Recognizing Ear Infections in Children

If your child has ever woken screaming in the middle of the night, tugging at their ear with a fever, you know how distressing ear infections can be for the whole family. Ear infections are among the most common childhood illnesses—by age three, three out of four children will have had at least one. AAP The good news is that understanding why they happen, recognizing the signs, and knowing when they need treatment versus when they'll resolve on their own can help you navigate these episodes with more confidence.

Understanding Why Children Get Ear Infections AAP

To understand ear infections, it helps to know a bit about ear anatomy. The middle ear—the space behind the eardrum—connects to the back of the throat through a small tube called the Eustachian tube. This tube normally drains fluid from the middle ear and equalizes pressure. AAP

In children, the Eustachian tubes are shorter, more horizontal, and softer than in adults. This anatomical difference makes it easier for bacteria and viruses to travel from the throat into the middle ear, and harder for fluid to drain properly. When a child gets a cold, the Eustachian tubes can swell and become blocked, trapping fluid in the middle ear where bacteria can multiply. CDC

The American Academy of Pediatrics notes that ear infections are most common between six months and two years of age, when Eustachian tubes are at their most horizontal and immune systems are still developing. AAP Infections tend to peak during winter months when colds and respiratory infections are more frequent. Most children have fewer ear infections as they get older and their Eustachian tubes mature into a more vertical position.

There are different types of ear infections. Acute otitis media (AOM) is a middle ear infection with fluid, inflammation, and often pain and fever. Otitis media with effusion (OME) involves fluid in the middle ear without signs of acute infection—this often follows an acute infection or occurs after a cold. AAP While OME doesn't typically require antibiotics, it can temporarily affect hearing.

Recognizing Ear Infection Signs AAP

Ear infection symptoms can range from obvious to subtle, and babies and young toddlers obviously can't tell you their ear hurts. Learning to recognize behavioral cues is important for parents.

Ear pain is the hallmark symptom, though babies express this differently than older children. You may notice increased crying or fussiness that seems different from usual—often more intense or inconsolable. Pain is typically worse when lying down because the position increases pressure in the middle ear. AAP

Tugging, pulling, or rubbing at the ear is a classic sign, especially when accompanied by other symptoms. However, babies also touch their ears for other reasons (teething, exploration, tiredness), so ear pulling alone doesn't necessarily mean infection. AAP

Sleep disturbances are common because lying down increases ear pain. Your child may wake more frequently, have difficulty settling, or refuse to lie flat. Some children seem better during the day but worse at night for this reason. CDC

Fever is present in many but not all ear infections. The AAP notes that fever with ear infection can range from mild to high (over 102°F), and some children have ear infections without any fever at all. AAP

Fluid draining from the ear may occur if the eardrum ruptures from pressure buildup. While this sounds alarming, it actually often provides pain relief as pressure is released. The drainage may be clear, cloudy, or bloody. AAP A ruptured eardrum typically heals on its own but should be evaluated by your pediatrician.

Hearing changes may be noticeable—your child might not respond to quiet sounds, need the TV louder, or seem to not hear you when you call. This occurs because fluid in the middle ear interferes with sound transmission. CDC Hearing typically returns to normal once the fluid clears.

Balance problems or clumsiness can occur because the inner ear plays a role in balance. Some children seem unsteady or more prone to falls during ear infections. AAP

Decreased appetite is common, particularly in babies. Sucking and chewing can increase ear pressure, making feeding uncomfortable. If your child refuses to eat or drink for an extended period, contact your pediatrician. AAP

When to See Your Pediatrician AAP

While some ear infections resolve on their own, certain situations warrant prompt medical evaluation. The AAP recommends contacting your pediatrician if symptoms persist beyond two to three days without improvement, as this suggests the infection may need antibiotic treatment. AAP

Call your doctor if your child has severe ear pain that doesn't respond to over-the-counter pain relievers, or if fever exceeds 102°F (39°C). High fever with ear symptoms may indicate a more significant infection. CDC

Fluid draining from the ear should be evaluated to assess whether the eardrum has ruptured and to determine if treatment is needed. While most ruptured eardrums heal without intervention, your pediatrician should examine the ear. AAP

Children under six months with suspected ear infection should always be seen by a doctor. The AAP recommends that infants this young be evaluated because their immune systems are less mature and they're at higher risk for serious infection. AAP

If hearing seems significantly affected, or if your child has had multiple ear infections, discuss this with your pediatrician. Frequent infections or persistent fluid may warrant referral to an ear, nose, and throat specialist. AAP

What to Expect at the Doctor's Visit AAP

Your pediatrician will examine your child's ears using an otoscope—a handheld device with a light and magnifying lens. A healthy eardrum appears gray and translucent. With an acute ear infection, the eardrum typically looks red, bulging, and may have visible fluid behind it. AAP

Some offices use pneumatic otoscopy, which involves gently puffing air against the eardrum to see how it moves. A healthy eardrum moves freely; one with fluid behind it moves very little or not at all. AAP

Based on the examination, your pediatrician will determine whether antibiotics are needed. Not every ear infection requires antibiotics—this is an important change from past practice.

