Do Kids Need Antibiotics for Ear Infections?

By 3 years old, 50-85% of children have been diagnosed with at least one episode of AOM. It is the most frequent reason why children receive antibiotics.

Take-home points

Prevent ear infections by avoiding tobacco smoke, formula, and minimizing use of pacifiers
Reduce risk of infection by providing breast milk, a nutrient-dense diet, plenty of outdoor exposure and adequate sleep
During times of infection, use natural immune boosting treatments such as echinacea, elderberry, vitamin C, propolis and raw garlic
For an active ear infection, try applying warmth to the ear, garlic-mullein oil (ear drops), xylitol nasal spray and probiotics
For children who are not showing signs of systemic illness, do not have immune deficiency and do not have anatomic anomalies, most episodes of acute otitis media will self-resolve

If you are mainly here looking for natural alternatives to antibiotics, please see my recommendations for alternative treatments.

Page contents:

Why is ear infection so overdiagnosed?

What causes ear infections?

Risk factors and protective factors

Does your child need antibiotics?

What is the risk of giving antibiotics?

What can we do instead of giving antibiotics?

“My 11-month-old has had fevers, runny nose and cough for a few days. I brought him to his pediatrician yesterday, who diagnosed him with an ear infection and prescribed antibiotics (Augmentin). We haven’t filled the antibiotic prescription yet, and the fever has already gone away. Does my child need antibiotics for an ear infection?”

Sarah, Jordan’s mother

Jordan’s been diagnosed with acute otitis media (AOM); it’s an inflammation or infection of the middle ear, the part behind the ear drum. Acute otitis media is one of the most overdiagnosed and overtreated conditions in children. (1,2,3)

Why are ear infections so overdiagnosed?

There are several explanations. One of the main reasons is that health care providers often diagnose AOM even when there are no clear signs of infection (1). To diagnosis acute otitis media, the child must have a middle ear effusion (which is fluid behind the ear drum) and evidence of inflammation of the middle ear. Signs of inflammation include bulging of the ear drum or ear discharge draining from the ear (in a patient who does not have swimmer’s ear, which can also cause discharge). (5 ,6)

Often, the diagnosis is made only based on the presence of fluid, which can be present without infection. A diagnosis may also be made based solely on redness of the ear drums with no bulging, but infection is not the only cause of red ear drums. For example, red ear drums can be caused by fever itself, a viral infection with congestion, crying, or trauma to the ear drum (including from the doctor scraping wax out of the ear canal to see the ear drum or from the child sticking something into his ear).

The clinician is often swayed by the caretaker’s story of the child tugging on their ears (which kids do for several reasons other than infection), or they are looking for something to explain the fever and have a low threshold to call the illness an ear infection. Another clinician may do the same exam and find no signs of infection.

When I worked in inpatient pediatrics, I frequently saw emergency room physicians diagnose children with AOM. However, when we would examine those children very shortly after, we saw no signs of ear infection. To put it plainly, there is inconsistency in interpretation of the exam.

What causes ear infections?

Usually the child first has a viral upper respiratory tract infection (a cold that may cause nasal congestion, runny nose, sore throat and/or cough). This causes swelling of the Eustachian tube, which is the tube that allows fluid to drain from the middle ear to the upper part of your throat connected to your nose (called the nasopharynx).

When the Eustachian tube gets blocked due to this inflammation, it causes poor ventilation of the middle ear and negative middle ear pressure. This leads to accumulation of fluid in the middle ear, which allows viruses and bacteria to grow in there and cause infection.

Risk factors and protective factors

Risk factors:

Secondhand exposure to tobacco smoke
Pacifier use
Anatomic anomalies such as cleft palate (although there is data showing breast milk can help decrease risk in children with cleft palate), down syndrome
Immune dysfunction (7)
Formula feeding (especially within the first 6 months) (8)

Protective factors:

Breastfeeding protects against ear infection through many mechanisms (9, 10, 11, 12, 13):

Allows important bacterial and hormonal interaction between the mother and baby, which helps promote changes in breast milk to specifically address active infection
Antibodies present in mother’s milk
White blood cells in breastmilk that help fight infection
Immune factors such as lactoferrin and interleukins-6 -8, and -10
Prebiotics and probiotics in breast milk that are critical in establishing a healthy gut microbiome
The development of facial musculature associated with breastfeeding and position maintained during breast feeding in contrast with bottle feeding
Leads to less bacteria that cause ear infections taking residence in the kids’ respiratory tract or ear (11)

In addition to breastfeeding, there are many aspects in diet and overall lifestyle that can help prevent infection. Below is a brief summary. For more detailed information, see my article on boosting the immune system by strengthening your child’s immune health.

