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Ear infections: If not antibiotics, then what?

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Your 3-year-old was up half the night crying because of pain in one ear. He’s still tugging on it this morning, but he doesn’t have a fever. If you’re like most parents, your first instinct will be to take him to the doctor, pronto. You’ll ask for a course of antibiotics to make the ear infection go away quickly. After all, it’s tough to see him feeling uncomfortable. And you’d dearly like to avoid more missed days at child care and at work.

Ear infections are common in children. Signs and symptoms include pain in one or both ears (especially while lying down), pulling of the ear, difficulty sleeping, difficulty hearing, fever, and vomiting.

Parents often ask for antibiotics to treat ear infections. But these drugs aren’t always the right choice.

Nipunie S. Rajapakse, M.D., M.P.H., a pediatric infectious diseases specialist at Mayo Clinic in Rochester, Minnesota, says, “Ear infections can be caused by both viruses and bacteria. Some of the common cold viruses can cause inflammation of the middle ear.”

Up to 80% of ear infections in children get better on their own without drugs. A big reason: Infections caused by viruses have to run their course and don’t respond to antibiotics.

Children younger than 2 years old are more likely to be prescribed antibiotics for their ear infections. A wait-and-see approach is generally advised for kids with a temperature less than 102.2 F who are:

  • Ages 6 months to 23 months who have mild inner ear pain in one ear for less than 48 hours
  • Age 2 and older who have mild inner ear pain in one or both ears for less than 48 hours

According to Jason (Jay) H. Homme, M.D., a Mayo Clinic pediatrician in Rochester, Minnesota, treatment at home for 2 to 3 days with acetaminophen (Tylenol) or ibuprofen (Advil, Motrin, others) is fine for older kids who are otherwise healthy and don’t have a history of frequent or complicated ear infections.

“After that,” he says, “if there’s no improvement, it’s time for the child to be seen by a doctor. These days, it wouldn’t be unusual for COVID-19 testing to be recommended because of the overlap of symptoms with a respiratory infection.”

Before using acetaminophen or ibuprofen, Dr. Homme advises that a parent read the product label carefully to determine the correct dose based on the child’s current weight.

Generally, acetaminophen can be given every four hours, but not more than five times in 24 hours. Ibuprofen can be given every 6 to 8 hours.

To help your child cope, you can place a warm, damp washcloth over the affected ear or give nonprescription ear drops that have a local anesthetic. Says Dr. Homme, “Topical ear drops or a little olive or mineral oil is fine as long as the ear isn’t draining and the child doesn’t have a tube in it.”

Many homeopathic, naturopathic, chiropractic and acupuncture treatments are marketed for ear infections. Homeopathy isn’t recommended because the products haven’t been studied well and are subject to only limited regulatory oversight by the Food and Drug Administration. Chiropractic manipulations could injure a child. Children also shouldn’t be given decongestants or antihistamines for ear infections because the side effects of these drugs can be dangerous.

If your child’s ear pain and fever aren’t better after a few days, call your health care provider. They may examine the ear by looking at the eardrum, and prescribe an antibiotic, if necessary. If you are given a prescription, be sure to use all of the medication as directed. Failing to do so can result in recurring infection and resistance of bacteria to antibiotics.

Dr. Homme notes, however, that “medical literature suggests that 75% to 85% of fully immunized, otherwise healthy children age 2 years and older don’t need antibiotics if they get an ear infection.”

Nipunie Rajapakse, M.D.

Dr. Rajapakse is a pediatric infectious diseases physician at Mayo Clinic in Rochester, Minnesota. Her clinical focus includes management of pediatric infections. Her primary research interests include studying ways of optimizing antibiotic use in children (antimicrobial stewardship) to decrease antibiotic resistance and other harmful effects. She has worked for the World Health Organization and has an interest in global health and outbreaks of emerging infectious diseases.

Jason (Jay) H. Homme, M.D.

Dr. Homme is a pediatrician at Mayo Clinic in Rochester, Minnesota. His clinical and research interests include diagnosis and treatment of the common condition of group A streptococcal (GAS) pharyngitis (strep throat). Additionally, as program director for the Pediatric and Adolescent Medicine Residency at Mayo Clinic, Dr. Homme aspires to provide the highest quality training experience possible for the pediatricians of tomorrow.

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