Dr. Brown is Assistant Professor of Family Practice, Southern Illinois University, and a family physician in Mt. Zion, IL. Dr. Brown reports no commercial conflict of interest.

Otitis media (OM) is the medical name for an infection of the middle ear. While it affects people of all ages, it is far more common in young children; in fact, it is the number one reason that children under one year old are taken to the doctor.

Despite advances in drugs and other treatments, the percentage of children who develop otitis media has remained quite steady over time. About half of all infants will come down with an ear infection before their first birthday; and those who do will have an increased risk of further attacks, as well as a higher risk of developing repeated infections later in childhood.

From the point of view of keeping ears healthy and avoiding otitis media and other infections, breast-feeding is best for infants. Just as clearly, if parents cannot breast feed, it is critical to use feeding bottles that are designed to prevent nipple collapse and air bubble formation.

The disease is more common in boys than in girls; it is also more common in whites, in lower socioeconomic groups, in Native Americans (particularly in Alaska), and in children born with a cleft palate and other structural problems of the face or skull. OM is also somewhat seasonal, more likely to occur in early spring and winter.

How Doctors Diagnose Otitis Media
Often the first indication a parent has that something is wrong with their child's ear is a higher than normal temperature and general irritability. Infants may not eat well; older children may rub their ear. The key sign doctors and other medical professionals look for in suspected cases of otitis media is a loss of flexibility in the ear drum. This is detected by using instruments that test how the ear drum responds to changes in air pressure. The same instruments sometimes also detect bulging or redness of the ear drum.

Causes of Otitis Media
We do not know everything about why some children are more prone than others to develop otitis media but researchers have identified sniffing as at least one possible major cause. And studies indicate that another culprit may be bottle feeding.

The vacuum created by bottle-feeding can play havoc with the ear's inner auditory tube.

When a child uses a typical feeding bottle, lack of ventilation or inadequate ventilation causes a vacuum to form, and this can cause problems inside the ear. It works like this: the non-vented bottle is simply a solid walled vessel with a nipple held in place with a cap. The cap holds the enlarged flange end, or base of the nipple, firmly against the top of the bottle forming a tight seal. This arrangement does not permit any air entry, resulting in the creation of a vacuum (negative presssure) during sucking. Fluid may only be removed by the infant in small amounts by overcoming the stiffness of the wall of the nipple or bottle.

The vacuum created by bottle feeding can play havoc with the ear's inner auditory tube. Negative pressure generated in the mouth is transmitted up the tube and into the middle ear where, as a result, fluid can build up. The increased fluid can cause hearing difficulties and infections. Interestingly, none of this occurs with breast feeding, which does not create any kind of vacuum and which actually creates positive pressure within the ear.

How to Lower Your Child's Risk for Otitis Media
Sucking on pacifiers, toys, thumbs and similar objects can cause the same problems inside the ear as bottle feeding. The common factor in all of these activities is that negative pressure is generated in the mouth and the vacuum is then transferred to the middle ear. So the first step in preventing ear infections would be to consider taking pacifiers and the like away from children, and training them not to suck their thumbs. As for feeding, the answer is simple — to breast feed or, failing that, to use special feeding bottles that are designed to prevent the creation of negative pressure.

Not only does negative middle ear pressure increase a child's risk for otitis media, but severe cases of otitis media can have even worse long-term consequences. Studies have shown a definite relationship between this kind of negative pressure in the ear and development of more serious ear disease. It may lead to a condition known as secretory otitis, which can cause permanent hearing loss, along with delayed speech development. It may also contribute to the development of other, irreversible kinds of middle ear disease (examples include atelectasis, adhesive otitis, and cholesteatoma).

If breast feeding is out of the question, parents should try to reduce the risk of vacuum and air bubble formation by using feeding bottles with continuous positive pressure at the nipple during the entire feeding cycle.

Treatment of "Non-Toxic" Otitis Media
What happens if your child does come down with otitis media? Obviously, he or she should be seen by a doctor. But not all cases of otitis media need to be treated with antibiotics. In so-called "non-toxic" cases, where the symptoms are mild and the danger of damage to the ear remote, there is a growing consensus among doctors simply to observe infants and make sure that the disease does not become toxic.

Treatment of "Toxic" Otitis Media
As with many common infections, doctors have to walk a fine line in treating otitis media. On one hand, children with acute otitis media must be given antibiotics; on the other hand, both because of overprescription and misuse of antibiotics, the organisms that cause otitis media are becoming more and more resistant to antibiotic drugs. For example, according to recent studies, between 30 to 60 percent of Streptococcus pneumoniae bacteria are now partially resistant to the antibiotics penicillin and amoxicillin. Often, antibiotics lose their effectiveness in children who have been given them repeatedly in a short period of time.

In response to this problem, the U.S. Centers for Disease Control (CDC) has given out new recommendations on how to treat otitis media more effectively with antibiotics. To paraphrase these recommendations, if the infant has not received antibiotics in the last month, it is recommended that the infant be started on usual-dose or high-dose amoxicillin. If the treatment is not working by day three, then the infant should be given high-dose amoxicillin-clavulanate (Augmentin®) or cefuroxime axetil (Ceftin®) or injections of ceftrianone.

For an infant who has received antibiotics in the last month, it is recommended that high-dose amoxicillin, high dose amoxicillin-clavulanate or cefuroxime axetil be started. If there is no improvement by day three, treatment options include injections of ceftrianone, clindamycin or tympanocentesis, which means using a needle to puncture the ear drum and remove trapped fluid. In both cases, infants are reexamined on days 10 to 28.

From the point of view of keeping ears healthy and avoiding otitis media and other infections, breast-feeding is best for infants. Just as clearly, if parents cannot breast feed, it is critical to use feeding bottles that are designed to prevent nipple collapse and air bubble formation. Both are indicators that negative pressure has formed in the feeding container. Studies have shown that this pressure can be transferred into the middle ear. Sucking on a pacifier or a thumb can cause the same problem. Negative pressure within the ear may lead to serious infection or other ear disease, causing hearing impairment and a risk for delayed speech development. It may also put a child at risk for a host of other, potentially serious ear problems.

Whether, when and how to treat otitis media with antibiotics or other treatments are decisions that should be made in close consultation with your doctor. Parents can and should reduce their child's risk factors as discussed above but children who do come down with an ear infection should see a doctor immediately.