Ear Pain in Children: Causes, Symptoms & When to See a Doctor

What Causes Ear Pain in Children?

Ear pain in children is most commonly caused by middle ear infections (otitis media), which develop when bacteria or viruses infect the fluid behind the eardrum, often following a cold. Other causes include outer ear infections (swimmer's ear), fluid buildup without infection (otitis media with effusion), earwax impaction, foreign objects in the ear, and referred pain from teething or throat problems.

Ear pain in children can have many different causes, and it's often difficult to determine the exact cause without a medical examination. The pain may affect one or both ears and can range from a dull ache to sharp, intense discomfort that disrupts sleep and daily activities. Understanding the common causes helps parents know when home treatment is appropriate and when to seek medical care.

The anatomy of children's ears makes them particularly susceptible to ear problems. The Eustachian tube, which connects the middle ear to the back of the throat, is shorter and more horizontal in children than in adults. This anatomical difference means that bacteria and viruses from upper respiratory infections can more easily travel to the middle ear, and fluid doesn't drain as effectively. As children grow, the Eustachian tube becomes longer and more angled, which is why ear infections become less common with age.

Additionally, children's immune systems are still developing, making them more vulnerable to infections in general. Children who attend daycare or have older siblings may be exposed to more germs, increasing their risk of both respiratory infections and subsequent ear problems. Seasonal factors also play a role, with ear infections being more common during fall and winter months when colds and flu are prevalent.

Ear Pain from Middle Ear Infection (Otitis Media)

Middle ear infection (otitis media) is the most common cause of ear pain in children and frequently occurs alongside or shortly after a cold. During a cold, the mucous membranes in the throat, nose, and sinuses become swollen and inflamed. This swelling can block the Eustachian tube, preventing normal drainage of fluid from the middle ear. When fluid accumulates and becomes trapped, it creates an ideal environment for bacteria to multiply, leading to infection.

The infection causes pus to form in the middle ear, making the eardrum red, swollen, and inflamed. The buildup of fluid and pus creates pressure behind the eardrum, which is what causes the pain. This pressure can be intense, particularly at night when the child lies down and fluid doesn't drain as well. Children with middle ear infections often become irritable, have trouble sleeping, and may pull or tug at their ears.

Sometimes the pressure becomes so great that the eardrum ruptures (perforates). While this can be alarming for parents, it actually often provides immediate pain relief as the pressure is released. When the eardrum ruptures, fluid or pus drains out through the ear canal. In most cases, the eardrum heals on its own within a few weeks without any long-term consequences. However, if your child has ear drainage, they should be evaluated by a healthcare provider.

Middle ear infections are particularly common in preschool-aged children because they haven't yet built up immunity to many common bacteria. The bacteria responsible for ear infections often live harmlessly in the back of the nose but cause problems only when the Eustachian tube becomes blocked due to a viral infection.

Fluid in the Middle Ear (Otitis Media with Effusion)

Otitis media with effusion (sometimes called "glue ear") occurs when clear, non-infected fluid accumulates in the middle ear. Unlike an acute ear infection, there's no active infection, so antibiotics won't help. The fluid makes the eardrum less mobile, which dampens sound waves and can cause temporary hearing loss. Children may complain of a feeling of fullness or pressure in the ear, though it typically doesn't cause significant pain.

This condition commonly develops after a cold or following an acute ear infection when fluid remains in the middle ear even after the infection has cleared. In most children, the fluid gradually drains on its own over several weeks to months. However, some children develop persistent fluid that affects their hearing and may impact speech and language development if left untreated. Your child's healthcare provider can monitor the situation and recommend treatment if the fluid persists.

Outer Ear Infection (Swimmer's Ear)

Outer ear infections (otitis externa or swimmer's ear) affect the ear canal rather than the middle ear. This type of infection can cause significant pain, especially when the outer ear is touched or when the child chews. The ear canal may become red, swollen, and itchy, and there may be discharge. Mild cases are very common, particularly in children who swim frequently, use earplugs, or have a habit of putting things in their ears.

When the ear canal is infected or inflamed, it can make it difficult for a doctor to see the eardrum clearly. If your child has an outer ear infection along with suspected middle ear problems, treatment for the outer infection may be needed first before a complete evaluation can be done.

