

• Otitis media with effusion. OME is commonly confused with acute otitis media. It must be ruled out because it does not respond to antibiotics.
• Dental problems (such as teething).
• Infection in the outer ear. Symptoms include pain, redness, itching, and discharge. Infection in the outer ear, however, can be confirmed by wiggling the ears, which will produce pain. (This movement will have no significant effect if the infection is in the middle ear.)
• Foreign objects in the ear. This can be dangerous and a physician should always check for this first when a small child indicates pain or problems in the ear.
• Viral infection can produce redness and inflammation. Such infections, however, are not treatable with antibiotics and resolve on their own.
• A parent's or child's attempts to remove earwax.
• Intense crying can cause redness and inflammation in the ear.

Physical Examination

Instruments Used for Examining the Ear. An ear examination should be part of any routine physical examination in children, particularly because the problem is so common and many children have no symptoms.

• The physician first removes any ear wax (called cerumen) in order to get a clear view of the middle ear.
• The physician employs a small flashlight-like instrument called an otoscope to view the ear directly. This is the most important diagnostic step. This instrument will reveal signs of acute otitis media, bulging eardrum, and blisters. The physician will also check color.

 

• To determine ear infection the physician should always use a pneumatic otoscope. This device detects any reduction in eardrum motion. It has a rubber bulb attachment that the physician presses to push air into the ear. Pressing the bulb and observing the action of the air against the eardrum allows the physician to gauge the eardrum's mobility.
• Some physicians may use tympanometry to evaluate the ear. In this case a small probe is held to the entrance of the ear canal and forms an airtight seal. While the air pressure is varied, a sound with a fixed tone is directed at the eardrum and its energy is measured. This device can detect fluid in the middle air and also obstruction in the Eustachian tube.
• A procedure similar to tympanometry, called reflectometry, also measures reflected sound to detect fluid and obstruction but does not require an airtight seal at the canal.

Neither tympanometry nor reflectometry are substitutes for the pneumatic otoscope, which allows a direct view of the middle ear

Findings Indicating Ear Infection. The physician will then assess the results of this examination to determine a diagnosis. There are two requirements for a diagnosis of ear infections: inflammation and fluid in the middle ear. Certain findings indicate the following:

• The eardrum is grayish-pink and translucent and there is no fluid. No infection is present.
• The eardrum is opaque and may be red, white, or yellowish. The child complains of pain. If is also less mobile than usual, acute otitis media is likely. If the eardrum is bulging, then bacterial infection is probably present.
• The eardrum is red and inflamed but no fluid is present. The cause is more likely to be irritation than a bacterial infection.
• The eardrum is clear and translucent but is not mobile and if fluid is present. It is not painful and the child has no other symptoms. Otitis media with effusion (OME) is likely to be present.

A scarred, thick, or opaque eardrum may make it difficult for the physician to distinguish between acute otitis media and OME.

Tympanocentesis

On rare occasions the physician may need to draw fluid from the ear using a needle for identifying specific bacteria, a procedure called tympanocentesis. This procedure can also relieve severe ear pain. This is most often performed by ear, nose, and throat (ENT) specialists, and usually only in severe or recurrent cases. In most cases, tympanocentesis is not necessary in order to obtain an accurate enough diagnosis for effective treatment.

Determining Hearing Problems

Hearing tests performed by an audiologist are usually recommended for children with persistent otitis media with effusion. A hearing loss below 20 decibels usually indicates problems.

Determining Impaired Hearing in Infants and Small Children. Unfortunately, it is very difficult to test children under two years old for hearing problems. One way to determine hearing problems in infants is to gauge the baby's language development:

• At four to six weeks most babies with normal hearing are making cooing sounds.
• By around five months the child should be laughing out loud and making one-syllable sounds with both a vowel and consonant.
• Between six and eight months, the infants should be able to make word-like sounds with more than one syllable.
• Usually starting around seven months the baby babbles (makes many word-like noises) and should be doing this by 10 months.
• Around 10 months, the baby is able to identify and use some term for the parent, dada, baba, or mama.
• The baby speaks his or her first word usually by the end of the first year.

