My phone rang around 11 pm. I was on call covering our clinic so the late night call wasn’t surprising. “Hello,” I said kindly, in spite of rolling out of bed, trying to catch a little sleep in case I had to admit a patient to the hospital over night. I anticipated it might be a worried patient on the other end of the line and a kind voice can go a long way toward reassurance.
Sure enough, an anxious mom responded “Hello, Dr. Romm?” I could hear a toddler’s slight coughing in the background.
“Dr. Romm, I’m so sorry to bother you at night… My daughter Janie is almost 2. She’s had a temperature of a max of about 100.2 since this afternoon, and she’s been fussy and pulling on her right ear since just after dinner. Before that she was playing with her older brother, but by dinner she was cranky and didn’t eat much. She’s clingy. She’s taking juice and water which I’ve been giving her to keep her hydrated, and I gave her a Tylenol about an hour ago just to see if it would help her sleep. Her fever has been down to 99.6 since then and she’s settled down some. My son has had ear infections before, and both kids have had a cold for a few days. I’m a bit worried and don’t know if I should bring her to the emergency department or whether she needs an antibiotic right away. My son has gotten antibiotics every time he’s had an ear infection, so I just didn’t know what to do…
Hi Natural Mommas,
I know it’s super confusing to figure when your little one actually does – or doesn’t – need an antibiotic for an ear infection. I’m here to help you sort that out. In this article I’ve laid out the basics of ear infections, exactly when using antibiotics is appropriate, and my go-to natural treatments.
Here’s how it really rolls in my own practice…
Ear Infection Basics
Acute otitis media (AOM) refers to those typical painful ear infections kids get with fevers and upper respiratory infections – and that’s what we’ll be focusing on in this article.
AOM is generally mildly to severely painful, making most babies and children fussy and irritable. Typically your child will start out with a cold, especially a runny nose, but occasionally the earache seems to come out of nowhere. There is often a fever. Younger children may pull on their ears or may scream or cry suddenly and unexpectedly; older children will generally tell you that they have ear pain. Ear infections are super common in kids under 12, and especially before grade school. Viruses generally cause them.
As I discussed in Part 1, antibiotics are highly over prescribed for kids with ear infections, and can lead to
- Serious resistant infections in your child, for example, pneumonia
- Can cause antibiotic reactions, and
- May cause long-term consequences including asthma, allergies, and inflammatory bowel disease
Antibiotic overuse also contributes to the global problem of antibiotic resistant infections.
But when it’s your kid that’s sick all you want to do is the right thing to keep him healthy and safe. So what should you do?
When to See Your Doctor
Any time you are seriously worried about your child, it is absolutely appropriate to call or make an appointment to see his doctor. Like most docs who take care of kids, I never mind getting a late night call or an office visit from a worried parent.
When I received the call mentioned earlier, I reassured Janie’s mom that since Janie had a cold, was able to be settled easily with only one age-appropriate dose of Tylenol, and had what I would consider a low fever at its highest (did you know that below 100.2 is not medically considered a fever?), this was likely a mild case of an ear infection and that waiting and watching overnight would be totally safe and appropriate.
I asked her to please call me back if Janie got worse. But if by morning she was better or even about the same, she could continue to wait and watch – but that at this point, and in most cases of acute otitis media, no antibiotics were needed. We discussed the safe use of Tylenol and ibuprofen, since she didn’t have any herbal remedies for pain relief at home (stocking a home herbal medicine chest is a great idea and will be discussed in a future blog and will be extensively covered as a whole lesson in my course Pediatrics for Parents – coming soon – I’ll tell you when!).
Here’s when I absolutely ask my patients to bring their little one in for a look-see:
- Your child is under 6 months old
- There is pain that won’t resolve
- There is high fever (> 39 C or 102.2 F) and persistent ear pain
- There is drainage from the ear
- There is neck pain or stiffness
Janie, whose momma called me, met none of these criteria. Watching and waiting at home was safe – and actually best – for her baby.
When Are Antibiotics Needed?
The latest guidelines from the Academy of Medicine have come around to recommending what natural practitioners have known for a long time – that prevention and a watch-and-wait attitude are the best approaches for most kids with ear infections, most of the time. The new guidelines encourage doctors not to overuse antibiotics.
