I remember, not long ago, seeing many children with ear infections every day I was in the office – children that were often up screaming the night before. Today it’s not surprising to go an entire day in clinic without seeing a single one.

Visits to doctors’ offices for ear infections more than doubled between 1975 and 1990, from about 10 million per year to about 25 million per year. They kept increasing through about 1994, when they started to decline steadily by about 5% per year, now at their lowest level in three decades.

Over thirteen years, office visits for ear infections in kids under age 6 dropped from about 640 visits per 1000 children per year to about 380 visits. The drop for hospitalized children being diagnosed with an ear infection is even steeper. And the annual price tag for ear infection treatment in the US has fallen by about $2 billion.

Why the dramatic disappearance?

Several things have changed since the early 1990s. Air pollution, linked to ear infections, fell significantly after the Clean Air Act of 1990. Breastfeeding, protective against ear infections, increased modestly from less than 2/3 of babies starting on mother’s milk to more than ¾ today. A vaccine that may help prevent some ear infections came into wide use in 2002.

But the strongest link, according to a May 2011 study from researchers at Harvard University, came from a drop in tobacco smoke inside children’s homes. We’ve known since the 1990’s that exposure to second hand smoke causes millions of ear infections every year. In 1993, most US children were still exposed to tobacco smoke in their own home. Today only 14 percent of kids live in a home where smoking is allowed inside – a change big enough to account for the difference.

Four thoughts for responding to this good news.

1. If you smoke, smoke outside.
2. Keep the air in your home fresh. Avoid cleaners with harsh fumes. Consider houseplants to clean the air. Open windows when practical.
3. Given the option, breast feed. After weaning, choose foods that support healthy gut bacteria.
4. If your child does get an ear infection, choose a gentle treatment first, if appropriate. Antibiotics are wonderful, when needed, but each time they are given it makes another ear infection more likely. With more resistant bacteria.

Alpert HR, Behm, I, Connolly GN, Kabir Z. “Smoke-free households with children and decreasing rates of paediatric clinical encounters for otitis media in the United States.” Tobacco Control. May 2011; 20:207-211.

Bhattacharyya N and Shapiro NL. “Air quality improvement and the prevalence of frequent ear infections in children.” Otolaryngology – Head and Neck Surgery. Feb 2010; 142:242-246

Chronic ear infections are a frustrating problem for many young children. A study published in the February 9, 2002 issue of The Lancet suggests a dramatic new approach to dealing with ear infections.

The researchers analyzed the fluid in the ears of 54 children with ear infections (OME). Surprisingly, 45 of the children had digestive enzymes from the stomach (pepsin and pepsinogen) at concentrations 1000 times higher than expected.

It appears that when a young child is lying in his back, the acidic liquid from the stomach can flow to the back of his throat and then drip into the Eustachian tube. This would cause irritation and swelling (ear burn?), thus setting up an ear infection.

I look forward to seeing if measures to control reflux prove effective for preventing ear infections. I suspect they will.

I heard from a reader about an extremely common practice that most of us have been warned never to do:

My wife was cleaning our three-year old daughter’s ear with a cotton swab. She turned into the swab causing it to penetrate her ear causing bleeding. How severe can this be? She doesn’t seem to be experiencing any pain or hearing loss. Why do parents use cotton swabs in kids’ ears?

We want our children’s ears to be clean and when we do try using a white cotton swab we vividly see how much wax there is to remove. Cotton swabs do remove the ear wax, but the irritation they cause also silently stimulates the body to create excess new ear wax, confirming parents’ sense that the swabs are necessary. A cycle develops.

Most of us have not been told why ear wax is good, and how the body is designed to dispose of it.

A slow-flowing river of ear wax is created by our bodies to protect, lubricate, and clean our ear canals. Hairs within the ear canal move the wax out to the surface of the ear where it is visible and may easily be wiped away. If there is too much wax or the wax is too thick, the natural flow can be restored with ear drops that thin the wax. Cotton swabs are absolutely unnecessary. They can also be harmful.

When a cotton swab is introduced into the ear, it can cause infection in the ear canal, injury to the skin lining the ear canal, or injury to the eardrum. Eardrum perforations might heal on their own or might require surgery to repair. If the eardrum is torn there will be pain, but that will disappear quickly (while minor torn skin in the canal might remain tender). There will be hearing loss, but parents may not notice it at home. Thus, painful foreign body injuries in the ear, especially those with bleeding, should be checked.

