Management of Ear Pulling in a 6-Month-Old Infant with Teething and No Fever
This infant does not require antibiotics or medical intervention—reassure the parents that ear pulling is a normal self-soothing behavior during teething and does not indicate ear infection in the absence of fever, irritability, or signs of acute illness. 1
Key Diagnostic Considerations
Why This is NOT Acute Otitis Media (AOM)
The diagnosis of AOM requires three specific criteria that are absent in this case: 1
- Middle ear effusion (MEE) confirmed by pneumatic otoscopy showing bulging tympanic membrane, limited/absent mobility, air-fluid level, or otorrhea
- Acute onset of symptoms (less than 48 hours of illness)
- Signs of middle ear inflammation including distinct erythema of the tympanic membrane OR moderate-to-severe bulging OR new onset otorrhea 1
This infant has none of these findings—no fever, no acute illness, no irritability, and the behavior has been present for "a few weeks" rather than acute onset. 1
Normal Teething Behavior vs. Ear Infection
Ear pulling in infants is commonly associated with teething and represents normal exploratory behavior or self-soothing, not pathology. 1 The critical distinguishing features of true AOM that are absent here include: 1
- Fever (temperature ≥39°C or 102.2°F suggests severe AOM)
- Acute irritability or inconsolability
- Sleep disturbance (new onset)
- Decreased feeding or refusal to eat
- Otalgia manifested as excessive crying or holding/tugging ear with distress 1
Recommended Management Approach
Observation Without Intervention
No examination or treatment is necessary for this well-appearing infant with chronic bilateral ear pulling behavior in the context of teething. 1 The observation option for AOM specifically applies to children with confirmed diagnosis of AOM who meet low-risk criteria—this child doesn't even meet diagnostic criteria for AOM. 1
Parent Education and Reassurance
Counsel parents on red flag symptoms that would warrant medical evaluation: 1
- Development of fever (especially ≥39°C/102.2°F)
- Acute onset of irritability, inconsolability, or excessive crying
- Pulling at ears accompanied by crying or signs of pain
- Decreased oral intake or refusal to feed
- New sleep disturbances
- Drainage from the ear canal 1
Teething Symptom Management
For teething discomfort (not ear infection), appropriate measures include: 1
- Age-appropriate analgesics (acetaminophen or ibuprofen) for irritability or discomfort
- Teething rings or cold washcloths for gum relief
- Reassurance that ear pulling is self-limited behavior 1
Common Pitfalls to Avoid
Do not prescribe antibiotics based solely on ear pulling behavior without confirmed AOM diagnosis by pneumatic otoscopy. 1 Overdiagnosis of AOM commonly occurs when clinicians rely on nonspecific symptoms like ear pulling or simple otoscopy showing tympanic membrane erythema from crying. 1
Do not perform unnecessary examinations in well-appearing infants with chronic behavioral patterns and no acute illness. 1 The natural history of teething-related ear pulling is self-resolution without intervention.
Avoid topical ear preparations like Ciprodex, which are indicated only for acute otitis externa with infection or tympanostomy tube otorrhea—not for simple ear pulling or teething. 2