Relieving children’s earaches

21 November 2018

First published October 2012

How do earaches affect babies and young children and what is the latest evidence-based management advice?

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This learning module is for health visitors, school nurses, and other community practitioners who may have a role in advising parents about treating children’s earache symptoms. It provides an overview of the management of earache in babies and young children, together with up-to-date and practical treatment advice to help you guide parents appropriately. After studying this module and completing the self-assessment, you should: 

  • Understand that earache can be distressing for babies and young children
  • Recognise the common cause of earache 
  • Be aware of the appropriate treatment options 
  • Gain confidence in recommending suitable treatments 
     

Earache (otalgia) is a common symptom and a frequent reason for consulting a healthcare practitioner. Possible causes include:

  • a foreign body in the ear
  • inflammation due to trauma, inappropriate probing, seborrhoeic dermatitis, contact dermatitis or infection of the external ear canal (otitis externa)
  • otitic barotrauma (following air travel, diving, or a blow to the ear)
  • parotitis (e.g. due to mumps)
  • enlarged tonsils or adenoids
  • referred pain from toothache, sinusitis, pharyngitis or tonsillitis.
     

However, earache in children is usually due to acute otitis media (AOM) - an infection of the middle ear. The pain of AOM can be intense and distressing and is most frequent between 6 and 15 months of age.1

WHAT IS THE CAUSE?

AOM can be caused by both bacterial and viral infections. The most common bacterial causes are Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae and Moraxella catarrhalis - commensals of the upper respiratory tract.1 The most common viral causes are rhinovirus and respiratory syncytial virus.1 Sometimes these microbes enter the air-filled cavity of the middle ear through a perforated tympanic membrane (eardrum). However, the usual route is through the Eustachian tube from the nose and throat. AOM frequently follows an upper respiratory tract infection. One in every five of children's colds is followed by AOM.When the microbes reach the middle ear, they cause inflammation of the surrounding tissue. The Eustachian tube may become inflamed and blocked, preventing drainage of pus from the infected ear. 

 

HOW COMMON IS IT?

In a 12-month study of the incidence of AOM in children under 3 years of age from a general practice population of about 10,000 patients, incidence in the first, second and third year of life was 11.5%, 28.6% and 30.8%, respectively.3 AOM accounted for 1 in 10 of all episodes of illness presented. 3 The global incidence of AOM in 2005 was estimated at 10.85%, corresponding to 709 million cases each year, with 51 % occurring in children under 5 years of age.4
 

WHY ARE CHILDREN SO SUSCEPTIBLE?

Children are susceptible to AOM because their immune systems are still developing. Also, their Eustachian tubes are shorter and lie horizontally, so microbes pass more easily through them into the middle ear. Below are the known risk factors.
 

RISK FACTORS

  • Young age
  • Exposure to tobacco smoke
  • Daycare (nursery) attendance
  • Use of formula milk (rather than breast milk)
  • Craniofacial abnormalities (e.g. Down's syndrome, cleft palate)
     

HOW DOES EARACHE AFFECT CHILDREN?
Earache due to AOM results from a build up of pressure and fluid ( effusion) behind the tympanic membrane, and inflammation in the middle ear. The fluid can interfere with the tympanic membrane's ability to vibrate in response to sound, thus causing a slight conductive hearing loss. The infection may also cause a fever (below 38°C). The intense pain, inflammation and fever can be uncomfortable and distressing, and can lead to irritability and sleepless nights for children (and their parents). 

In most cases, the symptoms settle within 2-3 days and hearing quickly returns to normal. Sometimes, the child's tympanic membrane perforates. This releases the fluid from the middle ear into the external ear canal, thus reducing the pressure and providing a welcome release from the pain. However, perforation causes a hearing loss that will not resolve until the tympanic membrane heals. This usually occurs naturally within a few weeks.
 

DOES IT LEAD TO COMPLICATIONS?

Very few children develop complications or any long-term problems, but recurrence is common. After an initial episode of AOM, children have, on average, three episodes in the following year.1 Also, following resolution of the acute symptoms, some children develop otitis media with effusion (OME) in which the fluid in the middle ear becoll1es viscous, causing a further deterioration of hearing. This condition is also known as secretory-, serous- or non-suppurative otitis media, or more commonly 'glue ear'. It is the most common cause of hearing problems in children, but it often resolves within 3 months and in 90% of children, OME resolves completely within a year.5
 

THE ROLE OF THE COMMUNITY PRACTITIONER

All community practitioners should be able to address parents' concerns and provide support. This section provides best-practice advice to help you. 

