Many sleepless nights are spent soothing children as they struggle to deal with ear infections. It’s no coincidence that ear infections are the number one reason antibiotics are prescribed in the U.S. However, there’s no need for these pesky infections to keep coming up like a greatest hits playlist from last year’s Spotify.
Agatha and Dr. Greene discuss ways to identify an ear infection, how to treat them naturally, and even ways they can be prevented. The surprising twist is that many ear infections don’t need to be treated with antibiotics at all – oftentimes they heal just fine on their own. Good news for kids and parents alike!
Join Agatha and Dr. Greene each week as they discuss common pediatric ailments and the many ways they can be treated from home.
Below is a transcript of the episode, modified for your reading pleasure. For more information on the people and ideas in the episode, see the links at the bottom of this post.
Full Episode Transcript
[00:00:00] Agatha Hi, I'm Agatha Luczo, mother of four.
[00:00:08] Dr. Greene And I'm Alan Greene, pediatrician.
[00:00:10] Agatha Welcome to Bambini Fortuna's podcast "Mom Driven"
[00:00:14] Dr. Greene "Doctor Aligned".
[00:00:15] Agatha Hello Alan, how are you today?
[00:00:17] Dr. Greene Doing well. So, start off by telling us about one of your experiences with ear infections.
[00:00:22] Agatha Yes. So, ear infections for little ones who have had challenging evenings and in the middle of the night, the kids waking up and screaming and you just want to do anything possible to help your child and to relieve the pain. How common are ear infections?
[00:00:40] Dr. Greene So I hear you about those endless nights with the kid in pain, and you just want to do something to help. And unfortunately, they're very common. Ear infections are the number one reason that kids take antibiotics. Ear infections are the number one reason that kids have surgery, and certainly, one of the most common reasons that kids wake up in the middle of the night in pain and crying. It's somewhere around 20% of kids will have an ear infection in the first year of life. By age two, it's 40%; by age four, it's 60%; and some people put that number even higher at 80%. It's a lot of kids.
[00:01:16] Agatha Those are a lot of kids.
[00:01:18] Dr. Greene And, it's especially really early in life, the peak time of ear infections is between six months old, and about two years old. And the peak season is October through about March. So, if you happen to be in that older infant, younger toddler age in the winter, that's the winter.
[00:01:37] Agatha What causes ear infections?
[00:01:39] Dr. Greene Well, to explain what causes them, I need to explain a little bit of what's going on in the ear in general. But first, I want to say ear infections are caused typically as a plumbing problem. So, it's a little hard to describe the ear without visuals here, but when you look at the hole in the ear in the ear canal, it's just a little tube that ends in the stretched tight membrane. The tympanic membrane or called the eardrum, and that's it. It ends, it's a blind pouch and water getting in there won't cause the kind of ear infection we're talking about.
[00:02:11] But behind that drum is a space filled with air. Just like any drum would have a space filled with air to transmit the sound. And that space, the middle ear is lined with tissues pretty similar to the lining of the inside of the mouth.
[00:02:24] Inside your cheek, it's moist, there's fluid that's being produced, and because of that, there has to be a drainage tube for that fluid to go out. And that drainage tube is called the Eustachian tube after an Italian guy, Eustachio. And he figured this out in the 1500's, there's a little tube that drains and keeps the pressure equal inside. So, if you change elevation, it doesn't all burst. We call the ear popping, it's just air going in or out or that Eustachian tube.
[00:02:51] So here's the thing, that goes from the middle ear to the back of the throat. And if that tube gets clogged, that's the problem. So, there's bacteria all the time in our mouth, and our nose, and that middle ear space, and generally it doesn't cause a problem. It's a good thing.
[00:03:07] Agatha Right.
[00:03:07]Dr. Greene But if the tube gets plugged, right, then the fluid builds up, the bacteria multiply, that pressure builds up in the space, there's inflammation and everything gets red in the lining of the middle ear space, the eardrum gets red, it starts to bulge. That's an ear infection.
[00:03:24] Agatha Right? So, what can parents do to help relieve that? Like is there any way to prevent the tube getting plugged up?
