Middle ear infection (acute otitis media) in children: pain relief, antibiotics and warning signs

The middle ear is the area behind the eardrum. NHS inform describes otitis media as inflammation with a build-up of fluid there, and says it is most common in young children. Most cases begin when a cold leads to a build-up of mucus in the middle ear, causing the Eustachian tube, which runs from the middle ear to the back of the nose, to swell or block. An enlarged adenoid can also block it.

The NHS separates three kinds of ear infection: inner, middle (usually affecting children, caused by viruses like colds and flu) and outer (otitis externa, from irritation of the ear canal). NICE notes acute otitis media can be caused by viruses and bacteria and that it is difficult to distinguish between them, because both are often present at the same time.

NHS inform lists earache, a high temperature, being sick, a lack of energy and slight hearing loss. The NHS says symptoms usually start quickly, with pain inside the ear, high temperature, difficulty hearing, discharge and pressure or fullness. Babies and young children may also rub or pull their ear, not react to some sounds, be irritable or restless, be off their food or keep losing their balance.

NHS inform says that sometimes a hole develops in the eardrum and pus runs out of the ear, after which the earache, caused by fluid stretching the eardrum, settles.

NICE advises regular doses of paracetamol or ibuprofen for pain, using the right dose for the child's age or weight and the maximum doses for severe pain, which is guidance for prescribers and families should follow the leaflet or pharmacist. The NHS suggests removing any discharge by wiping the ear with cotton wool. NHS inform adds placing a warm cloth over the affected ear.

The NHS says not to put anything inside the ear, such as cotton buds, not to let water or shampoo into the ear, not to go swimming during an infection and not to use decongestants or antihistamines, because there is no evidence they help.

NICE says antibiotics make little difference to symptoms or to complications such as short-term hearing loss, perforated eardrum or repeat infection in children who are less likely to benefit, and may cause diarrhoea and nausea. It suggests considering no prescription or a back-up prescription, to use only if symptoms do not start to improve within 3 days or worsen rapidly.

Children who may be more likely to benefit are those of any age with discharge from the ear (otorrhoea) and children under 2 with infection in both ears, and NICE says an immediate prescription can be considered for these. For children who are systemically very unwell, have signs of a more serious condition or are at high risk of complications, NICE says to offer an immediate antibiotic prescription, and to refer to hospital if there is a severe systemic infection or acute complications such as mastoiditis, meningitis, intracranial abscess, sinus thrombosis or facial nerve paralysis. The prescriber chooses the drug and dose.

The NHS says to see a GP for a child under 12 months, for earache that does not get better after 3 days, or for repeated infections. It says to ask for an urgent GP appointment or get NHS 111 help now if a child feels generally unwell, has a very high temperature or feels hot, cold or shivery, has swelling around the ear, fluid coming from the ear, a change in hearing or new hearing loss, feels sick or is being sick, feels dizzy or has a severe sore throat, is under 12 months with earache in both ears, or has a long-term condition or weakened immune system.

NHS inform also lists a regular pattern of ear infections, a lot of pain, a discharge of pus, and underlying conditions such as cystic fibrosis or congenital heart disease as reasons to speak to the GP practice.

The NHS says a GP or pharmacist may use an otoscope, an instrument with a small light and magnifying glass, to look in the ear. Prevention cannot be guaranteed, but the NHS suggests making sure a child has had all childhood vaccinations, keeping them away from smoky environments and trying not to give a dummy after 6 months old. NHS inform mentions the pneumococcal and 6-in-1 vaccines, breastfeeding, not giving a dummy after 12 months and not feeding a child lying flat on their back.

NHS inform notes that certain conditions raise the risk, including cleft palate and Down's syndrome, and that removing an enlarged adenoid can be considered if it often causes ear infections.

The NHS says that if a child has a high temperature or does not feel well enough for normal activities, they should stay at home until better. Ear infections are not listed in the UKHSA exclusion table, so a child who is comfortable and without fever can usually attend. Fluid left behind after an infection can cause temporary muffled hearing; NHS inform describes glue ear as often clearing on its own over a few months, with grommets considered if persistent.