Ear infections in babies: signs, antibiotics and when to get help

A middle ear infection (otitis media) is an infection in the small space behind the eardrum. It usually starts with a cold, and it's very common: the American Academy of Pediatrics (AAP) says nearly 5 out of every 6 children have one before their third birthday. Most get better within about 3 days to a week, and many settle without antibiotics. At home, the main jobs are pain relief, feeds and comfort, while watching for the few signs that need a doctor today or emergency care.

What is a middle ear infection?

The Royal Children's Hospital Melbourne (RCH) says the middle ear is the space behind the eardrum, that viruses and bacteria cause most infections there, and that young children often get several in a year. The NHS says middle ear infections are caused by viruses like colds and flu.

The middle ear drains into the back of the throat through a narrow passage called the Eustachian tube. Australia's healthdirect explains that this tube can become blocked during an infection, trapping fluid behind the eardrum. The RCH says young children's tubes are smaller and more horizontal, so they drain poorly and fluid builds up more easily. Australia's healthdirect says most children have at least one middle ear infection before school age, and get fewer as they grow.

This guide is about the middle ear. An infection of the ear canal (outer ear) is different; the NHS says it's caused by something irritating the canal, such as water or eczema.

What are the signs of an ear infection in a baby?

The RCH says an ear infection often starts with a cold: a runny or blocked nose, a sore throat and a cough. Babies can't tell you their ear hurts, so the signs are often indirect:

• Fever. The RCH lists a temperature of 38°C or more, and says fever can be the only sign in young children.
• Crying more at night. Australia's healthdirect lists this for babies, and the AAP says ear pain is often worse at night.
• Being irritable or restless. The NHS and Australia's healthdirect both list this.
• Going off feeds or vomiting. Australia's healthdirect says babies may lose their appetite or vomit.
• Not reacting to sounds as usual. The NHS says babies may not react to some sounds, and the AAP says they may not respond as they normally do when spoken to.
• Losing balance. The NHS lists this for children who are moving about.
• Yellow fluid from the ear. This usually means the eardrum has burst (see below).

What about pulling at the ear?

The NHS and Australia's healthdirect both list rubbing or pulling the ears. But the RCH says rubbing or playing with the ears is usually not a sign on its own, and the AAP says many babies tug their ears to soothe themselves or simply play with them. Treat ear pulling as one clue among others, and take it more seriously when it comes with a fever, a cold, unusual crying or poor feeding.

Only a doctor can confirm an ear infection. The AAP's earache guide says the only way to be sure is to look at the eardrum. Ear rubbing also comes up with teething; see teething and sleep.

How long does an ear infection last?

The RCH adds that a cough and blocked nose can last up to 3 weeks, and that hearing may take up to a month to return to normal.

Does my baby need antibiotics for an ear infection?

Often not. The AAP says around 80% of childhood ear infections clear up on their own without medication. The UK's NICE guideline says most children get better within 3 days without antibiotics, that antibiotics make no difference to pain at 24 hours, and that they can cause side effects such as diarrhoea and nausea. The RCH says rest is the best treatment for most infections, and that antibiotics won't help when a virus is the cause.

Doctors do prescribe antibiotics in some situations:

The AAP says doctors may wait 48 to 72 hours before prescribing. NICE describes a back-up prescription, to use only if symptoms haven't started to improve within 3 days or get much worse. In the UK, the NHS says a GP should see any child under 12 months who may have an ear infection. If antibiotics are prescribed, give them exactly as the doctor or pharmacist directs.

The NHS, NICE and Australia's healthdirect all say decongestants and antihistamines don't help.

How can I ease my baby's ear pain?

1. Use pain relief as the label says. The NHS, the RCH and the AAP say paracetamol or ibuprofen can ease ear pain. Australia's healthdirect says to check with your doctor or pharmacist for the right dose for your child.
2. Know the age limits. The NHS fever page says not to give paracetamol to a baby under 2 months, not to give ibuprofen to a baby under 3 months, under 5 kg or who is dehydrated, and never to give aspirin to children. A baby under 3 months with a temperature of 38°C or more needs emergency care, not treatment at home first.
3. Keep feeds going. The RCH suggests plenty of fluids. For a baby, that means offering breast or bottle feeds often. Fewer feeds or fewer wet nappies than usual need a doctor today; see dehydration signs.
4. Put nothing in the ear. The NHS says not to use cotton buds. Australia's healthdirect says a doctor may suggest anaesthetic ear drops, but not to use ear drops without checking with your doctor first.
5. Let them rest. Extra cuddles and quiet time help. The AAP says many night-time earaches without warning signs can wait until your doctor's surgery opens, but use the tiers below if anything worries you.
6. Keep sleep safe. The RCH says older children may sleep better propped up on pillows, but not to put pillows in a cot. Babies still sleep on their back on a firm, flat mattress with nothing added. See sleep when your baby is sick.

For fever care, see fever in babies. The AAP says ear infections can't spread to others, so children can go back to childcare once the fever has gone.

What happens if my baby's eardrum bursts?

Pressure behind the eardrum can make it burst. Australia's healthdirect says the pain may improve straight away, and you may see yellow fluid coming from the ear. The RCH says pus from the ear usually means a small hole in the eardrum, which often makes the child feel better and heals over time. The AAP says the discharge may be tinged with blood.

