Dr Preeya’s Fast 5: Middle Ear Infections in Kids

  1. There are 2 main types of ear infections – external ear infections (otitis externa) that involve the skin in the outer ear canal and middle ear infections (otitis media) which involve infection of the middle ear, behind the ear drum. Middle ear infections are common and 75% of children will have an episode before they reach school. Exposure to cigarette smoke increases a child’s risk of these.


  1. Most kids, when they get a viral infection (AKA a cold), get some involvement of their middle ear. In all of us, there is a structure called the Eustachian tube – it links the middle ear to the nose and ensures that the middle ear gets ventilated so we can hear properly. In kids, because they are smaller in every way, when they get a cold and mucous secretion ramps up the Eustachian tube easily gets blocked. Once it’s blocked due to mucous the middle ear can get a bit inflamed, with less air coming into it from the nose- as a result, the ear drum can look a bit red; that’s the bit I see when I look inside the ear. If I look in every child’s ear who has a cold I will often see a slightly red, flushed ear drum – but this does not necessarily mean they have a middle ear infection and need antibiotics.


  1. To diagnose an acute middle ear infection, we look for certain diagnostic criteria – the rate at which the symptoms came on, what we see on examination (we need to see specific features of middle ear inflammation like a bulging ear drum or fluid changes inside the middle ear). When we ask you to pin your child’s head and get the precious 2 seconds to look at the ear drum I am looking for 4-5 features rapidly to see what we’re dealing with.


  1. Even if a child has a class middle ear infection, antibiotics are not always required – and I find this is where parents get confused. If a child is over 6 months old and is otherwise well (no fever, eating, drinking, happy), we generally use the “watch and wait” policy and paracetamol to control pain. IF the symptoms are ongoing in 48 hours (the child has ongoing ear pain for example), THEN we treat with antibiotics. Why not use antibiotics first off? (I get asked this a lot) Because we know kids in this group do well without antibiotics and that for most children, antibiotics do not change the course of illness significantly (studies have shown that kids get better without antibiotics most of the time anyway). Also, antibiotics can cause more harm through side effects, so if we don’t have a clear reason to use them we tend not to. For kids who are under 6 months old (they are more vulnerable) or who are unwell with fever/vomiting, we do treat with antibiotics first off.


  1. LOTS of parents want quick fixes when their kids are sick – and being a parent, I am no different, trust me! BUT we are trying very hard now as a medical community around the world to try and only use antibiotics when they are essential and their use is backed by medical evidence. As a mother and GP I have tried very hard to limit my child’s exposure to antibiotics to reduce risk of side effects and resistance – I’ve seen now over time more and more of my patients align that way, reluctant to use antibiotics unless required (as opposed to begging for them!). If your child needs them I’ll give them to you I promise, but know that if I say they aren’t indicated it’s a well thought out decision backed by guidelines and research and that I’ll always review the ear again in 24 or 48 hours.


As I always say, you are the patient so ask questions, leave the room feeling reassured and in the loop; I hope background information like this helps you feel empowered to get the most out of your visits to the doctor.