If a child's progress is significantly delayed beyond these times, a parent should suspect possible hearing problems.

Determining Impaired Hearing in Older Children. Hearing loss in older children may be detected by the following behaviors:

• They may not respond to speech spoken beyond three feet away.
• They may have difficulty following directions.
• Their vocabulary may be limited.
• They may have social and behavioral problems.

WHAT ARE THE MEASURES FOR PREVENTING EAR INFECTIONS?

Avoiding Pacifier Use

There is some evidence to suggest that use of pacifiers may increase risk of otitis media in children under three years old. Nevertheless, some physicians believe any association is exaggerated and that the comfort a child derives from sucking (either thumb, breast, or pacifier) is more important than any presumed increase risk for ear infection.

Breastfeeding

Breastfeeding offers protection against many early infections, including ear infections. For one, the mother's milk provides immune factors that help protect the child from infections. Also, to be breastfed, infants are held in a position that allows the Eustachian tubes to function well. If possible, new mothers should breastfeed their infants for at least six months. For bottle-fed babies, to improve protection mothers should not lay babies down with their bottle; they should hold the infants in the same way they would to breastfeed them.

Preventing Colds and Flus

The best way to prevent ear infections is to prevent colds and flus in the first place.

Good Hygiene. Colds and flus are spread primarily when an infected person coughs or sneezes near someone else. A very common method for transmitting a cold is by shaking hands. Everyone should always wash his or her hands before eating and after going outside. Ordinary soap is sufficient. Waterless hand cleaners that contain an alcohol-based gel are also effective for every day use and may even kill cold viruses. (They are less effective, however, if extreme hygiene is required. In such cases, alcohol-based rinses are needed.) Antibacterial soaps add little protection, particularly against viruses. In fact, one study suggests that common liquid dish washing soaps are up to 100 times more effective than antibacterial soaps in killing respiratory syncytial virus (RSV), which is known to cause pneumonia and has been associated with ear infections. Wiping surfaces with a solution that contains one part bleach to 10 parts water is very effective in killing viruses.

Reducing Stress. Interestingly, giving children affection and helping them relax could help prevent colds. More than one study has reported that people with low stress who also have an active social life have fewer colds than people who have high stress levels or those who have low stress and few social connections.

[For more information see Well-Connected Report #94, Colds and Influenza (the Flu).]

Dietary Factors and Supplements

Healthy Diet. Daily diets should include foods such as fresh, dark-colored fruits and vegetables, which are rich in antioxidants and other important food chemicals that help boost the immune system.

Foods Containing Lactobaccilli (Good Bacteria). Researchers are also studying the possible protective value of certain strains of lactobacilli, bacteria found in the intestines. Some of these strains, particularly acidophilus, are used to make yogurt. According to one Finnish study, children attending day care who ate milk containing the strain lactobacilli GG could reduce respiratory infections in these children by 10% to 20%. More research is warranted. (The strain used was not the kind found in most commercial yogurt products,)

Xylitol. Xylitol, a sugar alcohol produced naturally in birch, strawberries, and raspberries, has properties that fight Streptococcal pneumonia bacteria. Studies are reporting that children who chew gum or swallow a syrup containing xylitol experience significantly fewer ear infections. It also reduces cavities. Chewing gum (Clen Dent) may be more effective than the syrup. Although in one study, xylitol did not reduce bacteria in the nose and throat, it did prevent ear infection. (It does not appear to prevent ear infections in children who are having colds or flus.) Some health providers report that even children one and a half years old can learn to chew and not swallow gum. Studies have not been clinically tested children between six and 18 months, the highest-risk age group for otitis media. This is an area for further research. The gum is not widely available in the US although it can be purchased on the Internet (http://www.xylitolworks.com/) .

Avoiding Exposure to Cigarette Smoke

Parents or others should not smoke around children. Several studies have found that children who live with smokers have a significant risk for ear infections. One study even suggested that the more the mother smoked the higher the risk.

