Ear infections cause significant and sometimes serious ear pain, overnight awakening, missed school, missed work, and lots of parental heartache. For some children, infections in the ear can be a chronic problem and lead to repeated clinic visits, multiple courses of antibiotics, and rarely a need for tube placement by surgery. For most children, ear infections occur more sporadically, just bad luck after a cold. Fortunately the majority of children recover from ear infections without any intervention. But about 20-30% of the time, they need help fighting the infection.
Ear infections can be caused by viruses or bacteria when excess fluid gets trapped in the middle portion of the ear, behind the eardrum. When that space fills with mucus or pus it is put under pressure and it gets inflamed causing pain. Symptoms of ear infections include pain, fever, difficulty hearing, difficultly sleeping, crankiness, or tugging and pulling at the ear. This typically happens at the time or soon after a cold—therefore the fluid in the ear can either be filled with a virus or bacteria.
The most important medicine you give your child when you first suspect an ear infection is one for pain.
Antibiotics only help if bacteria is the cause. When a true infection is present causing pain and fever, antibiotics are never the wrong choice. Often you’ll need a clinician’s help in diagnosing a true ear infection.
Three’s been a lot of work (and research) over the last 15 years to reduce unnecessary antibiotics prescribed for ear infections. There has been great progress. Less children see the doctor when they have an ear infection (only 634/1000 in 2005 versus 950/1000 back in the 1990’s) and they’re prescribed antibiotics less frequently. Recent data finds that less than half of children with ear infections receive antibiotics (only 434 of every 1000 children with ear infections). However, the far majority who go in to see a doctor do still receive a prescription for antibiotic (76%).
The American Academy of Pediatrics(AAP) just released new guidelines to help physicians do a better job treating ear infections. Sometimes children really benefit from using antibiotics and new research has led to an update on the 2004 previously published recommendations. Over-use of antibiotics can lead to more resistant and aggressive bacteria so we want to use them at the right time. These recommendations may help improve care for children.
In my opinion, NPR published the best article I’ve read covering the new recommendations. I especially liked the balance provided:
“When the diagnosis is correct, then antibiotic treatment is never wrong,” says Dr. Ellen Wald of the University of Wisconsin School of Medicine and Public Health in Madison. “Kids tend to recover more often and they recover more quickly if they’re treated appropriately with antibiotics.”
That’s especially important for working parents, Wald notes.
“We live in a society where there is so much pressure for both parents to be working outside the home and it’s just complicated when our child is sick. Besides which, there’s always parental anxiety and concern when their child is sick,” she says.
Information For Parents: New Ear Infection Guidelines
- Pain: Use medication like ibuprofen and/or acetaminophen to treat pain when a child has a suspected or confirmed ear infection. These infections really hurt and don’t wait for antibiotics to “kick in” or make your child tough it out. Here’s a summary on dosing pain meds for infants and children.
- Diagnosis: The AAP recommendations apply more strict criteria for making the diagnosis of an ear infection. For true diagnosis they say, the ear drum has to be bulging, there has to be middle ear fluid and/or draining fluid from the ear. The ear can’t just be red or have a bit of fluid behind it. It’s important that the doctor confirm an ear infection is present before antibiotics are prescribed. If a clinician says to you, “It looks like an early ear infection” or “The ear drum is a little red” or “I think this may be an ear infection” chances are it doesn’t meet criteria and shouldn’t be treated with antibiotics. Press the clinician to explain to you if the ear drum is bulging and full of fluid. If no proof, antibiotics may not be necessary. Time may be the best medicine.
- No Antibiotics: Many children don’t need antibiotics to heal from ear infections. When a confirmed ear infection is discovered in a child over 2 years of age who has no fever or no severe ear pain, they can be observed without antibiotics. However, if pain is still present or symptoms not improved in 48 hours, it is suggested they have follow-up. Make sure you have a good follow-up plan or a prescription to use if you child isn’t improving.
- Follow up: the recommendations remind us that if you chose not to use antibiotics, you need to have a system in place for a follow-up visit or call or electronic visit in place 48-72 hours later. If symptoms of the ear infection resolve in 2-3 days with use of pain medications and time, the ear infection is likely healing. If symptoms (on or off medications) aren’t better in 2-3 days, your child needs to be re-seen either to start antibiotics or switch medications.
- Antibiotics: All infants under 6 months of age, children 6-23 months of age with a double ear infection, those with severe infections, and those at risk for complications all need antibiotics. Penicillin (Amoxicillin typically–the pink stuff) is the medication used first for ear infections. However, if your child has had Amoxicillin in the last month then the clinician should advance the antibiotics (typically to a penicillin with an ingredient called clavulanate to fight resistant bacteria that may be present). Lots of parents worry that Amoxicillin isn’t the best first choice. Data continue to suggest it is. Read a summary of recent studies in The New England Journal of Medicine on treating ear infections.
