6 Facts Parents Don’t Know About Pediatric Ear Infections (Archived Pedcast)

Photograph provided by Pixabay, Holger Kraft


Here are 6 childhood ear infection facts that parents often don’t know. How do I know that many parents don’t know these things you ask… because I’ve been practicing pediatrics for 37 years , that’s how. Let’s test your pediatric ear infection knowledge in this edition of Portable Practical Pediatrics.


This pedcast was originally posted on may 19, 2019.

Musical Intro

What Causes Ear Pain? 

Have you ever wondered what is going on when your child complains of ear pain while having a cold. And how do you know if your young child, with little ability to talk or localize pain, if he or she is hurting?  It reminds me of an afternoon 30 something years ago when I was taking care of my son Ben who had a bad cold. He was two years old at the time. I couldn’t get him to play, read a book with me, or eat anything. He was just acting strange. And he cried about everything. He was old enough to be verbal but wasn’t complaining of anything, just crying, crying, crying. After a few hours of this, his genius pediatrician father, yours truly, wondered if he might have an ear infection complicating his bad cold. I pulled out my otoscope and oh yes, he had a hot one. I felt terrible that I didn’t think about this earlier in the day and he had suffered all day. So much for that medical degree and 4 years of pediatric training… I learned that day that being a parent is different.

So what was causing little Ben’s pain? Any of the structures around the ear can cause ear pain including your child’s teeth, their muscles of chewing, the joint in their jaw that moves with chewing, or their tonsils, but…when it comes to causes of ear pain, the big gorilla in the room is a middle ear infection caused by trapped infected mucous behind their ear drum.  Sure enough, Ben’s infection was the middle ear type, an extension of his cold back into his ear, and his pain was caused by a sudden outward pressure on his ear drum from the pus that developed in his middle ear. “Ow!”  You may not be aware but a child’s eardrum is as sensitive as their corneas and when it gets pushed on, its not fun!

History of Treatment of Middle Ear infections

   —  In my childhood, ear infections were treated by lancing your eardrum. My pediatrician, let’s call him Dr. X, simply reached into his pocket and pulled out a little instrument called a myringotomy knife (that means eardrum knife) and he simply cut your eardrum letting the pressure and pus out of my eardrum.  Needless to say Dr. X was not my favorite person and I learned quickly not to EVER complain of an earache.  When he was not cutting my eardrum, his nurse was always giving filling my bottom full of penicillin.  Dr. X and his nurse made quite a team.  Fortunately, medicine has moved forward from those days.  For the rest of the twentieth century, antibiotics alone became the mainstay of treatment for otitis media. More humane and very effective until the era of antibiotic resistant bacteria arrived… you know those super bugs that just laugh at our strongest medicines and refuse to die. Their existence has forced a revolution in treatment in the past decade.

Some Interesting Facts About Otitis Media

Parents need to consider otitis media when their children have a snotty nose, usually for a few days, and they start acting like they have pain-maybe by just crying a lot like Ben did, or pulling at their ears, or not sleeping, or a myriad of other more subtle signs. Most ear infections afflict preverbal children so knowing when to take them to the pediatrician can be challenging. At the beginning of my pediatric career, a full 40% of all visits to my office were related to ear infections. Not today, mainly because a vaccine that most children in the U.S. get called pneumococcal 13 and 23 vaccines.  These vaccines really reduced the number of ear infections children were getting. Today, I would estimate that ear infections are about 10% of all pediatric visits. And all those antibiotics we had in our arsenal back then to control the germs causing middle ear infections, they to a large degree, just have stopped working with ever stronger germs coming down on today’s children.

Fast Forward 40 Years

Let’s fast forward to today’s children and their ear infections. Pediatricians have an entirely different approach once they realized that about 60% of ear infections go away without treatment. Had you told me in 1982 when I started my pediatric career that 60%-85% of those hot ears I was treating would go away without treatment, I would have thought you insane but that is the reality in today’s world. In 1982, every pediatrician was worried that every ear infection in a child could become meningitis in a few hours. We saw that happen all the time. But fortunately, the vaccines that children are given today have essentially eliminated any chance that a nose and ear infection will turn into a blood stream infection or meningitis, the fear we had before the vaccine era and the reason that we can now avoid immediate treatment of children with ear infections.

