What To Know About Ear Infections

Common Childhood Conditions

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A young girl being examined by her pediatrician.
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Middle ear infections (acute otitis media) are a common cause for a visit to the pediatrician.


About 20 percent of visits to the doctor for preschool age children are because of ear infections. Ear infections are also the most common reason that children are prescribed antibiotics. That makes it important for parents to recognize the symptoms of ear infections and understand the current treatments to help their kids get quick relief.


Typical symptoms of ear infections can include:

  • ear pain
  • irritability or excessive crying
  • rubbing or tugging at the ears
  • fever
  • ear drainage (otorrhea), which can be a sign of draining ear tubes or a burst ear drum
  • lethargy
  • decreased appetite
  • runny nose and cough
  • vomiting

Of course, not every child with ear pain has an ear infection.


Younger children with a suspected ear infection, especially when they are just tugging at their ears and have no other symptoms, may be teething or just have a sore throat. So how do you know if your child really has an ear infection, especially as ear infections get less common thanks to vaccines?

A physical exam and looking for other signs of an ear infection besides ear pain become important so that your child doesn't get over-diagnosed with ear infections.

According to American Academy of Pediatrics (AAP) guidelines, children should be diagnosed with an ear infection when they have all of the following:

  1. the rapid onset of symptoms of an ear infection
  2. a middle ear effusion (fluid behind the eardrum) with a bulging ear drum (tympanic membrane), decreased or absent mobility of the ear drum, an air-fluid level behind the eardrum, and/or ear drainage (otorrhea)
  3. signs or symptoms of middle-ear inflammation with redness or the ear drum or distinct ear pain that is interfering with normal activities

    These rather strict criteria are important because many children are over-diagnosed as having an ear infection when they just have a middle ear effusion or a 'red ear drum' from crying during their exam.

    Children who only have a middle ear effusion likely have otitis media with effusion and won't need antibiotics. The effusion will usually go away on its own after one to three months. If it doesn't, especially if the effusion is affecting your child's hearing, then a persistent middle ear effusion can be a reason to need ear tubes.


    Although ear infections usually follow a cold or upper respiratory tract infection, they are usually thought to be caused by bacteria, especially Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarrhalis.

    According to the American Academy of Pediatrics, typical treatments for ear infections can include:

    • high-dose amoxicillin (first line option for most children)
    • high-dose augmentin (Augmentin ES)
    • a cephalosporin, such as Omnicef (cefdinir), Ceftin (cefuroxime), or Vantin (cefpodoxime)
    • a shot of Rocephin (ceftriaxone) for one to three days
    • Zithromax (azithromycin) or Biaxin (clarithromycin) for children with a type I allergy (hives or anaphylaxis) to penicillin

      Keep in mind that the AAP now advocates not treating many ear infections with antibiotics, since most children with ear infections get better on their own. This also helps avoid side effects from taking antibiotics unnecessarily, including diarrhea and allergic reactions.

      Children are candidates for the 'observation option' (seeing if they improve for 48 to 72 hours before starting an antibiotic) if they:

      • are at least two years old and have a mild ear infection with mild ear pain and fever that is less than 102.2
      • are at least six months old, have mild symptoms (mild ear pain and fever that is less than 102.2), and the pediatrician isn't sure if the child really has an ear infection

        Infants under six months of age should always be treated with antibiotics when they have a suspected ear infection. Older infants and toddlers should always be treated with antibiotics when they have severe symptoms and when the doctor is sure of the diagnosis.

        When the 'observation option' is used, the child should be rechecked or antibiotics should be started if the ear infection is getting worse or isn't improving within 48 to 72 hours.

        Children can be treated with pain relief medications, including Tylenol (acetaminophen) or Motrin (ibuprofen), during the 'observation period' to help control their fever and ear pain.

        Risk Factors

        Since ear infections are so common, most parents would appreciate any way to reduce their child's risk for getting more ear infections, especially if it means that they are going to need ear tubes soon.

        Unfortunately, some risk factors for getting infections can't be changed, such as having a family history of recurrent ear infections, having siblings, or being male.

        Most other risks can be changed, though, such as:

        • breastfeeding for at least six months
        • avoid propping your baby's bottle while he is lying down flat
        • reducing or stopping the use of a pacifier after your infant is six months old
        • not exposing your baby to second-hand smoke
        • not missing the Prevnar vaccine

        The most helpful thing that can decrease your child's risk of getting ear infections is often the thing that is the hardest to change—decreasing his exposure to other kids who are sick with upper respiratory tract infections. For example, if your child didn't get a cold at daycare, then he likely wouldn't get an ear infection, which usually follows having a cold.

        What You Should Know

        Other things to know about ear infections include that:

        • If your child isn't better after taking an antibiotic for 48 to 72 hours -- for example, he still has a fever or ear pain—then his antibiotic should likely be changed.
        • Consider asking your doctor if the 'observation option' might work for your child the next time he has an ear infection.
        • If you think your child has had too many ear infections, then ask your pediatrician for a referral to a pediatric ENT specialist to discuss if ear tubes would be appropriate.


        American Academy of Pediatrics Clinical Practice Guideline. Diagnosis and Management of Acute Otitis Media. Pediatrics 2004 113: 1451-1465.

        Bhetwal, N. The evaluation and treatment of children with acute otitis media. Prim Care. 01-MAR-2007; 34(1): 59-70.

        Gershon: Krugman's Infectious Diseases of Children, 11th ed.