Earache (Acute Otitis Media)

A child who wakes in the night clutching one ear, hot and miserable, is one of the most familiar sights in family life. Most of the time the cause is acute otitis media: an infection of the small air-filled space behind the eardrum. It is painful and frightening, but it is also one of the most self-limiting infections children get, and the right first step is usually a proper look in the ear rather than a rush for medicine. Under Pharmacy First, our pharmacist can examine a child aged 1 to 17 in the consultation room at Timperley and manage the infection on the spot when it fits the NHS pathway.

Why children get middle-ear infections so often

The middle ear drains through a narrow channel, the Eustachian tube, into the back of the nose. In young children this tube is shorter, softer and more horizontal than in adults, so when a cold causes swelling and mucus at the back of the nose, the tube blocks easily. Fluid then builds up behind the eardrum, germs from the nose multiply in it, and the eardrum becomes inflamed and bulges outward. That pressure is what causes the pain.

Most episodes follow a cold, and both viruses and bacteria are involved. Around 7 in 10 children have had at least one episode by the age of 2, with a peak between roughly 6 and 15 months. Nursery attendance, exposure to smoke at home, dummy use and the winter cold season all make infections more likely. It is not caused by getting water in the ear or by going out with wet hair.

Telling it apart from other kinds of ear pain

Not every sore ear is a middle-ear infection, which is one reason the examination matters:

• Outer-ear infection (otitis externa) affects the ear canal itself. The ear is tender to touch or when the earlobe is pulled, it often follows swimming, and the pain is on the surface rather than deep inside.
• Glue ear (otitis media with effusion) is fluid behind the eardrum without acute infection. It causes muffled hearing rather than pain and is not treated with antibiotics; the pathway routes it back to the GP.
• Referred pain from teething, tonsillitis, a dental problem or the jaw joint can feel like earache when the ear is completely normal.
• A blocked ear or something lodged in it can mimic infection in a toddler.

An otoscope settles the question in seconds by showing whether the eardrum is red, cloudy or bulging, whether it has burst, and whether the canal is the real problem.

What happens when you bring your child in

This condition must be seen face to face, because the diagnosis depends on looking at the eardrum. The pharmacist will ask when the pain started, whether one or both ears are affected, how your child has been feeding, sleeping and behaving, what pain relief has already been given and how well it worked, and whether there is any discharge. They will check your child’s temperature and general appearance, then examine both ears with an otoscope.

It helps to bring a note of any pain relief given in the last 24 hours (what and when), any allergies, and your child’s approximate weight. If your child has had ear infections before, mention how many and when, as this changes what the pharmacist can offer. Young children are examined on a parent’s lap; the whole appointment normally takes about 10 to 15 minutes, and the GP surgery is updated afterwards.

Which children we can see, and which need the GP

The NHS pathway is for children and young people aged 1 to 17 with a first or occasional ear infection. Babies under 1 are excluded because infection in infants behaves differently and needs a doctor’s assessment. Adults are outside the pathway too, since middle-ear infection is far less common after childhood and other causes need considering.

The pharmacist will also refer on, rather than treat, if a child has had three or more infections in six months or four in a year; if the affected ear has a grommet; if the picture looks like glue ear or a foreign body rather than infection; if the child is very unwell in themselves or shows signs of a more serious illness; or if a long-term condition (significant heart, lung, kidney, liver or neuromuscular disease, cystic fibrosis, prematurity, or a weakened immune system) raises the risk of complications. These are not brush-offs. They are the situations where the evidence says a doctor’s input, and sometimes a broader examination, is needed.

How the pharmacist decides what treatment fits

The starting point for every child is good pain control and time. Over 80 per cent of middle-ear infections settle within two to three days without an antibiotic, and in trials antibiotics shortened pain by very little for most children while causing side effects such as vomiting, diarrhoea or rash in around 1 in 14. So the pharmacist weighs a small number of specific findings:

• Is the eardrum intact? If it has burst and the ear is discharging, an antibiotic is usually appropriate, because children with a perforation gain more benefit. Pain-relieving drops are not used in a burst ear.
• Is your child under 2 with both ears infected? This group also benefits more. If symptoms have lasted more than three days, or are severe, an antibiotic may be supplied; if symptoms are milder, the pharmacist will advise watchful waiting with a review in three to five days.
• Is the pain moderate to severe despite regular pain relief, with an intact eardrum? Here the pharmacist may supply ear drops containing a local anaesthetic to take the edge off while the infection runs its course.
• Are the symptoms mild? Self-care alone, with an open invitation to come back if there is no improvement within three to five days.

Nothing is guaranteed in advance; the decision follows the examination, and the pharmacist will explain the reasoning so you know what to watch for.

Keeping your child comfortable at home

Regular pain relief given by the clock, rather than only when the crying starts, makes the biggest difference. The pharmacist will confirm the right children’s pain reliever and dose for your child’s age and weight. Offer plenty of fluids, let your child rest, and keep them upright when awake if that eases the pressure. A warm (not hot) flannel held against the ear soothes some children.

Do not put cotton buds, oils or home remedies into the ear, and avoid swimming or getting water in the ear until it has settled, particularly if there is any discharge. Decongestants and antihistamines do not help and are not recommended for young children. If fluid is draining, wipe it gently from the outer ear with clean cotton wool.

How long an ear infection takes to settle

Pain usually improves within 24 hours in the majority of children and has gone in most by day three, although a mild cold and a feeling of fullness can linger for up to a week. A burst eardrum sounds alarming, but it typically relieves the pain and heals on its own within a few weeks. Hearing may stay slightly muffled for some weeks afterwards because fluid takes time to drain; if it has not cleared after six to eight weeks, or your child seems not to be hearing well, ask the GP for a check.

Ear infections are not passed directly from child to child, but the colds that trigger them are. Handwashing, catching sneezes in a tissue, keeping your child’s vaccinations up to date and a smoke-free home all reduce the number of colds and therefore the number of infections.

Signs that need a doctor today, not a pharmacist

Go straight to A&E, or call 999, if your child develops a stiff neck, dislike of bright light, a rash that does not fade under a glass, or becomes drowsy, confused or hard to wake; if there is swelling, redness or tenderness in the bone behind the ear, or the ear itself is being pushed outwards; if one side of the face droops; if there is a severe headache with vomiting; or if your child is struggling to breathe or is floppy and pale. Contact NHS 111 or the GP the same day if your child has a very high temperature or one that will not come down with pain relief, if the child is under 1, if pain is worsening rather than easing after two to three days, or if you are simply worried that something is not right. Trust that instinct; the pharmacist will always rather see a child again than have a parent wait.