Ear Infections in Children: Symptoms and Treatment

Your child wakes up in the middle of the night screaming. They're pulling at their ear, are restless, and may have a fever. Could it be an ear infection?

Ear infection — or acute otitis media — is one of the most common infections in young children. It most often affects children between 6 months and 3 years, and most children experience at least one episode before turning 3. The good news: 8 out of 10 children recover without antibiotics.

What Is an Ear Infection?

Acute otitis media is an infection in the middle ear — the space behind the eardrum. The ear canal (outer ear) and middle ear are two different parts of the ear, and it's the middle ear that's most commonly affected in children.

In young children, the Eustachian tube (connecting the ear to the throat) creates problems. It's shorter and more horizontal than in adults, making it easier for bacteria and viruses to spread from the nose and throat up to the middle ear.

Ear infections almost always follow a cold. When the mucous membranes in the nose swell, the Eustachian tube gets blocked, creating a moist environment where bacteria can thrive.

Symptoms of Ear Infection

Symptoms vary with age. Older children can say their ear hurts, while infants show discomfort in other ways.

In infants and toddlers:

• Cries more than usual, is restless and hard to comfort
• Pulls or rubs their ear
• Refuses food or drink (sucking motion can increase pressure in the ear)
• Sleeps poorly, wakes up crying
• Fever (but not all children with ear infections get fever)
• Fluid or pus draining from the ear (indicates a ruptured eardrum)
• Decreased hearing in the affected ear

In older children:

• Says their ear hurts or they can't hear well
• Feels pressure or fullness in the ear
• Fever and generally reduced well-being

Treatment: Pain Relief Is Most Important

For most children, pain relief is the most important treatment. Ear infections are painful, and the child deserves to be spared unnecessary suffering.

Pain Relief with Medicine

• Acetaminophen (e.g., Tylenol) — dosed by weight and age. Read the package instructions carefully.
• Ibuprofen (e.g., Advil, Motrin) — can be used from 6 months of age and at least 11 lbs body weight. Also has anti-inflammatory effects.

Give pain relief regularly for the first 2-3 days, not just when the child is crying. This prevents pain from building up.

Other Measures

• Let the child lie with their head slightly elevated — this can reduce pressure in the ear
• Give plenty of fluids
• A warm cloth against the ear can provide relief for some children
• Keep the child home from daycare until they're feeling better

What About Antibiotics?

8 out of 10 children with ear infections recover without antibiotics within 2-3 days. The body handles the infection on its own. Unnecessary antibiotic use can cause side effects like diarrhea and increases the risk of resistant bacteria.

The doctor considers antibiotics for:

• Children under 1 year — lower threshold for treatment
• Bilateral ear infection in children under 2
• No improvement after 2-3 days of pain relief
• Very poor general condition or high fever
• Persistent fluid from the ear

Antibiotics vs. Watchful Waiting

AAP guidelines are clear: most children with uncomplicated ear infections don't need antibiotics. This recommendation is based on the fact that 80 percent of ear infections heal on their own.

Watchful Waiting (48-72 hours)

For children over 2 with uncomplicated, one-sided ear infections, guidelines recommend watchful waiting for 48-72 hours:

1. Good pain relief — acetaminophen and/or ibuprofen in correct doses
2. Observation — monitor the child's general condition, fever, and pain level
3. Reassessment — contact doctor after 2-3 days if the child isn't improving
4. Safety-net prescription — many doctors write a prescription you can fill only if the child doesn't improve

When Are Antibiotics Right?

Antibiotics should be used — and used promptly — in these situations:

Always antibiotics:

• Children under 6 months with confirmed ear infection
• Children with discharge from the ear (perforated eardrum with pus)
• Bilateral ear infection in children under 2
• Children with cochlear implants
• Immunocompromised children

Consider antibiotics:

• Children between 6 months and 2 years with one-sided ear infection and clearly reduced well-being
• Children with persistent high fever (over 102.2°F)
• No improvement after 48-72 hours of pain relief

Treatment Summary

*Watchful waiting with a safety-net prescription if the child is otherwise in reasonable condition.

When Should You Contact a Doctor?

Contact your pediatrician or urgent care for:

• Children under 1 year with signs of ear infection
• Severe pain not relieved by acetaminophen/ibuprofen
• High fever (over 104°F)
• Discharge or pus from the ear lasting more than 2 days
• The child seems very ill
• No improvement after 2-3 days of pain relief

Call emergency services (911) for:

• Neck stiffness (child refuses to bend head forward)
• Swelling or redness behind the ear (may indicate mastoiditis)
• Child is very lethargic, difficult to wake, or not responding normally

Prevention: How to Reduce the Risk

You can't prevent all ear infections, but you can reduce the risk:

• Good hand hygiene — wash hands often, especially during cold season
• Smoke-free environment — children exposed to secondhand smoke get ear infections more often
• Breastfeeding — studies show that breastfed children in the first year have a lower risk of ear infections
• Pneumococcal vaccine — part of recommended childhood vaccinations, protects against bacteria that often cause ear infections
• Avoid pacifier use after 6 months — the sucking motion can affect pressure in the middle ear

Recurring Ear Infections

Some children get ear infections repeatedly. If your child has had 3 or more episodes in 6 months, or 4 or more in 12 months, you should talk to the doctor about further evaluation.

In some cases, the doctor may consider placing ventilation tubes (grommets) in the eardrum. The tube ensures ventilation of the middle ear and reduces fluid accumulation. The procedure is short and done under anesthesia in children.

Fluid Behind the Eardrum

After an ear infection, fluid can collect behind the eardrum (otitis media with effusion). This can cause decreased hearing for weeks to months. The condition usually resolves on its own but should be followed up if it lasts more than 3 months. Decreased hearing can affect the child's language development.

Myths About Ear Infections

"The child gets ear infections from cold ears" — No. Ear infections are caused by viruses and bacteria, not cold. But colds are more common in winter, and a cold is the most common precursor to an ear infection.

"Ear drops help" — Regular over-the-counter ear drops work against outer ear infections (swimmer's ear), not middle ear infections.

"The child always needs antibiotics" — No. Most children recover without them. Antibiotics should be used judiciously to avoid resistance.

Frequently Asked Questions

How long does an ear infection last?

Most children are noticeably better after 2-3 days. Full healing takes about 1-2 weeks. Slightly decreased hearing may last a few weeks after the infection is over.

Can the child swim with an ear infection?

Regular bathing is fine, but avoid submerging the head. If fluid is draining from the ear, keep the ear dry.

When can the child return to daycare?

The child can return to daycare when they're fever-free and in reasonably good shape. There's no set quarantine period for ear infections.

Are ear infections contagious?

Ear infections themselves are not contagious, but the cold that triggers them is. Good hand hygiene and cough etiquette can reduce spread.

See also: Fever in Children | Common Childhood Illnesses

Sources

1. AAP - Ear Infections in Children
2. CDC - Ear Infections