Quick answer: Ear infections are the most common reason for paediatric antibiotic prescriptions and one of the most frequent causes of infant distress and sleepless nights.
Ear infections are the most common reason for paediatric antibiotic prescriptions and one of the most frequent causes of infant distress and sleepless nights. Here’s how to recognise them, when antibiotics are actually needed, and how to reduce recurrence.
Signs of an Ear Infection in Babies
Ear infections in pre-verbal babies are particularly challenging to diagnose because babies can’t tell you their ear hurts. Signs to watch for: Ear tugging or pulling: Not diagnostic on its own (babies tug ears for many reasons including teething) but significant when combined with other symptoms. Fever: Often present, typically 38–39°C. Unusual crying and irritability: Particularly worse when lying flat (increased pressure in the ear in supine position) or when sucking (changes in eustachian tube pressure). Difficulty sleeping: Often waking more than usual, difficulty settling. Reduced feeding: Sucking and swallowing can be painful with middle ear infection. Discharge from the ear: Yellow or bloody discharge indicates the eardrum may have ruptured — this is not a disaster (it relieves pressure and heals) but does require assessment.
Acute Otitis Media vs Otitis Media With Effusion
Acute otitis media (AOM) is bacterial or viral middle ear infection with fluid behind the eardrum, pain, and systemic symptoms (fever, illness). This is the type that may require antibiotics. Otitis media with effusion (OME / ‘glue ear’) is fluid in the middle ear without acute infection — no pain, no fever, but reduced hearing. Very common after AOM or upper respiratory infections. Usually resolves spontaneously over weeks to months. Persistent OME causing hearing loss may warrant grommets.
Treatment: When Are Antibiotics Needed?
Current evidence-based guidance (AAP 2013, updated) recommends: Antibiotics immediately for: any ear infection in a child under 6 months; severe infection (fever above 39°C or significant ear pain); infection in both ears in a child under 2; or discharge from the ear. Watchful waiting (no immediate antibiotics) is appropriate for: children 6–24 months with mild unilateral AOM; children over 2 with mild symptoms. In watchful waiting, antibiotics are prescribed but filled only if symptoms don’t improve in 48–72 hours. Most ear infections (up to 70%) resolve without antibiotics, and unnecessary antibiotic use contributes to resistance.
Pain Management
Regardless of antibiotic decision, treat pain: paracetamol or ibuprofen at appropriate doses are effective. Warm compress against the ear may provide comfort. Maintain upright or semi-upright positioning if possible. Nasal decongestants and antihistamines have not been shown to benefit ear infections and are not recommended for young children.
Prevention: Reducing Recurrence
- Breastfeeding for at least 6 months — reduces ear infection risk by approximately 50%
- Avoid passive smoke exposure — smoking in the home significantly increases risk
- Keep immunisations up to date — pneumococcal and influenza vaccines reduce ear infection risk
- Avoid dummy/pacifier use during sleep (but can still use in the newborn period for SIDS reduction)
- Avoid bottle-feeding in the supine (lying down) position
- Daycare attendance increases exposure — not preventable but worth knowing
Frequently Asked Questions
How can I tell if my baby has an ear infection without seeing a doctor?
You can’t diagnose an ear infection without examining the eardrum — and neither can most parents or even most non-specialist healthcare providers without an otoscope. The only reliable sign in pre-verbal babies is eardrum examination. If you suspect an ear infection based on symptoms, contact your GP or paediatrician — don’t wait to see if it improves on its own in babies under 6 months.
Do ear infections cause permanent hearing loss?
Acute ear infections rarely cause permanent hearing loss. Persistent glue ear (OME) causes temporary conductive hearing loss that can affect speech and language development if it persists for months. This is why recurring ear infections with associated hearing difficulties warrant audiological assessment and possible grommet insertion.
My baby has had 4 ear infections in 6 months — what can be done?
Recurrent AOM (4+ episodes in 12 months, or 3+ in 6 months) warrants ENT (ear, nose, throat) referral. Options include: watchful waiting with careful monitoring, prophylactic antibiotics (not first choice due to resistance concerns), or tympanostomy tube insertion (grommets) — small tubes placed in the eardrum to ventilate the middle ear, which significantly reduces recurrence.
Related Reading
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