Ear Infections in Children: Why Antibiotics Are Not Always the Answer

Tonight, the thing to do is treat the pain. A dose of acetaminophen or ibuprofen, weight-based, works on ear pain and works well — and pain relief is not a delaying tactic, it is the main treatment for the first stretch of most ear infections. Then call us in the morning.

The part that surprises parents is the next sentence. Most ear infections in children get better without antibiotics, and for a lot of children the right first step is pain relief and a couple of days of watching rather than a prescription. That is not a practice trying to save a visit. It is what the evidence supports, and it changes what “being taken seriously” looks like.

Why the ear, and why children

The middle ear drains into the back of the throat through a narrow tube. In a young child that tube is shorter, narrower, and more horizontal than an adult’s, so it blocks easily and drains badly.

A cold swells the tube, fluid collects behind the eardrum with nowhere to go, bacteria or viruses multiply in it, and the pressure on the drum is the pain. That is the whole mechanism, and it explains nearly everything parents find confusing about ear infections:

• They follow colds rather than arriving out of nowhere. The cold is the setup.
• They hurt more lying down, which is why this is a 2am problem.
• They stop being common around age five or six, when the tube grows into a steeper adult shape.
• They are not caused by cold weather, wind, or a draught, and in Phoenix they are not caused by the pool either — swimmer’s ear is a different infection in a different part of the ear, covered below.

What it looks like in a child who cannot tell you

An older child says their ear hurts. A toddler does not.

• Tugging or batting at the ear — worth knowing that on its own this is a weak sign. Babies pull their ears when they are tired, teething, or just discovering they have ears.
• Waking in pain, especially in the first half of the night
• A fever, often but not always — plenty of ear infections run no fever at all
• Suddenly not wanting to feed or take a bottle, because sucking and swallowing change the pressure
• Irritability that does not settle, in a child a few days into a cold
• Fluid or pus draining from the ear. This often means the eardrum has perforated — which sounds alarming and is usually the moment the pain stops, because the pressure released. It generally heals on its own. It does need to be looked at.
• Not responding to quiet sounds, or turning up the volume

What we do at the visit, and why we might not prescribe

We look at the eardrum. That is genuinely the whole diagnosis, and it is why this is hard to assess over the phone: fluid behind the drum, a bulging drum, and a normal drum look completely different and feel identical from the outside.

What we find determines the answer:

Antibiotics straight away for a child under two with infection in both ears, for any child who is significantly unwell, for a high fever, for a draining ear, and for children with certain underlying conditions.

Pain control and a planned recheck for many children over two with a mild or one-sided infection. If it has not improved in 48 to 72 hours, we treat. This is a recognised approach with a name — watchful waiting — and it is not the same as being sent home with nothing. If we take this path we will tell you exactly what “worse” looks like and exactly when to come back. If you leave without knowing that, ask us before you go.

Nothing, when it is fluid without infection. Fluid can sit behind the drum for weeks after an infection clears. It is not painful, antibiotics do not clear it faster, and it usually drains on its own. It matters mainly because it muffles hearing while it is there, which is worth knowing in a child who is learning to talk — our vision and hearing page covers why a hearing problem often shows up as a behaviour problem first.

The reason we are careful with antibiotics is not caution for its own sake. Every unnecessary course makes the bacteria a child carries a little more resistant, and it brings its own diarrhoea, rash, and yeast infections. Using them when they help is what keeps them working when they are needed, and a child who has had four unnecessary courses is a harder child to treat on the day it is serious.

If we do prescribe, finish it. Stopping when the pain goes is how a partly treated infection comes back.

What helps at home

Pain relief, properly dosed by weight. This is the most useful thing you will do. Acetaminophen, or ibuprofen for children over six months. If you are not sure of the dose, call and ask rather than estimating from the box. Out of hours a pharmacist can check a weight-based dose with you — and if you think a child has had too much of anything, Poison Control answers at any hour on 1-800-222-1222.

Upright is more comfortable than flat. Extra propping for sleep, and for a baby, feeding held more upright than usual.

Warmth on the ear — a warm, not hot, compress — helps some children and does no harm.

Fluids and rest, as with any infection.

Nothing goes in the ear. No oil, no garlic, no drops of any kind unless we have prescribed them, and never a cotton bud. If the drum has perforated, anything poured in goes somewhere it should not.

No ear candles, ever. They do not remove wax, they are a genuine burn risk, and they have caused perforated eardrums.

Call us if

• Your child has ear pain that pain relief is not touching
• A fever above 102°F, or any fever in a baby under one month — see our fever page, where any fever under one month is an emergency
• Fluid, pus, or blood draining from the ear
• No improvement after 48 to 72 hours, or improvement that reverses
• Pain in both ears in a child under two
• Ear pain with a facial droop, severe dizziness, or a headache that is not like their usual
• Swelling, redness, or tenderness on the bone just behind the ear. This is the one to treat as urgent — it can mean the infection has spread into the bone, and it needs seeing the same day.
• Recurring infections — roughly three in six months, or four in a year
• You are worried about their hearing, or their speech seems to be slipping

Swimmer’s ear is a different thing

Worth its own paragraph in a city where children swim eight months of the year.

Swimmer’s ear is an infection of the ear canal, not the middle ear. It comes from water sitting in the canal, and it feels different: the outside of the ear is tender, pulling on the earlobe or pressing in front of the ear hurts, and the canal may itch or feel blocked. It is usually treated with drops rather than oral antibiotics, and it is not a middle ear infection at all.

Prevention is simple. Tip the head to drain each ear after swimming, dry the outer ear with a towel, and do not put cotton buds in the canal — they strip the wax that is protecting it. If your child gets it repeatedly, ask us about drops to use after swimming.

When to talk about tubes

If a child has infection after infection, or fluid that will not clear and is affecting hearing or speech, the next conversation is a referral to an ear, nose and throat specialist about ventilation tubes — small tubes placed through the drum to let the middle ear drain and stay ventilated.

The threshold is usually about frequency and about hearing, not about how bad any single infection was. If your child is on their fourth course of antibiotics this year, that is the conversation to have, and it is reasonable to raise it yourself.

Sources

3. Ear infection — acute — MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000638.htm
4. Otitis media with effusion — MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine. https://medlineplus.gov/ency/article/007010.htm

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