- Eye & Ear Infection: If your child has conjunctivitis (“Pink Eye”) or drainage from their eyes along with an ear infection, they should immediately get a dose of amoxicillin-clavulanate (Augmentin) rather than amoxicillin (penicillin). Infections that cause both infections (ear and eyes) tend to be more likely to be resistant to amoxicillin.
- Vaccines: Immunizations do a good job preventing many ear infections. Make sure your child is up-to-date on all vaccines but specifically ensure your child is up to date on Hib, Prevnar 13 (updated pneumococcal vaccine) and their annual Flu Shot. Both Prevnar 13 shots and expanded recommendations to use Flu Shots for all children over 6 months are attributed in part to decreasing rates of ear infections.
- Prevention: Breast feeding and avoidance of cigarette smoke remain data-proven strategies to prevent ear infections in children.
My son had antibiotics at 11 months for a double ear infection. As much as I worry about over diagnosis, I was relieved that she put him on antibiotics. Glad to read the official recommendation agrees. Gladder that that’s the only time he’s had to be on antibiotics!
Thank you for this article! My son (1 year old) goes to daycare and is always coming down with some type of cold.
At around 10 months old, my son had two ear infections about three weeks apart. Both times he was treated with a course of amoxicillin and ended up with hives on his torso and legs around day 8 of antibiotics. Is this type of allergic reaction common with amoxicillin? Is this something that he will eventually grow out of? For now his pediatrician has put amoxicillin on his allergy list. Thanks in advance!
Wendy Sue Swanson, MD, MBE says
I’ll defer to the pediatrician who saw your son. Rash is a common sign of allergy after medications. Especially when widespread and all over the body. Often the second time an antibiotic is used the rash comes on more suddenly (rather than at day 8) but allergy responses can be very varied!
However, it sounds like a safe plan to keep that on his allergy list for now. You can always consider consulting with an allergist as well.
Sorry to add something here, it is sooo typically to have a rash between day 7 – 10 on Amoxicillin with an viral infection (mononucleosis being the most known culprit here – but far from the only one). This is a toxic reaction to the virus – not an allergy. It is something like one of the key signs of mononucleosis. Want to know if it is mononucleosis? PUt the child on amoxi, after eight days, you know. THERE IS NO ALLERGIC REACTION AFTER EIGHT DAYS. An allergic reaction happens after the second contact to the allergen, rarely an allergy develops after that, but certainly not after eight days. Ever. This is the reason why I don’t put kids with throat infection on amoxi. This skin reaction is not nice to have.
I don’t know how many patient are wrongly under the impression that they are allergic to amoxicillin/penicillin because doctors are not able to tell these two apart. *sigh*
John Clapper MD says
Thanks for all the work you do to get the right messages out there to our patients!
John Clapper MD, Pediatrics Northwest, Tacoma, WA
Great article – thanks so much for getting this good info out there.
My own dim memories of having a childhood ear infection center around an older sibling doing her best to get my mind off the pain; she gathered all the funny hats from around the house and took turns putting them on and making up characters to amuse me. I believe at one point Mickey Mouse swam up to an imaginary life boat where my mother reluctantly played a sailor standed at sea! Oh, the things we do to relieve the pain of an earache!
We’ve had all the possible outcomes you mentioned, which illustrates that my kids pediatrician’s practice is on top of it! We just hit the pink eye & ear infection scenario a few weeks ago. So interesting that my kids share a room and play together for hours daily and ony 1 got the pink eye version (which I found out is caused by a variant of Hib!).
So here’s a question for the ear & eye infection: if the pink eye reoccurs shortly after treatment, should I assume that the ear infection has also reoccurred? Currently, I’m re-treating the eyes and waiting for signs of ear pain. It seems inevitable the ear infection will reoccur because he’s got a sinus infection. On the one hand, I hate wasting time and co-pays on “ear checks.” On the other hand, I feel guilty when it appears the inevitable does come about and the dr shows me my child’s about-to-rupture eardrum that hadn’t presented any symptoms till arlier that day.
Wendy Sue Swanson, MD, MBE says
HIb is often the cause of otitis/conjunctivitis but not always. However, because it’s more likely and can sometimes be resistant to high-dose Amoxicillin, that’s why the rec has been to start with Augmentin right away when both infections are present.
