A Pediatrician Explains a Spike in Ear Infections After COVID-19 Restrictions Lifted

While masking and social distancing mandates were lifted across the country with the surge in COVID-19 vaccines this spring and summer, other respiratory viruses, such as rhinovirus and respiratory syncytial virus — which are known to peak in the winter — reversed. returned and spread, especially among children. The CDC said in a July statement that as coronavirus avoidance measures were eased, other viruses began to circulate at an increased rate at an unusual time of year.

dr. Abigail V. Kumral of the University of Virginia described the local increase in ear infections and viral infections of the upper respiratory tract in a piece for The conversation, republished below. Kumral has been a member of UVA’s General Clinical Faculty of Pediatrics since 2016 and sees patients at UVA Northridge Pediatrics.

Here’s what she had to say in The Conversation.


Pain is one of the most common reasons young children go to the doctor, and acute middle ear infection — meaning “middle ear infection” — is the most common cause for antibiotic use in children under the age of 5. Twenty-five percent of children will have an ear infection by their first birthday and 60% by age 5.

As a pediatrician, I see children in my clinic every day for ear infections. Because these are associated with viral upper respiratory infections, we usually see most ear infections in the fall and winter, when flu and cold viruses are predominant. However, with near-universal masks due to COVID-19 last winter and many children out of school, the number of viral upper respiratory infections dropped dramatically. As a result, we saw very few ear infections in our clinic.

This summer, with the lifting of the COVID-19 restrictions, we saw a return of many respiratory viruses, and with them middle ear infections.

How an ear gets infected

The middle ear space, the space behind the eardrum, is connected to the back of the throat via the Eustachian tube. When people, especially children, become constipated, they tend to collect liquid in this space.

If a child has a cold and remains constipated for a while, that buildup of fluid can become infected, usually by bacteria that have migrated from the back of the nose or throat. As children grow, their skull lengthens and the Eustachian tube can drain more easily as it begins to slope down toward the back of the throat. Over time, children also build up immunity to cold viruses and get sick less often, so overall ear infections decrease with age.

The three most common bacteria that cause middle ear infections are Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.

Interestingly, before we had pneumococcal vaccines against Streptococcus pneumoniae, these bacteria caused about 60% to 70% of all ear infections in children between 6 months and 5 years of age. But after these vaccines were added to the childhood immunization series in 2001, the overall rate of ear infections dropped and the proportion due to streppneumo has gradually declined to 15% to 25%. Haemophilus influenzae now causes most ear infections.

Diagnosis and Treatment Guidelines

The most recent guidelines from the American Academy of Pediatrics for acute otitis media, which is diagnosed by physical examination, came out in 2013. A doctor will look inside a child’s ears with an instrument called an otoscope to see if it is eardrum is red, bulging, or has fluid behind it. Sometimes the doctor uses a small smell in the ear to see if the eardrum is moving properly. If there is an infection behind the eardrum, it will not move with the air.

Acute otitis media is usually treated with antibiotics, which are generally recommended for ear infections in children under 2 years of age. For children older than 2 years, antibiotics are recommended if there is a fever or severe pain, or if both ears are infected. If there is no fever or if the infection is only on one side, it is recommended to wait a day or two before starting antibiotics, as these infections sometimes clear up on their own in older children.

This is different from the treatment of external ear infections — otitis externa or “swimmer’s ear” — which can be treated directly with antibiotic ear drops. If the ear canal is very swollen, gauze may be used to gently push the antibiotic drops deeper into the ear canal.

Prevent ear infections?

Following recommended childhood vaccination schedules is a big part of preventing ear infections, or at least reducing their frequency. Pneumococcal vaccines are especially important. Ear infections are a common complication of the flu in children; about 40% of children under the age of 3 get an ear infection with the flu. So getting a flu vaccine every year can also help prevent ear infections.

Breastfeeding has also been shown to be protective against ear infections, with exclusive breastfeeding providing the most protection for the first six months. Higher levels of protective antibodies in breastfed infants, as well as immunological factors found in breast milk, help provide this protection.

Children exposed to more viral upper respiratory infections are at an increased risk of ear infections. Children in day care centers are exposed to more infections and thus have more ear infections. That said, as a mother of a child who loves his daycare, it’s important to note that group daycare is often the most affordable or the only option for families, so it’s unclear whether avoiding daycare is really possible. Because ear infections are much less common in older children, school is less risky than daycare.

Exposure to tobacco smoke is also a risk factor. Quitting smoking whenever possible and minimizing children’s exposure to tobacco smoke reduces the risk of ear infections.

Some children get ear tubes to prevent recurrent ear infections. If your child has had at least three ear infections in six months or four in a year, your pediatrician may refer you to an ear, nose, and throat doctor to decide if this surgery is beneficial for your child.

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