Ear Infections in Kids: Acute, Ear Fluid, or Swimmer’s Ear?

Acute infection, lingering fluid, or swimmer’s ear: how to tell them apart and what actually helps

“Ear infection” is one of the most common reasons young children see a doctor, but the phrase covers three quite different conditions. An acute middle ear infection is painful and comes on fast. Fluid behind the eardrum is often painless and can linger quietly for weeks. Swimmer’s ear is an infection of the ear canal, not the middle ear at all. Each one is treated differently, and mixing them up leads to antibiotics that do not help or to hearing problems that go unnoticed. As a fellowship-trained pediatric ENT in Frisco, I see children at every point along this path. This guide explains how current national guidelines sort these conditions out, when antibiotics are and are not needed, how to lower your child’s risk, and when it is time to see a specialist.

Key takeaways

• There are three different “ear infections”: acute otitis media (a painful middle ear infection), otitis media with effusion (fluid behind the eardrum without infection), and swimmer’s ear (an ear canal infection).
• Treat the pain first. The American Academy of Pediatrics (AAP) makes pain control a core part of treating every acute ear infection.
• Not every acute ear infection needs an antibiotic right away. For many children 6 months and older with mild symptoms, careful observation for 48 to 72 hours is an accepted option.
• When an antibiotic is used, amoxicillin is the usual first choice unless your child has had it recently or has certain other features.
• Fluid that lingers after an infection usually clears on its own. Antibiotics, antihistamines, decongestants, and steroids do not help it.
• Ear tubes are considered for recurrent infections only if fluid is present when your child is evaluated, or for fluid that lasts three months or longer with hearing difficulties.
• Swelling behind the ear, facial weakness, a stiff neck, or a child who seems very ill are emergencies.

Three conditions, one confusing name

Middle ear infections usually follow a cold. The virus inflames the lining of the nose and the Eustachian tube, which connects the back of the nose to the middle ear. Pressure in the middle ear drops, and fluid and germs from the back of the nose move in. That is why ear infections cluster in the fall and winter and in children who are in group child care.

Swimmer’s ear is a separate problem. It is most common in swimming season, it does not usually cause fever, and the hallmark is pain when you gently tug the outer ear. I cover it in more detail in What Is Swimmer’s Ear? and How to Get Water Out of Your Ears.

How an acute ear infection is diagnosed

An accurate diagnosis is the foundation of good treatment. The AAP guideline sets specific criteria based on what the doctor sees on the eardrum, not just on symptoms:

• A clear diagnosis: moderate to severe bulging of the eardrum, or new drainage from the ear that is not caused by swimmer’s ear.
• A probable diagnosis: mild bulging of the eardrum plus recent ear pain (less than 48 hours; in a baby, holding, tugging, or rubbing the ear) or an intensely red eardrum.
• Not an ear infection: an eardrum without fluid behind it. A pink eardrum in a crying child, by itself, is not enough.

Fluid behind the eardrum is confirmed with a pneumatic otoscope, which puffs a small amount of air at the eardrum to see whether it moves, or with tympanometry, a quick pressure test. An ear full of wax may need to be cleaned before the eardrum can be seen.

Treating an acute ear infection

Pain relief comes first

Ear pain is the main reason children are miserable, and it does not wait for an antibiotic to start working. Acetaminophen or ibuprofen, dosed by your child’s weight according to your pediatrician or the package label, is the usual choice. Antibiotics do little for pain in the first day. A Cochrane review of placebo-controlled trials found that about 60 percent of children had recovered by 24 hours whether or not they received an antibiotic.

Antibiotic now, or observe?

The AAP guideline, which covers children 6 months through 12 years, bases the decision on age, how severe the symptoms are, and whether one or both ears are affected. “Severe” means moderate or severe ear pain, ear pain lasting at least 48 hours, or a temperature of 102.2°F (39°C) or higher.

