What are the treatment options for a pediatric patient experiencing teething and ear pain?

Treatment of Teething and Ear Pain in Children

The primary treatment for a child with teething and ear pain is immediate pain control with weight-based acetaminophen or ibuprofen, while determining whether true ear infection exists through pneumatic otoscopy—antibiotics should never be prescribed for ear pain alone without documented infection. 1, 2

Step 1: Immediate Pain Management (First Priority)

Analgesics are the cornerstone of treatment and must be started immediately, regardless of infection status. 3, 1, 2

• Administer weight-based acetaminophen or ibuprofen to provide symptomatic relief within 24 hours 1, 2
• Ibuprofen may be superior to acetaminophen alone because it addresses both pain and inflammation 1
• Continue pain medication as long as the child has discomfort—this is the primary therapeutic intervention 2
• Pain relief should be addressed whether or not antibiotics are prescribed 3

Step 2: Diagnostic Examination to Rule Out Infection

Perform pneumatic otoscopy to differentiate between infectious and non-infectious causes of ear pain. 1

• Document the presence or absence of middle ear effusion with pneumatic otoscopy 3
• Diagnose Acute Otitis Media (AOM) only if there is:
  • Moderate to severe bulging of the tympanic membrane, OR
  • New onset otorrhea, OR
  • Mild bulging plus recent onset of ear pain or intense erythema 1
• If the tympanic membrane does not move perceptibly with gentle positive or negative pressure, middle ear effusion is likely 3

Step 3: Antibiotic Decision (Only If AOM Diagnosed)

Antibiotics are NOT indicated for ear pain without signs of infection and should not be prescribed. 2

If AOM is diagnosed:

• Prescribe antibiotics immediately if severe symptoms are present:

  • Moderate to severe ear pain, OR
  • Temperature ≥39°C (102.2°F) 1

• Consider observation with close follow-up if:

  • Unilateral AOM in children 6-23 months with non-severe symptoms, OR
  • Any AOM in children ≥24 months with non-severe symptoms 1

If no infection is documented:

• Do NOT prescribe antibiotics—this contributes to antibiotic resistance and exposes the child to unnecessary adverse effects 1, 2

Step 4: Teething-Specific Supportive Measures

For teething symptoms without infection:

• Cold teething rings can provide relief for sensitive and painful gums 4
• Topical analgesic gels may be applied directly to gums to relieve pain and inflammation 4
• These measures address drooling, feeding difficulties, and sleep disturbances associated with teething 4

Step 5: Parent Education and Follow-Up

Educate families regarding the natural history and need for follow-up. 3, 2

• Instruct parents to monitor for development of fever, worsening symptoms, or new signs suggesting infection 2
• Schedule follow-up or provide clear return precautions if:
  • No improvement in pain within 24-48 hours of analgesics
  • Persistent symptoms after 48-72 hours of antibiotics (if prescribed)
  • Development of fever, worsening symptoms, or new signs of infection 1

Critical Pitfalls to Avoid

• Never prescribe antibiotics for ear pain alone without evidence of infection on examination—this is the most common error and contributes to antibiotic resistance 1, 2
• Do not dismiss pain management as peripheral—otalgia is often the most distressing symptom for children and families, and adequate analgesia improves quality of life immediately 1, 2
• Do not use systemic steroids, antihistamines, or decongestants for treating otitis media with effusion—these are strongly recommended against 3
• Do not routinely screen healthy children for middle ear effusion who are not at risk and do not have symptoms 3