Fact sheet: Acute middle ear infections in babies and children

Sleepless nights are part of life for the parents of small children. Acute middle ear infections, causing a fever and earache, are often the reason for their lack of sleep. These infections can be very painful, and children who have an ear infection may cry a lot and have difficulties sleeping. This condition is particularly common in children between the ages of six months and three years. It normally develops as part of a cold. But an acute middle ear infection (acute otitis media, AOM) is usually not a serious illness and typically gets better on its own within two to three days. It is important, however, to keep an eye on how the illness is progressing, because treatment can sometimes be necessary.

Even though there normally is no reason to be very worried, acute middle ear infection can be bothersome for you and your child. This fact sheet describes the course of the infection, when treatment is needed, and what you can do to relieve your child’s symptoms. You will find more detailed information in our feature.

What does the ear look like?

To be able to understand how middle ear infections develop, it helps to see what the ear looks like. The middle ear, also called the tympanic cavity, lies directly behind the eardrum. The eardrum is a thin membrane which seals the middle ear so that air, water and dirt cannot get in. Incoming sound waves make the eardrum vibrate, and the vibrations are passed on from the air-filled middle ear to tiny ear bones (ossicles), and then to the inner ear. Here the sound waves are converted into signals which travel along nerves to the brain.

The Eustachian tube, also known as the auditory tube, connects the middle ear to the throat. It lets air into the middle ear and can drain fluid from the ear too. It opens briefly when we swallow or yawn. This is also where pressure equalization takes place, which is why your ears “pop” when the air pressure around you changes.

In young children the Eustachian tube is still very narrow and short, so it is easy for germs to spread from the nose and throat to the middle ear. 


 

How do acute middle ear infections develop?

When you have a cold, the mucous membranes in your nose and throat swell to fight off viruses and bacteria. The mucous membrane in the Eustachian tube may swell also, gradually blocking the passageway which is normally filled with air. This means that the fluid produced by the mucous membranes can no longer drain off. If this fluid also builds up in the middle ear, it stops the ear bones from moving the way that they normally do, and it presses on the eardrum. This condition is painful and affects hearing because the sound waves can no longer be passed on to the inner ear properly.

If the secretions that build up in the middle ear press too hard on the eardrum it can burst. If this happens, the thick fluid, often also mixed with pus and blood, flows out into the auditory (ear) canal and the pain quickly goes away. The tear in the eardrum is usually only small and heals on its own within a few days or weeks. A small amount of fluid may continue to drain out of the ear until it heals. The medical term for ear discharge that is caused by an infection is “otorrhea”.

What are the signs of an acute middle ear infection?

Generally speaking, acute middle ear infections develop as part of a cold, flu, sore throat or a similar infection. In many cases the child will have just recovered from a cold, or the cold might be getting better, when it suddenly gets worse again.

Common signs of an acute middle ear infection include very painful earache, a fever and hearing problems. Small children often cannot describe where their pain is coming from and may say they have a stomach ache although it is their ears that are hurting. Some children vomit, shake their heads a lot, hold their ears or rub them when they have earache. The infection can lead to reddening and swelling in the throat and ears, too. Sometimes children’s cheeks are also red and swollen. In about 8 out of 10 children (80%) the fever and pain go away after two to three days. It might take a bit longer for their hearing to return to normal.

A lot of parents feel very worried if their child falls ill and want to know what the cause is. If you go to the doctor with your child, the doctor will first ask you and your child (if possible) about acute symptoms as well as how the illness developed. This is followed by an examination of both ears, the neck and the throat. The ear examination involves taking a close look at the eardrum with a so-called otoscope. This is a device with a magnifying glass and a small lamp that makes it possible for the doctor to look into the auditory canal.

If the fever and pain get worse over time or do not go away after two to three days, it is important to take the child to a doctor to make sure no complications develop. Complications from middle ear infections are rare. But if he or she has symptoms like a headache with vomiting and nausea, a stiff neck and decreased consciousness, quick medical help is needed. Because these can be symptoms of a much more serious illness than middle ear infection.