Other Causes of Ear Pain

Several other conditions can cause ear pain in children:

• Foreign objects in the ear: Young children sometimes put small items like beads, stones, or food into their ears. Insects can also enter the ear canal. These can cause pain and should be removed by a healthcare provider.
• Earwax buildup: Excessive earwax can cause a feeling of fullness, reduced hearing, and sometimes pain. Special ear drops from the pharmacy can help with mild cases, but significant wax buildup may need to be removed by a doctor.
• Injury to the ear: A blow to the ear or head, or sudden pressure changes (like during flying or diving), can rupture the eardrum and cause pain, bleeding, hearing loss, and sometimes dizziness.
• Referred pain: Problems in other areas, such as the jaw joint, throat, or teeth (including teething), can cause pain that feels like it's coming from the ear.

What Are the Symptoms of Ear Infection in Children?

Common symptoms of ear infection in children include ear pain (especially when lying down), pulling or tugging at the ear, difficulty sleeping, irritability and crying, fever, fluid drainage from the ear, hearing problems, and loss of balance. Infants may show fussiness, poor feeding, and difficulty settling, while older children can describe their symptoms more clearly.

Recognizing ear infection symptoms in children can be challenging, especially in infants and toddlers who cannot verbally describe their discomfort. The symptoms can vary depending on the child's age, the type of ear problem, and the severity of the condition. Understanding the range of possible symptoms helps parents identify when their child might have an ear infection and when medical attention is needed.

Ear infections typically develop quickly, with symptoms appearing within hours. The pain often worsens at night because lying down increases pressure in the middle ear. Many children with ear infections also have cold symptoms like a runny nose or congestion, since upper respiratory infections commonly precede middle ear infections. The combination of ear pain and general illness symptoms can make children particularly miserable and disrupt sleep for the entire family.

It's important to note that not all children with ear infections will have all symptoms, and some children may have significant infections with relatively mild symptoms. This variability is why a proper examination by a healthcare provider is necessary for definitive diagnosis.

Pain and Discomfort

The most prominent symptom of middle ear infection is pain, which can range from mild to severe. The pain typically worsens at night and when the child lies down because this position increases pressure on the inflamed eardrum. Children may cry inconsolably, especially at bedtime, and may wake frequently during the night. The pain is usually worst in the first 24-48 hours before gradually improving.

Young children and infants who cannot verbally express their discomfort may pull or tug at their ears, though this behavior alone isn't a reliable indicator of ear infection since babies often touch their ears for other reasons. More telling signs include persistent fussiness, especially after being put to bed, and difficulty being comforted.

Fever and General Illness

Many children with ear infections develop a fever, though not all do. The fever can range from mild (around 100.4°F or 38°C) to high (over 102°F or 39°C). High fever, especially combined with ear pain, increases the likelihood that antibiotics may be needed. Children may also appear generally unwell, with decreased appetite, lethargy, and irritability.

Hearing Changes and Drainage

Fluid or pus in the middle ear can temporarily affect hearing. Parents may notice that their child doesn't respond to normal conversation, asks for the TV or music to be louder, or seems to be "ignoring" them. This hearing change is usually temporary and resolves as the infection clears and fluid drains.

If the eardrum ruptures due to pressure buildup, fluid (which may be clear, yellow, or bloody) will drain from the ear. While alarming to see, this actually often brings pain relief. If your child has ear drainage, keep the outer ear clean and dry, and consult a healthcare provider.

When Should You See a Doctor for Ear Pain?

See a doctor if ear pain lasts more than 24 hours, if there's fever with ear pain, fluid drainage from the ear, significant hearing loss, or if symptoms don't improve within 2-3 days. Seek immediate medical care for symptoms like neck stiffness with ear pain, very high fever with appearing very unwell, dizziness or balance problems, swelling or redness behind the ear, or if the ear appears to stick out more than normal.

While most ear pain in children is not serious and will resolve on its own, certain symptoms warrant prompt medical attention. Understanding when to seek care helps ensure children receive appropriate treatment while avoiding unnecessary medical visits for mild, self-limiting conditions. The key is to balance watchful waiting with timely intervention when needed.