If the pink eyes recur shortly after treatment I have no idea if ears recurred. You’d have to be seen. But watching your child for discomfort, complaints, or fever is an important step. Unfortunately I don’t know any data about recurrances. Sometimes children will come into the office in that scenario with healed ears. And if it’s only the eyes you can get away with using topical antibiotic drops.
Don’t think of “ear checks” as a waste of time. This set of recs is here to help confirm that the time and money used for those checks is worth it — avoiding unnecessary oral antibiotics is a huge priority for all of us — specifically our children.
Erika Castro says
Thank you for this article explaining precisely what the new recommendations are. This is timely since we will be going in to our pediatrician today because I suspect my son has yet another ear infection. He just finished abx for his last one last week. 🙁 Each time they have put him on abx, and I’m glad in some ways because it immediately relieves the symptoms, but I also worry that it’s too much. I will see what they say today in light of the new guidelines.
Hi, I posted this question a couple days ago, but maybe it didn’t go through. … My 17 month old currently has her first ear infection and is taking an antibiotic. Could you please post some information about the proper way to care for babies’ and toddlers’ ears? How does ear wax contribute to ear infections? What’s the best way to remove the wax? The pediatrician has told us to use over-the-counter ear drops, one drop in each ear, once or twice a week during/after bath. Currently I don’t clean her ears with anything, and using drops makes me nervous only because I’ve never used them. The instructions say to be cautious not to get it in the eyes or mouth, which seems difficult with a squirmy toddler. Also, some reviewers of the product online claim that it’s caused ear ringing or ear pain. What do you recommend to the parents of your patients? Thanks.
David Hoffman, DO says
Lynn, I’m a pediatrian (who loves Dr. Swanson’s work), and I’ll take a stab at your question.
Ear wax, or cerumen, actually has NOTHING to do with middle ear infections! Neither does cold air or getting water in kids’ ears. Cerumen is part of the body’s natural housekeeping for the ear canal, trapping dust, dirt, and other grime … gradually bringing it to the outer ear where it can be washed out. The best way to take care of the wax is to clean it off of the outer ear with a washcloth or tissue. As tempting as it might be, don’t insert cotton swabs into the ear canal. You might get a little bit of wax on the swab, but you will also pack more wax inward, and might even damage the eardrum. One of my mentors used to say that you should never clean the ears with anything smaller than your elbow! So, the best care for wax in the ears is usually to simply let it flow out on its own.
If you are concerned about hard, impacted wax in your child’s ears, it’s really best to have the pediatrician take a look before trying any over-the-counter drops. It may be necessary to soften the wax or perhaps flush it out with irrigation.
Barbara Smithson says
I’d like to consult why my child is having this fluid coming out from his ears? Something must be wrong with his condition. He sometimes hear a high pitch in his ears. Having done my research, https://www.tinnitusgoaway.com states this infection Tinnitus is curable. But, I am still worried. Please give me some advice. Thank you.
Barbara, is this still happening? Have you considered that your child could be hearing a high pitched noise that is aggravating your child’s ears, and that it’s not actually tinnitus?
There are devices out there, such as cat deterrents, that emit virtually constant high pitched noises, often in the hearing range of children. There are many stories of these causing problems in residential areas.
Geza Kiss says
“When the diagnosis is correct, then antibiotic treatment is never wrong,” …
“We live in a society where there is so much pressure for both parents” …
Since the use of antibiotics, even if resistent strains are not developed, harms the childs benefitial bacteria in the guts and elsewhere, which may cause numerous problems including immune deficiency * and thus recurring ear infections and other issues, the “pressure on parents” should not be a reason to use antibiotics if its use can be avoided. For the love of your child, but also the love of yourself (recurring problems are worse than single ones).
* See for example:
Lisa researching vision problems says
Infections are really interesting in the eye and ear and how our body adapts to this. Thanks for sharing.
I have an ear infection but there’s no way to get to the doctors and I don’t know what to do.
Wendy Sue Swanson, MD, MBE says
I suggest you call the doctor’s office and talk with RN or phone triage about symptoms and your options.
Jen edd says
My 6 yr old got tubes in her ears 9 months ago. She has an ear infection currently. We went to the doctor today and they started her on ciprodex. My concern is that she has so much goup draining from her ear the drops are not going in. Does she need an oral antibiotic?
Wendy Sue Swanson, MD, MBE says
I can’t provide individual health advice here. I suggest you call your pediatrician’s office to discuss so they can present the rationale for the treatment they chose and explain what to do if your 6 year-old isn’t getting better within a day or two. If you’re not satisfied, you can always seek another opinion or consult the ENT who put the tubes in?
