Ear Infection in Kids: Signs & When to Be Seen

Key takeaways

It is commonest at an age when children cannot yet talk — so the child cannot tell you their ear hurts. What you have is a change in behaviour: crying that is hard to settle and worse lying down, pulling and rubbing at an ear, refusing to feed, restless sleep, fever.
It usually comes AFTER a cold or a nose and throat infection. A child whose cough and runny nose were improving who suddenly becomes unsettled again and feverish — connecting those two things is the earliest way to spot it.
Fluid or pus coming from the ear means the eardrum has perforated. A doctor must see it, and absolutely nothing should be put into the ear: hydrogen peroxide, herbal water, garlic water, oil, ground tobacco and breast milk all go straight into the middle ear.
Do not buy antibiotics yourself. According to CDC, many cases settle on their own and a doctor may choose to watch for a few days — while a severe case needs antibiotics straight away. Telling those two situations apart requires LOOKING INTO THE EAR, which cannot be done at home.
Pain gone does not mean fluid gone. Hearing that stays reduced after the episode needs reviewing, because in a child who is learning to talk it affects language development.

Middle ear infection is commonest at an age when children cannot yet talk, so it is often picked up late: the child cannot tell you their ear hurts. The two things families most often do both come at a cost: putting all sorts of things into the ear, and buying antibiotics themselves.

Recognising it: what to look at when the child cannot talk

According to CDC, the viruses that cause colds can lead to a middle ear infection — so it often follows a cold or a nose and throat infection. A child whose cough and runny nose were improving who suddenly becomes unsettled again and feverish: think of the ear.

Crying that is hard to settle, worse when you lay the child down — lying down raises the pressure in the ear so it hurts more.
Pulling, rubbing, scratching or batting at one ear. An older child holds the ear or tilts their head to one side.
Refusing to feed, or taking a few sucks then pulling away and crying — sucking and swallowing make the ear hurt more.
Restless sleep, waking often in the night; fever; eating poorly.
Yellow fluid, pus or blood-stained fluid coming from the ear canal, sometimes with the pain stopping suddenly. This means the eardrum has perforated — a doctor must see it, do not manage it at home.

None of the signs above belongs to ear infection alone. The commonest things it is confused with are:

Confused with	The difference you can see
Outer ear infection	Pain clearly worse when the outer ear is pulled or the area in front of the canal is pressed; often after swimming
A plug of earwax	Reduced hearing and a blocked feeling without much pain, no fever, no crying at night
A foreign body in the ear	Sudden, in a child who was playing, on one side only; sometimes with foul-smelling discharge

What to do at home

Nothing at home can treat a middle ear infection. Your job is to keep the ear dry, keep the child more comfortable, and watch the right things — the ones the doctor is going to ask about.

Keep the ear dry: quick baths, no water into the ear, pause swimming and dunking the head.
If the ear is discharging, only wipe gently what comes out onto the outer ear with a clean cloth. Do not push cotton wool deep into the canal to soak it up.
Keep the child feeding and drinking. If sucking is painful, give small amounts often through the day.
Raise the head a little to ease the pressure in the ear; do not let the child lie on the painful side.
Do not let anyone smoke in the house or in the car — according to CDC, avoiding tobacco smoke is one way to prevent middle ear infections.
Write down: what day the unsettledness started, whether there is fever, which ear, whether there has been discharge, whether the child is still feeding and playing. These are exactly the points the doctor will ask about.
If you need something for pain or fever, ask a doctor or pharmacist. Paracetamol (acetaminophen) is a commonly used option for children, but the dose is for a doctor or pharmacist to decide.

What NOT to do

Do NOT put anything into the ear unless it has been prescribed: hydrogen peroxide, herbal water, garlic water, oil, ground tobacco, breast milk. If the eardrum has perforated, those things go straight into the middle ear.
Do NOT poke the ear, do not dig out wax with a cotton bud or anything hard, do not syringe the ear while the child is in pain or a perforation is suspected.
Do NOT buy antibiotics yourself on the assumption that an ear infection must mean antibiotics — the reason is in the section just below.
Do NOT reuse an old prescription of the child's or a sibling's. The last prescription was for the last consultation.
Do NOT take the child for ear suction, ear blowing, heat treatment, steaming or leaf poultices applied to the ear.
Do NOT treat the pain stopping suddenly as recovery — especially not when you have just seen fluid come out of the ear.

Why an ear infection does not automatically mean antibiotics

This is where the decision most often goes wrong, right at the pharmacy counter. According to CDC, the immune system usually clears a middle ear infection by itself, so a doctor may choose to watch for a few days before giving antibiotics, or write a prescription with instructions to wait before filling it. Conversely, CDC also says that a severe case, or symptoms lasting more than two or three days, needs antibiotics straight away.

What distinguishes those two opposite situations is LOOKING INTO THE EAR — seeing the eardrum directly. That cannot be done at home with the naked eye. So whether or not to use antibiotics is the doctor's decision after looking.