Understanding Treatment Approaches AAP

Modern guidelines for ear infection treatment have evolved based on research showing that many ear infections resolve without antibiotics. The AAP recommends what's called "watchful waiting" for certain cases: observing for 48 to 72 hours before prescribing antibiotics, provided the child can be monitored and receives adequate pain management. AAP

Watchful waiting is appropriate for children over six months with mild symptoms in one ear, or children over two years with mild symptoms in one or both ears. During this observation period, parents should have a plan to reach their provider if symptoms worsen. AAP

Antibiotics are recommended more promptly for children under six months with suspected ear infection, children six months to two years with infection in both ears, any child with severe symptoms (moderate to severe ear pain, high fever, or appearing ill), and children with compromised immune systems. AAP

When antibiotics are prescribed, amoxicillin is typically the first choice unless your child has an allergy or has taken amoxicillin recently. It's important to complete the full antibiotic course even if your child seems better after a few days—stopping early can lead to resistant bacteria. CDC

Pain management is important regardless of whether antibiotics are used. The AAP emphasizes that treating pain should be a priority because ear infections hurt. AAP

Pain Relief Strategies AAP

Managing your child's discomfort while waiting for the infection to resolve or for antibiotics to take effect is essential. There are several evidence-based approaches.

Acetaminophen (Tylenol) or ibuprofen (for children six months and older) can provide significant pain relief. Follow age-appropriate dosing on the package or as directed by your pediatrician. Ibuprofen also reduces inflammation, which may be particularly helpful for ear pain. AAP

A warm compress applied to the outside of the ear can provide comfort. Use a warm (not hot) washcloth or heating pad on low. Test the temperature carefully and never leave a heating pad on a sleeping child. AAP

Keeping your child upright when possible can reduce pressure in the middle ear and ease discomfort. For babies, holding them upright or keeping the crib mattress slightly elevated may help. AAP

Adequate hydration is important, and the swallowing motion can help relieve ear pressure. Encourage your child to drink fluids regularly. For babies, nursing or bottle feeding provides both comfort and this swallowing benefit. CDC

Distraction with quiet activities, extra cuddles, and comfort can help your child cope with discomfort. Sometimes the best medicine is your reassuring presence. AAP

Never put anything in your child's ear—no drops, oils, or other substances—unless specifically prescribed by your doctor. AAP

Preventing Ear Infections CDC

While you can't prevent every ear infection, certain strategies can reduce their frequency.

Keeping vaccinations current is important. The pneumococcal vaccine and flu vaccine both help prevent infections that can lead to ear infections. The CDC notes that vaccination has reduced ear infection rates. CDC

Breastfeeding provides antibodies that help protect against infections. The AAP notes that breastfeeding for at least six months is associated with fewer ear infections. AAP

Avoiding secondhand smoke exposure reduces ear infection risk. Smoke irritates the Eustachian tubes and increases susceptibility to infections. If anyone in the household smokes, encourage them to smoke only outside and never around the child. CDC

Proper bottle-feeding position matters. Never prop a bottle for a baby or allow a child to lie flat while drinking from a bottle, as this can allow milk to flow into the Eustachian tubes. AAP

Limiting pacifier use after six months may reduce ear infection risk according to some studies, though the evidence is mixed. Discuss with your pediatrician. AAP

Hand washing and avoiding sick contacts reduces exposure to the cold viruses that often precede ear infections. Teaching good hand hygiene as children get older helps prevent illness transmission. CDC

When Ear Infections Become Recurrent AAP

Some children experience frequent ear infections despite prevention efforts. The AAP defines recurrent ear infections as three or more episodes in six months, or four or more in one year. AAP

For children with recurrent infections or persistent fluid, your pediatrician may recommend referral to an ENT (ear, nose, and throat) specialist. Ear tube surgery (tympanostomy tubes) may be considered. This outpatient procedure involves placing tiny tubes in the eardrums to allow fluid drainage and equalize pressure. AAP

Ear tubes typically stay in place for six to twelve months before falling out on their own. They can significantly reduce infection frequency and improve hearing in children with chronic fluid buildup. AAP

The Bottom Line

Ear infections are an uncomfortable but common part of childhood. Understanding the signs—particularly in babies who can't verbalize their pain—helps you recognize when your child needs attention. Many ear infections resolve without antibiotics, but knowing when to seek care ensures your child gets treatment when it's truly needed.

Focus on pain relief while the infection resolves, watch for warning signs that warrant medical attention, and know that most children outgrow their susceptibility to ear infections as their anatomy matures.

Clara is here to help you evaluate your child's specific symptoms, understand treatment recommendations, or decide when it's time to call the pediatrician. Don't hesitate to ask.