Ear Infections in kids

By Heather M. Jones | Aug. 24, 2020 Medically reviewed by Laura K. Grubb, MD, MPH

Endless coughs and sneezes, runny noses, and unexplained itchy bumps—kids seem to be a magnet for germs. In our parent’s guide to childhood illnesses, we talk about the symptoms and treatments for the most common conditions. Read the full series here.

Few smells transport me back to my childhood faster than the “banana medicine.” As a child who suffered from frequent ear infections, I became well-acquainted with that bright yellow liquid that tasted like candy, but was really an antibiotic. That I have had so many occasions to wax nostalgic at the smell in my days as a daycare teacher, and now a parent, makes one thing clear: Ear infections and childhood go hand-in-hand.

What is an ear infection?

A middle ear infection (acute otitis media, or AOM) is an inflammation of the middle ear. It occurs when fluid builds up behind the eardrum and is usually caused by bacteria. Ear infections in kids are especially common, with 5 out of 6 children experiencing at least one by the time they are 3 years old, with peak incidence occurring between ages 6 and 12 months.

While ear infections are an infection within the middle ear, they typically start with an upper respiratory tract infection caused by viruses, including influenza viruses. Bacteria or viruses from the nose and throat move into the middle ear and to the eardrum (tympanic membrane), causing increased secretions, swelling, and pain.

Some children are more prone to ear infections than others. Children under the age of 6, who attend daycare, who are exposed to cigarette smoke, who have other health conditions such as asthma, ear or facial abnormalities, who live in polluted areas, or who drink from a bottle lying down are at a higher risk for ear infections. Also, lack of breastfeeding or pneumococcal and influenza vaccines increase the risk for ear infections. Ear infections may also run in families.

Symptoms of an ear infection in kids

When there is a fluid build-up in the middle ear without infection, the condition is called otitis media with effusion. This typically doesn’t cause fever, pus, or drainage, but can still cause pain from pressure or other problems.

“When there is fluid in the middle ear, the eardrum cannot vibrate so the first symptoms you may notice are a feeling of fullness in the middle ear and a decrease in your ability to hear out of that ear,” says Leann Poston, MD, a medical contributor for Ikon Health.

This fluid build-up can become more serious. “Any time fluid sits still, just like in a pond, bacteria and viruses can start to increase in number and cause an infection,” says Dr. Poston.

Verbal children can tell their parents about an earache—but because ear infections typically start before children are able to express themselves clearly, it’s important for parents to watch for other signs of ear infection. These include:

Tugging/pulling at the ears
Fever, particularly in infants and young children
Trouble sleeping
Fussiness/irritability/crying
Trouble hearing/lack of response to quiet sounds
Fluid draining from the ear
Clumsiness/problems with balance

When should I take my child to the doctor for an ear infection?

Ear infections don’t always necessitate a visit to the doctor, but it’s a good idea to see a healthcare provider if an ear infection is suspected—even if just to confirm that the symptoms are due to an ear infection and not something else. “The teeth, sinus infections, a build-up of earwax, or infected tonsils can also result in ear pain that is not due to an infection,” says Dr. Poston.

A visit to a healthcare provider (usually a family physician, pediatrician, or nurse practitioner) is necessary if there is:

Fever of 102.2 degrees Fahrenheit or higher in children older than 6 months
Fever 100.4 degrees Fahrenheit or higher in children younger than 6 months
Discharge, pus, or fluid coming from the ear
Hearing loss
Headache, stiff neck, or sore throat
Any other symptom that is concerning or severe

You should also schedule an appointment if symptoms last longer than two to three days, worsen, or pain is uncontrollable with over-the-counter medication.

At your visit, your child’s healthcare provider will usually do a physical exam to check symptoms. “A medical provider uses an otoscope, which is a magnifying glass on a tube with a light, to look through the ear canal to the eardrum,” says Dr. Poston. “If it is infected it will look red and swollen and you can usually see yellow fluid behind it. If the pressure builds up too much it can pop a hole in the eardrum. This relieves the pressure and pain and infected fluid drains out of the ear.”

Treatments for ear infections in kids

“Antibiotics are prescribed if fluid is seen behind the eardrum, the ear infection is painful, or the child has a fever and ear pain,” says Dr. Poston. “The first choice for antibiotics is usually Amoxicillin unless you are allergic, have recently been on Amoxicillin, have recurrent ear infections that are resistant to treatment with Amoxicillin, or have an eye infection with the ear infection. The dosage for Amoxicillin is based on weight.”