[00:03:32] Dr. Greene So a couple of things. Let's back up and talk maybe about what causes that to happen and that'll help .
[00:03:37] Agatha Yeah, what causes that to happen?
[00:03:38] Dr. Greene So, several things that can cause the swelling in the lining of the station to have a cold is probably the most common. When you get swelling in your nose and your throat, and also around the Eustachian tube. It could also happen if you're exposed to something that's irritating. Like tobacco smoke will do it. There's probably a couple million ear infections in the U.S. each year caused by tobacco smoke still.
[00:03:59] Agatha Wow!
[00:03:59] Dr. Greene Smoke from a wildfire or even a fireplace could do it.
[00:04:02] Agatha So allergies.
[00:04:03] Dr. Greene So, and allergies. Yes. If people have allergies, the estimates are somewhere between 25% and 40% of ear infections are triggered by swelling from allergies.
[00:04:14] Agatha Right. I mean, my daughter's ear tube was once swollen for four months, and you remember this.
[00:04:21] Dr. Greene Yeah.
[00:04:21]Agatha And she even lost over 60% of her hearing.
[00:04:25] Dr. Greene When fluid fills that space, that drum can't move very well and hearing is decreased, as long as it's there.
[00:04:31] Agatha That's right. So, we had to take out her tonsils and adenoids and put ear tubes in to finally relieve and open that up. So, ear tubes is a way as well.
[00:04:39] Dr. Greene So ear tubes is one way to do it. In fact, that was one of the original treatments, more or less. It used to be back before there were antibiotics and modern medicines that if there was a really bad earache, people noticed that if the pressure built up so much, that fluid came out, that was a little hole in the eardrum, that the pain went away instantly and they started getting better after that.
[00:05:01] Agatha Right. But it's usually the last, I remember for our daughter that it was the last solution. So, we tried the antibiotics and we tried everything to try to relieve it, but because her allergies were so intense, nothing wanted to relieve, and the swelling didn't want to go down in her ear tube.
[00:05:19] Dr. Greene Yeah, that's right. These days the ear tubes are only put in if an ear infection just won't go away with other treatment. Or, it's worth thinking about them or talking about them if you get three ear infections within six months or four ear infections within a year. It's certainly worth considering.
[00:05:36] Agatha And how can you tell when your child is getting an ear infection?
[00:05:40] Dr. Greene So, normally when you look into an ear, what you see is this translucent, really thin membrane and behind it air, and you can even see the little bones in the ear. But with an ear infection, the eardrum is red, it's inflamed, it's bulging out from pressure inside. So, you have to have that as one part of the definition of an ear infection.
[00:05:59] And the other part is, there has to be fluid inside the ear. So, there are clues though, for parents. One of them is ear infections hurt. And for an older child, they'll say, "my ear hurts". But for a kid that's not verbal yet, often the best signs are that they wake up in the middle of the night from pain or they're really fussy. Even when they're being held, they're fussy. That's something to look at.
[00:06:22] Agatha And what about if they tug on their ears?
[00:06:24] Dr. Greene Yeah, parents ask about that all the time and it's not that great a sign. Sometimes kids will tug on the ear if they've got an ear infection, but they'll often tug on the ear for other reasons.
[00:06:34] Maybe just fluid that's not infected, it's kinda itchy in there, or maybe there's a pressure change, or maybe they just like tugging on ears. A lot of babies will reach out and tug your ear and their own. And on the flip side, a lot of times when they do have an ear infection, they won't tug cause it hurts. They don't want to tug on it. So, it turns out to be not as reliable as people think.
[00:06:53] Agatha Right. I know for me, when I see my child tugging on their ear, or if they're starting to complain about, you know, their ear hurting them, one of the first things that I do is I'm a big believer in olive oil. You know, a few little drops will remedy it.
Can you speak a little bit on, like, what's the best way of treating an ear infection? What should parents do first to help their child?