Preventing Viral Influenza

Preventing influenza (the "flu') may prove to be a more important protective measure against ear infections than preventing bacterial infections. For example, studies report that children who were vaccinated against influenza experienced 33% to 36% fewer ear infections during flu season than unvaccinated children. (The vaccine provided no additional protection at other times.)

Viral Influenza (Flu) Vaccines. Vaccines against influenza (the "flu') currently employ inactivated (not live) viruses to produce an immune response that will then attack the active virus. Vaccines are now given by injection in the fall, usually between October and December. Antibodies to the influenza virus usually develop within two weeks of vaccination, and immunity peaks within four to six weeks, then gradually wanes. A live but weakened intranasal vaccine (FluMist) is proving to be effective and safe in children and is awaiting approval by the FDA at the time of this report.

In general, experts recommend that the flu vaccine be given to all children over six months with a condition that requires regular medical care. Children who are susceptible to recurrent ear infections should probably be given vaccinations against influenza viruses. In fact, in 2003 the American Academy of Pediatrics (AAP) and the CDC encourages vaccination in all children, including healthy children, between six months and two years of age. This recommendation may vary from year to year depending on the supply of the vaccine.

Possible negative side effects include the following:

• Allergic Reaction. Newer vaccines contain very little egg protein, but an allergic reaction still may occur in people with strong allergies to eggs.
• Soreness at the Injection Site. Up to two thirds of people who receive the influenza vaccine develop redness or soreness at the injection site for one or two days afterward.
• Flu-like Symptoms. Other side effects include mild fatigue and muscle aches and pains. They tend to occur between six and 12 hours after the vaccination and last up to two days. These symptoms are not influenza itself but an immune response to the virus proteins in the vaccine. Anyone with a fever, however, should not be vaccinated until the ailment has subsided.

Antiviral Drugs. Antiviral agents have now been developed to treat influenza. One such drug, oseltamivir (Tamiflu), is approved for use in children age one and older. Studies report significant reduction in symptoms and in the incidence of ear infections with this agent. In another study, when the antiviral drug, zanamivir (Relenza), was administered in the nasal passages of adults with influenza, middle ear abnormalities were reduced from 73% to 32%. This drug is available for children greater than seven years old for treatment of influenza, but no research has determined it value for preventing or treating otitis media in children.

Preventing Bacterial Infections

Preventive Antibiotics. Antibiotics have been used to prevent bacterial infections in children with recurrent ear infections (four or more episodes a year). Studies suggest, however, that overall they only prevent one episode a year, and are not generally recommended for prevention, except for specific situations.

Pneumococcal Vaccine. The pneumococcal vaccine protects (Prevnar or PCV7) against S. pneumoniae (also called pneumococcal) bacteria, the most common cause of middle ear infections and other respiratory infections. It has now been added to the Recommended Childhood Immunization Schedule and is also specifically approved for preventing otitis media. An important 2003 study indicated that these vaccinations could result in 1.7 million fewer office visits among four million children, 24% fewer procedures for tube implants, and significantly fewer antibiotic prescriptions.

The recommended schedule of immunization is four doses, given at two, four, six, and 12 to 15 months of age. Infants starting immunization between seven and 11 months should have three doses. (Parents should be sure their infants receive their second and third doses by six months in order to achieve on-going protection from ear infections.) Children starting their vaccinations between 12 and 23 months only need two doses. And those who are over two years old need only one dose.

Experimental Agents

Researchers have observed that the noses and throats of children who are prone to ear infections harbor smaller numbers of the "friendly" bacteria, notably alpha-streptococci. These bacteria, normally found in the upper airways, compete for space with harmful bacteria. They therefore help prevent overproduction of the harmful bacteria. Interesting research is underway using a nasal spray containing alpha-streptococci. In early studies, the nasal spray has helped to protect against recurrent otitis media in susceptible children.

WHAT ARE THE GENERAL GUIDELINES FOR TREATING EAR INFECTIONS?

