New research suggests that taking a “wait-and-see” approach to the treatment of ear infections may be best. A recent study, published in the Journal of the American Medical Association, found that 62%, or nearly two-thirds, of children diagnosed with a middle ear infection got better on their own—without antibiotics—within 48 hours.

Ear infections are currently the most common use of antibiotics in children. But like all drugs, antibiotics pose risks, including allergic reactions, severe diarrhea, which may result in dehydration, and antibiotic resistance. The study did not specifically address children with cleft palate and/or craniofacial conditions, who often suffer from middle ear infection, known medically as acute otitis media.

“Otitis media is more frequent and more prolonged in kids with cleft palate and craniofacial conditions compared with the general population,” says Mark Volk, MD, DMD, an otolaryngologist or ear-nose-and-throat doctor at Children’s Hospital Boston. “But they have no greater complications or more severe symptoms.”

Symptoms that may indicate a middle ear infection are: pain, irritability, poor appetite, and difficulty sleeping. Tugging at the ears and fever may also be signs of infection.

Most middle ear infections are associated with colds. “The average child will get six to eight colds per year,” says Dr.Volk,“so that’s a lot of opportunity. And since the immune system is still maturing, it’s not equipped as well to fight off those infections.”

Ear infections result from fluid buildup in the middle ear, the space behind the eardrum. Doctors theorize that fluid forms because of a problem with the Eustachian tubes, the narrow tubes that connect the middle ear to the back of the nose. Normally, the Eustachian tube acts as a pressure-equalizing valve, opening every time you yawn or swallow. But if the tube doesn’t work properly, negative air pressure can develop in the ear. (You may feel this uncomfortable sensation during airplane takeoffs and landings when the ears are subject to pressure changes.)

Fluid eventually fills this void, causing the ears to feel stuffy and muffling sounds. If bacteria from the nose or bloodstream sneaks into the fluid, it can become infected.

The risk of infection is greater for children with cleft palate. When the palate is clefted or split, the small rubber band-like muscles that insert through the palate and control the opening of the Eustachian tubes don’t work very well. Often, but not always, their function is at least partially restored when the cleft is repaired. Craniofacial disorders can also increase the chance of ear infection. “One theory is that abnormalities in the back of the nose cause air turbulence, which leads to inflammation of the surface of the Eustachian tube,” says Dr.Volk. “Another is that the [facial] configuration of some people can create a reservoir for bacteria to set up shop.”

Children with fluid in their ears or frequent ear infections can experience hearing loss, language delays, and speech problems. The ability to hear well is especially important at eight to nine months of age, because that’s when the brain begins to make connections critical to speech development.

“If a child has fluid in the ear, hearing fluctuates,” says Dr.Volk. “It’s very tough for parents to pick up on this. They’ll say,‘One day I’ll be whispering to Johnny, and he hears everything. But the next, I’ll be speaking loudly, and he doesn’t pay attention.’

“This is the worst kind of hearing loss, because words sound different every day. Compared to kids with low level permanent hearing loss, kids with fluid don’t do as well with language acquisition.”

If parents or the physician are concerned about a child’s speech/language development, an evaluation by a speech and language specialist is generally recommended.

Middle ear infections may decrease with the removal of the adenoid glands—whether enlarged or not—which lie close to the Eustachian tubes. The child may also outgrow the problem as the Eustachian tubes grow in size and the immune system matures.

But if a speech delay occurs or if antibiotics do not effectively control infections, the child probably needs ear tubes. These tiny tubes, about the size of a very small bead, can drain fluid from behind the eardrum. Tubes may be inserted at the time that a cleft palate is repaired. Depending on their design, tubes last about 6 to 18 months. The entire insertion procedure, which requires general anesthesia, takes only 15 minutes from start to finish. Once in place, tubes need to be checked by a medical professional every three to six months.