Does your child need antibiotics?

According to the American Academy of Pediatrics (AAP) guidelines, “watchful waiting” can be used for children over 6 months old with non-severe AOM. This means that in most cases, we can give the ear infection 48 to 72 hours to resolve on its own because more than 80% of infections will resolve on their own.

However, they do recommend antibiotics for:

All children who do not improve within that time frame
AOM in children under 6 months old
Children under 2 years old with acute otitis media on both sides
All children with severe otitis (which they describe as severe pain, pain for over 48 hours or fever over 102 °F).

The committee behind the guidelines based these recommendations on studies that show benefit of antibiotics in those cases. The main benefit that was focused on in the included studies was the time it took for pain to resolve. Another benefit was the potential for antibiotics to prevent infection from occurring in the opposite ear.

There are many questions that arise in response to those recommendations.

If the pain doesn’t resolve in 48 hours, are antibiotics the only option? If the pain is severe, will it not resolve without antibiotics? In cases in which the ear infection is not due to bacteria, the antibiotics will not help resolve the otitis at all. Even in bacterial ear infection, the pain — even if severe — will likely resolve on its own. If not, it will likely resolve with natural treatments.

Does fever over 102 °F indicate the ear infection will not resolve without antibiotics? No, the body is just elevating the temperature to fight the infection. There is not a magic cut-off point in temperature that indicates the ear infection cannot resolve on its own.

Otitis media is commonly due to viral infection (14). In some cases, allergic rhinitis, especially due to food allergies (e.g. allergy to pasteurized dairy), can cause recurrent ear infection because the allergic rhinitis contributes to obstruction of the Eustachian tubes in children. (15, 16, 17) In both cases, antibiotics will not treat the underlying cause.

One might assume that antibiotics are necessary for bacterial infection, which can occur after a viral upper respiratory tract infection. However, even in these situations, most otherwise healthy children in high-income countries will clear the infection on their own within 48 hours with no complications. (3)

There may be situations in which antibiotics are necessary:

Signs of systemic infection (the child appears very unwell with signs such as lethargy, mottled skin, fast breathing, racing heart rate)
The child does not have normal immune function
Anatomic anomalies in their facial/ear structure make it difficult for the body to clear the infection

However, the majority of children will clear the ear infection on their own.

So, what drives health care providers to routinely prescribe antibiotics for ear infection? In medical school, we are taught that there could be frightening complications, such as spreading of the infection to the skull or brain. This could result in mastoiditis (infection of the mastoid bone behind the ear), meningitis (infection of the membranes covering the brain) or brain abscess. Yet, in high-income countries, it is extremely rare for healthy children without compromised immune systems to develop complications from AOM.

In fact, in a study comparing antibiotic treatment to placebo, the placebo group had a lower rate of recurrent otitis media, meaning antibiotics actually may have increased risk of recurrent ear infection. Most likely, the antibiotic treatment changed the gut microbiome, reducing the ability of the child’s immune system to fight infection.

According to one study, only one child in 20 being treated with antibiotics will see even a slight benefit (18). In another study, a meta-analysis (a study combining data from multiple studies) found that 86% of children had resolution of their pain without antibiotics at 2 to 7 days after seeing their health care provider. For children who had been prescribed antibiotics, 92% had resolution of their pain at 2 to 7 days after seeking care. (19)

When the study’s authors summarized the results, they stated, “To prevent one child from experiencing pain by 2-7 days after presentation, 17 children must be treated with antibiotics early.” Putting that in perspective, 16 out of the 17 children being treated with antibiotics would not benefit from the antibiotics. (19)

The other argument for antibiotics is to prevent complications from the ear infection such as mastoiditis. Mastoiditis is rare. There aren’t many studies evaluating risk. There is even less data on the very rare complications of meningitis and brain abscess.

The incidence of mastoiditis decreased dramatically over the last century from 50% to 0.2%. Since the 1990s, there were several small studies showing an increase in incidence. This increase has been attributed to guidelines that no longer recommended immediate use of antibiotics.

