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Treating Ear Infections: Recommendations
Middle ear infection, also known as “acute otitis media,” is one of the most common childhood illnesses. In fact, most children get at least one in their first three years of life.

For a long time, the standard medical practice in the United States was to treat all ear infections with antibiotics. But recent research has shown that only some children have a bacterial ear infection that needs antibiotics, while most have a viral infection that will get better on its own without antibiotics. As a result, in May 2004, the American Academy of Pediatrics and American Academy of Family Physicians released new treatment guidelines.

To parents who are used to giving their children antibiotics for ear infections, the new guidelines may sound scary and confusing. But everyone should rest assured: They’re safe and healthy for children. Remember, giving antibiotics only when they are absolutely necessary helps prevent many children from experiencing antibiotics’ potential side effects, such as diarrhea, diaper rash, thrush and allergic reactions. It also helps reduce the development of antibiotic-resistant bacteria, preserving the ability of antibiotics to treat future infections.

The following is a summary of the guidelines. They cover children 2 months through 12 years of age with “uncomplicated” ear infections—in other words, an isolated episode of an ear infection in an otherwise healthy child.

Diagnosing an ear infection
When your child has symptoms that might indicate an ear infection—abrupt onset of an illness with ear pain (or pulling of the ear in an infant), irritability, fever or drainage of fluid from the ear—be sure to take your child to the doctor to make the diagnosis. Although these symptoms often indicate an ear infection, they could also be signs of a cold, sinus or throat infection, or even a more serious infection, such as meningitis. The doctor will do a complete exam and use an otoscope to examine your child’s ear and look for signs of fluid buildup and inflammation (bulging and redness) of the eardrum, which indicate a middle ear infection.

Treating an ear infection
The treatment of an ear infection involves two questions: Does your child have significant pain, requiring treatment to relieve the pain? Does your child need antibiotics to treat the infection?

Treating pain
If your child has significant pain, especially in the first 24 hours of the ear infection, the following treatments may be helpful:
  • Acetaminophen or ibuprofen (for children over 6 months of age): These can relieve pain and fever. Follow your doctor’s recommendations for the proper dose. Never give your child aspirin since it can cause a serious illness called Reye Syndrome.
  • Anesthetic ear drops (e.g., Auralgan, Americaine otic, or Otikon otic solution): Your doctor may prescribe eardrops to help numb the pain of the eardrum. Follow the directions on the package. Eardrops cannot be used if your child’s eardrum has burst or if your child has surgical tubes in his ears.
Treating the infection: Antibiotics or not?
The decision whether or not to give antibiotics to treat the infection is based on your child’s age, your doctor’s assessment of the severity of your child’s illness and the likelihood of a bacterial infection:
  • Under 6 months of age: Antibiotics should be prescribed because babies this young are at higher risk for a serious infection.
  • 6 to 24 months of age: Antibiotics should be given if the symptoms are severe (e.g., severe ear pain and fever of at least 39 degrees Celsius or 102.6 degrees Fahrenheit) or if the doctor strongly suspects a bacterial illness. If your child is only mildly ill, your doctor may recommend “observation,” which I explain below.
  • 2 years and older: Antibiotics should be given if your child has severe symptoms. If your child is only mildly ill, your doctor may recommend observation.
If your doctor recommends observation: It is safe to go without antibiotics and observe your child over several days (also known as “watchful waiting”) if your child is over 6 months of age and is not severely ill, and if you can keep a careful eye on your child, communicate easily with your doctor and get a follow-up appointment with the doctor and medication if necessary. Trust your doctor’s judgment and your own ability to care for your child.

If your doctor determines that antibiotics are necessary: She will select the appropriate antibiotic and provide a prescription for five to 10 days, depending on the antibiotic. If the ear infection is caused by a virus or by bacteria adequately treated by the antibiotic, you can expect your child feel to better—less fever and irritability, and improved eating and sleeping—within a few days. If your child is not better or is worse after 48 to 72 hours, be sure to contact your doctor. If your child hadn’t been given the antibiotic, the doctor will probably recommend starting one. If your child had been taking an antibiotic, the bacteria may be resistant, and the doctor may decide to change to a different antibiotic. If your child is severely ill, it is important to have the doctor re-examine your child to make sure there is not another cause of the illness.

What about alternative medicines? Some parents use homeopathy, acupuncture, herbal remedies, chiropractic, cranial-sacral treatment and nutritional supplements to treat ear infections. However, the medical guidelines state, “Although most treatments are harmless, some are not. Some treatments can have a direct and dangerous effect, whereas others may interfere with the effects of conventional treatments… To date there are no studies that conclusively show a beneficial effect of alternative therapies used for acute otitis media.” Further research is needed to evaluate the safety and effectiveness of alternative medical treatments. If you are using alternative medical treatments, be sure to discuss these with your doctor.

Preventing ear infections
There are some things you can do to help reduce your child’s chance of getting ear infections:
  • Breastfeed your baby. Try to breastfeed for at least a year, if possible. Breast milk contains antibodies that help protect your baby against many illnesses including ear infections, colds and diarrhea.
  • Feed your baby sitting upright. Don’t put your baby to sleep with a bottle because the milk can enter the Eustachian tubes leading from the throat to the middle ear, making ear infections more likely.
  • Reduce pacifier use from 6-12 months of age. Babies who use a pacifier are more likely to develop ear infections. This may be due to their exposure to germs on the pacifier, or the continual sucking motion, which can draw germs into their Eustachian tubes and middle ear.
  • Don’t smoke and don’t let anyone smoke around your baby. Exposing your baby to tobacco smoke increases her chance of getting ear infections, colds, bronchitis, pneumonia and asthma. If you smoke, get help to quit. Ask others not to smoke around your baby, in your home or in your car.
  • Make sure your baby gets his vaccines on time. Babies who receive the pneumococcal and influenza/flu vaccines have a reduced chance of ear infections.
  • Limit your baby’s exposure to germs.
  • Follow good hygiene and hand-washing practices. If your child gets frequent ear infections, consider looking for a child- care setting with fewer children and less exposure to germs.
Karen Sokal-Gutierrez M.D., M.P.H. Pediatrician