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Middle ear infection in children


Expert reviewer, Mr Anil Banerjee, Ear, Nose and Throat Consultant
Next review due January 2020

If you’re a parent you’ll probably know that middle ear infections are common in children, and unfortunately they’re often painful. Your child may need painkillers, but they should get better in a few days. Antibiotics aren’t usually needed.

The middle ear is the space behind the eardrum, which is normally filled with air. After a cold or sore throat it can become filled with fluid because of blockage to the Eustachian tube. This is the tube which connects the middle ear to the back of the throat. In middle ear infections (otitis media) the fluid becomes infected and the middle ear becomes inflamed and painful.

More than four out of five children will get a middle ear infection at least once before they’re two. These infections are most common in children, but adults can get them too.

Image showing the outer, middle and inner ear

Symptoms of middle ear infection

A middle ear infection can be triggered soon after your child gets a cough or a runny nose. Symptoms can include:

  • earache (young children may rub or tug at their ear)
  • a raised temperature
  • irritability, crying
  • not sleeping well
  • seeming generally unwell
  • not feeding/eating well, being sick
  • cough or runny nose

Older children may tell you that they can’t hear properly and their ear feels ‘blocked’.

In some children the eardrum bursts (perforates) because of the pressure. If this happens you may see pus coming out of the ear. Although a burst eardrum sounds nasty, your child will probably feel better after it happens because their pain eases.

The symptoms of middle ear infection usually clear up on their own within four days. If you’re concerned about your child’s symptoms or if they get worse, contact your GP.

Diagnosis of middle ear infection

Your GP will ask about your child’s symptoms and about other illnesses they’ve had. If they think it is a middle ear infection they may then look at your child’s eardrum using an instrument called an otoscope. This is a small, hand-held device which has a magnifying glass and a light.

In most cases your GP will be able to diagnose a middle ear infection without further tests. If your child is under three months old, they may advise that you take him or her to hospital for further assessment.

Your GP may recommend further tests or referral to a specialist if your child doesn’t get better as expected over time. They might, for instance, suspect that your child has developed glue ear. This is when the middle ear remains blocked with fluid which stops your child hearing properly.

Treatment of middle ear infection

Self-help

It’s upsetting to see your child in pain with a middle ear infection. But you can be reassured that in most cases they’ll get better in a few days without any specific treatment. Often, the best treatment is just to relieve your child’s symptoms with painkillers until the inflammation has cleared up. You can buy paracetamol or ibuprofen in forms suitable for children at a pharmacy. Don’t give aspirin to children under 16. 

Always read the patient information leaflet that comes with your child’s medicine. If you have any questions, ask your pharmacist. If your child’s condition doesn’t clear up after four days, or it gets worse, see your child's GP.

Antibiotics

Usually, middle ear infections clear up on their own within four days and no antibiotics are needed. Your GP will explain to you that antibiotics probably won’t make a difference to your child’s symptoms. And they may have side effects such as diarrhoea, vomiting or a rash. 

Or your GP may give you a ‘delayed prescription’. This means that they’ll give you a written prescription but advise you only to use it if the symptoms continue for at least four days.

Your GP may prescribe antibiotics straight away if your child: 

  • has already had symptoms for four days
  • is under two and both their ears are infected
  • has a perforated eardrum (a hole or tear in their eardrum)

If your child is very young (under three months) your GP may also refer them to a hospital for further treatment. 

If your child does have antibiotics, it’s important to complete the course even if their symptoms get better. Read the patient information leaflet that comes with your child’s medicine carefully. If you have any questions about the medicine or about how your child should take it, ask your pharmacist.

Surgery

Most children with middle ear infections get better without specific treatment. There are some occasions, however, when your doctor may recommend a surgical procedure. 

The most usual surgical procedure is called myringotomy. This is when your doctor makes a small cut in your child’s eardrum to drain the fluid. Your doctor may recommend this if your child keeps having middle ear infections. Small ventilation tubes called grommets may be put in at the same time. See our topic on glue ear for more information about grommets.

If your doctor recommends a surgical procedure they will explain exactly what will happen and what the benefits might be.

Causes of middle ear infection

The middle ear is normally filled with air, but can become filled with fluid if your child has a virus, such as a cold. This happens because their Eustachian tube is swollen or blocked and the fluid can’t drain away. The fluid in the middle ear then becomes infected with bacteria, which travel up the Eustachian tube from the nose or throat. Pus builds up and causes pain.

Acute middle ear infections are very common in young children. Their Eustachian tubes are still quite short and horizontal so fluid and mucus can build up in the middle ear more easily.

Other factors that can increase the chance of your child getting an acute middle ear infection include:

  • using a dummy. See our FAQ on dummies below for more information
  • formula feeding rather than breastfeeding, particularly if your child lies down when they feed. See our FAQ on breastfeeding below for more information
  • secondhand smoke – if someone in the household smokes, your child is at higher risk

Boys tend to be affected more than girls and the condition is more common in winter than in summer. Your child has a higher chance of infection if they have a lot of contact with other children, for example, at a nursery or playgroup. Children who are born with a cleft lip or palate, or who have Down’s syndrome, are more likely to get middle ear infections.