Gitanjali Pachori says
hello , I had feeling of fullness and congestion in my left ear since two weeks and now it pain a lot , i tried antibiotics and candibiotic eardrop but whenever i use eardrop it pains a lot. i cant sleep easily due to this, kindly suggest what to do.
Jennifer Took says
Thank you for this article on the proper use of anti-biotics in the case of ear infections. I have just taken my daughter, 22 months, to the doctor because of a high fever. He examined her ears and said, “There is a little redness.” And prescribed a course of amoxicillin. I think he misinterpreted her crying in the office as from pain, but she was resting happily at home before and has shown no other signs of discomfort. Just the high fever and tiredness.
I have already given her 1 5ml dose, but wish I had waited. Would it be safe to stop the course or would it be best to finish it now?
Please help, thank you
Wendy Sue Swanson, MD, MBE says
Please call your child’s office to discuss. I can’t offer medical advice like this here on the blog. However, this brings up a good point: I need to write a post on antibiotic duration and what to do in similar situations.
John Dyson says
My daughter is 3 months old and the pediatrician recommends antibiotics. However, my wife, first daughter, and myself have been passing a viral cold around the family. All of us have the same symptoms and I also had an ear infection because of it. I did not take antibiotics for it.
My question is that although the guidelines says to prescribe antibiotics to my 3 months old daughter, we pretty much can induce that it’s a virus that caused the ear infection. Furthermore, my 3 months old does not have a fever, is not fussy, but has a slight cough and running nose. We have been using an aspirator to suck out the mucus.
We’ve very hesitant in wanting to use antibiotics because we don’t want to start so early unless it’s absolutely necessary. Also, my wife is taking antibiotics and some of the medicine does get transferred to our 3 months old via breast feeding.
So finally, do you think it is necessary to give the antibiotics given all the facts I have provided?
I am a mother of two children one 5 year old girl and 8 month old boy, Friday they both woke up running a fever and coughing so I took them to the pediatritian. By the time we got there my sons temp was 103 and daughters 101.1 the doctor didn’t do much she looked in both ears said both my daughters ears were real red and my sons left ear was red. Both my kids are allergic to amoxicillin,penicillin so she prescribed them both azrithromycin/ z pack for 3 days. My daughter is pretty much better but my son is not! His fever is down but he has devoloped a very scary cough that sounds just sounds horrible it doesn’t last long but comes in spurts and he has no runny nose I’m just wondering if I should be worried? I’ve been doing some research on bronchitis but every page tells you something different, I did a little test to see how many breaths he takes a min and I counted 32, Im worried and don’t know if I should be?
I’ve always wondered about the pain drops for ears. At times our pediatrician will prescribe to us in lieu of abx and instruct to give to our child with tylenol. Why is this not suggested here? Is this not an evidence based recommendation?
My daughter just turned 5 and has had over 30 confirmed ear infections, with tube placement twice already. We are seeing the ENT again this week, and expecting tubes again. She has lost both tubes as of 2 weeks ago. Anyone else dealt with ear infections this severe before? Poor little thing is really in a lot of pain!
Marissa Dominguez says
I am a 21 yr old I have had reaccuring ear infections happening every week. My doctor would prescribe me antibiotics for a 10 day period. then it clear. 3 days later its back again. this has happened 6 times in a month. I have so much pain in my right ear. Sometime I cry to sleep, I get dizzy a lot since it happened. I feel like I need more options than antibiotics. I feel like my doctor isn’t doing enough. I feel like giving up on antibiotics and let it hurt.
what could be causing my 5yr old grandson to have repeated ear infections treated with antibiotics. Most of the times he has no cold systems such as cough sneezing runny nose etc. Sometimes he has fevers though but not always. Julie
My four year old daughter has had ear infections since infancy and has almost always been prescribed amoxicillin. Recently, I was almost positive she had a sinus infection and took her to her pediatrician.. She said my daughter had an ear infection (she also had her hearing tested for kindergarten she’ll be starting in sept and had some trouble with hearing some of the sounds with her left ear). Anyway, she just took her last dose of amoxicillin and her right ear is hurting her so much she can’t sleep. What could be causing this? She was doing great until tonight
My 11 month old daughter developed a fever on Monday night, it ranged from 101-104.4 and came down with use of tylenol/ibuprofen. Her doctor checked her ears on Wednesday and did not see an infection. I was told to bring her back on Friday if her fever was still returning at over 102.5 on Thursday (after 72 hrs). When I got her ears re-checked on Friday, the right ear was clear and the doctor could not see the left ear drum as it was covered with liquid wax that she could not clear. To err on the side of caution, she prescribed amoxicillin assuming the left ear was infected. However the fever didn’t return that evening and I did not start the amoxicillin. Today is Monday, the fever hasn’t returned but she is still quite cranky. Is it possible that although the fever is gone, she still has the ear infection?
