What are the recommended treatments for infant ear discomfort caused by teething?

Treatment of Infant Ear Discomfort Attributed to Teething

Teething does not cause true ear pathology, and any infant presenting with ear discomfort requires proper otoscopic examination to rule out acute otitis media before attributing symptoms to teething alone.

Critical Diagnostic Distinction

The most important clinical pitfall is misattributing ear discomfort to teething when acute otitis media (AOM) or other pathology is present. This can delay appropriate treatment and lead to serious complications 1.

• Perform otoscopic examination to assess for tympanic membrane bulging, erythema, decreased mobility, or otorrhea—all signs of AOM requiring different management 2, 3
• Ear pulling in infants is nonspecific and commonly reported by parents during teething (35-55% attribute it to teething), but this does not confirm teething as the cause 4
• True teething symptoms are localized to the gums and include drooling, gum sensitivity, mouthing/biting, and mild irritability 5, 1

Management Algorithm When Ear Pathology is Excluded

Step 1: Parental Reassurance and Education

• Explain that teething is self-limiting and does not cause fever, systemic illness, or true ear infection 1
• Advise parents that symptoms lasting beyond a few days or accompanied by fever >38°C, severe distress, or systemic illness require medical evaluation and are not due to teething 1

Step 2: Non-Pharmacological Interventions (First-Line)

• Cold teething rings or chilled washcloths for the infant to chew on provide gum counter-pressure and cooling relief 5, 6
• Gentle gum massage with a clean finger can provide temporary comfort 5

Step 3: Pharmacological Options (If Non-Pharmacological Measures Insufficient)

• Acetaminophen or ibuprofen at age-appropriate doses for pain relief if the infant appears distressed (60% of parents use paracetamol for teething) 4, 6
• Topical benzocaine gels (20% formulation) may be applied to affected gums in children ≥2 years, up to 4 times daily, though evidence for efficacy is limited 7, 5
  • Caution: Benzocaine is not FDA-approved for children <2 years due to methemoglobinemia risk 7
  • Evidence quality is very low for topical analgesics in teething 6

Step 4: Safety-Netting

• Instruct parents to seek urgent medical review if the infant develops fever, becomes systemically unwell, has severe or prolonged distress, or shows signs of dehydration 1
• Re-evaluate if symptoms persist beyond what is expected for normal teething (typically a few days per tooth) 4

What NOT to Do

• Do not prescribe antibiotics for presumed teething-related ear discomfort without confirmed AOM 2, 8
• Do not use topical anesthetic gels in infants <2 years due to safety concerns 7
• Do not dismiss persistent ear symptoms as teething without proper examination, as this can delay diagnosis of true otitis media 1

When to Treat as Acute Otitis Media Instead

If otoscopic examination reveals:

• Moderate to severe tympanic membrane bulging or new-onset otorrhea not from otitis externa 3
• Bilateral AOM in children <2 years: treat with high-dose amoxicillin (80-90 mg/kg/day) for 10 days 2, 3
• Pain management with acetaminophen or ibuprofen is essential regardless of antibiotic use 3

The key clinical principle is that ear discomfort requires objective examination to differentiate true otitis media from referred discomfort during teething, as management differs completely between these conditions.