If the infection and the tear in the eardrum have not got better after several weeks, it is considered to be a persistent middle ear infection. Although the pain and fever subside, fluid remains in the middle ear and regularly leaks out of the ear. Even if the infection clears up and the eardrum heals, fluid may stay in the tympanic cavity, a condition called tympanic effusion. These lasting effects may have an adverse impact on the child’s hearing, and on speech and language development as well. It is therefore important not to ignore a persistent middle ear infection.

How are acute middle ear infections treated?

An acute middle ear infection can be very painful. Fast pain relief is therefore the most important part of therapy. Many children with this illness can barely sleep at night, are very unsettled and cry a lot. Other children may be weak and quieter than usual. To ease the pain you can give your child appropriate pain relief medication. Fever develops when our bodies are trying to fight germs. But the fever can sometimes become a problem itself.

In Germany, the medications paracetamol (acetaminophen) and ibuprofen are available for treating pain and fever in children. They can be used in the form of suppositories or syrup. The dosage depends on the child’s weight and age. You will find more information about how to use this medication in the package insert that comes with it. If you are unsure about your child’s treatment, talk to the doctor or ask a pharmacist.

Antibiotics do not help much in most children. They only have a small impact on the length of the illness and symptoms such as pain. Antibiotics can have adverse effects too, so they should only be used after carefully considering whether it is really necessary. It seems to be a good idea to consider “watchful waiting”. In this approach, after diagnosing an acute middle ear infection, the doctor writes a prescription for antibiotics and asks the parents to only pick the antibiotics up from the pharmacy if their child’s symptoms get worse or have not gone away within two to three days. If this approach is taken, talk to your doctor about whether and/or when a check-up is needed. Doing things in this way may be a good option for parents who are unsure whether or not they should give their child antibiotics.

However, taking antibiotics immediately can speed up the recovery of two groups of children: those who are under two years old and have an infection in both ears, and those who are leaking pus from their ear. You can read more about antibiotics and middle ear infections here.

Decongestant nose drops are another commonly used treatment. The aim is to clear the Eustachian tube via the nose and throat, but they have not been scientifically proven to work. In order to protect the mucous membranes of the nose from becoming damaged, nose drops should only be used for a short amount of time.

Ear drops are used to relieve the pain caused by acute middle ear infections. In Germany, these ear drops are usually made up of a combination of the drugs phenazone and procaine. But it is not clear whether ear drops can relieve the pain associated with a middle ear infection. Moreover, they should only be used if the eardrum is not damaged.

Many parents also use traditional remedies such as cold leg compresses to reduce the fever and onion bags or infrared light to ease the pain. Others use homeopathic remedies. However, none of these treatments have been proven to be effective.

How can I protect my child from middle ear infections?

Particularly if your child keeps on getting middle ear infections, you might ask yourself if there is anything you can do to stop this from happening. Some possible risk factors for getting acute middle ear infections have been identified. Children whose parents smoke are at higher risk of both acute and persistent middle ear infections. This means that it is important to make sure that children grow up in as smoke-free an environment as possible. Passive smoke increases the general risk of infections of the airways, nose and throat. It also weakens the child’s immune system.

There is a theory that babies or toddlers who use a pacifier a lot are at higher risk of getting middle ear infections. One explanation for this is that sucking on a pacifier could change the pressure in the throat and ears. Infections can also be spread through the use of pacifiers. But this link between pacifiers and the spread of infections has not been confirmed.

Even if your child keeps on getting acute middle ear infections, it might help to know that there is no need to be overly concerned. Acute middle ear infections may be painful and lead to sleepless nights for both you and your child, but they usually go away on their own after a few days, without complications. You can read more about how you can protect your child from getting a cold or other infections here.


Author: Institute for Quality and Efficiency in Health Care (IQWiG)

© IQWiG (Institute for Quality and Efficiency in Health Care)