We’ve known now for several years that discontinuing the use of a pacifier can reduce ear infections in children. A study published in the September 2000 issue of Pediatrics looked at the effect of simply having nurses give a leaflet to parents about the side effects of pacifier use and also instructing them to limit pacifier use to moments when the child was falling asleep (and stopping it entirely at about 10 months of age). The results?

Continuous pacifier use decreased by more than 20% and ear infections dropped by almost 30% at the clinics where this education took place. I hope you will consider Daily Dose a leaflet:^) How much better to prevent ear infections than to treat them with round after round of antibiotics!

A study in the August 2000 issue of the Archives of Disease in Childhood found that parents who smoke increase the risk of meningococcal meningitis for their children by about 200% for every 20 cigarettes smoked at home on an average day (220% if the mother smokes, 170% if only the father smokes).

Meningitis can strike suddenly and without warning.

Keeping your kids in a smoke-free environment is one way you help keep them safe — from this and from other childhood problems ranging from ear infections to SIDS.

Testing a baby’s cord blood for levels of maternal antibodies to pneumococcal bacteria can predict the frequency of ear infections.

Information presented at the May 2000 American Society of Pediatric Otolaryngology meeting in Orlando, Florida indicates that low levels of antibodies mean more ear infections.

Perhaps routinely giving the pneumococcal vaccine to women will enable them to produce the antibodies that can protect their children. This may prove to be even more effective at preventing ear infections than giving it to babies and depending on their immature immune systems to create the antibodies over time.

The Great American Smokeout is the American Cancer Society’s call to stop smoking. We all know that smoking leads to serious health problems for adults, but many people just don’t get that being in a room that smells like smoke increases and prolongs colds, coughs, sinus infections, and asthma in children. Secondhand smoke is responsible for 2 million ear infections in children each year.

I know smoking is a tough habit to quit. If adults choose to continue to smoke, please don’t do it in the same room as a child. Invest in HEPA air filters, houseplants, and a fresh coat of paint.  Even better — use the Great American Smokeout as a time to give yourself and your child a tremendous gift by starting a new, smoke-free life.

Since ear infections are the most common diagnosis in pediatrics, it is worthwhile for a parent to learn to become a Sherlock Holmes — able to notice the clues and suspect an ear infection before it becomes advanced. Here are some important things every parent should know about ear infections:

• Throughout the United States, and in the United Kingdom, ear infections are markedly more common in December through March. Their incidence is particularly low from July to September.
• Shockingly, careful studies (e.g. Pediatrics December 1992; 90:1006) have found that 0% of children with ear pulling as the primary sign had ear infections. Even in conjunction with other important clues, such as fever, only 15% of those brought in for ear pulling actually had ear infections. Most commonly, children pull their ears from itching (caused by soap or shampoo in the canal, or by a healing infection), teething, exploration, comfort, or habit.
• Most ear infections hurt. The pain builds as the pressure in the ear builds, from a dull ache to a sharp stabbing pain. The pressure is relieved intermittently, so the pain comes in waves. The pain is worse at night. Most ear infections occur in children under age two. The best clue is evidence of pain, such as crying or screaming (usually less than half an hour), fussiness or irritability (worse when lying down), or suddenly increased difficulty sleeping, especially at night. They often have no pain the following morning.
• In an ear infection, fluid fills the middle ear. Older children often mention a feeling of fullness or decreased hearing in the affected ear. This is difficult to detect in an infant, but you might notice shaking of the head.
• Only one third to one half of children with an ear infection will develop a fever. Temperatures over 104 occur in fewer than 5% of ear infections. Fevers are more common in infants and toddlers than in older children. By itself, a fever is not a powerful clue; but in conjunction with the clues outlined above, it is quite incriminating indeed (the combination of fever and pain is most often an ear infection in infants and toddlers).
• Don’t let other symptoms, such as loose stools or vomiting, throw you off the trail. Ear infections are sometimes accompanied by systemic symptoms.
• Something must plug the Eustachian tube for an ear infection to occur. An upper respiratory infection is often the culprit. The accomplice might also be a change in elevation, allergies, an irritant (such as cigarette smoke), reflux, or drinking a bottle while lying on the back.
• Even with the above clues, only objective evidence can clinch the diagnosis. There is now a wonderful device that uses sonar-like technology to detect fluid in the ear. The device, called an EarChek, is inexpensive, accurate, and simple to use at home. If there is no fluid, there is no ear infection. If fluid is present, only direct visualization of the eardrum by a skilled observer can determine if this is an acute ear infection.
• Remember, it is possible to have an ear infection in an infant with no clues. Here, a positive reading on the EarChek may be the first sign. Also, regular well-child pediatric visits in the first two years screen for these silent episodes.