What to do:

• Get medical help today. The NHS lists fluid coming out of the ear as a reason for an urgent GP appointment, and NICE says children with discharge are more likely to benefit from antibiotics.
• Wipe, don't plug. The AAP says to wipe away discharge as you see it and not to plug the ear canal with cotton.
• Keep the ear dry. The RCH says no swimming or going underwater, including in the bath, while there's pus.
• Check it has healed. The NHS perforated eardrum page says a burst eardrum usually heals within 2 months, and Australia's healthdirect suggests seeing your doctor after 6 weeks to check.

What is glue ear, and can ear infections affect hearing?

After an infection clears, sticky fluid can stay behind the eardrum. This is glue ear (otitis media with effusion). Australia's healthdirect says it can affect hearing, balance and sleep but usually isn't painful. The RCH says fluid can muffle hearing for a month or two, and that longer than that may be glue ear.

The NHS glue ear page says it often clears up on its own within 3 months, and children may be monitored for up to a year. If it lasts a long time, it can affect a child's speech development. A child whose glue ear has lasted more than 3 months may be referred for hearing tests, and treatment can include temporary hearing aids or grommets (small ear tubes), which usually fall out within 6 to 12 months.

The AAP says hearing usually comes back when the infection clears, but some children with prolonged hearing loss from ear infections have delayed speech and language. The RCH says repeated infections rarely cause longer-term hearing loss. If your baby stops turning to voices or startling at loud sounds, mention it; see first words for hearing and talking milestones.

What makes ear infections more likely?

Colds are hard to avoid, and most ear infections follow one. Other risk factors that sources name:

Australia's healthdirect also says Aboriginal and Torres Strait Islander children are at higher risk.

To lower the risk:

1. Keep your baby away from smoke. The RCH recommends a smoke-free home, and the AAP says second-hand and third-hand smoke raise a child's risk.
2. Breastfeed if you can. The AAP and Australia's healthdirect both say breastfeeding helps protect against ear infections.
3. Feed upright, and no bottle in bed. Australia's healthdirect says to hold your baby upright when feeding and not to give them a bottle in bed. See paced bottle feeding.
4. Limit the dummy. Australia's healthdirect suggests limiting dummy use or trying to stop. If your baby gets repeated ear infections, talk to your GP or child-health nurse; see dummies.
5. Keep vaccinations up to date. The NHS, the RCH and Australia's healthdirect all recommend on-time vaccinations, and the AAP says the flu vaccine can help prevent ear infections. See vaccinations.

When to get help

If you're unsure which tier fits, call a health advice line (Pregnancy, Birth and Baby on 1800 882 436 in Australia, NHS 111 in the UK, your pediatrician's after-hours line in the US).

Call your local emergency number (000 in Australia, 999 in the UK, 911 in the US) now if your baby:

• is floppy, much sleepier than usual, hard to wake, can't be woken, or isn't interacting with you
• has a stiff neck or can't turn their head
• is struggling to breathe, or has blue, grey, very pale or blotchy skin, lips or tongue
• has a rash that doesn't fade when you press a glass on it, or has a seizure
• is under 3 months and has a temperature of 38°C (100.4°F) or higher
• is 3 to 6 months old and has a temperature of 39°C (102.2°F) or higher
• has had no wet nappy or wee for 12 hours

The RCH says to call an ambulance for a child who is very drowsy, not waking properly or not interacting. The NHS fever page and the NHS urgent-help guide list a stiff neck and the temperature thresholds; the AAP earache guide says to seek care now for a stiff neck, and we use the stricter tier.

Go straight to the nearest emergency department, or call your local emergency number (000 in Australia, 999 in the UK, 911 in the US), if:

• there's swelling, redness or tenderness behind the ear, or the ear is pushed forward or sticks out
• the outer ear is red and swollen
• your baby is in severe pain or very irritable and pain relief isn't helping

These can be signs of mastoiditis, an infection of the bone behind the ear. The NHS mastoiditis page calls it rare but serious. The RCH and Australia's healthdirect advise going to hospital; the NHS page gives an urgent GP appointment, and we use the stricter tier.

Get medical help today (same-day GP, after-hours doctor or a health advice line (Pregnancy, Birth and Baby on 1800 882 436 in Australia, NHS 111 in the UK, your pediatrician's after-hours line in the US)) if your baby:

• has fluid, pus or blood coming out of the ear
• is under 12 months and has earache in both ears, which the NHS lists for an urgent GP appointment
• still has pain or fever that hasn't started to improve after 48 hours, or is getting worse
• seems generally unwell, has a very high temperature or has a change in hearing
• is refusing feeds or feeding much less than usual, or has fewer wet nappies
• has had a temperature for 5 days or more

Talk to your GP or child-health nurse (book a visit soon) if:

• you think your baby under 12 months has an ear infection and none of the signs above apply
• ear infections keep coming back; the RCH says to see a doctor for more than 4 in a year
• hearing problems or irritability last 2 weeks after an infection, as the RCH advises, or your baby isn't reacting to sounds as usual
• your baby had a burst eardrum and you'd like it checked, or you're planning to fly soon after an ear infection, which Australia's healthdirect says to discuss with your doctor first

What's worth noting during an ear infection?

Write down when the pain or fever started, each temperature with the time, every dose of medicine and when it was given, and feeds and wet nappies. Note any discharge and which ear it came from. Over the months, a simple record of how many ear infections your baby has had helps your GP decide whether a hearing test or referral is worth considering.