The Most Common Ear Infection In Kids

As a Pediatric ENT, the most common diagnosis that I see every day in clinic is that of recurrent or chronic ear infections. However, I find information on this topic, a general understanding of indications and how ear tubes work to be lacking. Parents and the public, as well as pediatricians and primary care physicians, still have some misconceptions about how and who ear tubes may help, and just as important, once a child has tubes, what an ear infection now looks like and how to best treat it.  

Even though there is a wealth of research and effort by specialists and pediatricians from the American Academy of Pediatrics focused on developing “Clinical Practice Guidelines” to try and standardize what is best for patients, busy doctors and families often do not know the latest or updated recommendations based on research data. Day in and day out I continue to focus on sharing updated information so that parents and caretakers understand how to take care of their child without the overuse of urgent care centers and emergency rooms, or subjecting children to unnecessary and prolonged use of oral antibiotics (which is not guaranteed to “clear” the ear infection). 

TERMINOLOGY AND DIAGNOSIS   

First, terminology and the correct diagnosis is important. There are 3 kinds of ear infections depending on where the problem is anatomically.  

1. Otitis externa affects the outer ear or ear canal, which is lined by skin.
2. Otitis media is an infection in the middle ear, where liquid, inflammation and pus form behind the ear drum. In healthy people there should be no fluid behind the ear drum, only air. 
3. Inner ear infections affect the hearing and balance organ (labyrinthitis). Inner ear infections are serious, but EXTREMELY rare. Symptoms are typically SEVERE imbalance, vomiting and/or sudden hearing loss.   

Otitis externa is what lay people call “Swimmer’s Ear.” Here is a great trick: you can tell if your child has a “middle” or “outer” ear infection by simply tugging or gently wiggling your child’s ear. If they scream angrily at you, then it is Swimmer’s Ear, which can be treated successfully and easily with antibiotic ear drops, with or without a steroid. Swimmer’s Ear DOES NOT need oral antibiotics! If treated early, you may even be able to avoid a visit to the doctor.  

The majority of ear infections children get are otitis media or middle ear infections. It is most common when they also have a cold, a fever, scream at night, experience poor sleep or a decreased appetite, and these symptoms are what drives parents to seek medical care. Based on research, a fever is the most sensitive indicator, not “ear pulling,” which is what most mothers tell me is the single symptom that convinces them their child has an ear infection. Your child may tug on their ear because having fluid behind the ear drum may not feel comfortable and often feels like something is stuck there! 

It’s also important to distinguish between “acute” versus “chronic” ear infections. Acute means the child has a middle ear infection and fluid (whatever type) while the child has a cold. Chronic means the fluid is not clearing even after the child has gotten over the acute illness. Did you know that majority of children will have fluid behind the ear drum for up to one month? Some may take 8 weeks or longer before all the fluid is gone! 

As a parent, what you need the healthcare professional to be clear with you about is whether, on the day of the visit, your child has fluid in the middle ear or not. If the doctor says there is fluid, then you must ask whether it is infected. If it’s infected and pus like, then that’s an acute otitis media. If it's not infected, then ENTs may call it serous or mucoid otitis media, describing the nature of the fluid. By definition, a child does not have an ear infection if there is no fluid behind the ear drum!  

While children with acute otitis media benefitted from oral antibiotics compared to a placebo, they also had twice as many side effects (especially diarrhea followed by a rash).¹ Research has shown that oral antibiotics will help to reduce fever and the duration of “ear infection” symptoms when compared to a control group (placebo). A dear colleague, Dr. Margaret Kenna, wrote a terrific summary: Acute Otitis Media—The Long and the Short of It.² Also, ear infections are NOT JUST bacterial! There is a virus involved, which antibiotics usually do not “kill.” I always explain to families that fluid behind the ear drum is a “plumbing” issue and taking antibiotics does not unclog the plumbing, only time and luck will. 

It’s always concerning when a mom comes in with an infant/toddler who was diagnosed with an ear infection in the last 24 hours somewhere else and was prescribed oral antibiotics, but when I look, his/her eardrum is perfect and there is not a drop of fluid indicating any inflammation or infection whatsoever! If there is truly an ear infection, then the fluid really does not magically clear up within 24 - 48 hours. It takes days, and antibiotics do not make the middle ear fluid “drain” or clear out faster.   

I always explain to families that once a child is prescribed an antibiotic, even though the child may finish taking 7 - 10 days of the medication, about 80% of children need up to 4 weeks for the middle ear fluid to completely go away, while another 10% may need up to 8 weeks to clear the fluid completely. So, unless someone who is very good at looking at ears is taking a look and documenting whether the fluid is gone and the eardrum is perfect again after treatment, it is very difficult to accurately count the number of ear infections.  

Once your child has ear tubes (which stay in between 12 - 24 months), then you should be able to tell if there is truly an “infection” because you would see pus or mucus/liquid, NOT WAX, come out of the ear canal. In this case, my partners and I teach our patient families with children we put tubes in to use antibiotic ear drops, and not to go to urgent care centers, emergency rooms or even a pediatrician if they can manage it themselves. Healthcare has become a giant business, and businesses thrive when there are customers. Our children and their health should not be the basis for profit and margin, and I firmly believe we want only the sickest to require hospital level care.  

HEALTHCARE CHALLENGES

There remain significant challenges in the healthcare system when it comes to pediatric healthcare delivery and access. First, both physicians and the public should prioritize and promote evidence-based medicine, meaning diagnosis and treatment plans must reflect more than someone’s opinion and how we were “trained” years ago. Second, there must be efforts for standardizing competency and training for healthcare professionals when it comes to how to accurately make the diagnosis of an ear infection. “Redness” does not mean there is an ear infection. One may be looking at the ear canal instead of the ear drum, which may appear “reddish.” Crying babies often have a “reddish” ear drum, but it doesn’t mean they have fluid or an infection.  

I am not trying to make this topic sound simple. In fact, it’s difficult for all involved. The number one professed concern by parents I meet is always about the “pain” their child may be having, followed by the number of times their doctor or others have prescribed antibiotics. Then there is missed school and work, and poor sleep, a change in appetite, and all else that worry parents when their child is sick. On the day a specialist like myself meets a patient, the ear may be normal or not, but even if it looks normal and a hearing test is normal, that doesn’t mean the child has not had repeated ear infections. Well intentioned doctors and nurse practitioners may or may not be able to provide you with clarity nor take time to explain. Physicians are NOT trained to explain all details, and given the immense work demands the practice of medicine has evolved to, we can’t even breathe or go to the bathroom, let alone have the luxury of time to go over all these details, but it DOESN’T MEAN WE SHOULDN’T STRIVE FOR THIS! There is so much research evidence and clinical practice guidelines but the information doesn’t make it to the frontline, so this is where you need to learn and help. Finally, by giving families information, we can empower everyone to minimize the over-utilization of our resources and reclaim health for your hopefully-not-but-likely-at-times misdiagnosed and overmedicated children.   

P.S. I have met many children who do not have “acute” ear infections but chronically have fluid, even mild hearing loss, because their head/nose/middle ears are NOT clear. These are often the children I have diagnosed with the “Milk and Cookie Disease.” They consume excessive juice, dairy and have bad eating habits, which lead to increased acid reflux. Learn more about the "Milk and Cookie Disease."