Parents know their children best. If your child seems unusually unwell or you're concerned about their symptoms, it's always appropriate to seek medical advice. Healthcare providers would rather see a child who turns out to have a mild illness than miss a child with a serious condition. Trust your instincts while also using the following guidelines to help determine the urgency of your child's situation.

Contact Your Healthcare Provider If:

• Ear pain lasts more than 24 hours
• Your child has ear pain along with fever
• There's fluid drainage from one or both ears
• Your child has decreased hearing in one or both ears
• Symptoms don't improve within 2-3 days after initial evaluation
• A feeling of ear fullness, ringing, or ringing in the ears persists for 3-4 weeks after an acute ear infection

Special Considerations for Different Age Groups

Children under 6 months: Always consult a healthcare provider before giving any medication. Ear infections in very young infants require medical evaluation and typically require antibiotic treatment.

Children under 1 year: Should be evaluated by a healthcare provider for suspected ear infections. Infants are at higher risk for complications and typically need antibiotic treatment.

Children over 12 years and adults: Follow the same guidelines as for younger children, though adults are less likely to develop ear infections. Adult ear pain may have different causes and should be evaluated if persistent.

How Is Ear Infection Diagnosed?

Ear infections are diagnosed through physical examination using an otoscope (a lighted instrument to see the ear canal and eardrum) or otomicroscope. The doctor looks at the eardrum's appearance, checks for fluid behind it, and assesses eardrum mobility. Tympanometry, a painless test measuring eardrum movement and middle ear pressure, may also be used to provide additional information about fluid presence.

When you bring your child to the healthcare provider for ear pain, they will first ask about the symptoms: what kind of discomfort your child is experiencing, how long symptoms have been present, whether there's been a recent cold, and how quickly symptoms appeared. This history helps the provider understand the likely cause and severity of the problem.

The physical examination focuses on directly visualizing the ear canal and eardrum. The provider uses an otoscope, which looks like a small flashlight with a funnel-shaped tip, to look into the ear. Some providers use an otomicroscope, which provides a magnified view similar to looking through binoculars. These examinations are not painful but may be uncomfortable if the ear canal is inflamed.

What the Doctor Looks For

During the examination, the healthcare provider evaluates several key features:

• Eardrum appearance: A healthy eardrum is pearly gray and translucent. In ear infection, it may appear red, bulging, or cloudy.
• Fluid behind the eardrum: The provider looks for signs of fluid accumulation in the middle ear space.
• Eardrum mobility: Using a pneumatic otoscope (which puffs a small amount of air against the eardrum) or tympanometry, the provider can assess how well the eardrum moves. Fluid behind the eardrum restricts movement.

Tympanometry is a painless test where a small soft probe is placed in the ear canal opening. The device makes a humming sound and measures how the eardrum responds to small pressure changes. This test is particularly helpful for detecting fluid in the middle ear that might not be clearly visible on examination.

If your child has outer ear canal inflammation (otitis externa), it may be difficult for the provider to see the eardrum clearly. In such cases, treatment for the outer ear inflammation may be needed first, with a follow-up appointment scheduled to complete the evaluation once the swelling has subsided.

How Can You Treat Ear Pain at Home?

Home treatment for ear pain focuses on pain relief and comfort measures. Keep your child's head elevated to reduce pressure, give age-appropriate pain relievers (acetaminophen from 3 months, ibuprofen from 6 months), use saline nasal spray to relieve congestion, and ensure rest. Never put anything in the ear canal. Avoid swimming until the infection clears, and if there's ear drainage, protect the ear from water for one week after drainage stops.

Most ear pain improves on its own with supportive care at home. The primary goals of home treatment are to relieve your child's discomfort and support their body's natural healing process. Even when antibiotics are prescribed, they don't provide immediate pain relief, so comfort measures remain important throughout the illness.

Understanding that ear infections often resolve without antibiotics can be reassuring for parents. Research shows that 80% of ear infections in children aged 1-12 years heal on their own within 2-3 days. For many children, watchful waiting with good symptom management is the most appropriate approach, avoiding unnecessary antibiotic use and its associated risks.