[00:07:17] Dr. Greene Yeah, the olive oil remedy is a pretty traditional one. It's been used for generations. I've heard about it from people almost all over the world. And there's something that's very soothing and anti-inflammatory and a few drops on the eardrum can be very helpful. And we now know things can actually go through the eardrum and get inside. It's best that they're a little bit warm. You can take a little bottle with a dropper and roll it between your hands to get it warm. And some studies have shown that by adding other natural anti-inflammatory things in there, like garlic and Mullen and St. John's Wort, there's increased antimicrobial properties and anti-inflammatory properties. It's great. But from the medical perspective, for a long time, the treatment was, there's bacteria in the ear, the thing you have to do is antibiotics.
[00:08:02] Agatha When do you know when to prescribe the antibiotics? Cause it sounds like, I know a lot of people are prescribing antibiotics, but it sounds like we're over prescribing them and it's not necessary. When do you know when your child really needs to be on antibiotics for an ear infection? And how long can you let them go with an ear infection before giving it to them?
[00:08:25] Dr. Greene What amazing questions. So, when antibiotics were first discovered, or invented, they were so good at knocking out bacteria, and ear infections were so common. And when antibiotics were given for ear infections, kids got better. So, it became the standard that if you see an ear infection, you treat it with antibiotics and doctors everywhere did that.
[00:08:47] But a long time ago, it was back in the late 90's, I did a deep dive trying to understand ear infections. I actually wrote a book, 'The Parent's Complete Guide to Ear Infections', which was the bestselling book ever on ear infections, which says almost nothing about how good, how well the book did. But at the time figured out that, yeah, it gets better 85% of the time or so if you give an antibiotic, but it gets better about that often if you don't give the antibiotic, and began calling for a little restraint and a watch and see.
[00:09:15] Agatha And how long after?
[00:09:17] Dr. Greene Yeah. So, the Academy of Pediatrics has started to look into that as well and has guidelines, most recently in 2013. And for kids under six months, it may make sense to go ahead and treat because their ear tubes are so small and they're young and their immune system is not fully developed, so under six months treat. But over six months, consider how sick they are. If they have a high fever over 102.2, might need antibiotics. If they're in severe pain, you can't help with pain relievers, oral pain relievers, or drops in the ear, probably good to treat. If it's in both ears, the odds of getting better on its own are much less, probably good to treat. But if it's in one ear and they don't have a super high fever and you can calm the pain, it's good to wait for 48 to 72 hours to treat the pain, to help them get better before starting the antibiotics
[00:10:34] Agatha Whereas one of my other children, he doesn't show any signs of an ear in pain, he doesn't complain about his ear bothering him until it's a full-blown ear infection. But the drops did help relieve the pain and calm the inflammation down along with the antibiotics.
[00:10:51] Dr. Greene And that's the thing, either way, kids deserve pain relief. If you're going to watch and see, they absolutely deserve it. But if they're in enough pain to need the antibiotics, they absolutely deserve it as well.
[00:11:00] Agatha Right.
[00:11:00] Dr. Greene But it turns out about 90% of ear infections will get better on their own, according to a big study recently.
[00:11:07] Agatha So if you wait 48 hours to start antibiotics, will it take longer to heal?
[00:11:12] Alan Oh that's exactly what researchers thought. And so some folks set out to prove that. How quick do you have to start to make it get better? And they did this using chinchillas, because they have ears closest to human ears. And what they did is they gave them ear infections via injections so they know exactly when the ear infection started. And then they started antibiotics very quickly or a little bit delay, or quite delayed, to see how fast you need to start to get a good response. And they were shocked to find that by watching and waiting first, they got better faster at the end when they did get the antibiotics.
[00:11:47] Agatha And why would that be?
[00:11:49] Dr. Greene Well the thinking is that with that little bit of a delay, the chinchilla's own immune system geared up and joined the attack. And so that by the time the antibiotics came, they had overwhelming force against the bacteria. But if the antibiotics started right away, then the immune system wasn't triggered to gear up quite as much. And so they were fighting on their own.
[00:12:08] Agatha But I know there's different types of antibiotics as well. After starting 48 hours of antibiotics, can you use a different strength of antibiotics versus do they test on the strengths of antibiotics or the types of antibiotics given?