Overview

Although ear infections in children are extremely common, the research on this condition is oddly unclear. Experts continue to argue about the best approach for treating ear infections. The major debates rest on the use of antibiotics, surgery, and watchful waiting in both acute otitis media and OME. Treatments for ear infections cost the country between three and four billion dollars each year, and many of these treatments, particularly heavy antibiotic use and surgical procedures, are often unnecessary in many children.

Treatment Guidelines for a Single-Episode of Acute Otitis Media

Antibiotics have been the mainstay treatments of acute otitis media. Major studies indicate, however, that between 80% and 90% of all children with uncomplicated ear infections ear recover within a week without antibiotics. (About 70% of even severe cases have been cured without antibiotics.) Antibiotics do reduce symptoms more quickly, but only after a day, at which time the pain is less in all children. In one study, compared to a group given no antibiotics, the treated children experienced only 13% fewer persistent symptoms at day four and fever was only reduced by a day. In terms of residual fluid, there was little difference at one month and no difference at three months. [For warnings on overuse of antibiotics see What Are the Antibiotic Choices for Treating Otitis Media?]

Unfortunately, there are no objective tests available to determine specifically the small percentage of children with AOM that would actually benefit from antibiotics. An approach used in the Netherlands has helped to produce a S. pneumoniae resistance rate to penicillin of only 1%. An example of this method involves the following steps:

• Children with bulging eardrum and evidence of pus or other indications of a severe condition (i.e., high temperature and vomiting) should be immediately treated with antibiotics.
• Other children are monitored for two to three days (depending on the age of the child). They are given full doses of acetaminophen (Tylenol) to relieve pain and reduce fever.
• For children under two, if there is no improvement within one or two days, antibiotics are started.
• For children two and over, antibiotics are started if there is no improvement after three days.

With this approach, only about 30% of children with ear infections require antibiotics (a far lower rate than is common in the United States). It would also incur savings of about $185 million dollars a year. Until recently, most US physicians and parents are very reluctant to abandon the standard use of antibiotics. The greatest concern in not using antibiotics is a risk for mastoiditis--a serious infection. However, evidence suggests that the risk for untreated children is only an additional two cases each year for every 100,000 children. Fortunately, encouraging 2002 studies have reported a significant decline in antibiotic prescriptions over the past few years.

The bottom line is that parents should question their physician closely if they recommend antibiotics and feel comfortable waiting to see if they are truly necessary. They should not pressure a physician into prescribing an antibiotic if it is clearly inappropriate. The physician very often will give in.

[For specific information on antibiotics, see What Are the Antibiotic Choices for Treating Otitis Media? below.]

Guidelines for Managing Persistent or Recurrent Acute Otitis Media

Persistent or recurrent acute otitis media is determined under the following circumstances:

• If the child has had three or more separate ear infections every six months.
• If the child has had four or more ear infections within a year.

In children with this condition, the following treatment options are available:

• Watchful waiting. This is especially appropriate for children with a history of ear infections that resolve without antibiotics.
• Second-line and other powerful antibiotics. Powerful antibiotics are used to treat severe infections and are stopped when they clears. (Less potent antibiotics have also been used an on-going basis for prevention recurring infection, but they offer little benefits and almost all physicians are moving away from this practice because of concerns about resistance.) [For specific antibiotics in these cases, see What Are the Antibiotic Choices for Treating Otitis Media?]
• Tympanostomy. This is a surgical procedure that implants tubes to drain fluid and prevent build-up and infection. [ See What Are the Surgical Procedures for Ear Infections?]

Treatment Guidelines for Otitis Media with Effusion (OME)

Watchful Waiting. The child is typically monitored for the first three months. Antibiotics are not helpful for most patients with OME. For one, the condition resolves without treatment in nearly all children, especially those whose OME followed an acute ear infection.

The Role of Antibiotics. Antibiotics tend to be used only if the condition persists after three months or one or both of the following has occurred within the three months period:

• The child is suffering.
• Hearing loss occurs. (A hearing test should be conducted if the condition persists for over three months, in any case, whether antibiotics have been given or not.)