When you must be seen

GO TO EMERGENCY CARE NOW, or call 115 (the emergency number in Vietnam), if any of the following is present: swelling, redness, heat or pain over the bone behind the ear; the ear sticking out further than the other one; a stiff neck; repeated vomiting; drowsiness, hard to rouse; seizures; a drooping mouth or an eye that will not close fully on the painful side; severe ear pain that will not ease. A baby under three months with a fever goes in straight away, with no waiting. — NEEDS A DOCTOR SOON BUT IS NOT AN EMERGENCY if: the ear is discharging fluid or pus; high fever; pain and fever not easing after two or three days; both ears painful; a baby under six months with a suspected ear infection; a child with an underlying condition or on medication that weakens the immune system; ear infections that keep coming back; hearing that stays reduced after the pain has gone.

Pain gone does not mean fluid gone

This is the part most often missed, because there is no pain and no fever. Fluid can remain behind the eardrum for a while after the infection has settled — CDC calls this otitis media with effusion — and it makes the child's hearing worse. In a child who is learning to talk, reduced hearing that goes on affects language development. So go back if the child often asks you to repeat things, turns the television up louder than before, or does not react when you call from behind.

When to call a doctor to the house

Families usually need a clinician for three things: whether this really is the ear or something else, whether antibiotics are needed yet, and how to relieve the pain appropriately for the child's age. A Y Te Xanh (GreenCare) doctor can do the examination and the initial advice at your address; for children we take examination and acute care, not long-term care at home. But if a complication over the bone behind the ear is suspected, or a hearing test is needed, that has to happen at an ear, nose and throat facility — and if any warning sign above is present, go to hospital first and call afterwards.

The information above follows the public guidance of the US CDC on middle ear infection and does not replace being examined. Citing CDC here does not imply that CDC endorses Y Te Xanh or our services.

Need personalised advice for your loved one? Call our hotline 094 368 81 15 (24/7) — calling to ask a question or to book costs nothing. GreenCare has doctors who come to examine, nurses who carry out doctor's orders (injections, infusions, dressing changes), remote consultation by video call, and a review of the medicines you are taking; an in-depth remote consultation, or any one after the first, is a paid service. For children we take examination and acute care only — not long-term care at home, and not newborns or expectant mothers. We confirm we have staff in your area and provide transparent pricing before we begin.

Sources

CDC — Ear Infection Basics

Frequently asked questions

My child cannot talk yet — how do I tell ear pain from teething?

Look at the child's hands and at the context. With teething, the child dribbles a lot and puts their hands in their MOUTH, likes to chew on things, and usually has no high fever. With ear pain, the child pulls or rubs at an EAR, is much more unsettled when you lay them down, and it often appears after a cold or runny nose. Even so, nobody can tell reliably by looking. If the child has a fever, refuses to feed, or is unsettled all night, let a doctor examine them rather than guessing.

Pus came out of the ear and then the pain stopped — does that mean it is better?

No. Pain stopping suddenly just after you see fluid come out is usually because the eardrum has perforated, releasing the pressure in the ear. That is the reason to be seen, not a reason to relax. While you wait: only wipe the fluid gently on the outer ear, keep the ear dry, do not push cotton wool deep into the canal, and put absolutely nothing into the ear.

Does a middle ear infection always need antibiotics?

Not always. According to CDC, the body usually clears a middle ear infection by itself, so a doctor may watch for a few days, or write a prescription with instructions to wait before filling it. But a severe case, or symptoms lasting more than two or three days, needs antibiotics straight away. Which group your child is in can only be known when a doctor looks into the ear — so the answer is not at the pharmacy counter. And if a doctor has prescribed them, do not stop part way because the child seems better.

Can I put hydrogen peroxide, herbal water or oil into the ear?

No. While the ear is infected you cannot tell by eye whether the eardrum is intact or has perforated — and if it has perforated, anything you put in goes straight into the middle ear. This holds for hydrogen peroxide, herbal water, garlic water, oil, ground tobacco and breast milk alike. The same goes for ear drops: use only the ones a doctor has prescribed after looking into the ear.

How do I stop my child getting ear infections again?

According to CDC, the things to do are: keep up with influenza and pneumococcal vaccination on schedule; breastfeed exclusively for the first six months and continue breastfeeding to at least one year; wash hands often, the child's and the carer's; and keep the child away from tobacco smoke. One practical point that is often missed: do not let a child drink from a bottle while lying flat on their back. If episodes keep recurring, tell the doctor how many there have been — it changes how the doctor assesses the situation.

Can a child with a middle ear infection be bathed, or go swimming?

Bathing is fine and does not need to be avoided — just keep it quick, keep water out of the ear and dry the outside gently. Swimming, soaking in a tub and pouring water over the head should pause, especially while the ear is discharging or the eardrum has not healed, and ask the doctor before going back to swimming. Also, do not use shop-bought earplugs while the ear is still discharging.