Ear Infections: Watch, Wait or Treat

Ear infections are the most common reason children are prescribed antibiotics, and most of them get better without them. Since the 2000s, guidance in many countries has recommended watchful waiting for older children with mild symptoms, and the trials behind that shift were clear.

Recognising one

A child with an ear infection is usually unwell in a particular way: pain, often worse when lying flat, tugging at one ear, irritability, poor sleep and sometimes a fever. A cold with no fever and no pain is usually not an ear infection. Fluid behind the eardrum after an infection is common and can linger for weeks, reducing hearing slightly and sounding like your child is ignoring you. That is fluid, not infection, and it does not need antibiotics.

• Under six months: always assessed the same day.
• Six months to two years with clear pain: usually treated with antibiotics.
• Over two years with mild symptoms: paracetamol and a review in 48 hours is reasonable.
• Ear drops do not treat a middle ear infection, only a perforation or outer ear infection.

What helps at home

Pain relief is the main intervention and often the only one needed: paracetamol or ibuprofen at the correct weight-based dose, given regularly rather than as needed while the pain lasts. Keep the child upright when awake and offer extra fluids. Do not put anything in the ear canal, including cotton buds or oil, unless a doctor has advised drops for a specific reason. Most children improve markedly within 48 hours.

Call back if a child is no better after two days, develops swelling or redness behind the ear, has a stiff neck, or is significantly drowsy. Recurrent infections, more than three in six months, or persistent fluid with hearing concerns, are a reason to ask for an ENT referral, usually for grommets. Ear infections are painful and disruptive, but almost always harmless when treated appropriately.