In cases when they are prescribed for OME, antibiotics are typically given for 14 days. [ See What Are the Antibiotic Choices for Treating Otitis Media?]

Treatment Failure at Six Weeks. If OME persists for six weeks in spite of antibiotic therapies, the following two options are generally considered:

• Antibiotics are continued and stopped when the condition has cleared, usually in 14 days. (Although some physicians continue to prescribe antibiotics even after the condition has cleared to prevent recurrence, this practice is generally not recommended. First, extended treatment does not appear to add any benefits, and second, it increases the risk for emerging bacteria strains resistant to antibiotics.)
• Surgery (tube insertion) is usually recommended if OME is still present for more than three months, there is evidence of hearing loss of over 20 decibels, and the child has been effectively treated with antibiotics. As with antibiotics, however, some experts believe surgery, too, is overused for otitis media. [ See What Are the Surgical Procedures for Ear Infections?]

Inappropriate Treatments. The following treatments are not recommended for otitis media with effusion:

• Corticosteroids (Steroids). Corticosteroids reduce inflammation and have been investigated for OME. When used in combination with antibiotics, they clear OME more rapidly than antibiotics alone, but two weeks after treatment there are no differences. Steroids are, therefore, not recommended.
• Antihistamines, Decongestants, or Both. These agents are not effective for OME, either used alone or in combination. Antihistamines are useful for controlling seasonal allergies, which might contribute to ear infections, but it is not clear if they have any effect on OME.
• Adenoidectomy or Tonsillectomy. These are invasive surgeries that are not recommended to treat OME. They may be used in combination with ear tube insertion for children who have accompanying complications in the adenoids or tonsils.

Investigative Treatments for OME. Preliminary research suggests that glutathione, an antioxidant, may be an effective treatment for OME. More research is needed.

WHAT ARE THE HOME REMEDIES USED FOR EAR INFECTIONS IN CHILDREN?

Watchful Waiting

Careful monitoring of the child's condition (watchful waiting) along with home remedies and common over the counter cold medicines may be a viable alternative to antibiotic treatment for many children with a first episode of acute otitis media.

• In one 2000 study, 240 children under age two who were diagnosed with acute otitis media were treated with watchful waiting. After four days, only 3% of the children required treatment with antibiotics, while the infection cleared in the other 97%.
• Children, however, must be monitored carefully.
• High fever, severe pain, or other signs of complications should warrant immediate attention by a medical professional.
• Parents of infants should contact their doctor immediately if they have any fever, regardless other symptoms.

Natural Remedies for Ear Aches

Before antibiotics, parents used home remedies to treat the pain of ear infections. Now, with current concern over antibiotic overuse, many of these remedies are back in favor.

• Depending on regional cultures, parents may have pressed a warm water bottle or warm bag of salt against the ear. Such old-fashioned remedies may still help to ease ear pain.
• Drops of tea tree oil may be beneficial. This herbal treatment has mild anti-bacterial properties, but it may irritate the skin.
• Studies have reported that Otikon, an extract made of various plants, including garlic and St. John's Wort, is an effective anesthetic in treating the pain associated with ear infections. Plants contained in Otikon may have side effects.

Herbal remedies are not standardized or regulated, and their quality and safety are largely unknown. Parents should never give their child herbal remedies, including oral remedies, without approval from a physician.

Valsalva's Maneuver. A simple technique called the Valsalva's maneuver is useful in opening the Eustachian tubes and providing occasional relief from the chronic stuffy feeling accompanying otitis media with effusion. It may also be useful for unplugging ears during air travel descent as well. It works as follows:

• The child takes a deep breath and closes the mouth.
• He or she then blows the nose gently while, at the same time, pinching it firmly shut.
• The parent should be sure to instruct the child not to blow too hard or the eardrum could be harmed.

This technique should not be used if an infection is present.

Pain-Relievers

A number of pain relievers are available to help relieve symptoms.