Antibiotics are recommended for:
- Babies under 6 months old, or babies 6-23 months old with ear infection of both ears
And any children with severe infection defined as:
- Rapid onset of symptoms
- Moderate or severe ear pain
- Ear pain lasting 48 hours, and
- Signs of an ear infection on exam
- Temperature > 39°C [102.2°F])
The American Academy of Pediatrics and Centers for Disease Control and Prevention (CDC) agree: Both recommend a watch and waiting period of 48-72 hours to see if mild ear infections in babies over 6 months resolve on their own before using an antibiotic.
When there is ear pain, treatment to reduce pain – not antibiotics – should be recommended unless there is a severe ear infection. Antibiotics should never be prescribed preventatively to reduce the frequency of AOM episodes in children with recurrent AOM. Keep in mind that just because antibiotics are recommended, it does not always mean they are necessary. Use good common sense and talk with your child’s doctor if your child meets these criteria but you’d like to try natural approaches before the antibiotics.
Here’s What I Tell My Patients
Most ear infections are self-limiting – that means they go away with time, patience, and supportive therapies.
Amazingly, approximately 80% of kids with acute otitis media get better without antibiotics in 2-7 days! Not only that, they have no increased risk of hearing problems, ear infections in the other ear, or need for more invasive medical intervention. Also, they do not have any of the adverse outcomes that kids who received antibiotics experienced – including the development of antibiotic resistant pneumonia. Those who went on to need antibiotics did just as well as kids who had received them from the onset of infection.
So a watch and wait attitude with some comfort measures is often all that’s needed. But if your child doesn’t recover in 48 or so hours, or worsens, an antibiotic can still be prescribed. Let’s check in in 24 hours and see how things are going. You can speak with my nurse, and if she feels things aren’t improving, she’ll put you through to talk with me and we’ll figure out the next steps together.
In the meanwhile, you might want to consider natural therapies and comforting treatments. I’ve used natural remedies for kids’ ear infections for 3 decades and have not been disappointed! Herbal treatment can work quite well to relieve earache symptoms and infection. These are the first-line treatments I suggest to my own friends and family – in addition to my patients.
What can you expect? With a combination of the following approaches, ear pain and associated symptoms usually start to improve within a few hours, and are almost or completely resolved by 48 hours. Again, I always tell my patients to come see me if symptoms get worse or don’t improve noticeably within 48-72 hours.
For reducing pain:
- Use a hot water bottle wrapped in a towel (to avoid burning your child) can bring a lot of comfort to a painful ear. Let your child sleep on a slightly filled hot water bottle – if it is overly full it will be too firm to rest on comfortably. (Do NOT use a heating pad.)
- Give firm but gentle massage all around the jaw and head in the area adjacent to the ear. Massage in a downward direction behind the ear on the neck and apply gentle inward pressure in front of the ear toward the cheek (about where sideburns would be). This will facilitate drainage of ear fluids and stimulate pressure points in the area. It may be uncomfortable to your child so do it a few times a day for short periods.
- Give Children’s Herbal Compound (Herb Pharm) every 1-4 hours depending on the pain severity. Their formula contains chamomile, lemon balm, catnip, and fennel. It is very soothing and also helps with fever symptoms. For babies the dose is ¼ teaspoon, for children 2-6 ½ tsp., and for older children even up to 1 tsp. each time. It can be diluted in water, and is quite tasty. You can get it on Amazon. Of course, you can also make your own tincture or tea using these same ingredients if you prefer.
- You can always give children’s doses of Tylenol or ibuprofen if needed. The herbs, which I prefer, are gentler and safer, but don’t necessarily work as quickly. I try to avoid things that reduce the fever much, because fever is an important natural process for fighting infection.
In addition to the above, I like a combination of Garlic Mullein Oil in the affected ear, and a combination of Elderberry Syrup- Echinacea- and Anise Seed Blend to boost the immune system and break up upper respiratory congestion.
Garlic-Mullein Earache Oil
The classic herbal remedy for ear infections is garlic-mullein oil. Garlic is a natural antimicrobial, addressing infections of both a bacterial and viral nature. Mullein is an analgesic, relieving the pain associated with earaches. It’s very easy to make at home or can be purchased.
To prepare garlic mullein oil, place one whole bulb of finely chopped fresh garlic and 1 oz. of mullein flowers in a pint-sized jar. Add olive oil until the jar is full. Stir with a chopstick or the handle of a wooden spoon to release air bubbles. Cover the jar and place in the sunlight for 3 weeks (2 weeks in warm weather). Strain into a clean jar (discard plant material) and store in the refrigerator. This will keep for up to two years.
