Ear Infections in Children | A Parent’s Complete Guide
It is two in the morning. Your child is screaming, pulling at their ear, and nothing is settling them. You are exhausted, frightened, and about to Google something that will probably make this worse.
This article will give you clarity.
Ear infections are the most common reason parents bring their child to a doctor. Five out of six children will have at least one before their third birthday.1 In the UK alone, they account for an estimated half a million GP consultations every year.2 And yet the information available to parents is often either too vague to be useful or alarming without context.
This guide gives you a framework. Not just a list of symptoms, but a way of thinking about ear infections in children that will serve you every time this happens.
Parent’s Red Flag Card
A single printable page: when to wait, when to call your doctor, and when to go to A&E
The Basics
The three zones of the ear, the framework that makes everything clear
To understand ear infections in children, think of the ear in three zones because the type of infection and the right response to it, depend entirely on which zone is involved.
Zone 1 — The outer ear canal, the visible canal leading from the outside world to the eardrum. This is where otitis externa (swimmer’s ear) happens.
Zone 2 — The middle ear: This is the small space situated behind the eardrum and connected to the back of the nose and throat via the Eustachian tube. This is where the vast majority of childhood ear infections occur.
Zone 3 — The mastoid, the bone immediately behind the ear, filled with air cells that connect directly to the middle ear. Under normal circumstances, you never think about it. In rare cases, it becomes an urgent concern.
Why do children get more ear infections than adults
The answer is almost entirely structural. In children, the Eustachian tube, the channel connecting the middle ear to the back of the nose, is shorter, more horizontal, and floppier than in adults. It drains poorly.
Think of the middle ear as a small room with one window (the eardrum) and one door (the Eustachian tube). When a child gets a cold, that door swells shut. The room cannot drain. Fluid accumulates. Pressure builds. That pressure is what causes the pain.
As children grow, the Eustachian tube lengthens and tilts. It starts to drain. The ear infections stop. This is why most children grow out of recurrent ear infections by school age.
The Four Conditions
Not all ear infections are the same — the four conditions parents need to know
Outer Ear
Infection of the outer ear canal. Common in children who swim regularly.
How to recognise it: Pain that gets significantly worse when you press the small cartilage flap at the ear entrance, called the tragus. This is the key differentiator from a middle ear infection. The pain is in the canal, not behind the eardrum.
Treatment: Antibiotic or antifungal eardrops prescribed by the doctor. Keep the ear dry. Avoid earbuds and earphones during active infection because these worsen inflammation and delay healing.
Swimming can cause otitis externa because water enters the canal. But swimming has nothing to do with middle ear infections. Those are caused by viruses during colds. The cold comes first, and the ear infection follows. Cold air, wet hair, and pool water do not reach the middle ear. Your child’s middle ear infections are not caused by letting them swim.
Middle Ear
The classic childhood ear infection. Almost always follows a cold.
How to recognise it: Deep ear pain, fever, irritability, difficulty sleeping. Pressing the tragus does not increase the pain, the pain is behind the eardrum. Often begins a few days into a cold.
On eardrum perforation: Sometimes the eardrum bursts under pressure. Discharge appears in the canal. And then, often immediately — the child settles. This is not a disaster. It is the ear’s own safety valve, releasing the pressure. The eardrum heals in the vast majority of cases.3
Middle Ear · Silent
Thick fluid in the middle ear with no active infection. Often painless, which is why parents miss it.
How to recognise it: Your child seems inattentive, turns up the television, doesn’t respond to their name, or their teacher raises concerns about attention or behaviour in class. Speech and language development may be slower than expected.
Why it matters: A child with glue ear typically has a 25–30 decibel conductive hearing loss, equivalent to hearing through a half-closed door. They are not ignoring you. They are genuinely struggling to hear.4 Glue ear is the most common cause of acquired hearing loss in children. If you suspect it, ask your doctor specifically for a hearing test.
Most cases resolve spontaneously within 3 months. If bilateral hearing loss persists beyond that, ENT referral and possible grommet insertion will be considered.
⚠ Emergency
Infection spreads from the middle ear into the mastoid bone behind the ear. Rare, but a genuine emergency when it occurs.
Mastoiditis affects approximately 1–4 children per 100,000 per year in the UK and Ireland. The overwhelming majority of ear infections never involve the mastoid. This section is not here to frighten you, it is here so that you can recognise the one presentation that must not wait.
How to recognise it: Swelling, redness, or tenderness in the area directly behind the ear. The outer ear appears pushed forward, displaced from its normal position. The child is systemically unwell beyond typical ear infection symptoms: very high fever, unusually drowsy, and not responding normally.
Swelling or redness behind the ear
The ear appears pushed forward or displaced
Child severely unwell, with very high fever, drowsy, not responding normally
Neck stiffness or severe headache alongside ear symptoms
Any facial weakness or drooping
Do not wait for a doctor’s appointment. Do not watch and wait. Go to A&E immediately.
Evidence & Management
Why your doctor didn’t prescribe antibiotics and why that was right
One of the most common and most frustrating experiences for parents is leaving a doctor’s appointment without a prescription, unsure whether the decision was correct. Here is the evidence behind watchful waiting, explained plainly.
According to NICE guidance (NG91, 2022), most ear infections in children over two years resolve without antibiotics within 72 hours.3 In straightforward, non-severe, one-sided infections in children over two, antibiotics reduce symptom duration by approximately one day. One day. In exchange, your child receives the side effects: diarrhoea, rashes, and contributes to the broader problem of antibiotic resistance.