• Either acetaminophen (e.g., Tylenol) or ibuprofen (e.g., Advil) is the pain-reliever of choice in children.
• Older children may be able to take prescription pain relievers that contain codeine if the pain is severe.
• Eardrops containing anesthetics (Auralgan) are also available by prescription. In one study Auralgan provides effective short-acting pain relief and helps children endure ear discomfort until an oral pain reliever takes effect. In one study, 89% of children who took eardrops were able to avoid antibiotics. Parents should check with a physician before using them. Eardrops could cause damage in children who have a ruptured eardrum. This might be indicated by fluid drainage from the ear canal.

Note: Aspirin and aspirin-containing products are not recommended for children or adolescents. Reports of Reye's Syndrome, a very serious condition, have been associated with aspirin use in children who have chicken pox or flu.

Cold and Allergy Remedies

Many non-prescription products are available that combine antihistamines, decongestants, and other ingredients, and some are advertised as cold remedies for children. Researchers have found little or no benefits for acute otitis media or for otitis media with effusion using decongestants (either oral or nasal sprays or drops), antihistamines, or combination product.

Precautions when Swimming Swimming can pose specific risks for children with current ear infections or previous surgery. Water pollutants or chemicals may exacerbate the infection, and underwater swimming causes pressure changes that can cause pain. The following precautions should be taken: Children with ruptured acute otitis media (drainage from ear canal) should not go swimming until their infections are completely cured. Children with AOM that is not ruptured should not dive or swim underwater. Children with implanted ear tubes should use earplugs or cotton balls coated in petroleum jelly when swimming to prevent infection.

WHAT ARE THE ANTIBIOTIC CHOICES FOR TREATING OTITIS MEDIA?

Overview on Antibiotics and Their Overuse for Otitis Media

Antibiotics have been the mainstay treatments of acute otitis media. Until recently nearly every American child who visits a doctor with an ear infection receives antibiotics. In one region of the US more than 70% of children received antibiotics before they were seven months old, and the most common reason for these medications was otitis media.

Major studies indicate, however, that in most cases of acute otitis media antibiotics are unnecessary. Between 80% and 90% of all children with uncomplicated ear infections ear recover within a week without antibiotics. (About 70% of even severe cases have been cured without antibiotics.) Antibiotics are rarely needed for otitis media with effusion.

The intense and widespread use of antibiotics is leading to a serious global problem--which is bacterial resistance to common antibiotics. For example, according to reports in 2002 and 2001, in Canada 15% of S. pneumoniae strains are resistant to penicillin, in the US between 30% and 40% are resistant, and in Hong Kong between 70% and 80% of strains no longer respond to penicillin. Furthermore, in the US about 23% of S. pneumoniae are currently resistant to at least three antibiotics. High rates of resistance strains are even being observed in infants. In general, regions and institutions with the highest rate of resistance are those in which antibiotics are heavily prescribed.

According to one study, children at highest risk for both ear infections and harboring bacterial strains resistant to antibiotics are boys who attend day care, who are exposed to cigarette smoke, who were bottle-fed, and who have siblings with recurrent ear infections.

Encouraging studies are now reporting that inappropriate antibiotic prescriptions are on the decline. In one study, there was a 47% reduction in prescriptions for otitis media since 1989. (Prescriptions for other common respiratory infections also decreased--by 47% for sore throat, by 61% for acute bronchitis, and 45% for colds and flus. Rates for sinusitis were unchanged.)

Antibiotic Regimens for Single-Episodes of AOM

When antibiotics are needed, a number of different classes are available for treating acute ear infections. Amoxicillin is a penicillin antibiotic and the drug of first choice. Other antibiotics are available for children who are allergic to penicillin or who do not respond within three to five days.

Duration. If a child needs antibiotics for acute otitis media, the following are some recommendations for duration of regimens.

• Five days of antibiotic therapy appears to be sufficient for most children with uncomplicated AOM. Such children are typically those over two years old, those who start to improve within 72 hours, and those who have no risk factors for complications.
• A full ten to fourteen day course of antibiotics (usually amoxicillin) is typically used for younger children and for those with complications such as a perforated ear drum, facial abnormalities, or impaired immune systems.