Keep the Head Elevated

Both children and adults feel better when they keep their head elevated during ear infections. This position helps reduce swelling in the nose and ears and decreases pain by allowing fluid to drain more easily. During sleep, this can be achieved by using extra thick pillows or raising the head of the bed by placing a pillow under the mattress.

For infants under one year, you can use a baby carrier or let them sit in your lap or a baby seat. Raising the head of the crib can also help - try placing thick books under the crib legs at the head end. Never place pillows directly in an infant's sleep space due to suffocation risk.

Pain Relief Medications

Over-the-counter pain relievers are the mainstay of symptom management for ear pain. These medications help regardless of whether the ear pain is due to infection, fluid, or another cause.

Nasal Care

Decongestant nasal sprays and drops can relieve nasal congestion and make breathing easier during a cold, but they do not help treat the ear infection itself. This applies to both children and adults. Do not use decongestant nasal sprays for more than 10 days, as this can lead to rebound congestion that's difficult to resolve.

Saline (salt water) nasal drops or spray can help loosen mucus and relieve congestion without the risk of rebound. Ready-made saline products are available at pharmacies and are safe for all ages.

Swimming and Bathing

When your child has ear pain or fluid draining from the ear, avoid swimming and be careful about getting water in the ears during bathing. If your child has had an ear infection with eardrum rupture (evidenced by drainage), avoid getting water in the ears for one week after the drainage stops. Cotton balls coated with petroleum jelly or earplugs can protect the ears during bathing.

Earwax Removal

If earwax buildup is causing discomfort, over-the-counter earwax removal drops can help soften the wax for mild cases. Never insert cotton swabs, fingers, or other objects into the ear canal, as this can push wax deeper or damage the ear canal and eardrum. If you have concerns about earwax buildup, a healthcare provider can safely remove it.

How Is Ear Infection Treated Medically?

Most ear infections in children aged 1-12 years heal without antibiotics and are managed with pain relief alone. Antibiotics are prescribed for children under 6 months (always), children 6-23 months with bilateral infection or severe symptoms, and older children with severe or worsening symptoms. Outer ear infections are treated with ear drops. Children with recurrent infections or persistent fluid may benefit from ear tube (tympanostomy) surgery.

The treatment approach for ear infections has evolved significantly over the past two decades. Current international guidelines, including those from the American Academy of Pediatrics and NICE, recognize that many ear infections resolve without antibiotics and recommend a more selective approach to antibiotic prescribing. This helps reduce unnecessary antibiotic use while ensuring children who need treatment receive it promptly.

The decision about whether to prescribe antibiotics depends on several factors: the child's age, whether one or both ears are infected, the severity of symptoms, and whether symptoms are improving or worsening. In many cases, healthcare providers recommend a "watchful waiting" approach, where antibiotics are held initially but started if symptoms don't improve within 48-72 hours.

Treatment of Middle Ear Infection (Otitis Media)

Children aged 1-12 years with uncomplicated middle ear infection often don't need antibiotics. Studies show that about 80% will improve on their own within 2-3 days. Pain management is the priority, and parents are typically given guidance on warning signs that would indicate a need for antibiotic treatment.

Children under 1 year and those over 12 years and adults with middle ear infections typically receive antibiotic treatment. Young infants are at higher risk for complications, and the natural resolution rate is lower, making antibiotics the safer choice.

When antibiotics are prescribed, the most common first choice is amoxicillin. The full course should be completed even if symptoms improve quickly. If your child has a penicillin allergy, alternative antibiotics are available.

Treatment of Outer Ear Infection (Swimmer's Ear)

The most important aspect of treating outer ear infections is keeping the ear canal clean. This may be done by a healthcare provider using gentle suction or irrigation. Antibiotic ear drops are usually prescribed, sometimes combined with steroid drops to reduce swelling. In rare cases of severe infection, oral antibiotics may also be needed.

Ear Tubes (Tympanostomy Tubes)

Children who have frequent ear infections or persistent fluid in the middle ear may benefit from ear tubes. This is a minor surgical procedure performed by an ENT (ear, nose, and throat) specialist.

During the procedure, a tiny plastic or metal tube is inserted through a small incision in the eardrum. The tube allows air to enter the middle ear and helps fluid drain out, rather than accumulating behind the eardrum. This can reduce the frequency of ear infections and improve hearing in children affected by persistent fluid.