The number of children who would need to be treated with antibiotics to prevent a single case of mastoiditis is estimated in the thousands. Your doctor is not dismissing your child. They are protecting them, with the full weight of current evidence behind that decision.
When antibiotics are the right answer
- Child under 2 years with infection in both ears
- Eardrum has perforated with discharge present
- No improvement after 48–72 hours of watchful waiting
- Child is systemically unwell
- Recurrent pattern of infections
What to Do
The complete management ladder
| Situation | What to do |
|---|---|
| Child >2 years, mild-moderate AOM, generally well | Paracetamol or ibuprofen for pain + watchful waiting 48–72 hours |
| Not improving after 72 hours | Contact the doctor, antibiotics are now appropriate to consider |
| Child <2 years, or bilateral AOM, or perforated drum with discharge | Same-day doctor appointment, antibiotics likely indicated |
| Otitis externa (swimmer’s ear) | GP, ENT, pediatric appointment — eardrops, keep ear dry, no earbuds during infection |
| Suspected glue ear with hearing or speech concerns | ENT referral for hearing evaluation (audiometry, tympanometry) |
| Glue ear confirmed, bilateral, persisting >3 months with hearing loss | ENT referral for adenoids and grommets discussion4 |
| Swelling behind the ear, ear displaced forward, child severely unwell | 🚨 A&E immediately, same day! |
At the Appointment
Questions worth asking your doctor
- Does my child need a hearing test (audiogram or tympanogram)?
- At what point should I come back if they are not improving?
- Could this be glue ear?
- Given how often this is happening, should we discuss grommets?
- Are there any warning signs I should watch for at home between now and the review?
If your child has been diagnosed with glue ear or recurrent acute otitis media and grommets are being considered, see the dedicated ENT for Everyone post: Grommets — A Parent’s Complete Guide. It covers what the procedure involves, what to expect on the day, and how to prepare your child.
Print and Keep: Parents’ Red Flag Card
All three tiers on one page: when to wait, when to call, when to go to A&E.
Print it. Keep it somewhere convenient.
FAQ
Frequently asked questions
Do ear infections in children always need antibiotics?
No. According to NICE guidance (NG91, 2022), most ear infections in children over two years resolve without antibiotics within 72 hours.3 Watchful waiting with pain relief is the evidence-based first approach for uncomplicated cases. Antibiotics are indicated in children under two with bilateral infection, when the eardrum has perforated, or when the child is not improving after 72 hours.
What is glue ear and how do I know if my child has it?
Glue ear (otitis media with effusion) is a build-up of thick fluid in the middle ear without active infection. It often causes no pain, making it easy to miss. Signs include appearing inattentive, turning up the television, not responding to their name, or speech and language concerns. A doctor can refer for a hearing test to confirm. Most cases resolve spontaneously within three months.4
What are the signs of mastoiditis in a child?
Mastoiditis is rare (approximately 1–4 per 100,000 children per year) but serious. Warning signs include swelling or redness behind the ear, the ear appearing pushed forward or displaced, and the child being systemically unwell beyond typical ear infection symptoms. This requires same-day A&E attendance. The vast majority of ear infections never progress to mastoiditis.
What is the difference between swimmer’s ear and a middle ear infection?
Swimmer’s ear (otitis externa) affects the ear canal. The key sign is pain that worsens when you gently press the small cartilage flap at the entrance to the ear (the tragus). Middle ear infections cause deep pain behind the eardrum and typically follow a cold. Pressing the tragus does not increase the pain. Swimming can cause otitis externa but does not cause middle ear infections.
When should I take my child to A&E for an ear infection?
Go to A&E the same day if your child has swelling or redness behind the ear, the ear appears pushed forward, there is facial weakness, neck stiffness, or the child is severely unwell beyond typical ear infection symptoms. For a standard ear infection in a child over two, watchful waiting with pediatric follow-up is appropriate.
Should I be worried if my child’s eardrum perforates?
A perforated eardrum in the context of acute otitis media is the ear’s own pressure-release mechanism. Discharge appears, and the child’s pain typically eases almost immediately. The eardrum heals in the vast majority of cases. If discharge persists beyond two weeks, or if you are concerned, see your doctor for review.
References
- National Institute on Deafness and Other Communication Disorders (NIDCD). Ear Infections in Children. Bethesda: NIH; updated 2022. Available from: https://www.nidcd.nih.gov/health/ear-infections-children
- Hayes CV, Ahmed H, Robotham JV, Verlander NQ, Lecky DM. A survey of parental health-seeking behaviour, knowledge, and expectations around ear infection symptoms in children. BJGP Open. 2026;BJGPO.2025.0131. doi:10.3399/BJGPO.2025.0131
- National Institute for Health and Care Excellence. Otitis media (acute): antimicrobial prescribing. NICE guideline NG91. London: NICE; 2018, updated March 2022. Available from: https://www.nice.org.uk/guidance/ng91
- National Institute for Health and Care Excellence. Otitis media with effusion in under 12s. NICE guideline NG233. London: NICE; August 2023. Available from: https://www.nice.org.uk/guidance/ng233
- Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngol Head Neck Surg. 2022;166(1_suppl):S1–S55. doi:10.1177/01945998211065662