[00:12:24] Dr. Greene So, the 48 to 72-hour mark in ear infections is a pretty big thing. If you're watching to see and helping them get better on their own, wait 48 to 72 hours. When you start an antibiotic, it's the same thing. You don't wait seven days or ten days to check and see if they need more. If they're symptomatic still, 48 to 72 hours after starting an antibiotic, it's time to kick it up to a different strength or a different antibiotic.
[00:12:49] Agatha And did they try not giving Chinchilla any antibiotics to see if the ear infection will heal on its own?
[00:12:56] Dr. Greene In that study with chinchillas, they didn't, but there've been other tests. There's a group called Cochran that does big evidence-based analyses of things and what they looked at was something called the number needed to treat for ear infections in kids, six months old and up. Six months to two years in this study. And they took the ones, half of them did what they call, watch and wait. But I would say, treat the pain and do other good things to support them. And the other got antibiotics, and they looked at both groups and they found that you had to treat, on average, twenty kids with antibiotics for one to benefit from it. That the other 19 would've gotten better on their own.
[00:13:35] Agatha Wow, that's a lot of wasted antibiotics in a time where the resistance is up.
[00:13:40] Dr. Greene So the more that we can tailor things to kids based on them and their symptoms, the better. And the more we can help kids be pain free and help reduce inflammation and reduce swelling and trigger their immune response in the first 48 to 72 hours, the better.
[00:14:00] Agatha And is there any way to prevent ear infections?
[00:14:03] Dr. Greene I think that's one of the most important questions is how do we prevent ear infections. And it mostly is preventing the swelling of the Eustachian tube. And there's several things that have been proven. In early childhood, breastfeeding helps. Breastfed kids are less likely to get ear infections as long as they're breastfeeding, and afterwards. So, it's any bit as helpful. And if you can get them through especially in that first six to twelve-month winter period, that's really good.
[00:14:27] Agatha But what about parents that can't breastfeed?
[00:14:30] Dr. Greene Yeah, there are other things that are really good for preventing ear infections. We know that when kids older than six months old are using a pacifier, they get more ear infections. We're not quite sure why. It's probably partly the suction. When you're sucking on it, you're pulling stuff up into your Eustachian tube, and partly that the pacifier may not be entirely clean. It might bring some extra bacteria. But trying to stop a pacifier before six months for an ear infection prone kid, that can help.
[00:14:57] Keeping daycare size small can be really useful. And kids that are in daycares bigger than six people tend to get a lot more ear infections in kids in smaller groups or at home, if you can make that work. Avoiding smoke, cigarette smoke, wildfire smoke, fragrances that can cause irritation also helps a bunch.
[00:15:16] Agatha That's so great. Thank you so much. So, some takeaways for our parents today and our listeners are some ear infections need antibiotics, but obviously most don't. So, wait and listen to your child and see their symptoms. And either way, kids deserve connected support and relief from their pain. And number three, if you're able to treat an infection, naturally, the child is less likely to get another infection soon. And less likely to get an infection with a resistant bacteria.
[00:15:47] Dr. Greene Yeah, I agree with those three takeaways are very important. The first one, as you said, that some ear infections really do need antibiotics, but most don't. And the second one is either way, that kids deserve relief from their pain and connection with you, and things to help reduce inflammation and swelling.
[00:16:06] Agatha And if we can just touch on that, the relief from the pain.
[00:16:26] Dr. Greene [Ear drops are great] but if it's not doing the trick, yeah, an oral pain reliever, either acetaminophen or ibuprofen are good choices. I like ibuprofen at night because it reduces not just pain, but inflammation. And because it lasts longer through the night. So one, some do need antibiotics, most don’t. They do deserve pain relief and other support during it. And that third one that if you can treat it naturally, you're leaving the body set up for health. If you have to resort to antibiotics, I'm so glad they're available, but they mess with the microbiome, they leave you more set up for infections everywhere in the body. And if you do get infected to a more resistant organism. So how great if you can trigger your own child's immune system to heal the ear infection themselves.
[00:17:29] Agatha So great. Thank you so much. Thank you everyone for joining us today on "Mom Driven
[00:17:35] Dr. Greene Doctor Aligned".
[00:17:36] Agatha And see you next time.