What could be causing a baby to pull at their ears without fever or other symptoms of illness?

Ear Pulling in Babies Without Fever or Illness

In a baby who has been pulling at their ears for weeks without fever or other signs of illness, this is most likely a normal self-exploratory behavior rather than acute otitis media (AOM), though otitis media with effusion (OME) or cerumen impaction should be considered if the behavior persists or other subtle signs develop. 1

Understanding the Clinical Context

The absence of fever and acute illness symptoms makes AOM highly unlikely, as AOM requires three essential diagnostic elements: acute onset of symptoms, presence of middle ear effusion, and signs of middle ear inflammation. 2, 3 The American Academy of Pediatrics specifies that AOM diagnosis requires moderate to severe bulging of the tympanic membrane or new-onset otorrhea, or mild bulging with recent onset (less than 48 hours) of ear pain plus intense erythema. 2

The prolonged duration (weeks) without fever or systemic symptoms argues strongly against AOM, which presents acutely. 4, 5

Most Likely Diagnoses Based on Evidence

Normal Self-Exploratory Behavior (Most Common)

• In a prospective study of 102 infants presenting with ear pulling, 46.1% had completely normal examination findings, representing the most common scenario. 1
• Normal ear tugging was statistically more common in infants who pulled their ears only when falling asleep, suggesting a self-soothing behavior. 1
• This behavior often represents normal developmental exploration or a comfort mechanism rather than pathology. 1

Cerumen Impaction (Second Most Common)

• Cerumen was found in 37.2% of infants presenting with ear pulling complaints, making it the second most common finding. 1
• This was particularly common in children with intermittent ear pulling throughout the day rather than constant symptoms. 1

Otitis Media with Effusion (Third Most Common)

• OME was diagnosed in 16.7% of infants with ear pulling complaints. 1
• Critically, OME presents without acute symptoms or fever, distinguishing it from AOM—it involves middle ear effusion without signs of acute inflammation. 2, 3
• Children with OME and ear pulling were more likely to have additional complaints beyond just ear tugging. 1
• OME was more common when symptoms occurred consistently throughout the day rather than only at sleep time. 1

Diagnostic Approach

Key Historical Features to Elicit

• Timing of behavior: Ear pulling only when tired/falling asleep suggests normal behavior, while constant daytime pulling increases likelihood of OME or cerumen. 1
• Associated symptoms: Presence of rhinitis, hearing concerns, speech delay, or behavioral changes increases suspicion for OME. 2, 1
• Recent upper respiratory infections: OME commonly follows viral URTIs, with 24% of children developing OME after such infections. 2

Physical Examination Priorities

Pneumatic otoscopy is essential to assess tympanic membrane mobility, which has the highest sensitivity and specificity (approximately 95% and 85%) for detecting middle ear effusion. 3

Key findings to assess:

• Tympanic membrane mobility: Reduced or absent mobility indicates middle ear effusion (OME). 3
• Tympanic membrane appearance: Look for air-fluid levels, retraction, or cloudiness without acute inflammation. 3
• Cerumen: Simple visualization may reveal impacted cerumen causing discomfort. 1
• Absence of acute inflammation: No moderate-to-severe bulging, no intense erythema, no fever effectively rules out AOM. 2

Management Recommendations

If Examination is Normal

• Reassure parents that ear pulling without other symptoms is commonly a normal self-exploratory or self-soothing behavior in 46% of cases. 1
• Consider psychosocial factors: In one study, 6 of 37 infants with normal exams had parental depression identified during family interviews, suggesting behavioral components. 1
• No intervention is needed beyond observation and parental education. 1

If Cerumen is Present

• Remove cerumen if it appears to be causing discomfort or obscuring visualization of the tympanic membrane. 1
• This often resolves the ear pulling behavior immediately. 1

If OME is Diagnosed

Watchful waiting is appropriate initially, as OME often resolves spontaneously, particularly when of recent onset. 2

• No antibiotics: Antibiotics do not hasten clearance of middle ear fluid in OME and are not recommended. 4
• No decongestants or nasal steroids: These have not been shown to help and are not recommended. 4
• Reassess in 3 months: Children with persistent OME beyond 3 months, especially with documented hearing loss, should be referred to otolaryngology. 2, 4
• Earlier referral is warranted if there are concerns about hearing loss, speech/language delay, or developmental issues. 4, 5

Critical Pitfalls to Avoid

Do not diagnose AOM based on ear pulling alone. Only 67.7% of children younger than 2 years with actual AOM have any ear-related symptoms, and conversely, ear pulling is present in 72.4% of children without AOM when they have other acute illnesses. 6 The American Academy of Pediatrics emphasizes that ear tugging is a nonspecific symptom that requires otoscopic confirmation of middle ear pathology before treatment. 2

Do not prescribe antibiotics without meeting strict diagnostic criteria for AOM, which requires acute onset, middle ear effusion, AND signs of inflammation—none of which are present in this scenario. 2, 3

Do not overlook OME, as it can cause subtle hearing impairment affecting speech and language development if persistent. 2, 4 However, the negative consequences of OME develop over months, not weeks, so immediate intervention is not required. 2