Another realization that has been a game changer is the fact that antibiotics probably only shorten the length of ear pain by about 1-2 days. These two facts have led pediatricians to back off automatic treatment of ear infections with antibiotics. So now when an older than 6 month old child, without a fever, has an ear infection and doesn’t look or act really sick, pediatricians take the “Wait and See” approach.  Today’s treatment of otitis media is not lancing, not broad spectrum antibiotics, but rather pain medicine and watchful waiting.  Treatment with antibiotics only occurs if the child looks very sick, doesn’t improve in 48 hours, or gets worse before then. Yes, today’s, treatment of ear infections is all about pain management, not treatment of the actual infection. Quite a change from the past.

How Should Parents Control The Pain of Otitis Media in Their Children?

So how should parents take on the pain of an ear infection in their children? Recently, the FDA decided to require safety and efficacy data on topical ear infection medicines that had previously been grandfathered. You may have heard of these medicines that went by familiar names like Auralagan and A/B otic. The companies making them were forced to remove them from the marketplace until their safety and efficacy could be proven at the companies expense. Well, that was the end of those medicines. Parents are still left with homeopathic drops to treat their children’s ear infections but little reliable information about effectiveness and safety are available here as well. Of course, there are the grandma approved home remedies of heat/cold/garlic/onion/olive oil. Maybe they work or maybe they are just distractions, taking the child”s mind off of their pain. I’m sure I would be distracted if my mother put a cut onion on my ear. I would think she was crazy. Fortunately, most parents that I see choose acetaminophen or ibuprofen, ibuprofen being the more effective.

What Should Parents Do When Their Children Have Ear Pain from Suspected Otitis Media

What should parents do when their children have ear pain from suspected otitis media- that means a cold with a change in behavior or complaint of ear pain?  Well, here is what I would suggest:

Take them to their doctor if:

–They have fever along with their suspected ear infection.

–Take them to their doctor if they are under 2 years old since they have little language to tell you how sick they are.

–Take them to the doctor if they act sick.

–Take them in if they have a history of chronic or complicated ear infections in the past.

–Take them to the pediatrician if you suspect an ear infection but they also have associated symptoms like vomiting, redness around their eye, tenderness behind their ear, generalized rash, or anything else that seems out of the ordinary.

–Take them to the pediatrician if your child is sick in anyway and not immunized or too young to have completed their first 6 month series of shots.

–Take them to the pediatrician if your parental instinct tells you to.

When to Consider Not taking them to the pediatrician with ear pain

But assuming your child has ear pain but doesn’t fall into the just mentioned categories, why not try the wait and see approach before taking them to the pediatrician? The wait and see approach says that if the pain is one sided, in a child without other signs of serious illness, that treating pain for 48 hours with acetaminophen or ibuprofen is the ticket. If the pain persists beyond 48 hours or the child gets sicker before the 48 hours is over, take them to the pediatrician and consider treating them with antibiotics. This approach doesn’t work well for children under 2 years of age and probably is only practical for children older than two. And of course, if you have any doubt about what to do, don’t hesitate to contact your child’s pediatrician. That is what they are there for!

The 6 Kid Ear Infection Facts Parents Often Don’t Know

  1. Your child’s eardrum is as sensitive to pain as their corneas, among the most sensitive cells in their bodies hence the high degree of pain with ear infections.
  2. The majority of ear infections in children go away without treatment.
  3. Antibiotics only shorten the duration of pain by a day or two compared to no treatment.
  4. Because of vaccines, serious complications or life threatening illness from ear infections is much rarer today than just a generation ago.
  5. The treatment of ear infections has drastically changed in the past 20 years, for most, consisting of the “Wait and See” approach previously described.
  6. The main treatment of ear infections today, is pain medicines.


Well, that’s it for this installment of Portable Practical Pediatrics. If you think the information you get on this podcast is valuable, consider writing a review on our Facebook page or iTunes and sharing some of the episodes with friends and family. This is Doc Smo, broadcasting from studio 1E, hoping that you know what to do the next time your little squirt has an ear hurt. Until next time.

Many thanks to Drs. Monica Miller and Charlotte Rouchouze for their assistance in the writing of this pedcast.