Revisiting Ear Infections in Infants: Is Anything New?

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Those of us that have been practicing pediatrics for a while have special memories of our early outpatient visits while we were in training. For most of us back in the day, there was a very good chance that our first “sick visit” was a child that either had an ear infection or came in to rule one out. (All right, in my case it was the second sick visit; the first one was something else.) And unless there was something unusual going around, it would seem like at least every other visit was for the same problem.

Times have changed, and during my last few years of full-time practice, I could go a day or two without seeing a single ear infection; in my current part-time situation, I rarely see one. Immunizations (the “Hib” and pneumococcal vaccines in particular), less smoking in the house, and being judicious in the amount of time infants and toddlers have contact with a bottle have all helped. But if you’ve read this far and your little one is unlucky enough to get a lot of ear infections, is unlikely that any of this is a great comfort to you. Ear infections are no fun, and although even in pediatrics, a lot of other news has hogged the headlines in recent years, they still pop up in the “recent research” column.

Such was the case last month, when the New England Journal of Medicine reported on research comparing two common treatments for kids that get a lot of bouts of otitis media, the common medical term for what we usually mean when we say “ear infection.” In order to explain the results of their research and what they might mean, it’s worth taking a couple of steps backward and looking at the how and why of ear infections.

Wherefore Art Thou an Ear Infection?

Any parent who has undergone the frustration of seeing their child go through one ear infection after another has the same question: Why do children get ear infections? Although it seems like a bit of a stretch, in order to answer this question, I’m going to take you to my backyard in South Florida in the summer. Largely due to our climate, we have a significant mosquito problem this time of year. Because of this, our local Mosquito Control folks do everything they can to safely reduce the problem. It turns out that one such problem is if people leave water standing around in buckets, kiddie pools and birdbaths, mosquitos congregate and reproduce—indeed, they’ll do that anywhere there is standing, nonmoving water. Mosquito Control sends representatives to our yards in order to look for standing water hazards.

Take that logic and apply it to the ear (more properly, the “middle ear,” the site of our ear infections—“otitis media” actually means “middle ear inflammation”). The middle ear contains fluid while usually drains off and is replaced; in other words, it moves. However, sometimes the fluid is blocked from draining because the drainage tube (“Eustachian tube”) is small (the reasons infants get ear infections), oddly shaped, or swollen and irritated (e.g., from a cold or from exposure to cigarette smoke). We again have stagnant fluid, which causes the “bugs” that are bacteria to reproduce, much like the mosquitos in that birdbath.

Treating Ear Infections, and the Study

You may be surprised to hear that not all ear infections need treatment. In an older child without an underlying medical condition, they’ve been shown, for the most part, to go away just about as quickly with no treatment as with treatment. Usually, though, most of us treat younger infants, and most would treat a child who is the past has not recovered from ear infections with watchful waiting alone. Such children receive antibiotics, the standard treatment used to kill the bacteria causing the ear infection.

When a child gets a lot of ear infections, people understandably want to look at different, ideally more definitive treatments. One such treatment is to put ventilation tubes in the eardrums. They help prevent ear infections by draining that potentially stagnant fluid from the inside out.

Whenever a treatment, especially a surgical one, is recommended, it’s worth now and then saying, “Wait a minute. Are we really doing any good with this procedure?” The recent study attempted to answer that question. The investigators enrolled children who had 3 or 4 (or more) ear infections in a short period of time. They then split them into two groups. One group was to continue to get the standard treatment—antibiotics—whenever they got a new infection. The other group was to have ventilation tubes inserted.

Any single study has limitations, and in this case, some of the study children ended up getting the opposite treatment—no tubes for the children in the “tube” group, and tubes for children in the “antibiotic” group. That said, when the data was examined, the frequency of ear infections going forward was statistically the same.

So, What’s a Parent To Do?

Although the conclusion wasn’t definitive enough to recommend a change in recommendations, it was recommended that researchers continue to study the treatments for effectiveness. Like so much else in medicine, treatments for the problem are individualized, and what’s better for one kid might not be as good for another. In the meantime, here are some things to think about if you have an infant or child who gets a lot of ear infections:

  • When possible, it’s desirable to stick with one provider (or provider group), preferably someone who’s had training and experience in diagnosing ear infections. One physician’s “ear infection” may be another’s “just a red ear” or “fluid in the ear.” Also, it becomes very difficult to keep track of ear infection frequency unless your child’s information is in one place.
  • Realize that these days, not every ear infection is treated. It’s always a good idea to check with your child’s provider to discuss her threshold for treatment (and for coming into the office for diagnosis!).
  • Remember that antibiotics or not, a little pain control can go a long way. Many providers would recommend either acetaminophen or ibuprofen and perhaps a warm compress to the ear.

When all is said and done, maybe there isn’t all that much that is new about treating ear infections in kids. But the good news is that we seem to be getting better at preventing them. While otitis media will never be totally gone, we can take a little comfort that the condition will affect less kids—and less often.

Stan Sack
Dr. Stan Sack has 29 years’ experience as a primary care pediatrician in Massachusetts and Florida. A medical writer since 2015, he enjoys blogging on topics that are on parents’ minds but are covered less often in books and on websites. He lives in the Florida Keys with his family and enjoys healthy cooking, fitness activities and singing in his spare time.

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