Q: What is the real deal on ear infections? Why has my toddler gotten more now that she's in daycare? What are the signs? What are the remedies? Should I take her in or shouldn't I? How do I know if the antibiotics took care of it or not? Should I always do a follow-up appointment or only if I still suspect an infection? When are tubes necessary? Should I really do tubes or wait it out through cold season?

A: The most common diagnosis among young children is an ear infection. Also known as otitis media (infection of the middle ear), it is most common among children ages 6 to 18 months. Ear infections are more common among children in day care or who are around smoke.

Usually an ear infection is preceded by a cold (day care = more colds = more ear infections). Most of the time, a child is brought into the office with a few days of cough and congestion, and now is acting miserable/doesn't want to eat/can't sleep/is pulling on the ears/has a fever. There is an anatomical reason for this:

The little tube you see going toward the nose on the right side of this illustration is the Eustachian tube. Normally, this is open and allows fluid from the middle ear to drain into the nose. However, when the nose is stuffy and swollen, this tube easily gets blocked. The fluid in the ear has nowhere to go, so it just sits there. If it sits there long enough, it can become infected with the bacteria that are commonly found in the upper respiratory tract. Then, a look in the ear shows the picture on the left – red and swollen, with pus behind the eardrum.

In children under 2 years of age, most of the time an antibiotic is prescribed to help the infection clear up. In children over 2 or when the diagnosis is unclear (because the eardrum doesn't show all the signs of a bacterial infection, for example) we may elect to wait a day or two and see how the child does. This is a perfectly reasonable approach to an ear infection because sometimes the infection will clear on its own.

Antibiotics typically improve symptoms within 2-3 days. Sometimes, it takes more than one course of antibiotics if the child has had many ear infections or has resistant bacteria. Most of the time, if the symptoms are improved and fever is gone, an ear re-check is not necessary. However, if the infection has required multiple courses of antibiotics or occurred shortly after finishing antibiotics, your doctor may want to re-check and make sure the ear is healing.

Usually, kids outgrow ear infections, as they develop immunity to infections and the head and Eustachian tubes grow.

Some kids need “tubes” (ventilation tubes placed in the eardrum) that allow the ear to drain and prevent the fluid buildup in the meantime. Tubes help prevent the hearing loss and speech difficulties that can accompany chronic ear infections. If a child has more than six ear infections in a year, most doctors will refer to an ear, nose and throat doctor to evaluate for tubes. It's an individual decision that should be discussed with your pediatrician and ENT.

Dr. Melissa St. Germain is a Children's Physician's pediatrician.