Ear infections and ear pain in children

Ear infections are one of the most common reasons young children see a doctor. Most get better within 3 days with pain relief alone, and many do not need antibiotics. Some children do need antibiotics, and a few need a closer look at their hearing. Here are short answers to the questions parents ask Dr Dutta most.

What is a middle ear infection?

A middle ear infection (acute otitis media) is an infection of the small air space behind the eardrum. It usually follows a cold.

The tube that drains the middle ear into the back of the nose is short and soft in young children. During a cold it swells and blocks, fluid collects behind the eardrum, and germs grow in it. This fluid presses on the eardrum and causes pain. Both viruses and bacteria can cause it, and often both are present.¹

How can I tell if my baby has an ear infection?

Babies cannot point to their ear, so look for crying that is worse lying down, poor sleep, fussing during feeds, and fever, often during or after a cold.

Older children may say their ear hurts, rub or pull at it, or not hear well. Ear pulling alone, without fever or crankiness, is often just a habit or teething. The only way to be sure is for a doctor to look at the eardrum with an otoscope (a small torch with a magnifier). A red, bulging eardrum points to infection.

How long does an ear infection last?

Ear pain from an infection usually eases within about 3 days, though it can last up to a week.¹

A review of studies found earache had settled in 9 out of 10 children by 7 to 8 days.² Fluid can stay behind the eardrum for weeks after the pain has gone. This leftover fluid usually clears on its own.

What is the best pain relief for ear infection?

Paracetamol or ibuprofen, given regularly in the right dose for your child's weight, is the most important treatment for ear pain.¹

Pain relief helps from the first hour, while antibiotics, if needed, take days to make a difference. Give doses at regular times for the first day or two rather than waiting for crying. A warm (not hot) cloth held over the ear can comfort an older child. Decongestants and antihistamines do not help ear infections.¹

Do ear infections need antibiotics?

Many do not. For most children with a mild ear infection, antibiotics make only a small difference, so doctors often suggest waiting 2 to 3 days with pain relief first.

A 2023 Cochrane review found antibiotics did not reduce pain at 24 hours. They reduced pain at 2 to 3 days in about 1 in 20 children treated, while about 1 in 14 had side effects such as vomiting, diarrhoea or rash.³ Serious problems were rare with or without antibiotics.

This approach is called watchful waiting. Your doctor may give you a "back-up" prescription to start only if your child is not improving after 3 days or gets worse at any time.¹ The American Academy of Pediatrics guideline also allows observation in selected children.⁴

Which children should get antibiotics straight away?

Antibiotics are more likely to help two groups: babies younger than 2 with both ears infected, and children whose ear is leaking pus or fluid.¹

Children who look very unwell, have a high fever, or have a weak immune system also need prompt treatment. Babies under 6 months with a suspected ear infection should always see a doctor. When antibiotics are used, amoxicillin is the usual first choice. Finish the course exactly as prescribed.

What does ear discharge mean?

Pus or fluid coming out of the ear usually means the eardrum has developed a small hole from the pressure of the infection. This often eases the pain, and in most children the hole heals by itself.

A child with ear discharge should see a doctor. Children with discharge are more likely to benefit from antibiotics, and the doctor will decide between starting them now, a back-up prescription, or none.¹ Discharge that keeps coming for more than 2 weeks, or that smells bad, needs an ENT (ear, nose and throat) check. Long-standing discharge with a hole in the eardrum is common in India and can harm hearing if left untreated. Gently wipe the outer ear only, and keep water out until a doctor says it is safe.

Is it safe to put mustard oil or other drops in the ear?

No. Please do not put mustard oil, garlic oil, breast milk or any home drops in a child's ear.

If the eardrum has a hole, oil and germs can get into the middle ear. Oil also hides the eardrum so the doctor cannot see it. Never put cotton buds, hairpins or matchsticks into the ear canal. Use only drops your doctor has prescribed.

Can bottle feeding lying down cause ear infections?

Feeding a baby flat on the back with a propped-up bottle may let milk reach the ear tube, so Dr Dutta advises feeding in a more upright position.

Breastfeeding protects against ear infections. A review of 24 studies found that babies exclusively breastfed for 6 months had about 43 percent fewer ear infections in the first 2 years.⁵ If you bottle feed, hold your baby semi-upright and never leave a bottle propped in the cot.

How can I prevent ear infections?

The best protection comes from breastfeeding, vaccines and a smoke-free home.

• Breastfeed, ideally exclusively for 6 months.⁵
• Keep all your child's vaccines up to date, and ask your paediatrician about the pneumococcal (PCV) and flu vaccines.
• Keep your child away from cigarette and bidi smoke, chulha smoke and mosquito coils.
• Wash hands often, especially in daycare.
• Avoid propped bottles and long dummy use after infancy.

What is glue ear?

Glue ear (otitis media with effusion) is fluid sitting behind the eardrum without signs of an active infection. It often follows an ear infection or a cold.

It does not usually hurt, but it can muffle hearing. Most glue ear clears on its own. Guidelines advise watching and waiting for 3 months before considering any procedure, and they recommend against antibiotics, steroids, antihistamines and decongestants for it.⁶ A hearing test is advised if the fluid lasts 3 months or more.⁶

Can ear infections affect hearing and speech?

Most ear infections cause only short-lived muffled hearing, and speech develops normally. Long-lasting fluid in both ears with hearing loss can affect speech in some children.

Children already at higher risk, such as those with Down syndrome, cleft palate, autism or a known hearing loss, need closer checks.⁶ Tell your doctor if your child does not respond to sounds, turns the TV up loudly, or has delayed words. Ongoing discharge from a hole in the eardrum can also harm hearing over time.

When are grommets needed?

Grommets (tiny tubes placed in the eardrum) are considered for children with fluid in both ears for 3 months or more plus hearing difficulty, or for frequent ear infections with fluid still present.⁷

They are not advised after a single short episode of glue ear lasting under 3 months.⁷ The tubes let air into the middle ear, and they usually fall out by themselves. An ENT surgeon will discuss the decision with you.

Should I clean my child's earwax?

Usually not. Earwax protects the ear and moves out on its own. Clean only the outer ear with a cloth.

Guidelines advise against treating earwax that causes no symptoms and does not block the doctor's view.⁸ Cotton buds push wax deeper. If wax causes blocked hearing or discomfort, a doctor can soften it with drops or remove it safely. Ear candling is not recommended.⁸

When should I take my child to a doctor or hospital?

See a doctor the same day, or go to hospital urgently, if your child has:

• Ear pain or fever in a baby under 6 months.
• Pus or fluid coming out of the ear.
• No improvement after 3 days, or worsening at any time.
• Swelling, redness or tenderness behind the ear, or the ear pushed forward.
• Severe headache, stiff neck, vomiting or unusual drowsiness.
• Weakness of one side of the face.
• Hearing loss or speech delay that worries you.
• A very unwell look or high fever that does not come down.