Ear Pulling in Infants with Ear Infections
Infants typically begin pulling on their ears as a sign of ear pain (otalgia) from acute otitis media during infancy and toddlerhood, though this behavior is nonspecific and occurs in infants without ear infections as well. 1
Age Range for Ear Pulling Behavior
- Peak incidence of acute otitis media occurs between 6-12 months of age, when ear pulling as a manifestation of otalgia is most commonly observed 1
- By age 12 months, 62% of children have experienced at least one episode of AOM, with the highest incidence during ages 6 months to 1 year 1
- The AAP and AAFP guidelines specifically identify "pulling of the ear in an infant" as a typical presentation of otalgia in acute otitis media 1
Critical Clinical Context
Ear pulling is a poor predictor of actual ear infection and should never be used as the sole diagnostic criterion. 1, 2
- In a prospective study of 102 infants presenting with ear pulling complaints, 46.1% had completely normal examination findings, 37.2% had only cerumen, and only 16.7% had otitis media with effusion 2
- Clinical history alone is poorly predictive of AOM presence, especially in younger children 1
- Pneumatic otoscopy must be performed to confirm middle ear effusion and tympanic membrane changes before diagnosing AOM 1
Distinguishing Features When Ear Pulling Indicates Infection
Ear pulling is more likely to represent true otitis media when accompanied by: 1, 3, 2
- Acute onset of symptoms (not chronic behavior)
- Additional complaints: fever, irritability, sleep disturbance, decreased appetite 1, 3
- Complaints occurring throughout the day rather than only at bedtime (when it's more likely normal behavior) 2
- Otorrhea (ear discharge), which indicates more severe bacterial infection 4
Important Pitfalls
- Infants pull their ears for many reasons unrelated to infection: exploring their bodies, tiredness, teething, habit, or even parental stress (depression was found in parents of 6 of 47 infants with normal exams and ear pulling) 2
- Referral patterns matter: When families self-refer for ear pulling, normal exams and cerumen are more common; when pediatricians refer, OME is more common, suggesting physicians pre-select cases more likely to have pathology 2
- Never diagnose AOM based on ear pulling alone—this leads to unnecessary antibiotic use when otitis media with effusion is mistaken for acute otitis media 1