However, a larger study from Australia found no increase in incidence of mastoiditis despite decreasing rates of antibiotic prescription for otitis media in their population. The takeaway is that although mastoiditis may be related to ear infection, it may not be prevented by antibiotic usage. (20)

Yet another study showed that antibiotics decreased mastoiditis occurrence by 50%, from 3.8 to 1.8 cases per 10,000. This translated into treatment of 4,831 otitis media episodes with antibiotics to prevent 1 child from developing mastoiditis.

According to the authors of that study, “The high number of episodes needing treatment to prevent 1 case precludes the treatment of otitis media as a strategy for preventing mastoiditis. Although mastoiditis is a serious disease, most children make an uncomplicated recovery after mastoidectomy [removal of infected cells/ bone] or intravenous antibiotics. Treating these additional otitis media episodes could pose a larger public health problem in terms of antibiotic resistance.” (21)

That doesn’t even take into account all of the significant health risks posed to the child from the antibiotics (discussed below).

There is not a lot of data on meningitis from AOM. One study that looked at the relationship between meningitis and AOM or otitis media with effusion found no relationship between bacterial meningitis and AOM. They examined patients with meningitis and did not find evidence of otitis media in any of the children, even those with hearing loss. (22)

At a pediatric ear, nose and throat conference, during a lecture titled “Sequelae of otitis media,” the presenters stated “Antibiotic treatment of acute otitis media is certainly not an absolute safeguard against the development of complications.” (23)

For decades, doctors have treated otitis media to prevent these rare complications because intuitively one would think that antibiotics would prevent spread of the disease from the ear canal. However, that has not been consistently shown.

We have probably been treating millions of children for ear infections that would have resolved by themselves without complication.

For those who did have complications (in high-income countries), they likely have other factors at play leading to those outcomes such as lack of optimal immune function or anatomical issues leading the infection to spread instead of resolve.

If antibiotics were harmless (and they were viewed that way for many decades), then taking antibiotics would be the “safe” approach even if most children didn’t need them.

However, now that we know how antibiotics can impact the immune system — putting children at risk for further infections and most pediatric and adult chronic diseases — this approach has to be questioned even further as the risk outweighs the benefit for most children.

What is the risk of giving antibiotics?

The main issue often brought up is that the more bacteria are exposed to antibiotics, the more antibiotic resistance is emerging. On a global scale, the rise of strains of bacteria resistant to antibiotics is concerning because it can lead to infections for which we have no antibiotics to treat.

The estimated numbers are hard to pinpoint without clearly accurate data, but most sources list the number of deaths attributed to antibiotic-resistant infections to be several million each year.

More immediately concerning to parents than the global issue is that the individual child exposed to the antibiotic can then be susceptible to more antibiotic-resistant strains of infection, creating infections that are harder to treat. This is what is being seen in cases of ear infection; patients are being unnecessarily treated with antibiotics. This is why doctors often need to escalate to broader antibiotics when a child has a recurrent ear infection.

However, the main issue that is often not addressed is the threat to that child’s health from significant disruption to their gut microbiome in its most critical period (the first three years of life).(24, 25, 26)

Once some beneficial organisms in the gut microbiome are eradicated by antibiotics early in life, they may never re-appear.

Disruption of the gut microbiome (also known as dysbiosis) is linked to almost every chronic disease in children and adults. According to Dr. Martin Blaser, an infectious disease expert, leader in microbiome research and author of the book Missing Microbes, overuse of antibiotics, especially in young children, has led to the spread of metabolic and autoimmune diseases, including asthma, food allergies, eczema, and inflammatory bowel diseases (ulcerative colitis and Crohn’s disease).

In fact, he co-authored a study of over 14,000 children and found that:

Antibiotic exposure in the first 2 years of life was associated with increased risk of asthma, allergic rhinitis, atopic dermatitis, celiac disease, being overweight, obesity, attention deficit hyperactivity disorder, autism and learning disorders.

There was higher risk for earlier exposure, and the risk increased with each additional antibiotic course. (27)

Ironically, children treated with antibiotics are also at risk for recurrent otitis media, likely due to disruption of the gut microbiome impacting immune function. Treating a child with antibiotics for ear infection may actually make them more susceptible to another episode of ear infection and other infections in the future.

It may also disrupt their nasal microbiome, which puts them at higher risk for otitis media. (28) As mentioned earlier, antibiotic treatment also puts children at risk for chronic medical diseases that are quickly rising in prevalence.

What can we do instead of giving antibiotics?

