What can parents do about middle ear infections?

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Children who have an acute middle ear infection (acute otitis media) usually have an earache and a fever. They sleep badly, are restless and cry a lot. What are the treatment options and when is it important to seek medical advice?

Middle ear infections usually clear up after a few days. Complications are very rare. The earache often already goes away again after one day. Until that happens, medication to relieve pain and reduce fever, such as ibuprofen and acetaminophen (paracetamol), can be used to relieve the symptoms. A lot of care and attention is also helpful, and some children feel that certain home remedies have a soothing effect too.

Antibiotics often do not work and can have side effects. So there's usually a good reason to wait two or three days at first, to see whether a middle ear infection clears up on its own. If the symptoms don't get better, the child can still take antibiotics then. Antibiotics also help in children who are leaking pus from their ear, and in children who are under two years old and have an infection in both ears.

If a child is unwell, it can be important to seek medical advice early on. The doctor can tell whether it's a middle ear infection and how severe it is. You can then discuss the most appropriate treatment approach together. If the symptoms don't get better despite treatment, or if the child has problems such as hearing loss, it's advisable to see the doctor again.

Pain relief and fever-reducing treatment

Fast pain relief is the focus of treatment. Children can be given acetaminophen (paracetamol) and ibuprofen. In Germany and other countries, these medications are available without a prescription. Both relieve pain and lower fever. They can be given as suppositories or syrup. Ibuprofen has an anti-inflammatory effect too.

The dosage of these medications depends on the child’s age and body weight. When using them, the minimum time interval between doses must be observed as well. You will find more information about how to use them and about their possible side effects in the package insert that comes with them. If you still have any questions, you can also ask your doctor or pharmacist.

Acetylsalicylic acid (ASA, the drug in “Aspirin”) should not be used in children and teenagers unless a doctor has prescribed it because it could lead to a rare, but dangerous, side effect called Reye’s syndrome.

Antibiotics

Antibiotics only slightly influence the course of middle ear infections, and they can have side effects. They do not help to relieve pain within the first 24 hours. The difference isn't noticeable until a little later: Research shows that about 15 out of 100 children are still in pain two to three days after taking antibiotics – in contrast to 22 out of 100 children who did not take antibiotics.

Antibiotics can also reduce the risk of the eardrum bursting. In studies, only 1 out of 100 children who took antibiotics had an eardrum burst – whereas this happened to 3 out of 100 children who did not take antibiotics. The hole in the eardrum is usually only small and heals on its own within a few days or weeks. It's more serious if the eardrum bursts several times or if the hole is large.

Antibiotics were considerably more effective in two groups of children:

  • Children under the age of two years with an infection in both ears
  • Children of all ages who have pus-containing discharge from their ear

Both are signs of a bacterial infection, which can be treated effectively with antibiotics. Antibiotics can relieve pain and reduce fever after three to seven days in about 25 to 35 out of 100 children in these groups.

Side effects of antibiotics

Antibiotics can cause side effects such as nausea, diarrhea and rashes. Around 5 out of 100 children who use antibiotics have one of these side effects. Using antibiotics too often also leads to the development and spread of bacteria that no longer react to antibiotics (“resistant” bacteria).

Watchful waiting treatment approach

Antibiotics work best in children who have symptoms that suggest their middle ear infection is caused by bacteria (see above). If a child doesn't have these symptoms, there are good reasons to not give them antibiotics right away, and instead only use them if the earache doesn't improve or even gets worse after two or three days. Sometimes doctors write a prescription for antibiotics after making the diagnosis, and ask the parents of the sick child to wait before picking the antibiotics up from a pharmacy. In the meantime, the child is given painkillers and, if necessary, something to reduce fever.

This “watchful waiting” approach avoids the possible side effects of antibiotics and doesn't have any long-term disadvantages. Studies have looked into whether this kind of approach leads to more complications or recurrences of middle ear infections. But this was not found to be the case.

If this approach is taken, it is important to carefully monitor the child’s symptoms and stay in contact with the doctor. That way you can react appropriately if the infection doesn't get better or if it gets worse.

Research summaries

Decongestant nose drops or nasal sprays

Nose drops and nasal sprays can reduce swelling in the mucous membranes. They are used to help open up the passages leading to the middle ear. But research has not shown that decongestants help make middle ear infections go away faster or relieve the symptoms.

Many children who have a middle ear infection also have a stuffy nose at the same time. Nasal sprays and nose drops can help unblock their nose for a few hours, making it easier for them to breathe. But decongestants should only be used for a few days, and only in the dose recommended for the child’s age. If they are used too long, too often or at too high a dose, they can permanently damage the lining of the nose. In Germany and other countries, decongestant nose drops and nasal sprays are available as over-the-counter drugs in pharmacies.

Ear drops

Earache can also be relieved with ear drops, which have a local effect. In Germany, these ear drops are usually made up of a combination of the drugs phenazone and procaine. There is no research on whether ear drops help in babies and children under the age of three. But they might relieve earache in children aged three and above.

Using ear drops can cause problems if the eardrum has burst. When in doubt, don't hesitate to ask a doctor.

Incision in the eardrum (paracentesis)

Sometimes a small cut (incision) is made in the eardrum to allow fluid to drain out of the tympanic cavity. But this minor procedure, called paracentesis, is used only if there are complications – for example, if the built-up fluid becomes very painful.

Home remedies and complementary medicine

Many parents also use home remedies or complementary medicine methods to treat middle ear infections. But the effectiveness of most of these treatments has either not been tested in scientific studies at all, or has not been confirmed by research.

Cooling wet towels are sometimes wrapped around the child's lower legs to reduce a fever. Some parents also place onion wraps on their child’s ear, or they warm the affected ear with infrared light. Although these home remedies have not been scientifically proven to work, some children find them soothing.

Other parents use homeopathic or herbal remedies. But here again, there is no proof that these kinds of remedies can help in children with acute middle ear infections.

Ear tubes

If a middle ear infection causes the mucous membranes to swell up and release fluid, the tympanic cavity fills up with the fluid. This is called otitis media with effusion or "glue ear." It usually goes away after a few days or weeks, but in some children it remains and causes hearing problems. This can slow the development of speech in small children.

When a child has persistent glue ear it's best to wait a few months to see if it clears up on its own. A doctor should check the child's ears regularly in the meantime. If the glue ear doesn't clear up, paracentesis may be considered. This small cut in the eardrum allows the fluid to drain, or it can be vacuumed up.

If fluid still keeps on building up in the child’s ear and he or she can't hear properly, ear tubes are often recommended. These are narrow tubes made out of plastic or metal, and they allow air to flow to and from the middle ear. Ear tubes can relieve glue ear quickly and improve hearing in the first few months, but there is no proof that they can provide long-term improvement and help to prevent problems with speech and language development.

Ear tubes can also be used in children who have middle ear infections very frequently. In these children, they can probably lower the risk of new infections.

Ear tubes are normally inserted while the child is under general anesthetic, and they usually fall out of the ear on their own after about six to twelve months. There usually aren't any complications during the procedure. Possible risks include infection or a tube slipping into the tympanic cavity. In rare cases hearing problems may develop after the procedure if the incision doesn't heal after the treatment or if there is scarring on the ear drum.

Research summaries