One of the most common questions I am asked by parents is if it is necessary to use antibiotics to treat an ear infection. To answer this question, let’s first look at what an ear infection is and then review the various treatment options.

What is an Ear Infection?

There are two main types of ear infections. Otitis externa, commonly known as swimmer’s ear, is an infection located in the ear canal (between the earlobe and the eardrum). Otitis media is a middle ear infection, located behind the eardrum. Middle ear infections are the most common type of ear infection in young children and the topic of this post.

Middle ear infections typically develop when there is decreased drainage from the middle ear, most commonly due to upper respiratory infections. Symptoms of ear infections differ depending on age. Older children will often complain of isolated ear pain and verbalize the symptom. Fever may present, but not always. Much younger and nonverbal children often have different symptoms: Irritability, pain, fever, vomiting, diarrhea, pulling or hitting the ears, difficulty nursing, difficulty lying down, or general sleep disturbance.

It’s important to remember that not all ear pain is an ear infection. Pain can also be caused by teething, upper respiratory inflammation and infections, teeth grinding or jaw clenching, or eardrum inflammation.

Proper diagnosis is crucial when dealing with an ear infection, as they are often inappropriately and overly diagnosed. A red eardrum alone is not enough to make the diagnosis. Proper diagnosis is made with a painful, red, bulging, or distorted eardrum that does not move when air is pumped into the ear canal. Many of my clients have seen the little bulb (insufflator) that is attached to my otoscope and ask me why other doctors don’t use one when examining their children’s ears. The bulb allows me to pump air into the ear canal to properly diagnose an infection.

Current Standards of Care for Ear Infection Treatment

Studies show that most middle ear infections are actually bacterial, with viral infections accounting for less than 50% of cases. Given that more than half of ear infections are bacterial in nature, the real question is whether these bacterial infections need antibiotic treatment. Pediatricians in the Netherlands have been treating ear infections without antibiotics since the 1990s, very safely and with minimal complications. Unfortunately, doctors in the United States have been much slower to adopt this practice.

In 2015 the American Academy of Pediatrics (AAP) began recommending a “watchful waiting” period before using antibiotics for ear infection treatment. Despite these recommendations, most pediatricians still treat all ear infections with antibiotics based on the belief that not doing so could increase the risk of complications (sinus infection, infection of the mastoid bone, and meningitis). As it turns out, studies have shown that these complications are very rare in both treated and untreated ear infections. Several studies have shown that using antibiotics does decrease the duration of the illness, but only by a few days in most children.

How we Treat Ear Infections at Mindful Pediatrics

For the last 13 years, I have been treating most ear infections without antibiotics. I have observed that our bodies are pretty amazing at getting rid of bacterial ear infections, without the need for antibiotics. Like everything we do here, the whole picture must be taken into account.

In general, the AAP recommends treating all children younger than 6 months with antibiotics.  Because younger children are unable to verbalize their complaints, are more likely to have complications from ear infections, and are in general more fragile, I also tend to treat them.

For children older than 6 months, I use my clinical observation to help me decide whether or not to treat with antibiotics. Children who have been sick for a long time, or those who are very ill or in extreme discomfort, are generally treated with antibiotics to help relieve the symptoms more quickly.

When using antibiotics, I always recommend protecting the gut with an age appropriate probiotic. 

Most other relatively well-appearing children with ear infections can be watched with close follow up. The mainstay of my ear infection treatment in these cases is pain relief. I find that I heal better when I’m in less pain and discomfort, and often taking pain out of the equation is sufficient treatment for an ear infection.

Though ear infections can cause intense pain, the pain is usually intermittent and lasting for a few minutes at a time, with hours of relief between.  I generally start children on Chinese herbs (to treat the infection more naturally) and herbal ear oil drops (as long as there is no discharge coming from the ears). Up until recently, there was a topical anesthetic that could be applied in the ear, which relieved pain immediately. This has been taken off the market due to safety concerns, but a study shows that using herbal ear oil drops is just as effective as the topical anesthetic.

In addition, pain relief can be achieved with both ibuprofen and acetaminophen. I usually recommend ibuprofen for children over the age of 6 months because it tends to be more effective and lasts longer. Recommendations for how and when to use ibuprofen and acetaminophen can be found in my fever post.

Some patients find relief from pain by taking warm baths, or using a warm compress over the ear on the affected side. I find that 80-90% of my patients respond to this combined treatment approach of Chinese herbs, herbal ear oil drops, pain relief, and immune support without the need for antibiotics.

In the small percentage of cases where things do not improve within 2-3 days, or seem to be getting worse, I ask parents to follow up by phone or appointment. I then recommend possibly starting antibiotics, depending on how the child looks and feels.

If parents are concerned about not treating with antibiotics, I offer the family a prescription to take home with them. I find that a very small percentage of these families actually ever fill the prescription, but having one creates a sense of security.

The AAP recommends antibiotics for all children with ear infections in both ears and ear infections with a perforated eardrum and discharge of pus. However, I generally find that my personalized wait-and-see-with-close-follow-up approach works best for these patients as well.

Though a ruptured eardrum and discharge of pus may be frightening to parents, it is rarely a sign of a more serious infection. As a matter of fact, most children find significant relief from discomfort once the eardrum has ruptured. The body has an amazing ability to heal the eardrum without complication.

Some children seem to suffer from recurrent, frequent, or persistent ear infections that are very difficult to treat. For these children, dietary modification, proactive immune support with basic supplements and herbs, as well as cranial sacral treatments or chiropractic adjustments often seem to help.