Ear Infection in Children

What this article covers

What is a middle ear infection, and does it go away on its own?
Signs of an ear infection in a baby who cannot talk yet
Why do children get ear infections more than adults?
How to ease your child's ear pain at home
Watchful waiting or antibiotics now: how does the doctor decide?
What do antibiotics actually do for an ear infection?
Why you should never put oil, garlic or anything else in the ear
Warning signs: when should you take your child to the emergency department?
Fluid behind the eardrum and repeated infections: will it affect hearing?

What is a middle ear infection, and does it go away on its own?

Acute otitis media is an infection of the small air space behind the eardrum. It usually starts after a cold or sore throat, when the tube that connects the ear to the back of the nose swells shut. Fluid collects behind the drum, viruses or bacteria multiply in it, the eardrum bulges outward and the child feels sharp pain.

The reassuring news is that most of these infections get better by themselves. A 2023 Cochrane review, which pooled 13 trials covering more than 3,400 children, concluded that in high income countries most cases of acute otitis media resolve spontaneously without complications, and that antibiotics do not reduce pain at all in the first 24 hours.

That does not mean you should ignore your child's ear pain. It means the first priority is relieving the pain, and the second is having a doctor look at the eardrum to decide whether your child needs an antibiotic now or whether a few days of watching is the better choice. A middle ear infection cannot be diagnosed without seeing the eardrum, because ear pain alone can come from the teeth or throat.

Young children are affected far more than older ones, with the peak roughly between six months and two years. Episodes usually become much less frequent once a child reaches school age and the ear tubes grow.

Signs of an ear infection in a baby who cannot talk yet

An older child will simply tell you their ear hurts. A baby shows it in other ways, and most of them are not specific. What parents notice most is unusual crying, especially at night or when lying down, because pressure inside the ear rises in that position. A baby may refuse feeds or pull away after a few seconds, because sucking and swallowing shift the pressure in the ear and make the pain worse.

Pulling or rubbing the ear is the sign everyone knows, but on its own it is weak evidence. Many babies touch their ears when teething or tired. It matters more when it comes with a fever, a few days after a cold, or with broken sleep and obvious irritability.

Sometimes you will see yellow or greenish fluid coming out of the ear, and the child may suddenly calm down when it appears. This usually means the eardrum has developed a small hole from the pressure. The hole normally heals on its own, but discharge is still a reason to see a doctor the same day or the next.

Keep in mind the difference between a middle ear infection and an outer ear infection, often called swimmer's ear. Swimmer's ear tends to follow swimming in pools or the sea in summer, hurts sharply when you touch or tug the outer ear, and is treated differently.

What parents may notice, and what it may mean

Sign	What it may mean	How much it counts
Crying at night or when lying down	Pressure and pain inside the ear	Important with fever or after a cold
Refusing feeds or stopping quickly	Swallowing makes the pain worse	Important if it happens at every feed
Pulling or rubbing the ear	Pain, teething or tiredness	Weak on its own
Temperature of 38 C or more	Active infection	Important, and urgent under 3 months
Fluid draining from the ear	Probably a small hole in the eardrum	See a doctor within a day

Why do children get ear infections more than adults?

The main reason is anatomy. The tube linking the middle ear to the back of the nose, the Eustachian tube, is shorter, flatter and narrower in a child than in an adult. It blocks easily with any cold, drains fluid poorly, and lets germs from the nose and throat reach the ear quickly.

The adenoids also play a part. This is lymph tissue at the back of the nose, and when it is enlarged in some children it presses on the opening of the tube and acts as a reservoir for bacteria. On top of that, young children catch many colds a year, especially in nurseries, schools and crowded homes.

Some risk factors are within your control. Exposure to cigarette and shisha smoke indoors clearly raises the risk of ear infection, and exclusive breastfeeding for the first six months is protective, according to the 2013 American Academy of Pediatrics guideline. Many paediatricians also advise against bottle feeding a baby who is lying flat on their back. The guideline recommends completing the pneumococcal vaccine and the yearly flu vaccine, because both reduce the infections that come before ear infection.

How to ease your child's ear pain at home

Pain is the central symptom of an ear infection and it is what keeps the child and the whole household awake. That is why guidelines treat pain relief as the cornerstone of care, before any decision about antibiotics. A 2023 Cochrane review of pain relievers found that 25 percent of children on placebo still had pain at 48 hours, compared with 10 percent on paracetamol and 7 percent on ibuprofen, although the number of trials was small.