Parents should be sure their child completes the drug regimen. Not completing it is a major factor in the growth of bacterial strains that are resistant to antibiotics.

What to Expect. Earaches usually resolve within eight to 24 hours after taking an antibiotic, although about 10% of children who are treated do not respond. Failure may be due to the following or other causes:

• In many cases in which the response to an antibiotic is incomplete, a virus is often present.
• In other cases, the bacteria causing ear infection may be resistant to the antibiotic and a different antibiotic may be needed.

Note: In some children whose treatment is successful, fluid will still remain in the middle ear for weeks or months, even after the infection has resolved. During that period, children may have some hearing problems, but eventually the fluid almost always drains away. Antibiotics should not be used to treat residual fluid.

Follow-Up. Follow-up may involve the following steps:

• If the infection clears up with a single regimen in children less than 15 months old or in children with risk factors for reinfection, an examination should be scheduled two to three weeks after therapy.
• If the infection clears up with a single regimen in older children with no specific risk factors, they should be reexamined three to six weeks after treatment.
• If signs of infection are still present (e.g., pus is still present in the ear) within 48 hours of taking the last antibiotic dose, the child should be re-examined. (Parents are excellent judges of whether their child's condition has cleared up.)

In cases where complications are suspected, consultation with an ear, nose, and throat specialist (called an otolaryngologist) should be strongly considered. This specialist may perform a tympanocentesis or myringotomy, procedures in which fluid is drawn from the ear and examined for specific organisms. But this is reserved for severe cases.

Specific Antibiotics Used for Acute Otitis Media (AOM)

While many different antibiotics may be used to effectively treat otitis media, the physician needs to balance effectiveness, safety, and convenience, as well as try to minimize the emergence of bacterial resistant to antibiotics. The prevalence of such antibiotic-resistant bacteria has dramatically increased worldwide, but regions vary widely. To this end, the Centers for Disease Control and Prevention (CDC) has made very clear recommendations about first and second line treatments for otitis media.

First Line of Antibiotics for AOM. The following are the standard antibiotics used for an initial infection.

• Amoxicillin (Amoxil, Polymox, Trimox, Wymox, or any generic formulation) is the most widely prescribed oral antibiotic for acute otitis media. This is a penicillin antibiotic and is both inexpensive and highly effective against the S. pneumoniae bacteria. Unfortunately, bacterial resistance to amoxicillin has increased significantly, so the CDC has advised doubling the standard dose. Amoxicillin is also not as effective against H. influenzae. In areas where bacterial-resistance to antibiotics is high, some physicians recommend high-dose amoxicillin.
• Ofloxacin (Floxin) is an antibiotic known as a fluoroquinolone (also simply called quinolone). It is available in eardrops and is now recommended as first-line therapy for children with AOM who also have perforated eardrums or infection after implanted tympanostomy tubes. Ofloxacin is proving to be very effective and safe for these children. (Drops are effective only in these cases.) Another quinolone, ciprofloxacin, is also available in eardrop form outside the US.

Second-Line Antibiotics for AOM. Second-line antibiotics are used under the following circumstances:

• If the condition persists after using first-line agents.
• If the ear infection is recurrent.
• If the patient has had other antibiotics within the past month.

Second-line antibiotics include the following:

• Amoxicillin/clavulanate combination (Augmentin). This agent is known as an augmented penicillin, and it works against a wide spectrum of bacteria. A new extra-strength formulation (Augmentin ES-600) has been approved. It is proving to be highly beneficial for recurrent or persistent AOM. It is effective against some amoxicillin- and penicillin-resistant bacteria. It also works well against other common bacteria that cause AOM, notably H. influenza and M. catarrhalis, including resistant strains.
• Cephalosporins. Cephalosporins belong to the same class as penicillins (those called beta lactam antibiotics). Certain second- or third-generation oral cephalosporin antibiotics may be good second-line options. Of these cefuroxime (Ceftin) and cefpodoxime (Vantin) have the best record to date among the cephalosporins for coverage against bacteria that infect the upper respiratory tract. (Their safety and effectiveness in infants under six months old are not proven.) Ceftriaxone (Rocephin), an injectable cephalosporin, is also an option. Administering it in a single injection may be sufficient for some children, although a 2001 study reported that a three-day regimen was more effective for children with non-responsive otitis media. A person who is allergic to penicillin has a 5% to 14% chance of being allergic to a cephalosporin.

