Ear Infections in Children: When Are Antibiotics Actually Needed?

What is a middle-ear infection?

The ear infection children get most often is called acute otitis media, or AOM.

It occurs in the middle ear, the small air-filled space behind the eardrum.

Many ear infections develop after a cold or another viral respiratory infection.

Swelling from the illness can block the eustachian tube, the narrow passage that connects the middle ear to the back of the nose and throat.

When that tube does not drain normally, fluid can collect behind the eardrum. Viruses or bacteria can then cause inflammation and infection in that trapped fluid.

Young children develop ear infections more often than adults partly because their eustachian tubes are shorter, narrower, and more horizontal, making drainage more difficult.

Why do some children get more ear infections?

Several things can increase the likelihood of ear infections:

• Being a young child, especially under age 2
• Frequent colds and other respiratory infections
• Group childcare or frequent exposure to other young children
• Exposure to tobacco smoke
• A family history of frequent ear infections
• Certain craniofacial conditions that affect eustachian-tube function

Breastfeeding may lower the risk of ear infections.

For babies who use bottles, feeding while the baby is lying completely flat is best avoided.

Keeping recommended vaccines up to date and reducing tobacco-smoke exposure can also help lower the risk.

What are the signs of an ear infection?

An older child may simply say that the ear hurts.

Babies and toddlers may instead have:

• Ear pain
• Fussiness or increased crying
• Trouble sleeping
• Fever
• Less interest in eating or drinking
• Tugging, rubbing, or holding an ear
• Fluid draining from the ear
• Temporary difficulty hearing
• Occasionally vomiting or increased tiredness

Ear tugging alone does not prove that a child has an ear infection.

Babies may pull at their ears when they are tired, teething, exploring their body, or simply because the ear is there.

Likewise, fever and fussiness can occur with an ordinary viral illness.

How does the doctor know whether it is really an ear infection?

This is an important distinction.

A true acute middle-ear infection cannot be diagnosed based only on symptoms or simply because the eardrum looks red.

The doctor looks for evidence that fluid is trapped behind the eardrum and that the eardrum is bulging or otherwise shows the characteristic findings of acute infection.

A red eardrum by itself may occur when a child:

• Has a fever
• Has been crying
• Has an ordinary viral infection

This is one reason examining the ear carefully matters before deciding whether antibiotics are necessary.

What does drainage from the ear mean?

Yellow, cloudy, white, or blood-tinged fluid coming from the ear can sometimes mean that pressure from a middle-ear infection has caused a small opening in the eardrum.

This often sounds frightening, but these small openings usually heal well after the infection improves.

Ear drainage can also occur in children who already have ear tubes or from problems involving the outer ear canal, so the ear should be examined.

Do not plug the ear canal with cotton.

When should I call the doctor?

Contact your child's pediatrician if your child:

• Has significant ear pain
• Has pain lasting more than about a day
• Has a fever of 102.2°F (39°C) or higher
• Has fluid, pus, or blood draining from the ear
• Is drinking poorly
• Seems significantly more ill than expected
• Has symptoms that are worsening rather than improving
• Develops new difficulty hearing
• Is a very young infant with possible ear-infection symptoms

Seek care sooner whenever you are concerned about how your child looks or behaves.

When does an ear infection need urgent evaluation?

Seek urgent medical care if your child develops:

• Redness, swelling, or significant tenderness behind the ear
• An ear that appears pushed outward because of swelling behind it
• A stiff neck
• Severe headache with significant illness
• Unsteady walking or other new neurologic symptoms
• Extreme sleepiness or difficulty waking
• A very ill appearance

Redness, pain, or swelling over the bone behind the ear can rarely indicate mastoiditis, a complication that needs prompt treatment.

Pain relief comes first

Whether or not an antibiotic is prescribed, controlling pain is an important part of treatment.

Acetaminophen or ibuprofen can help with:

• Ear pain
• Fever
• General discomfort

Use the correct dose for your child's age and weight.

Ibuprofen is generally used in children 6 months and older unless your child's clinician recommends otherwise.

For detailed weight-based dosing, see the Elite Pediatric Concierge Fever in Children: When to Worry and What to Do.

Do all ear infections need antibiotics?

No.

Many mild acute ear infections improve without antibiotics.

For selected children, the pediatrician may recommend watchful waiting for 48 to 72 hours while treating pain and watching closely for improvement.

If the child improves, an antibiotic may never be needed.

If symptoms worsen or fail to improve during that period, antibiotics can then be started.

This approach reduces unnecessary antibiotic exposure, including side effects such as:

• Diarrhea
• Stomach upset
• Rash
• Allergic reactions

It also helps reduce antibiotic resistance.

When are antibiotics more likely to be needed right away?