ASSESSMENT 

AOM can be diagnosed as the cause of a child's earache from a detailed history of the symptoms and by examining the tympanic membrane and external ear canal using an otoscope. Examination should help to rule out the presence of a foreign body and signs of otitis externa (redness, swelling or eczema) within the external ear canal. Both ears should be examined, starting with the normal or less symptomatic ear. A healthy tympanic membrane has a pearly sheen and reflects light. However, in babies, the tympanic membrane is often not visible due to the narrow ear canal, and symptoms may be non-specific. If the history suggests AOM but the tympanic membrane can't be seen, it is usual to assume AOM is present. 

Hearing loss is difficult to assess, but it can be helpful to observe the child's response to spoken words and ask the parents if they have any concerns. Parents may report unresponsiveness to sounds or other signs of difficulty in hearing, such as sitting close to the television or being inattentive.


COMMON SIGNS AND SYMPTOMS OF AOM

  • Earache (children may tug or rub the affected ear) 
  • Fever (>38°C)*
  • Irritability, crying, poor feeding and restlessness
  • Slight hearing loss
  • Coughing and nasal discharge (or a recent history of these)
  • A distinctly red, yellow or cloudy tympanic membrane
  • Bulging of the tympanic membrane
  • Ear discharge (if the tympanic membrane ruptures)
     

 

DIFFERENTIAL DIAGNOSIS 

The sudden onset of the signs and symptoms of infection associated with AOM allows it to be distinguished from:

  • Myringitis: Inflammation and mild redness of the tympanic membrane
  • OME: Fluid in the middle ear behind an intact tympanic membrane, without symptoms of acute infection
  • CSOM: Persistent inflammation of the middle ear without pain and fever, associated with a perforated tympanic membrane draining exudate for more than 2 weeks
  • Acute mastoiditis: Redness and swelling behind the ear. The ears may be displaced outwards and downward. There may be narrowing of the external ear canal.

ALARM SIGNS 

Urgent paediatric assessment is required if the child:
•    is less than 3 months old and has suspected AOM or a temperature 2'.38°C 
•    is less than 6 months and has a temperature 39°C 
•    has suspected complications, such as meningitis, mastoiditis or facial paralysis

REFERRAL

Community practitioners may be able to help identify a problem before the GP is aware of it and can help ensure children receive appropriate attention. However, referral from the GP may be necessary if a diagnosis cannot be confirmed, or if further assessment or management are needed. 
 

CSOM

A child suspected to have CSOM needs prompt referral to an ear, nose and throat (ENT) specialist. A specialist opinion is required to confirm the diagnosis and assess the risk of complications. If CSOM is confirmed, the infected ear is usually cleaned out and antibiotic therapy is initiated. 


OME
Where OME is diagnosed, it is usual for the clinician to follow a period of'active observation' over a period of 6-12 weeks. Children are referred to an audiologistor a formal hearing test if OME persists, or if the child appears to have significant difficulty hearing, or their development, social skills or education appear to be affected. An accurate assessment of hearing is required in order to assess further referral and treatment options. Assessment of the child's speech and language may also be required. 
Treatment may involve draining the fluid from the middle ear by means of a myringotomy and insertion 
of grommets (ventilation tubes). If the adenoids are enlarged, an adenoidectomy may also be performed. Hearing aids may be considered where surgical intervention is inappropriate or unacceptable. 

Acute mastoiditis
Children with acute mastoiditis require management in hospital. They are usually given broad-spectrum intravenous antibiotics for 1-2 days followed by oral antibiotics for a further week or two. Some children may also need mastoidectomy and tympanoplasty. Mastoiditis is serious, but most children make a full recovery. 

