Ear Infections in Toddlers

Ear infections, which are known medically as otitis media, are very common in children. Many are caused by viruses. This page gives an overview of otitis media in children, including why pre-schoolers are so prone to get them, what to do when your toddler has one and how to prevent them.

You can click on the link for a specific question or just keep reading.

To read more about otitis media with effusion (OME) which is also known as glue ear, and ear tubes, click here


How common are ear infections in pre-school children?

Very common. They are the second most common infection in young children after the common cold.

Between 30 and 50% of children will have had an infection of the ear (which is known as acute otitis media) by 3 years of age and it is estimated that 1 in 5 children less than 4 years of age are affected by acute otitis media at least once a year.

Otitis media is an upper respiratory tract infection and these are very common in children.

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What is acute otitis media?

Acute otitis media is infection in the middle ear. When children get a cold they get a runny, snotty nose and they also get runny, snotty ears (middle ears to be exact). The middle ear is connected to the back of the nose via the Eustachian tube. Fluid in the middle ear is cleared through the Eustachian tube. If the fluid in the middle ear becomes infected, acute otitis media (or ear infection) is the result. The fluid is more likely to become infected if it stays in the middle ear longer – ie. doesn't get cleared by natural body processes.

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Why are pre-schoolers particularly susceptible?

Young children have narrow Eustachian tubes. When they get a cold and all their membranes become swollen, the Eustachian tube lining becomes swollen and so the tube becomes even narrower. As well as that, the Eustachion tube is relatively horizontal in young children so gravity cannot help in clearing the fluid. So, it is harder for young children to clear middle ear fluid because they have narrow, horizontal tubes. As they get older, the Eustachion tubes become wider and less horizontal and draining fluid from the middle ear is easier, so they are less prone to ear infections.

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What are other risk factors for acute otitis media?

  • The most prominent risk factor is upper respiratory tract infections – the common colds that cause children to have a runny, snotty nose and so runny, snotty ears. These are usually caused by viruses. These upper respiratory tract infections are common anyway in young children but more common in those in day care, so being in day care is another risk factor for ear infections. Don't be alarmed though because if your child has many infections during preschool years because he is at daycare, he will have less infections when he starts school.
  • Exposure to cigarette smoke is thought to be another risk factor and we advise that children are brought up in a smoke-free environment for all sorts of health benefits.
  • Other risk factors include being male (it is a risk factor for many childhood illnesses!), having large adenoids, and bottle feeding.

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How do you know when your child has an ear infection?

Acute otitis media causes pain in the ear, fever and transient hearing loss. There may be an associated cold and the symptoms that go with that, ie. runny nose, miserable, grizzly child. A doctor will see a red, bulging eardrum with an auroscope (otoscope).

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Are ear infections a serious cause for concern?

Studies have suggested that up to 80%, acute otitis media will resolve by itself by 3 days. Some studies have suggested that up to 60% of children with otitis media will have improved within 24 hours with no antibiotic treatment. Ear infections (otitis media) that don't settle by themselves are usually responsive to antibiotics like Amoxicillin or Co-amoxiclav. With appropriate use of antibiotics, there are not usually any serious side effects.

However, occasionally there can be serious complications, including meningitis and mastoiditis, and if your child is not improving by 3 days or is very unwell at any time, you should see a doctor.

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Do all children need antibiotics?

Not all children will need antibiotics. Many ear infections will get better without antibiotics. In studies, antibiotics have shown that symptoms improve more by 7 days with antibiotics compared to children who did not get antibiotics. However, antibiotics cause more diarrhea.

So often there is a toss up between benefit from antibiotics and the side effects of taking them. For that reason, if symptoms are not that severe and there are no serious signs when looking at the ear drum, doctors will not prescribe antibiotics initially. If the symptoms last for 3 days, then they will usually prescribe antibiotics at that point.

Therefore if your child is only moderately unwell and you can control the pain with pain relievers like Paracetamol, Acetaminophen or Ibuprofen, then you could wait 2 or 3 days to see if things settle without antibiotics.

Giving antibiotics to all children with an ear infection has some unwanted consequences – for the child, they can get side effects from the antibiotics like vomiting, diarrhea and skin rashes. From a public health point of view, giving antibiotics to all children with an ear infection results in bacteria developing resistance to commonly used antibiotics and this eventually leads to multi-resistant organisms that we are unable to fight – not a good situation to be in.