Prevention is always the best method. Limit the risk factors, especially secondhand smoke exposure and formula feeding (if unable to breastfeed, donor milk can be an option). However, since you are reading this article, you are probably at a point where you are looking for treatments for an existing ear infection.

Since most children will clear an ear infection on their own, treatments should be aimed at supporting the immune system to function at its best and providing pain control.

As far as natural remedies for the ear infection itself, there are not a lot of studies. More studies have been performed on prevention rather than on treatment.

To clear an infection quickly and without complications, a strong immune system is required. My article on boosting the immune system can be found here. A few methods I highly recommend for treating ear infections are: Vitamin C (dosing recommendations can be found here, Echinacea tincture added to herbal tea (1 drop per 2 lb of body weight), elderberry syrup, raw honey (only for children over one year old) and propolis.

Raw garlic is very effective if your child will take it, but most ear infections are in children less than 5 years old, and they typically will not agree to swallow the raw garlic (though you can try to crush it and mix one clove with a tablespoon of raw honey [if the child is older than one] to make it more palatable).

Aside from supplements, other key elements of optimizing your child’s immune system include promoting outdoor exposure and adequate sleep.

Garlic mullein oil has been traditionally used to soothe ear pain and found to be effective. There was a study on an ear drop formulation including garlic and mullein oil, which was found to be as effective as anesthetic ear drops in treating pain from acute otitis media (29).

Applying warmth can also help with ear infections. Since there isn’t funding for hot water bottles from the pharmaceutical industry, you won’t find published studies on how effective it is. Despite the lack of randomized controlled trials on applying warmth, it is a traditional remedy that often brings relief for pain associated with ear infection, as well as many other bodily pains.

You can have your child lay down with the affected ear up and hold the hot water bottle on the affected ear. Make sure to avoid burns by wrapping the hot water bottle with a towel, rather than putting the bottle directly on the skin, and applying it for only 5 minutes at a time.

The following treatments have been studied more for prevention but may help with treatment of active infection as well:

Xylitol, a natural sugar, has been found to prevent otitis media. (30, 31) It works by breaking up biofilms (communities of bacteria, viruses and fungi that work together to stick to surfaces and build barriers to evade our immune system and antibiotics). By breaking up biofilms, it can help the body get rid of bacteria and viruses that stick to the nose and middle ear.

While studies have mainly looked at oral xylitol or xylitol in chewing gum, studies are now looking at xylitol nasal spray to target organisms that enter through our respiratory tract. The main concern with xylitol is that when it is used in large quantities as a sweetener, it can cause diarrhea; however, in a nasal spray, there are no significant concerns.

Probiotics are now being studied as preventative, adjunctive or alternative treatments for many diseases that were previously only treated with antibiotics. According to the author of a study on the otitis media microbiome, “Probiotics may have a role in preventing or disrupting infectious diseases of mucosal surfaces.” (28)

One study found that oral probiotics reduced AOM in otitis-prone children. (32) They may work through interactions between the gut and immune system since 75-80% of our immune cells are in our gut.

Another study looking at probiotic nasal spray found that it reduced AOM compared to placebo (33) Additionally, a 2019 meta-analysis of 17 randomized control trials (RCTs) reported that probiotic usage reduced the incidence of AOM and was more pronounced with Lactobacillus products, compared to Streptococcus ones. The effect, however, did not extend to children experiencing recurrent episodes. (34)

So far, studies have been conducted on oral probiotics and nasal sprays but not probiotic ear drops. Stay tuned for more research on this topic!

Disclaimer: None of the information in this article is intended for personal treatment. If you are concerned about your child’s ear infection, please contact your health care provider. If they diagnose an ear infection, find out how they came to that diagnosis. If they recommend antibiotics, find out why and discuss any concerns with them. It’s important to find a provider you trust who values your input and will work with you to come up with a treatment plan.

References

Do Kids Need Antibiotics for Ear Infections?

Why are ear infections so overdiagnosed?

What causes ear infections?

Risk factors and protective factors

Does your child need antibiotics?

What is the risk of giving antibiotics?

What can we do instead of giving antibiotics?

Dr. Charlotte Nussbaum

Hours

Contact

Specialties

Why are ear infections so overdiagnosed?

What causes ear infections?

Risk factors and protective factors

Does your child need antibiotics?

What is the risk of giving antibiotics?

What can we do instead of giving antibiotics?

Footer

Dr. Charlotte Nussbaum

Hours

Contact

Specialties