TREATMENT OPTIONS 
A suitable antipyretic analgesic can be given to help relieve earache and fever. Antibiotics are not prescribed routinely for AOM, because many cases (especially those accompanied or preceded by respiratory symptoms) are viral infections and the majority resolve without antibiotics in 2-3 days. Topical antibiotics have not proved to be effective in AOM, so these are not advised.7 Although there is limited evidence that topical analgesics containing lidocaine can provide short­term pain relief in AOM, the evidence is insufficient to recommend them.1

Eardrops containing olive oil will not help AO!yl and should not be used if the tympanic membrane has perforated. There is no evidence that holding either a warm or cold compress to the ear is effective. However, a child may find a compress soothing, and it is unlikely to cause any harm. If a child has a fever, the parent should be advised how to keep their child cool and hydrated, and when to seek further medical advice (in accordance with NICE guidance).6

 

Antipyretic analgesics

Ibuprofen and paracetamol are both licensed for the relief of earache and fever. Both medicines have favourable safety profiles, and cause few adverse effects when used according to the instructions, and they both provide effective relief from pain. In a multi­centre, double-blind and controlled study on 219 children aged 1-6 years, ibuprofen (10 mg/kg) was as effective as paracetamol (10 mg/kg) in reducing pain associated with otitis media. 8 However, ibuprofen has additional anti­inflammatory properties and is more effective than paracetamol at reducing a fever from 4 hours post-dose.Ibuprofen starts to relieve a fever in just 15 minutes (with a 10 mg/kg dose), lasts for up to 8 hours, and is clinically proven to last longer than paracetamol. Therefore, where suitable, parents may want to consider using ibuprofen first. 


Parents should use an easy-dosing syringe (available with some paediatric formulations) or a medicine spoon to give the appropriate dose (see Tables 1, 2 and 3). 

Antibacterial therapy

There is some evidence that antibiotics can reduce pain and fever after 2-7 days compared with placebo, and limited evidence that they reduce the risk of mastoiditis.1 However, the benefitsare marginal and have to be balanced against the increased risk of adverse effects and future treatment failure due to antibiotic resistance. Therefore for most children, when AOM first develops, it is usual to advise a 'wait and see' approach for 2-3 days. The child's immune system should quickly clear the infection without the need for antibiotics. 

The parent should be advised to see their GP if their child's symptoms don't improve within 2-3 days or if there is a significant worsening of symptoms at any time.

 

SUCCESSFUL MANAGEMENT

With guidance and reassurance, parents can learn to manage their children's earache symptoms appropriately. These case studies provide ideas to help you guide parents.


Situation 1

Billy is 3 years old. He is normally 5 healthy but has recently had a cold and this morning he has a right-sided earache and a slight temperature. His mother, Anna, has spoken to her GP who has diagnosed AOM and advised Anna to give Billy an antipyretic analgesic. Anna asks you if Billy needs antibiotics and whether Billy can attend nursery this afternoon. 

POINTS TO CONSIDER 

Most cases of AOM resolve within 2-3 days without antibiotics. For simple cases of unilateral AOM in a 3 year old who is normally fit and healthy, it is usual to follow a 'wait and see' approach, whilst relieving the symptoms using a suitable antipyretic analgesic.
NICE recommends keeping children away from nursery (or school) while they have a fever. 


SUGGESTED ACTION 

Reassure Anna that Billy's earache should resolve on its own within 2-3 days and encourage her to consider giving Billy a suitable antipyretic analgesic to relieve his pain and reduce his raised temperature. Explain that antibiotics are only needed if the earache doesn't settle. Advise Anna to see her GP if the symptoms don't resolve within 2-3 days or if Billy develops any worrying symptoms. Following an assessment, the GP will recommend an appropriate course of action.

Explain that nurseries are not equipped to care for unwell children. Advise Anna to tell the nursery that Billy is unwell and to keep him away from nursery until his symptoms resolve.

Situation two

Claude's son Alfie is 7 months of age. The GP has diagnosed AOM. Claude intends to treat Alfie's pain and fever with an oral ibuprofen suspension  (100 mg/5 ml). He wants to know how quickly Alfie's symptoms should resolve.  
 

POINTS TO CONSIDER 
Provided there are no contra­indications, parents can consider using either paracetamol or ibuprofen to relieve earache and fever. Ibuprofen can start to relieve a fever in just15 minutes (with a 10 mg/kg dose).