Wendy Sue Swanson, MD, MBE says
As the guidelines suggest the goal is to have an ear exam that confirms an infection prior to using antibiotics. So prescribing antibiotics without seeing an eardrum itself (you mention “to err on the side of caution, she prescribed amoxicillin assuming the left ear was infected”) isn’t recommended with the policy and isn’t backed up with evidence.
Ear infections, and the fluid that gets stuck behind the ear drum, can take weeks to gradually entirely heal and recede. However, as the post mentions many ear infections resolve on their own! Do know that if your daughter is not improving in ways you expect and you are concerned about her crankiness it is very reasonable to check in with her doctor again!
Hi.. My boy is 2 year old .. He had ear infection since he was 4 month… He had fluid accumulation in middle ear .. Tube place ment was also done.. Tibe in the right ear fall by itself after some month.. He was ok bt agin he had ear infection since 2 day .. He is under antibiotics and ibuprofenmedicine but stiil fever is not under control.. His eyes are red bt its nt conjuctivities.. Face is flushing and sunt want to eat anything… Went in emergwncy care they ask to follow the same course and wait and watch.. M worried…
Mary S. says
My daughter is 18 and has had a 3 week cold that came to a close. Three weeks later she is with cold symptoms , confirmed pink eye and ear infection. Currently on augmentin. She is off to college soon and I am concerned about the germ factor in dorm life. She has mild neutropenia and when she gets tired she gets sick. Do you recommend a probiotic and good multi vitamin when she’s off to college? Along with continued good hygiene ie; hand washing , anti bacterial soaps and sanitizer.
My son just finished Zithromax Wednesday for bronchitis now three days later we are back at the Pediatricians office getting clindamycin for ear and throat infection. Is back to back infections normal?
The Hearing Care Shop says
Hi Dr. Wendy,
This article is really great, you provide insights about ear infection which is I think commonly for children who does rapture of cleaning of ears.
Elaina M.Bishop says
Thank You,I’m the grandmother of one and I took care and gave him all kind of love for a week, and now I have all the symptoms and some. I’ve been taking Tylenol extra strength,and hot tea with some rest I just got the hearing back in my left ear about an hour ago. I have asthma and allergic to aspirin is there any thing else I should be doing.
Hi, Thanks for this post really good article on “Ear Infection” I loved it. My friend child is 6 month older, she used to get ear pain weekly once, then we consulted paediatrician they provided drops, now child is good and from past 15 days she did not find ear pain.
Hi I love the article, My 15 month old caught an ear and throat infection right after she finished battling with Hand, Foot and Mouth Disease. The Dr. gave her Amoxicillin and so far she has been taking it for 5 days, but she’s still not eating (only drinking liquids) and at night she cries and tugs on her ear. I called her doctor and they told me to just continue with the medicine. I have also been giving her Motrin for pain but it doesn’t seem to help. Its heart breaking to see her is so much pain any advice or suggestions would be greatly appreciated…Thank You
My six year old woke with eyes shut after a very minor cold that did not even cause fever or green nose/phlegm; clinic doc said one ear was red and told me to get polysporin antibiotic drops for the eyes and be seen again if anything got worse. That was 2 das ago but now his hearing has become very poor and I am seeing a very minimal amount of gunk building in the corners again…No pain at all and no fevers through any of these events. Sleeping fine through the night, sounds congested but no green from nose…viral and leave be or take him in and get him started?
Am apregnant mother aged 24yrs,i hv had an ear dicharge more than amonth now ..the docter prescribed for mi amoxillin with an ear drop as well,but to my dismay my ear still produces pus ,am wondering have i got chronic ear infection? .please kindly advice me.thx
David Greene MD says
Thank you for this awesome post to make sure if kid really has ear infections and if infection is bacterial, the best thing to use is antibiotics.
Pediatric ENT Associates says
Great information for the Parents who’s child facing ear infection problem
Pediatric ENT Associates says
Helpful info, thanks for sharing
My 15 month old is diagnosed for the second time with ear infection. He shows no signs of it in either case. Yes he had fever but he also had a cold at the same time, however no crankiness no ear tugging… i touch behind his ears, no reaction. I have been giving him the antibiotics because I am not the “expert” but I have my doubts he really did have it in either case and I am just giving him antibiotics for no reason… is it possible he doesn’t show signs but has an ear infection? Should he be taking these meds even though he gets a diarrhea from them and has lost a ton of weight??