Most of these visits, with healthy, growing babies and children, are not needed at all. When I look in the ear with my otoscope, I am looking through the external canal to the ear drum which lies at the end of the canal and transmits sound vibration to the bones and fluid of the middle ear.

The bones of the middle ear are "lubricated" by a mucus-like fluid which then drains from the middle ear into the Eustachian Tube and into the throat. In adults and older kids, this is a nearly vertical drainage tube but in babies and younger kids, it's nearly horizontal. As you might guess, horizontal drainage of middle ear fluid can be easily slowed or stopped if the mucus gets thicker or if the tube gets inflamed and narrowed.

This leads to a "stagnant puddle of water" in the middle ear which is prone to thickening and/or infection with viruses or bacteria. The fluid accumulates and, lacking the normal drainage through the Eustachian tube into the throat, causes pressure on the ear drum which hurts and shows visible inflammation when I look at it.

When viruses and/or bacteria manage to grow in the fluid, "acute otitis media" can be diagnosed. The traditional treatment with antibiotics has been shown to be quite ineffective and, as a matter of fact, not anymore effective than doing nothing at all during the first three to four days. Most experts now recommend pain control only during the first days of an ear infection, although I think that safe alternative care (homeopathy, ear drops, hot compresses, vitamin C, elderberry or echinacea) will improve the healing course.

Please understand that very small babies with fevers and obvious ear pain or children with special conditions and underlying problems deserve a visit to the doctor and your doc may want to use medicine right away even thought antibiotics don't work as well as we have claimed for decades. The advice here is mainly for healthy full term babies and children whose main problem is fever and ear pain. For most illnesses like this, I tell parents that the best way to evaluate a sick child is from a few feet away when the fever's down. Most kids will "bounce back" for a little while. They smile a little, play a little and are obviously not very sick.

Ear infections occasionally cause the ear drum to perforate which is in some ways analogous to a pimple popping: The infection may go away and the pain is gone. The ear drum heals and sometimes the fluid reaccumulates but often the infection is gone. The drainage and occasional blood from the ear looks frightening and your doctor may want to have a look. Don't put drops in a draining ear without first talking to your doctor.

As an ear infection heals, the drum may not look 100 percent normal for weeks or months. The current recommendation is to tolerate the appearance of increased fluid behind the drum for 60 to 90 days.

Ear tubes have very little benefit in the long term and don't even preserve hearing the way we pediatricians once believed. I have seen them seem to help a lot in the short term when the "ventilation" of the middle ear (a hole poked in the ear drum and kept open by a tiny tube for a year or so) led to a lot less pain, fewer doctor's visits and less missed school and fun. However, tubes, for the most part, are not worth it.

Treat ear infections with pain control, "watchful waiting" and a call to the doctor when you are uncomfortable.