Can Ear Pulling in a 9-Month-Old Be Due to Teething?
Ear pulling in a 9-month-old can be attributed to teething, but you must first rule out acute otitis media (AOM) or otitis media with effusion (OME) through proper otoscopic examination, as clinical history alone is poorly predictive and missing an ear infection can lead to serious complications. 1
Diagnostic Approach
First: Rule Out Otologic Pathology
Perform pneumatic otoscopy immediately to assess for middle ear disease, as ear pulling is a recognized sign of AOM in infants who cannot verbalize pain. 1
AOM diagnosis requires: moderate-to-severe bulging of the tympanic membrane, new-onset otorrhea, OR mild bulging with recent (<48 hours) ear pain/ear pulling plus intense erythema. 1
OME presents with: middle ear effusion (type B tympanogram or decreased tympanic membrane mobility) without acute infection signs like fever or severe irritability. 2, 3
A prospective study of 102 infants presenting with ear pulling found that 46.1% had normal examination findings, 37.2% had cerumen, and 16.7% had OME—demonstrating that otologic pathology is common enough to mandate examination. 4
Second: Consider Teething as Diagnosis of Exclusion
Teething becomes the likely diagnosis only after otoscopic examination is normal. 4
Infants typically begin teething around 6 months of age, making a 9-month-old developmentally appropriate for teething symptoms. 5
Parents commonly attribute ear pulling to teething (35-55% in surveys), but this belief correlates more with parental perception than objective findings. 6
The study on ear-pulling infants found that those with complaints only when falling asleep (not throughout the day) were statistically more likely to have normal examination findings, suggesting behavioral or teething-related causes. 4
Key Clinical Distinctions
When Ear Pulling Suggests AOM (Treat Immediately):
- Accompanied by fever, irritability, or recent upper respiratory infection 1
- Symptoms present throughout the day with significant distress 4
- Otoscopy shows bulging tympanic membrane or middle ear effusion 1
When Ear Pulling Suggests Teething (Reassure and Manage Symptomatically):
- Normal otoscopic examination 4
- Ear pulling occurs primarily when falling asleep or intermittently 4
- Associated with drooling, gum sensitivity, mouthing/biting, and mild irritability 5, 6
- No fever or systemic signs of illness 7
Management Based on Findings
If AOM is Diagnosed:
- Prescribe immediate antibiotic therapy (amoxicillin 80-90 mg/kg/day divided into 3 doses for 10 days) for infants under 6 months with bilateral AOM. 8
- Provide mandatory pain management with acetaminophen (15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours for infants ≥6 months). 8
If OME is Diagnosed:
- Recommend watchful waiting for 3 months, as most cases resolve spontaneously. 2, 3
- Do not prescribe antibiotics, as they are ineffective for OME. 2
If Examination is Normal (Teething):
- Reassure parents that teething is a normal, self-limiting process. 7
- Recommend non-pharmacological measures: cold teething rings, gentle gum massage. 5, 7
- Consider topical analgesic gels (avoiding benzocaine in infants) or systemic acetaminophen for significant discomfort. 5, 7
Critical Pitfalls to Avoid
Never diagnose teething without otoscopic examination, as clinical history alone cannot distinguish between teething and AOM. 1
Do not dismiss persistent or worsening symptoms as teething, as this can delay treatment of serious conditions like mastoiditis or meningitis. 7
Be aware that parents diagnose teething more by symptoms (65%) than by visible tooth eruption (36%), leading to potential misattribution of pathologic conditions. 6
If additional complaints are present (fever, feeding difficulties, persistent crying throughout the day), the likelihood of OME or AOM increases significantly. 4