Observation is not the same as doing nothing. It is a shared decision between you and your child’s clinician, with pain control, a plan for follow-up, and an antibiotic started if your child worsens or is not improving within 48 to 72 hours. Some offices provide a “wait-and-see” prescription to fill only if needed. The Cochrane review found that antibiotics modestly reduce pain after the first day and lower the chance of an eardrum perforation and of infection in the other ear, but they also cause more vomiting, diarrhea, and rashes, and they did not reduce later recurrences.

Which antibiotic

When an antibiotic is used, the AAP recommends amoxicillin for most children. A version with added coverage, such as amoxicillin-clavulanate, is recommended if your child took amoxicillin in the past 30 days, also has pus-like eye drainage (conjunctivitis), or has had repeated infections that did not respond to amoxicillin. Children with a penicillin allergy receive an alternative. Your child’s clinician chooses the medicine and dose based on age, weight, and history, and the course is generally longer for children under 2 than for older children. If your child is not better, or is worse, 48 to 72 hours after starting an antibiotic, call so the plan can be reassessed.

Fluid after the infection is expected

After the pain and fever settle, fluid commonly stays behind the eardrum. In the AAP guideline, 60 to 70 percent of children still had fluid two weeks after successful treatment, about 40 percent at one month, and 10 to 25 percent at three months. This leftover fluid is otitis media with effusion. It needs monitoring, not another antibiotic.

Fluid behind the eardrum (otitis media with effusion)

OME is common and often goes unnoticed because it usually does not hurt. Parents may notice that a child turns up the TV, says “what?” often, seems inattentive, or is a little clumsy. The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) guideline recommends:

• Watchful waiting for three months from when the fluid started (or was first found) in children who are not at increased risk for developmental problems.
• No antibiotics, steroids (nasal or oral), antihistamines, or decongestants for OME. They do not clear the fluid, and they have side effects.
• An age-appropriate hearing test if fluid lasts three months or longer, or at any point in a child at increased risk.
• Re-checks every three to six months for chronic fluid until it clears, significant hearing loss is found, or the eardrum shows structural changes.

Some children are more vulnerable to the effects of reduced hearing, including children with speech or language delay, autism, Down syndrome, cleft palate, permanent hearing loss, or vision problems. For them, fluid deserves earlier attention. If you are worried about your child’s hearing, see my page on pediatric hearing loss. Fluid can also cause a feeling of fullness or popping in older children, described in Understanding Clogged Ears.

Recurrent ear infections and when ear tubes come in

Recurrent acute otitis media is defined as three or more infections in six months, or four or more in 12 months with at least one in the most recent six months. The AAP advises against daily preventive antibiotics for these children.

Ear tubes are small ventilation tubes placed in the eardrums under brief anesthesia. The 2022 AAO-HNS tympanostomy tube guideline update draws a clear line for recurrent infections:

• Clinicians should not place tubes for recurrent acute otitis media in a child who has no fluid in either ear at the time of the tube evaluation.
• Clinicians should offer tubes to a child with recurrent acute otitis media who does have fluid in one or both ears at that evaluation.

For persistent fluid, the guideline recommends offering tubes when fluid has been present in both ears for three months or longer and hearing difficulties are documented. Tubes are an option for chronic fluid in one or both ears causing balance problems, school or behavior problems, ear discomfort, or reduced quality of life.

The evidence on tubes for recurrent infections is more nuanced than many parents expect. In a 2021 randomized trial in children 6 to 35 months old with recurrent infections, children who got tubes had about the same number of ear infections over two years as children treated with antibiotics for each episode. Tubes did lengthen the time to the next infection and reduced treatment failures, while children managed with antibiotics had fewer days of ear drainage. That is why the decision depends on whether fluid is present, how your child is hearing and developing, and your family’s preferences.

For what to expect from the procedure, follow-up, and swimming with tubes, see my ear tubes in Frisco and ear tubes in McKinney pages. The role of the adenoids, including when adenoidectomy is added to tubes, is covered in The ABCs of Adenoids. When surgery is needed, I perform these procedures at Stonebridge Surgery Center, and at Children’s Medical Center Plano or Texas Health Hospital Frisco when hospital care is the safer choice.