The two common children's pain relievers are paracetamol and ibuprofen, and the amount is based on your child's weight, not only their age. Use the children's syrup with the syringe that comes in the box rather than a kitchen spoon, and follow the pack or ask the pharmacist about the amount and the gap between doses. Ibuprofen is not usually given to babies under three months, and aspirin should never be given to anyone under 16.

Many parents mix up brand names that contain the same ingredient and end up giving a double dose of paracetamol without realising, once in a fever syrup and again in a cold syrup. Read the ingredients on every box before combining two medicines.

Alongside the pain reliever, some children find a warm, not hot, compress held against the outside of the ear comforting, and small frequent drinks or feeds help. Numbing ear drops should only be used on a doctor's advice, and never when there is discharge from the ear.

Children still in ear pain at 48 hours

Placebo 25%

Paracetamol 10%

Ibuprofen 7%

Source: de Sévaux et al, Cochrane, 2023

Watchful waiting or antibiotics now: how does the doctor decide?

The American Academy of Pediatrics guideline sorts children by age and by how severe the illness is. Severe means moderate or severe ear pain, pain lasting 48 hours or more, or a temperature of 39 degrees Celsius or higher. If fluid is draining from the ear, an antibiotic is the recommended choice.

For non severe illness in children over two, or in one ear in children between six months and two years, the doctor may suggest watching for 48 to 72 hours with pain relief instead of an immediate antibiotic. The key condition is that you can come back or contact the doctor, and that an antibiotic is started if your child gets worse or does not improve in that time. Some doctors give a delayed prescription, which you fill only if your child has not improved.

Babies under six months were not included in this watchful waiting option and should always be examined by a doctor. Any baby under three months with a temperature of 38 degrees or more needs urgent medical assessment, whatever the apparent cause.

When watching is enough and when antibiotics are advised

Your child	Usual approach in guidelines
Under 6 months	Always examined by a doctor, who decides
Any age with ear discharge	Antibiotic
6 months or older with severe symptoms	Antibiotic
6 months to 2 years, both ears, not severe	Antibiotic
6 months to 2 years, one ear, not severe	Antibiotic or watch for 48 to 72 hours
Over 2 years, not severe	Watch for 48 to 72 hours or antibiotic

Source: Lieberthal et al, Pediatrics, 2013

What do antibiotics actually do for an ear infection?

The 2023 Cochrane review gives a frank picture. Antibiotics do not ease pain in the first 24 hours. They spare one extra child out of every 20 treated from pain on days two to three. On the other side, one child in every 14 who takes an antibiotic gets vomiting, diarrhoea or a rash that would not otherwise have happened.

That does not make antibiotics bad. They matter in severe cases, in young babies and when the ear is discharging. It does mean that giving one for every earache is not in the child's interest. When a doctor does prescribe, amoxicillin is usually the first choice, and the length of the course depends on age and severity. The dose and duration are for the doctor to set.

In this region antibiotics are easy to buy at a pharmacy. A 2023 survey of 406 parents at primary care centres in Abha, Saudi Arabia, found that 28.8 percent had given their child an antibiotic without a prescription before seeing the doctor, out of fear the illness would get worse, and that 51 percent believed ear infections always need antibiotics. That reaction comes from understandable worry, but it often exposes the child to side effects without clear benefit and feeds antibiotic resistance.

If the doctor does prescribe an antibiotic, finish the course as instructed, do not use a sibling's leftover bottle, and do not increase the dose because the pain has not gone on day one. An antibiotic needs two to three days to show its effect.

Antibiotics for ear infection, in numbers

1 in 20 extra children free of pain on days 2 to 3 thanks to antibiotics

1 in 14 children who get vomiting, diarrhoea or rash from the antibiotic

28.8% of parents in Abha gave antibiotics without a prescription

Source: Venekamp et al, Cochrane, 2023, and AlHefdhi et al, Children, 2023

Why you should never put oil, garlic or anything else in the ear

Some of the most widely shared home remedies are a drop of warm olive oil, a crushed garlic clove, a drop of breast milk, onion juice or black seed oil. These recipes are passed down with the best intentions, but they never reach the infection, because it sits behind the eardrum and not in the outer ear canal.

Worse, they can cause harm. If the eardrum has a hole in it, which you cannot see at home, oil or juice can get into the middle ear and make the infection worse. Garlic can cause chemical burns to the skin of the canal, and warmed oil can scald if it is hotter than you think. Anything put in the ear also hides discharge and makes it harder for the doctor to see the eardrum.