To use place 3-7 drops of the oil into the affected ear while the child lays on his side with the affected ear upward. The oil should be at room temperature or slightly warm. To warm it, put the drops in a spoon or a glass eyedropper and briefly hold a lit match close to it. Test the oil against the underside of your wrist to make sure it is not too hot. Have the child rest with the affected ear up for 5-10 minutes, keeping a warm hot water bottle on the ear. After this time let the child roll over and rest on the hot water bottle for as long as this brings comfort. Repeat on the other ear if necessary. This treatment can be repeated 2-3 times a day but may only be necessary once or twice as it is very effective.
NOTE: NEVER PUT ANYTHING INTO THE EAR IF YOU SUSPECT THE EARDRUM HAS RUPTURED OR IF THERE IS ANY DRAINAGE FROM THE EAR.
Echinacea -Elderberry Syrup-Anise Seed Blend
You will need to purchase each of these products separately, and then mix them in equal parts (1/3 each) into a clean glass bottle. A medicine bottle with a dropper is ideal. This blend can be given preventatively starting during the season your child is most apt to ear infections, or at the start of an upper respiratory or ear infection. For prevention I give 1-2 teaspoons daily for children 2 and over (1/2 of that dose for babies), and or an acute infection, I give ¼-1 teaspoon 3-4 times daily, depending on severity. Continue at the preventative dose several times a week after all symptoms have cleared to prevent relapse. This product will stay good for a couple of years if stored in a cool, dark area. For babies under 1, make sure the Elderberry syrup is made without honey.
If your little one isn’t improving, or is getting worse, you can always start conventional treatment! But you might be delighted to find that you don’t need to!
- Keep your child well hydrated, preferably with water and non-caffeinated herbal teas.
Here’s when an antibiotic is appropriate:
- If your child’s eardrum looks angry, red, and bulging. Because there is enormous variability in skill amongst doctors when it comes recognizing a true ear infection – even with a proper otoscope exam, they are likely to be over diagnosed.
- If your child has severe symptoms and for some reason an effective ear exam is impossible to conduct (inconsolably screaming baby, narrow ear canals), it is also okay to prescribe an antibiotic
- In babies younger than 6 months old with severe signs or symptoms
- In children ages 6 months to 2 years with severe infection or if they have infection in both ears at once
- In children aged 6 to 24 months with non-severe ear infection, either antibiotic therapy or observation with close follow-up is appropriate.
- Antibiotic therapy should be started if symptoms worsen or fail to improve within 48 to 72 hours after onset.
As parents we have to do our part in the process of reducing antibiotic overuse – be informed and work in partnership with our children’s’ physicians – which sometimes may even mean educating them on antibiotic overuse (a great resource is CDC Get Smart!) . If you want to try alternatives, set up a reasonable plan for follow-up and switching to the antibiotic if needed, and offer to sign a waiver or informed consent that your doctor has explained the options and you have chosen the watch-and-wait approach.
Remember to refer back to Part 1 of this article for the prevention of ear infections! I’ll be sure to let you know when my amazing course, Pediatrics for Parents, is available. You’re going to love it! Now let me know how you roll with ear infections with your kids in the comments section below!
To your family’s good health,
Hersch A et al. Antibiotic Prescribing in Ambulatory Pediatrics in the United States. Pediatrics 128:6, 2011.
Kummeling, I et al. Early Life Exposure to Antibiotics and the Subsequent Development of Eczema, Wheeze. Allergic Sensitization in the First 2 Years of Life: The KOALA Birth Cohort Study. Pediatrics 119;e225, 2007.
McCormick, D et al. Nonsevere Acute Otitis Media: A Clinical Trial Comparing Outcomes of Watchful Waiting Versus Immediate Antibiotic Treatment. Pediatrics 115:1455–1465, 2005.
Plasschaert, A. Trends in Doctor Consultations, Antibiotic Prescription, and Specialist Referrals for Otitis Media in Children: 1995–2003. Pediatrics 117;1879, 2006.
Romm, A. Overprescribing of Antibiotics for Children’s Upper Respiratory Infections, Alternative and Complementary Therapies, 17:6, 2011.