By Pierrette Mimi Poinsett MD

Upper respiratory infections (colds) and ear infections are the most frequent reason for medical visits in childhood. In the US, up to 75% of all children have at least one infection by age 2. Although ear infections are a common in childhood, there are some children who experience complications with their ear infections including hearing impairment and hearing loss. The other concern is that with hearing impairment, speech and language delays may also occur.

An ear infection (otitis media) is not contagious. However the upper respiratory infection that precedes an ear infection is. Most ear infection happen with or after a cold. What makes them different from a cold is fever, ear pain and discomfort. A child with an ear infection is more likely to have pain lying down or wake up in the middle of the night with pain.

How is an acute ear infection (acute otitis media) diagnosed? An otoscope helps visualize the eardrum, look for redness and bulging. There are two different ways to check how well the ear drum moves. One is using a small tube connected to the otoscope with a bulb at the end. This is called a pneumatic or bulb inssufillator. By squeezing the bulb, a small puff of air goes into the ear canal. The other technique is using a tympanometer. This is a hand held instrument that also puffs air into the ear canal. The tympanometer documents how well the ear drum moves on a small graph. Visually an eardrum that does not move by insuffilator will show a “flat tympanogram” on a graph. This confirms fluid in the middle ear.

**** a picture of an eardrum and cross section of the middle ear would be helpful here

Sometimes an ear drum perforates during an ear infection. This happens when there is build up of pressure in the middle ear and eustachian tube due to excess pus or other fluid. The eustachian tube connects the middle ear to the nasopharynx. Often a child feels relief after the perforation occurs. In the days before antibiotics, physicians would pierce a small hole into the eardrum to drain the pus from the middle ear. Most eardrum perforations heal spontaneously.

Antibiotics are primarily used to treat ear infections as 80% are caused by bacteria. There are instances in which a health care provider might defer treating an ear infection by “watchful waiting.” This means to treat the pain component of the ear infection with pain relieving medication (such as acetaminophen, ibuprofen or anesthetic drops) and delay using antibiotics for several days. This approach is used if in children older than 6 months that have a mild infection such as a slightly pink ear with minimal pain and fever.

Antibiotics are started after 48-72 hours of “watchful waiting” if symptoms are not improving. It is important to complete the full course of antibiotics even if a child seems to be improving. Resistant organisms can develop if the full course of antibiotics is not completed.

Acute ear infections usually keep 4-6 weeks to heal. Fluid remaining in the middle ear is called an effusion. If this fluid persists, the diagnosis changes to otitis media with effusion. Current recommendations are to continue to check a child’s ear up to 3 months after the infection. If the otitis media with effusion persists beyond 3 months a child needs to have hearing evaluation a child may be referred to an Ear Nose and Throat doctor (ENT specialist or otolaryngologist) for further evaluation. Other reasons for referral to this specialist include a child having frequent acute ear infections (more than 4 in a year), or an ear infection with pus persisting despite antibiotic treatments. The concern is that persistent fluid or frequent ear infections may result in hearing loss which in turn may impact speech and language development.

The next treatment consideration is placement of tympanostomy tubes (also known as PE or pressure equalizing tubes) in the ear drum. These tiny tubes (1-2 mm or 1/8 inch in diameter) are placed in the eardrum to facilitate drainage of the middle ear. These tubes have been shown to reduce the frequency, duration and severity of ear infections. They usually fall out on their own in 6-14 months. Sometimes an ENT specialist may also remove the adenoids (adenoidectomy) or tonsils (tonsillectomy) if they are causing obstruction to the opening of the eustachian tube in the nasopharynx.

Persistent otitis media with effusion with hearing loss is of particular concern in children that have other risks for developmental delay. This includes children with a hearing impairment independent of ear infections, a cleft palate, other craniofacial disorders and Down syndrome. Children with other developmental delays such as Autism Spectrum Disorder, blindness, vision impairment and known speech and language delays also need ongoing evaluation and treatment.

There are several factors that impact the risk of developing ear infections. It is important to know that babies and toddlers have shorter and more horizontal eustachian tubes than older children and adults. The eustachian tube in babies and toddlers drain more poorly than older children and adults. As a result, the younger set are more susceptible to ear infections. Here are factors that can decrease ear infections:

  • Breastfeeding- breastmilk has multiple factors that decrease infection risk
  • Feeding position– avoid feeding babies/toddlers on their backs or propping bottles- which increases the chance of fluid pooling in the eustachian tube
  • Secondhand smoke– tobacco smoke is an irritant- children who live with second hand smoke in their household are more susceptible to colds, ear infections
  • Childhood pneumococcal vaccine (PCV14) and influenza vaccine– children who are vaccinated have a decreased rate of ear infections

Another challenge is that children in daycare are more susceptible to upper respiratory infections and subsequent ear infections. It is important in these settings precautions to limit spread of infection- good hand washing, proper cleaning of toys and furniture.

Listed below are helpful links:

Ear Infections in Children-National Institute on Deafness and other Communication Disorders

Get Smart, Know when infections work- ear infections- Centers for Disease Control and Prevention

Second Hand Smoke Facts- Centers for Disease Control and Prevention


This article is for information purposes and should not replace consulting your physician for information specific to your child or family’s medical issues.


Subcommittee on Management of Acute Otitis Media, Clinical Practice Guidelines, Pediatrics,
Volume 113, No 5, May 2004, pp 1451-1465,; 113/5/1451

Thrasher, R.D. and Meyers, A. D. Otitis Media with Effusion, Medscape Reference, update August 2011,