Lowering your child’s risk

The AAP guideline recommends:

• Pneumococcal conjugate vaccine (PCV) on the routine schedule. These vaccines reduce ear infections caused by the pneumococcal strains they cover.
• A yearly flu vaccine for every child 6 months and older.
• Exclusive breastfeeding for at least six months, when possible.
• No tobacco smoke exposure, at home or in the car.

The guideline also discusses, without a formal recommendation, avoiding bottle propping (feeding a baby lying flat with a propped-up bottle) and reducing or stopping pacifier use in the second six months of life. Because most ear infections follow colds, the guideline also notes that changes in child care attendance can significantly reduce recurrent infections, and everyday handwashing helps limit colds.

When an ear infection is an emergency

Serious complications of ear infections are uncommon, but they can happen. Go to the emergency department for:

• Swelling, redness, or tenderness behind the ear, or an ear that is pushed forward or outward (possible mastoiditis)
• Weakness or drooping of one side of the face
• A stiff neck, severe headache, confusion, or unusual sleepiness
• A child who looks very ill, with high fever, repeated vomiting, or trouble staying awake
• Sudden dizziness with loss of balance, or sudden loss of hearing

A baby younger than 6 months with fever or suspected ear pain should be seen promptly by a pediatrician.

When to see a pediatric ENT

• Three or more ear infections in six months, or four or more in a year
• Fluid behind the eardrum lasting three months or longer
• Concerns about hearing, speech, or language, at any age
• Ear infections that do not improve with appropriate antibiotics
• Ongoing drainage from the ear, an eardrum hole that does not heal, or a white mass behind the eardrum
• A child with Down syndrome, cleft palate, or another condition that raises the risk of ear problems

My ear infections in children and pediatric ENT pages describe how I evaluate and treat these children.

Frequently asked questions

Can an ear infection go away without antibiotics?

Yes, many do. In placebo-controlled trials, about 60 percent of children with an acute ear infection had recovered within 24 hours whether or not they received an antibiotic. The AAP allows careful observation for many children 6 months and older with mild symptoms, as long as follow-up is arranged and an antibiotic is started if the child is not improving within 48 to 72 hours.

How can I tell if my baby or toddler has an ear infection?

Young children often pull or rub at an ear, are fussy, sleep poorly, have a fever, or eat less, usually a few days into a cold. The AAP notes that these signs are not specific in young children, so the diagnosis depends on a doctor seeing a bulging eardrum with fluid behind it.

My child still has fluid after finishing antibiotics. Does that mean the infection didn’t clear?

Usually not. Fluid commonly lingers after a successful treatment, and in the AAP guideline 10 to 25 percent of children still had some at three months. Leftover fluid without pain or fever is otitis media with effusion, which is monitored rather than treated with more antibiotics.

Do antihistamines or decongestants help clear ear fluid?

No. The AAO-HNS guideline recommends against antihistamines, decongestants, and steroids for fluid behind the eardrum, because they do not speed recovery and can cause side effects. Watchful waiting, with a hearing test if the fluid lasts three months, is the recommended approach.

Will my child need ear tubes?

Most children with ear infections never need tubes. Tubes are considered for recurrent infections when fluid is present at the time of evaluation, and for fluid lasting three months or longer with hearing difficulties or other symptoms. The decision is made together with your family and depends on your child’s hearing, development, and history.

References

1. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964–e999. doi:10.1542/peds.2012-3488
2. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion (update). Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1–S41. doi:10.1177/0194599815623467
3. 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
4. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1–S24. doi:10.1177/0194599813517083
5. Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;(6):CD000219. doi:10.1002/14651858.CD000219.pub4
6. Hoberman A, Preciado D, Paradise JL, et al. Tympanostomy tubes or medical management for recurrent acute otitis media. N Engl J Med. 2021;384(19):1789–1799. doi:10.1056/NEJMoa2027278

If your child’s ear infections keep coming back or the fluid never seems to clear, I’m happy to take a look. You can contact my office to schedule a visit in Frisco or at the McKinney office of ENT and Allergy Centers of Texas.