SUGGESTED ACTION 

Explain that the underlying infection should start to resolve within 2-3 days, but that ibuprofen can start to relieve Alfie's fever in just15 minutes. Check Claude understands how much ibuprofen he should give (for a child who is 7 months old, the usual dose is 2.5 ml three to four times a day, if required) and that he should administer the appropriate dose using a medicinespoon or easy dosing syringe. Tell Claude to read the instructions for using the medicine carefully and point out that he shouldn't give Alfie ibuprofen for longer than 3 days. If Alfie's symptoms persist or worsen, Claude should consult his GP.
 

Situation three

Rosie is 4 years old. She has had several 5 episodes of AOM over the last year and another episode has started this evening. Rosie's ear is painful and she has a fever. Rosie's father, Dan, is concerned that Rosie won't be able to get a good night's sleep. What advice could you give?

 

POINTS TO CONSIDER 

After an initial episode of AOM, children have on average, three episodes of AOM in the following year. Parents can consider using either ibuprofen or paracetamol to relieve earache and fever, but ibuprofen lasts longer than paracetamol for fever relief. 

SUGGESTED ACTION 

Reassure Dan that Rosie's ear infection should resolve in 2-3 days and that the frequency of recurrence should reduce as Rosie gets older. Explain to Dan that he can considerusing either ibuprofen or paracetamol to relieve Rosie's earache and fever, but that ibuprofen offers fever relief for up to 8 hours, which will therefore help to provide Rosie with all night fever relief. IO 
If relevant, explain that AOM is particularly common in children exposed to tobacco smoke and encourage Dan to keep Rosie's environment smoke. 

Make sure parents know that an ear infection can cause hearing problems for a few weeks. Encourage parents to speak clearly to their child, face-to-face and keep background noise to a minimum. Parents may wish to consider discussing seating arrangements with their child's school -ideally placing the child close to the teacher. Young children may be bewildered by the loss of hearing and need reassurance. If the child's hearing doesn't return to normal within a few weeks, or the parent has any other 
concerns, advise them to see their GP.

 

References

1. CKS (2009) Otitis media - Acute. NHS Clinical Knowledge Summaries. Available at: www. cks.nhs.uk/otitis media acute [Accessed 1 June 2012].
2. CKS (2007) Common cold. NHS Clinical Knowledge Summaries. Available at: www.cks.nhs.uk/common cold [Accessed 1 June 2012]. 
3. ROSS AK et al (1988) Incidence of acute otitis media in infants in a general practice. Journal of the Royal College of General Practitioners 38:70-72. Available at: http://ukpmc.ac.uk/articles/ PMC1711282 [Accessed 1 June 2012].
4. MO NASTA Let al (2012) Burden of disease caused by otitis media: Systemic review and global estimates. PLoS ONE 7(4):e36226. Available at: www. ncbi.nlm.nih.gov/pmc/articles/ PMC3 34034 7 /?tool= pubmed [Accessed 1 June 2012].
5. PRODIGY (2011) Otitis media with effusion. PRODIGY. Available at: www.prodigy.claritv.co.uk/otitis media with effusion [Accessed 1 June 2012]. 
6. NATIONAL COLLABORATING  CENTRE FOR WOMEN'S AND CHILDREN'S HEALTH (2007) NICE Clinical Guideline 47. Feverish illness in children - Assessment and initial management in children younger than 5 years. London, RCOG Press. Available at: www.nice.org.uk/CG47 [Accessed 1 June 2012].
7. PAEDIATRIC FORMULARY COMMITTEE (2011) Section 12.1.2 Otitis media. In: BNP for Children 2011-2012. London, BMJ Group, Pharmaceutical Press and RCPCH Publications Ltd. Available at: www.bnfc.org rAccessed 1 June 2012].
8. BERTIN Let al (1996) A randomized, double-blind, multicentre controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children. Fundam Clin Pharmacol 10(4):387-392.
9.  PELEN Fet al (1998) Treatment of fever. Monotherapy with ibuprofen. Ibuprofen paediatric suspension containing 100 mg per 5 ml, multi-centre acceptability study conducted in hospital (in French). Ann Pediatr 45(10):719-728.
10. KELLEY MT et al (1992) Pharmacokinetics and pharmacodynamics of ibuprofen isomers and acetaminophen in febrile children. Clin Pharmacol Ther 52(2):181-189.
 

 

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