Management of Infant Ear Pulling with Scratches
For an infant pulling their ears and causing scratches, first perform pneumatic otoscopy to rule out acute otitis media (AOM) or otitis media with effusion (OME), as ear pulling is a recognized sign of middle ear pathology in infants, then address pain if present and protect the skin from further trauma. 1
Diagnostic Approach
Evaluate for Otologic Pathology First
- Ear pulling in infants is a recognized clinical sign of acute otitis media, particularly when accompanied by rapid onset of irritability, fever, or otorrhea 1
- Perform pneumatic otoscopy to assess for middle ear effusion, looking specifically for bulging or fullness of the tympanic membrane, limited mobility, air-fluid levels, or distinct erythema 1
- In a prospective study of 102 infants presenting with ear pulling, 16.7% had otitis media with effusion, 37.2% had cerumen impaction, and 46.1% had normal examination findings 2
- Infants with additional complaints beyond ear pulling (such as irritability, fever, or sleep disturbance) had significantly higher rates of OME compared to those with ear pulling alone 2
Clear the Ear Canal
- Remove cerumen if present, as cerumen impaction was the second most common finding in infants presenting with ear pulling 2
- Hearing evaluations should be considered if cerumen or middle ear effusion is suspected, as blockage can interfere with language development 1
Pain Management
If Middle Ear Pathology is Present
- Pain assessment and treatment is a strong recommendation for any infant with AOM 1
- Provide systemic analgesics (acetaminophen or ibuprofen) for pain relief if otitis media is diagnosed 1
- Consider that many cases of AOM are associated with significant pain that requires direct attention 1
If Teething is Contributing
- Teething typically begins around 6 months and can cause sensitive, painful gums, drooling, feeding difficulties, and distress 3
- Cold teething rings provide effective symptom relief through a cooling effect 3
- Topical analgesic gels containing choline salicylate can be applied directly to gums for pain and inflammation 3
- Systemic analgesics are commonly used by parents (76.1% in one survey) to manage teething discomfort 4
Skin Protection from Scratching
Immediate Measures
- Trim the infant's fingernails short and file smooth edges to minimize trauma (general pediatric practice)
- Consider soft cotton mittens or clothing with fold-over hand covers, particularly during sleep when scratching may be unconscious 1
- Apply emollient ointment to scratched areas to promote healing and reduce friction 1
Wound Care if Scratches are Present
- Clean scratched areas gently with emollient rather than water or commercial wipes to avoid further irritation 1
- Apply barrier cream or hydrogel dressing (such as Intrasite Conformable) to areas with broken skin 1
- Monitor for signs of secondary infection including increased redness, warmth, purulent drainage, or fever 1
Common Pitfalls to Avoid
- Do not dismiss ear pulling as "just teething" without performing otoscopy, as 16.7% of infants with this complaint have OME that can affect hearing and language development 2
- Do not attribute fever, diarrhea, or severe systemic symptoms to teething alone—these require evaluation for other causes 4, 5
- Clinical history alone is poorly predictive of AOM presence, especially in younger children, making physical examination essential 1
- Avoid inserting cotton swabs or objects into the ear canal, as this can cause trauma and bleeding 6
When to Escalate Care
- Refer to ENT if there is persistent ear pulling with pain, discharge, hearing concerns, or if OME is diagnosed and persists 1
- Consider evaluation by child development or mental health specialist if examination is completely normal and ear pulling persists, as parental depression was identified in 6 of 37 infants with normal findings in one study 2
- Seek immediate medical attention if the infant develops high fever, toxic appearance, severe irritability, or signs of serious infection 1