Ear tubes typically stay in place for 6-18 months before naturally falling out as the eardrum heals. During this time, it's important to keep water out of the ears, though many children with tubes can swim with proper ear protection. Your ENT specialist will provide specific guidance.

Can Children with Ear Pain Fly on Airplanes?

Flying with ear pain can be very uncomfortable due to pressure changes during takeoff and landing. If possible, avoid flying when your child has an active ear infection, significant ear pain, or feels "blocked." If flying is necessary, help your child equalize pressure by swallowing, chewing gum, or (for infants) sucking on a pacifier or bottle during ascent and descent. Decongestant nasal spray used before the flight may help.

Air pressure changes during airplane flights can cause ear pain in anyone, but children and those with existing ear problems are particularly vulnerable. The pressure changes that occur during takeoff and landing create a pressure difference between the inside and outside of the eardrum. Normally, the Eustachian tube opens to equalize this pressure, but when the tube isn't working properly (due to swelling from a cold or ear infection), pressure equalization becomes difficult or impossible.

In children with Eustachian tube dysfunction (which includes most children with ear infections or colds), the pressure difference can cause significant pain, and in some cases, may cause the eardrum to rupture. While a ruptured eardrum sounds alarming and can be quite painful, it usually heals on its own without permanent damage.

Pressure Equalization Techniques

Helping your child equalize ear pressure can make flying more comfortable. The simplest method is swallowing, which naturally opens the Eustachian tube. For older children and adults, the Valsalva maneuver (pinching the nose closed and gently trying to blow through the nose) can help push air up the Eustachian tube. Other helpful strategies include:

• Chewing gum during takeoff and landing (for older children)
• Offering a pacifier, bottle, or breastfeeding for infants during descent
• Using decongestant nasal spray before the flight to reduce swelling
• Staying awake during descent so the child can actively swallow

Special pressure-equalizing earplugs are available at pharmacies and may help some travelers. You can test your child's ability to equalize pressure before the flight by having them try the Valsalva maneuver.

How Can You Prevent Ear Infections in Children?

While not all ear infections can be prevented, you can reduce risk by keeping vaccinations up to date (especially pneumococcal and influenza vaccines), avoiding secondhand smoke exposure, breastfeeding (provides protective antibodies), and practicing good hand hygiene. For children prone to swimmer's ear, drying ears thoroughly after swimming and avoiding putting objects in the ear canal can help.

Complete prevention of ear infections isn't possible, especially in young children who are frequently exposed to cold viruses. However, several strategies can reduce the frequency and severity of ear infections. These measures work by either reducing exposure to the infections that trigger ear problems or by supporting the child's immune system and Eustachian tube function.

It's important to have realistic expectations about prevention. Even with optimal preventive measures, most children will still experience at least one ear infection during childhood. The goal is to reduce frequency and minimize the impact on your child's wellbeing and development, particularly regarding hearing and language development.

Vaccination

Keeping your child's vaccinations current is one of the most effective ways to prevent ear infections. The pneumococcal vaccine protects against Streptococcus pneumoniae, one of the main bacteria causing ear infections. Since its introduction, there has been a significant reduction in ear infections requiring antibiotics. The influenza (flu) vaccine also helps by preventing viral infections that often precede bacterial ear infections.

Avoid Smoke Exposure

Children exposed to cigarette smoke have significantly higher rates of ear infections. Secondhand smoke irritates the mucous membranes and impairs Eustachian tube function. If you or family members smoke, smoking outside and away from the child, and never in the home or car, can help reduce this risk.

Breastfeeding

Breastfeeding provides antibodies that help protect against infections, including ear infections. Exclusive breastfeeding for the first six months and continued breastfeeding alongside solid foods offers the best protection. If bottle-feeding, hold the baby in an upright position rather than lying flat to reduce the risk of milk entering the Eustachian tube.

Hand Hygiene

Since ear infections usually follow viral upper respiratory infections, good hand hygiene helps reduce the spread of these viruses. Teach children to wash hands frequently, especially after using the bathroom, before eating, and after playing with others. This is particularly important in daycare and school settings where respiratory viruses spread easily.