Antibiotics are generally recommended when an acute ear infection is accompanied by:

• Drainage from the ear caused by acute otitis media
• Moderate or severe ear pain
• Ear pain that has lasted 48 hours or longer
• Fever of 102.2°F (39°C) or higher

Antibiotics are also generally recommended for children 6 to 23 months old who have confirmed acute infections in both ears, even when symptoms are otherwise mild.

Very young infants are managed more cautiously and should be evaluated promptly when an ear infection is suspected.

When can watchful waiting be reasonable?

Depending on the child's examination and ability to obtain follow-up, observation for 48 to 72 hours may be reasonable for:

• Children 6 to 23 months with a mild infection affecting only one ear
• Children 2 years and older with a mild infection affecting one or both ears

Watchful waiting is appropriate only when symptoms are mild and there is a clear plan for starting treatment if the child worsens or does not improve.

This is a decision to make together with your child's clinician.

Sometimes the clinician may provide a delayed prescription to fill only if symptoms fail to improve.

Which antibiotic is usually used?

When antibiotics are needed, amoxicillin is usually the first choice.

A different antibiotic—often one with broader coverage—may be recommended if your child:

• Has taken amoxicillin during the previous 30 days
• Has purulent, goopy conjunctivitis along with the ear infection
• Has had certain recurrent infections that did not respond to amoxicillin
• Has a significant penicillin allergy

Tell your child's clinician about previous antibiotic reactions and recent antibiotic use.

If an antibiotic is prescribed, give it for the full duration and exactly as directed.

What about decongestants and antihistamines?

Cold medicines, decongestants, and antihistamines do not treat an acute middle-ear infection or clear the fluid behind the eardrum.

They are generally not recommended simply to treat an ear infection and can cause side effects in young children.

How long does it take to get better?

Most children begin feeling better within 2 to 3 days.

Ear pain and fever usually improve first.

It is common, however, for fluid to remain behind the eardrum for several weeks after the infection itself has resolved.

This is called otitis media with effusion.

The fluid is not necessarily infected and does not automatically mean another antibiotic is needed.

It can temporarily cause muffled hearing.

In most children, the fluid gradually disappears on its own.

Let your child's doctor know if hearing problems seem persistent or are affecting speech, communication, school, or development.

What if my child keeps getting ear infections?

Some children have repeated acute ear infections or persistent middle-ear fluid.

Your pediatrician may consider a hearing test or referral to an ear, nose, and throat specialist if your child has:

• Frequent recurring ear infections
• Middle-ear fluid that persists for several months
• Persistent hearing difficulty
• Speech or language concerns
• Other risk factors that make temporary hearing loss more important

What about ear tubes?

Ear tubes are tiny tubes placed through the eardrum to ventilate the middle ear and allow fluid to drain.

They can be helpful for selected children.

However, having several ear infections does not automatically mean a child needs tubes.

For children being considered for tubes because of recurrent acute ear infections, whether middle-ear fluid is actually present at the time of the ENT evaluation is an important part of the decision.

Persistent fluid accompanied by hearing problems may also be a reason to consider tubes.

Your pediatrician and ENT specialist can help decide whether the potential benefit outweighs the risks for your child.

Can ear infections be prevented?

No strategy prevents every ear infection, but several steps can lower the risk.

Keep vaccines current

Recommended vaccines—including pneumococcal vaccines and the annual influenza vaccine—help prevent infections that can lead to ear infections.

Avoid tobacco smoke

Children exposed to tobacco smoke have a higher risk of middle-ear infections.

Keeping your child's environment smoke-free is one of the most useful preventive steps.

Breastfeed when possible

Breastfeeding is associated with a lower risk of ear infections.

Use good bottle-feeding positioning

Hold bottle-fed babies in a semi-upright position rather than feeding them while they are lying flat.

Reduce respiratory infections when practical

Handwashing and other reasonable measures that reduce the spread of respiratory viruses may also reduce some ear infections.

The bottom line

Ear infections are extremely common in childhood, and many mild infections improve without immediate antibiotics.

The most important points for parents are:

• Ear tugging or a red eardrum alone does not prove an ear infection is present.
• A careful ear examination is needed to diagnose acute otitis media.
• Pain relief matters whether or not antibiotics are used.
• Some children can safely be watched for 48 to 72 hours before starting antibiotics.
• Younger children, severe infections, infections in both ears in certain young children, and ear drainage are more likely to need antibiotics immediately.
• Amoxicillin remains the usual first treatment when antibiotics are needed.
• Fluid may remain behind the eardrum after the infection is gone and does not automatically require more antibiotics.
• Persistent hearing concerns or repeated infections deserve follow-up.

If your child's ear pain is severe, symptoms are worsening, or you are unsure whether your child needs to be seen, contact your pediatrician.