Antibiotics are not always necessary. “Antibiotics are usually used for children who get recurrent ear infections; however, not all children need to be treated with antibiotics, says Soma Mandal, MD, board certified internist at Summit Medical Group. “Most ear infections can clear on their own and pain relievers such as acetaminophen can be taken for pain relief. Antibiotics play no role in the treatment for a viral ear infection, and they can be associated with side effects and potential antibiotic resistance.” Alternative initial antibiotics include cefdinir, cefuroxime, cefpodoxime, or ceftriaxone.

Approximately 80% of children with acute ear infections will recover without the use of antibiotics. If the child is not in great discomfort, or showing signs of serious infection, the healthcare provider may suggest “watchful waiting”—rechecking the child’s ears at intervals to make sure the fluid is draining on its own. Studies show that delaying antibiotic treatment, combined with watchful waiting, does not increase the likelihood of the child developing serious problems. If the infection is viral, antibiotics will not treat the infection.

The American Academy of Pediatrics advises, “The decision not to give initial antibiotic treatment and observe should be a joint decision of the clinician and the parents. In such cases, a system for close follow-up and a means of beginning antibiotics must be in place if symptoms worsen or no improvement is seen in 48 to 72 hours.”

Symptom management is an option while waiting for ear infections to clear on their own. This might include:

Pain and fever medication such as ibuprofen (Advil, Motrin) or Tylenol (for children under 6 months, use only Tylenol—never give a child Aspirin)
Numbing ear drops—read the label and make sure they do not contain any ingredients warned against by the FDA for children, and consult a healthcare provider before using ear drops. For tips on how to apply ear drops, check out this tutorial from The American Academy of Pediatrics.
Rest
Hydration with water and other fluids

Words of caution:

ALWAYS check with a healthcare provider before giving a child over-the-counter cough, cold, or decongestant medications. These medications can cause dangerous effects in children.
NEVER put anything inside the child’s ear canal (aside from drops if recommended by the child’s doctor). This includes cotton swabs, cotton balls, or any other objects, or liquids unless directed by a healthcare professional.
ALWAYS finish the entire course of antibiotics, if prescribed—even if the child feels better.

Children will usually start to feel better after two to three days, but fluid in the ear may remain for three to six weeks.

Ear infections are not contagious. Children can return to school or daycare once the fever is gone and they feel well enough to do so, even if still on a course of antibiotics. However, some of the illnesses that cause ear infections are contagious, so make sure the cause of the ear infection is also taken care of before allowing the child near other children.

What are some potential complications from ear infections?

Most ear infections will heal without issue, but there are some complications that can arise.

Hearing loss due to prolonged fluid in the ear, which can affect speech and language in young children
Ruptured eardrum, which will release the pressure but may heal with scar tissue. Multiple ruptures can cause problems with the membrane vibrations.
Mastoiditis when the infection spreads to the air cells in the mastoid bone behind the ear. This may require surgical drainage.

If the child’s symptoms are not going away within two to three days, with or without treatment, see a healthcare provider. If a follow-up is recommended, make sure to follow through on the appointment.

What are recurrent ear infections and how are they treated?

“Recurrent ear infections are due to persistent fluid behind the eardrum that gets re-infected,” says Dr. Poston. “Younger children are more likely to get recurrent ear infections because their Eustachian tubes (drainage tubes in the ears) are both more horizontal and smaller in diameter.”

Antibiotics do not get rid of the fluid behind the eardrum, but will eliminate most of the bacteria. Children who get more than three ear infections in six months, or four ear infections in 12 months, may get “tubes” in their ears. These small, plastic tubes are inserted into the eardrum, usually under anesthesia, and help fluid drain from behind the eardrum. They require checkups and usually fall out on their own after six to nine months. If other treatment isn’t productive, a healthcare provider or ear, nose, and throat specialist may suggest removing the child’s adenoids to prevent the spread of infection into the Eustachian tubes.

How to prevent ear infections in children

While ear infections can’t be prevented entirely, there are some ways to reduce the risk factors associated with them:

Keep cigarette smoke away from children, especially babies. Research shows that children around secondhand smoke have more ear infections.
Keep children’s vaccinations up to date, especially the pneumococcal and influenza (flu) vaccines.
Use good hand washing hygiene for everyone, including children.
Don’t bottle-prop or allow babies or young children to go to bed (or nap) with a bottle.
Keep children away from people who are sick.
Breastfeed exclusively for six months, and continue to breastfeed until the baby is at least 12 months old.