As many ear infections will get better by 3 days, we generally do not give antibiotics until symptoms have been present for at least 3 days. This limits antibiotic use. When antibiotics are needed, we usually use Amoxicillin or Co-amoxiclav (augmentin).

It is important if your child is given antibiotics that he finishes the whole course. If there is no sign of improvement after 48 hours of antibiotics, see your doctor again - your child might need a different antibiotic.

To read the Center for Disease Control (CDC) leaflet on why antibiotic use should be limited, click here

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How can I treat my child's earache?

  • Pain relievers, like Paracetamol (Acetaminophen in North America) and Ibuprofen, have been shown to effectively reduce the pain of an ear infection. So, a good first treatment choice would be Paracetamol or Acetominophen (eg. Pamol or Tylenol), given in the first 24 hours, including before bedtime - read more. Remember antibiotics do not relieve the pain of earache in the first 24 hours.
  • A study has shown that putting lignocaine (lidocaine) drops (lignocaine or lidocaine is an anesthetic agent) in the painful ear reduces pain, so you could ask your doctor about prescribing some. 2% lignocaine (lidocaine) solution is used and 3 drops are put in the painful ear, while your child lies with the ear up for 5 minutes. Relief is almost immediate and sustained. Only one dose of drops is needed per ear.

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What causes a burst ear drum?

If the fluid behind the ear drum (in the middle ear) builds up to a high pressure, the ear drum can perforate. The fluid that has been building up in the middle ear is then released into the outer ear. The pain that occurs with fluid in the ear is relieved when the pressure is reduced by the fluid leaking into the outer ear, (so the burst drum means reduced pain). You may notice a discharge from the ear when the drum perforates.

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What is the treatment of a burst ear drum?

There is no treatment needed for most cases of perforated ear drum. The drum will heal itself as long as it is kept clean and dry. Put a small piece of cotton wool in the ear to keep it dry and clean.

See your doctor if your child is unwell as he may need antibiotics for the ear infection.

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When should I take my child to the doctor?

If earache or other symptoms persist beyond 3 days, see your doctor as your child may need antibiotics.

See your doctor at any time you feel your child is seriously ill - read more.

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How can I prevent my child getting ear infections?

  • A good start to preventing ear infections is by breast-feeding your baby and ensuring your child avoids cigarette smoke.
  • Children who are vaccinated against Pnuemococcus, one of the main bacteria causing otitis media, have less ear infections.
  • Xylitol chewing gum and syrup (for those too young to chew gum) have also been shown to reduce ear infections. Xylitol is a "good" sugar – found in raspberries and strawberries – and does not cause tooth decay. It stops the growth of the pneumococcus bacteria and also stops bacteria attaching to the cells in the upper respiratory tract, (the ear, nose and throat region). For children old enough to chew gum, the recommendation is 2 pieces of gum chewed for at least 5 minutes, 5 times a day after meals or snacks. It hasn't been shown to be effective in children who have needed ear tubes (or grommets), though. The other good thing about xylitol is that it has been shown to prevent dental caries.

    Xylitol is the main ingredient in air-liftTM chewing-gum which is available in pharmacies.The syrup isn’t available in NZ, though. To read more or order online, including links to online shops, click here
  • Teach your child to blow his nose correctly to keep the nose and air passages clear of mucus. The right way to teach your child to blow his nose is first to breathe in through the mouth, then blow through the nose into a tissue (without pinching the nose)
  • Tympanostomy tubes (ear tubes or grommets) have been shown to prevent recurrent ear infections for the first six months after they are inserted, but don’t have a significant effect for the following 18 months.

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  • Clinical Evidence, 2006 edition. BMJ Publishing Group
  • AAP (American Academy of Pediatrics) – http://www.aap.org/advocacy
  • National Guideline Clearing House (www.guideline.gov) – Otitis Media Ann Arbor: University of Michigan Health System; 1997 Nov. 12p
  • Uhari et al. Xylitol in preventing acute otitis media. Vaccine 19 (2001) S144-147
  • Bolt P, Barnett P, Babl F, Sharwood L. Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomised trial. Arch Dis Child 2008; 93:40-44. doi:10.1136/adc.2006.110429

To return to the top of Ear Infections, click here

To find out more about Ear Tubes (Grommets), click here

To return to the main Ear Nose Throat page, click here

To return to Home page, click here

Last reviewed 16 June 2011

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Dr Maud MD

Dr Maud MD (MBChB, FRACP, FRCPCH), a specialist pediatrician, provides health information and medical advice for parents of babies and toddlers. Read more about Dr Maud.

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