Complications of middle ear infection

Most children with middle ear infections get better without any lasting problems.

It’s not unusual for middle ear infections to lead to glue ear. This is when fluid stays inside the middle ear after the infection clears up. It makes it difficult for your child to hear. This often doesn’t need any specific treatment and will usually go away on its own within about three months. You can find out more information from our topic on glue ear.

In some children, middle ear infections can cause the eardrum to burst (perforate) under the pressure of built up fluid. You may notice pus or fluid coming from your child’s ear. Fortunately, the eardrum usually heals within weeks. However, sometimes the eardrum doesn’t heal and there is long-term infection of the ear. If your GP thinks your child may have a long-term infection they’ll refer them to an ear, nose and throat (ENT) specialist for treatment.

Although it’s rare, infection can spread from the middle ear to surrounding tissues. These infections usually need hospital treatment. Infection in the bone behind the ear is called mastoiditis. You may notice a soft, red lump behind your child’s ear, which is tender to touch. Very rarely the infection can spread deeper, affecting the inner ear, the brain, or the membranes surrounding the brain.

The symptoms of middle ear infection usually clear up on their own within four days. If you’re concerned about your child’s symptoms or if they get worse, contact your GP.

Prevention of middle ear infection

You probably won’t be able to prevent your child getting a middle ear infection at some point. But there are things you can do to lessen the chance.

It’s important to make sure that all your child’s vaccinations are up to date, and make sure your child isn’t exposed to tobacco smoke. This includes not smoking in your house or car.

Breastfeeding reduces the chance of your baby getting middle ear infections. See our FAQ on breastfeeding below for more information.

When your child is feeding, keep their head up rather than letting them lie flat. Consider avoiding dummies (see our FAQ on dummies below for more information).

It’s usually impractical to avoid your child mixing with other children with viral infections such as colds. But if they’re old enough it’s really worth teaching your child about good basic hygiene and regular hand washing.

Frequently asked questions

  • Unfortunately, middle ear infections are very common. More than four out of five children will get at least one before their second birthday. And it’s thought that a half of these children will get more than three episodes.

    Every child is different. But you can see that there’s quite a high chance that your young child will get more than one middle ear infection. Some babies who get their first episode shortly after birth may be particularly prone to getting further middle ear infections.

    It may help you to know that your child’s risk of getting a middle ear infection lessens as they get older. See our section on prevention above for ways that you can reduce the chance of middle ear infections for your child.

  • Babies who use dummies are more likely to get middle ear infections but doctors aren’t sure why. It may be that sucking on a dummy allows more fluids to get into the middle ear from your baby’s nose and throat. Or it may be that dummies affect the way your baby’s teeth develop. This in turn may affect the way their Eustachian tube works.

    It’s your decision whether your baby uses a dummy – many parents find them helpful in getting their baby off to sleep. If you can’t avoid using a dummy completely, try saving it just for times when your baby’s falling asleep. If you stop your baby using it after the age of about six months this may reduce the chance of a middle ear infection too.

  • If you breastfeed your baby they could still get middle ear infections, but the risk is lower. Breastfeeding helps to protect your baby from middle ear infections for the first two years of their life.

    There is some benefit even if you breastfeed your baby for just three months. But breastfeeding for six months or more means your baby has an even lower chance of getting an infection.

    Unlike formula milk, a mother’s breast milk contains many vital nutrients and antibodies, which help a baby to fight infection. Breastfeeding may also pass ‘friendly’ bacteria from you to your baby. These may help protect your baby against harmful bacteria.

    Breastfeeding also helps to reduce your baby’s chance of getting other infections and conditions, as well as having many benefits for you too. Your midwife or health visitor will be able to talk to you about the benefits of breastfeeding and answer any questions you have.


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Related information

    • Otitis media – acute. NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised July 2015
    • Otitis media. BMJ Best practice. bestpractice.bmj.com, last updated 6 June 2016
    • Acute otitis media. Medscape. emedicine.medscape.com, updated 5 October 2016
    • Acute otitis media in children. PatientPlus. patient.info/patientplus, last checked 7 January 2016
    • Otitis media with effusion. PatientPlus. patient.info/patientplus, last checked 2 February 2016
    • Mastoiditis. PatientPlus. patient.info/patientplus, last checked 17 August 2015
    • Middle ear conditions. Action on Hearing Loss. www.actionhearingloss.org.uk, 2012
    • Glue ear. Action on Hearing Loss. www.actiononhearingloss.org.uk, published June 2016
    • Sexton S and Natale R. Risks and benefits of pacifiers. Am Fam Physician 2009; 79(8):681–85
    • Bowatte G, Tham R, Allen, K, et al. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatr 2015; 104:85–95. doi:10.1111/apa.13151
    • Perforated eardrum. American Academy of Otolaryngology – Head and Neck Surgery. www.entnet.org, accessed 1 December 2016
  • Reviewed by Dr Kristina Routh, Freelance Health Editor, Bupa Health Content Team, November 2016.
    Expert reviewer, Mr Anil Banerjee, Ear, Nose and Throat Consultant
    Next review due January 2020



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