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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

A Parent's Life A Parent's Life

Guidelines for Treating Earaches in Children

September 23, 2013

By Henry H. Bernstein D.O.

Harvard Medical School


Many parents remember their children saying, "My ear hurts," at some time or other (usually in the middle of the night). In fact, ear pain is one of the most common reasons for visits to the doctor's office.

For millions of children each year, ear pain is actually caused by acute otitis media (AOM), an infection in the middle ear. The middle ear is a small bony area covered by the eardrum (tympanic membrane), which plays an important role in allowing us to hear sounds. Sound passes through the eardrum to the middle ear bones and finally on to the inner ear, where nerve impulses carry the sound to the brain.

The middle ear is connected to the back of the nose and throat by a tiny opening called the Eustachian tube. This tube helps to aerate and drain the middle ear, balancing the air pressure inside and outside the middle ear.

When the Eustachian tube gets blocked or does not work well (for example, with a stuffy nose from a cold or allergies), fluid builds up in the middle ear and is unable to drain. Sometimes bacteria or viruses then grow in this fluid, causing an infection and a buildup of pressure in the middle ear. The eardrum becomes red, swollen, and painful. The middle ear fluid usually goes away once the infection is gone and the Eustachian tubes can drain properly.

It may take several weeks to months for the fluid to drain completely, even though the infection is gone. If the fluid stays in the middle ear too long after the infection clears, it is known as otitis media with effusion (OME). This is a fancy term that simply means that there is fluid in the middle ear. OME does not mean that the fluid is infected; it is simply not draining out of the middle ear well. OME can reduce hearing on the side with the fluid buildup, but it generally does not cause pain or other symptoms.

Doctors and parents usually think an antibiotic should be prescribed for an ear infection. However, most ear infections, even those thought to be caused by bacteria, can get better in a few days without antibiotics. Since OME is not an infection, it generally does not need to be treated with antibiotics.

The latest guidelines from the American Academy of Pediatrics help doctors and parents decide on the best treatment for uncomplicated AOM (acute otitis media) and for OME in otherwise healthy children from 2 months to 12 years of age.

Guidelines for Acute Otitis Media

The guidelines urge doctors first to make a careful diagnosis, remembering that not all ear pain is an infection. Doctors should focus on pain relief and consider not using antibiotics right away, especially in otherwise healthy children who are older than 2 years of age and have mild or moderate findings.

Note that these recommendations are not meant for children with certain medical conditions that could make ear infections more difficult to treat (such as cleft palate, Down syndrome or cochlear implants), children who just had an ear infection within the last month, or those children with chronic OME.

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The Option of Watchful Waiting

Many parents (and even providers) may feel uncomfortable with the decision to wait before giving an antibiotic to your child, but it is important to remember that antibiotics could cause your child more harm than good.

While treating AOM, antibiotics also kill normal bacteria that always are found in the mouth and throat, intestine, skin and vagina. When these everyday bacteria are eliminated, other potentially harmful bacteria strains can develop, which may be resistant to antibiotics. Bacteria that are resistant to an antibiotic prescribed for your child will survive treatment. They can live and multiply in your child's nose and airway, and eventually can cause an infection that may not respond to usual treatment.

As more and more drug-resistant bacteria are around in people's ears, noses and throats, they can spread and cause infections in others. Unfortunately, routine antibiotics won't work in these other people, either, which can be particularly dangerous if they have a serious infection.

Doctors are responding to the guidelines and prescribing antibiotics more sparingly. They are avoiding antibiotics for all OME and even some routine childhood ear infections.

These guidelines are for children who have uncomplicated ear infections. Children with complicated infections — ear infections in children younger than 6 months or in older children with more severe symptoms — will continue to be treated with antibiotics. Recent studies support this approach. Children younger than 3 years of age with a definitive AOM diagnosis improved more rapidly when treated with the combination antibiotic amoxicillin-clavulanic acid (Augmentin, generic versions).

It is still important to speak with your child's doctor if your child has symptoms of an ear infection. The guidelines emphasize the importance of a careful exam and a good history in helping to make an accurate diagnosis of AOM.

You can help your doctor to decide whether your child's ear infection is severe enough to need an antibiotic. Take your child's temperature and record the level of fever. If the doctor has specified a safe dose of acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) for your child, try treating symptoms before the doctor examines your child, so that the effectiveness of pain medicines can be evaluated.

If you and your child's doctor together decide not to give an antibiotic right away, the doctor will want to know if your child has more pain or fever or is not improving as expected. This is called "watchful waiting." Keep in touch with the doctor, because if the symptoms are not improving after waiting 48 to 72 hours, antibiotics then may be suggested.

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Guidelines for Recurrent Acute Otitis Media

A child is said to have "recurrent AOM" if he or she has had AOM

  • 3 or more times within 6 months, or
  • 4 times within a year, including once in the last 6 months

Doctors do not give preventative antibiotics to children with recurrent AOM. Instead, they may consider having the child evaluated for tympanostomy tubes ("ear tubes"). These small tubes are placed in the ear drum to keep the middle ear aerated and clear for a longer period of time. This prevents fluid from building up in the middle ear and causing problems with hearing. 

Guidelines For Otitis Media With Effusion (OME)

Doctors are urged to first make a careful diagnosis of OME, then assess whether children are at risk for speech, language and/or learning problems. If there is no risk of these problems, consider waiting for at least three months before recommending any other treatment. Regular follow-up exams are important. According to the guidelines:

  • Antihistamines and decongestants have no proven benefit for OME, and 
  • Antibiotics and corticosteroids are not recommended for routine management of OME.


  • The guidelines also emphasize prevention of ear infections.
  • Keep up-to-date on your child's immunizations, especially pneumococcal conjugate vaccine (PCV13).
  • Make sure your child gets the flu vaccine every year.
  • Maintain a nonsmoking home and do not let others smoke around your child.
    Do not give your baby a bottle while she is lying down.
  • Try to limit the use of a pacifier after 6 months of age.
  • Breastfeeding an infant for at least three months appears to lower that child's risk of ear infections.

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Henry H. Bernstein, D.O. is a senior lecturer in Pediatrics at Harvard Medical School. In addition, he is chief of General Academic Pediatrics at Children's Hospital at Dartmouth and professor of pediatrics at Dartmouth Medical School. He is the former associate chief of General Pediatrics and director of Primary Care at Children's Hospital Boston.

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