The same goes for cotton buds, which push wax and discharge deeper and can damage the eardrum. Antibacterial ear drops sold in pharmacies have specific uses, such as a perforated eardrum or ventilation tubes, and a doctor should decide on them after examining the ear.

Warning signs: when should you take your child to the emergency department?

Most ear infections pass safely, but in a small number the infection spreads into the bone behind the ear, called mastoiditis, or to the membranes around the brain. These complications are rare, but they need a hospital, intravenous antibiotics and sometimes surgery.

A multicentre Saudi study of children with mastoiditis, published in 2024, found an average of about 14 days between the first symptoms and diagnosis, and complications such as abscess and meningitis were not unusual among these children. The lesson is that pain, fever or discharge that persists or worsens despite treatment should not be left for two weeks.

For everyday concerns, see a doctor if your child has not improved within 48 to 72 hours, if fluid comes out of the ear, if infections keep coming back, or if you think their hearing has dropped. The signs in the box below should not wait for an appointment.

Fluid behind the eardrum and repeated infections: will it affect hearing?

Once the pain and fever have gone, many children are left with fluid behind the eardrum for weeks. This is called otitis media with effusion, or glue ear. It is not an active infection and is usually painless, but it can dull hearing for a while, so a child may seem not to listen, turn the television up or be slow to talk.

A study at two specialist centres in Upper Egypt, covering more than 2,000 children, found this fluid in 15.5 percent of them, and repeated episodes were linked with enlarged adenoids and tonsils, nasal allergy, frequent colds and reflux. The 2016 American guideline recommends watching for three months, because most cases clear on their own, and a hearing test if the fluid lasts three months or more. It advises against antibiotics, steroids, antihistamines or decongestants to treat this condition.

If fluid persists in both ears with reduced hearing, or acute infections come back three times in six months or four times in a year, an ear, nose and throat specialist may suggest small ventilation tubes placed in the eardrum during a short procedure, sometimes with removal of the adenoids. The decision depends on your child's hearing, speech and development, not just on the number of infections.

Following fluid behind the eardrum after an infection

First few days Pain and fever usually settle within two to three days
Following weeks Fluid may remain behind the drum, with slightly muffled hearing
Up to 3 months Watch and wait, most cases clear on their own
After 3 months Hearing test if the fluid is still there
Lasting fluid with hearing loss ENT assessment to discuss ventilation tubes

Source: Rosenfeld et al, Otolaryngology Head and Neck Surgery, 2016

Use Sihtak to log each ear infection your child has, the temperature, and whether an antibiotic was given and which one. That simple record is exactly what an ENT specialist needs to judge whether infections are truly recurrent, and it helps you keep track of hearing checks and vaccinations.

Frequently asked questions

How long does an ear infection last in a child?

Pain and fever usually improve within two to three days, whether or not the child takes an antibiotic. Fluid behind the eardrum and muffled hearing can last for weeks afterwards, and in most children it clears within three months.

Does every ear infection need antibiotics?

No. For mild cases in children over two, guidelines allow watching for 48 to 72 hours with pain relief. Antibiotics are advised for young babies, for severe symptoms and when fluid drains from the ear.

Does ear pulling mean my baby has an ear infection?

Not necessarily. Many babies pull their ears when teething or tired. The sign matters more when it comes with fever, night crying or refusing feeds after a cold.

Does warm olive oil help ear pain?

No. The infection is behind the eardrum where oil cannot reach, and if the drum has a hole, oil can make the infection worse. Use a pain reliever suited to your child's age and weight and see a doctor.

Can an ear infection cause hearing loss?

The fluid left after an infection can reduce hearing for a while. If it lasts three months or you notice delayed speech, ask for a hearing test. Permanent hearing loss is rare and is usually linked to complications or long neglect.

Can my child fly or swim with an ear infection?

Flying is usually possible, but pressure changes can increase pain, and feeding or sipping water during take off and landing helps. Swimming with discharge or a perforated eardrum needs a doctor's go ahead first.

When are ear infections considered recurrent?

Usually at three episodes in six months, or four in a year with one in the last six months. At that point your child should be assessed by an ear, nose and throat specialist, including a hearing test.

Sources

This content is for health education only and is not a substitute for medical advice. If you have symptoms that worry you, see your doctor.