Antibiotics for Other Circumstances. More powerful and expensive antibiotics are available for children under other circumstances, including the following:

• For children who are allergic to penicillin, cephalosporins, of both.
• For children with persistent or recurrent episodes of acute otitis media who do not respond to first- or second line agent (and who then probably have bacterial strains resistant to those antibiotics).

These antibiotics are usually very expensive, however, and are not commonly used. They include the following:

• Macrolides include erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), and roxithromycin (Rulid). Azithromycin is generally equivalent to Augmentin in effectiveness and needs to be taken for only five days. In fact, both a one-dose and three-dose regimen of Zithromax is approved for treatment of AOM. These antibiotics are effective against S. pneumoniae and M catarrhalis, but macrolide-resistance rates doubled between 1995 and 1999 as more and more children were being treated with these antibiotics. They are not effective against H. influenzae.
• Trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra) or a combination of erythromycin and sulfisoxazole (Eryzole, Pediazole) are useful for people allergic to penicillin. It should not be used in patients whose infections occurred after dental work or in patients allergic to sulfa drugs. Allergic reactions can be very serious. Bacterial resistance to these agents has increased dramatically, however, and failure rates are high in certain regions. An oral solution (Primsol) uses trimethoprim alone. It poses less risk for an allergic reaction than the combination and yet is still effective.
• Clindamycin (Cleocin). This antibiotic is known as a lincosamide and is useful against many S. pneumoniae bacteria but not against H. influenzae.

Side Effects of Antibiotics

• The most common side effects of nearly all antibiotics are gastrointestinal problems, including cramps, nausea, vomiting, and diarrhea. This can be a significant problem in infants and small children. One study reported that giving such children a soy-based formula that contained fiber (Isomil DF) was helpful in reducing these side effects.
• Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening anaphylactic shock.
• Some drugs, including certain over-the-counter medications, interact with antibiotics; patients should report to the physician all medications they are taking.

WHAT ARE THE SURGICAL PROCEDURES FOR EAR INFECTIONS?

General Guidelines for Surgery

Surgery to drain the ear drum ( myringotomy) with or without implanted ventilation tubes to drain the fluid ( tympanostomy) is the basic surgical procedure for otitis media. It is the second most frequently performed procedure for children under two (circumcision is first).

Surgery is usually recommend for the following:

• Children with persistent otitis media with effusion (OME) for more than three months and hearing loss in spite of aggressive antibiotic treatment.
• Children with more than four episodes of acute otitis media per year. (Evidence suggests that tubes are helpful only for recurrent AOM with bulging eardrums. It did not appear to prevent recurrence in children without bulging eardrums.)

Hearing is almost always restored following tympanostomy.

Debate on its Widespread Use. There is still some debate, however about the wide-spread use of surgery for ear infections. In 1996 tubes were placed in the ears of an estimated 280,000 children younger than three years of age underwent the operation.

• Arguments Against its Use. A number of studies have suggested, however, that the procedures in children who are between one and two years old make no difference in language development--one of the primary reasons for the procedure--by the time the child reaches three. The procedure, although extremely safe, is not risk-free.
• Arguments for Its Use. Still, a number of studies on this patient population report immediate improvement in ear problems and in the quality of both the child's life and that of the parents. In one study, for example, 84% of parents said they would make the same decision. (Some experts, in fact, prefer surgery over antibiotics initially for children with persistent OME and hearing loss because of the risk for drug-resistant strains of bacteria with antibiotic overuse.)

With inc