Ear infections in children — pain relief first, antibiotics when they help

About this guide

Ear infections are one of the commonest reasons a toddler is brought to see us, particularly in the week after a cold. They hurt, they wreck everyone’s sleep, and parents reasonably want them fixed. The good news is that most middle ear infections get better on their own within a few days. The important decisions are how to relieve the pain properly, which children benefit from antibiotics straight away, and how to make sure a child’s hearing is not affected in the months afterwards.

This guide covers acute otitis media, the fluid that can linger afterwards (glue ear), the different problem of swimmer’s ear, and the warning signs that need urgent care.

What an ear infection is

The middle ear is the small air-filled space behind the eardrum. It connects to the back of the nose through the Eustachian tube. In young children this tube is short, narrow and nearly horizontal, so when a cold causes swelling and mucus, the tube blocks easily, fluid collects behind the eardrum, and viruses or bacteria multiply in it. The result is acute otitis media (AOM): a bulging, inflamed eardrum and pain.

Most children have had at least one ear infection by their third birthday, and the peak age is 6 months to 2 years. They become much less common after the age of 5 or 6 as the tube lengthens and the immune system matures.

Symptoms

• Ear pain, which a toddler may show by crying, pulling or rubbing the ear, or refusing to lie down
• Fever, often after a few days of a cold
• Irritability and poor sleep, particularly at night when lying flat increases the pressure
• Reduced hearing or not responding to sounds as usual
• Poor feeding in babies
• Discharge from the ear: sometimes the pressure causes a small tear in the eardrum, fluid drains out, and the pain suddenly improves. This usually heals on its own within a few weeks.

Ear pulling on its own, without fever or distress, is a poor guide: teething babies and tired toddlers pull their ears too.

How it is diagnosed

By looking in the ear with an otoscope. A true infection shows a bulging, opaque, often red eardrum, sometimes with fluid visible behind it or discharge in the canal. A slightly pink eardrum in a crying, feverish child is not enough; screaming reddens the eardrum, and so does a cold. This distinction matters because it separates the children who might benefit from antibiotics from those who will not.

Most ear infections get better on their own

This is the key fact. In children over 2 with a mild to moderate infection, about 60% are pain-free within 24 hours and the majority have recovered within 3 days without antibiotics. Antibiotics shorten the illness only slightly for most children, and cause diarrhoea, rash or vomiting in a proportion of those who take them. They also contribute to antibiotic resistance, which is why guidance from the Ministry of Health’s Agency for Care Effectiveness, NICE and paediatric bodies worldwide has moved to a selective approach: pain relief for everyone, and antibiotics for the children most likely to benefit.

Pain relief comes first

Whatever else is decided, the first 48 hours are about controlling pain:

• Paracetamol or ibuprofen, given regularly rather than only when the child is already screaming, for the first day or two. Doses are by weight; we write the exact millilitres for your child. Ibuprofen is often particularly effective for ear pain, if your child is over 6 months and drinking well.
• Keep the child upright where possible; propping the head of the cot or mattress slightly can help older children sleep.
• A warm compress against the ear soothes some children.
• Decongestants, antihistamines and “cold and flu” syrups do not help ear infections and are not recommended for young children.
• Ear drops with a local anaesthetic offer limited, short-lived relief and cannot be used if the eardrum has burst. Antibiotic ear drops do not reach the middle ear and are not a treatment for AOM (they are used for swimmer’s ear, and for discharge through a grommet).

When antibiotics are given straight away

Following NICE guidance (NG91) and international paediatric guidelines, we usually prescribe antibiotics immediately when:

• The child is under 2 years old and has an infection in both ears
• There is discharge from the ear (a burst eardrum)
• The child is very unwell: high fever, marked pain, vomiting, or looking systemically ill
• The child is at higher risk of complications: a weakened immune system, a cochlear implant, Down syndrome, cleft palate, or significant other health problems
• Symptoms have already lasted several days and are worsening rather than improving

The usual antibiotic is amoxicillin for 5 to 7 days. For children with a genuine penicillin allergy we use an alternative such as clarithromycin.

When we wait, and the “back-up prescription”

For a child over 2 with a mild to moderate infection in one ear, who is otherwise well, we usually recommend pain relief and watchful waiting for 48 to 72 hours. Many parents are given a back-up (delayed) prescription: an antibiotic prescription to collect or start only if the child is no better after 2 to 3 days, or gets worse at any point. In practice most of these prescriptions are never used, and the child recovers just as well.

If you would rather not wait, or you are worried, say so; this is a shared decision, not a rule.

Glue ear: fluid that lingers

After an ear infection, fluid often stays behind the eardrum for weeks. This is called otitis media with effusion, or glue ear. It is not painful and is not an infection, but it muffles hearing while it is there. In about 4 children in 10 it is still present a month later, and in 1 in 10 at 3 months. Most clear on their own.

Signs to look for: turning the television up, saying “what?” a lot, not responding when called from behind, speech that seems less clear, or a preschool teacher noticing inattention. Glue ear that persists for 3 months or more, particularly if it affects both ears, speech or learning, warrants a hearing test and review by an ENT (ear, nose and throat) specialist, who may discuss grommets (tiny ventilation tubes) for a minority of children. Antibiotics, antihistamines, decongestants and steroid nasal sprays do not clear glue ear.

Recurrent ear infections

A child with 3 or more ear infections in 6 months, or 4 or more in a year, has recurrent AOM. We review the risk factors below, check that the diagnosis is genuinely AOM each time rather than a red eardrum from crying, arrange a hearing check, and refer to an ENT specialist to discuss options, which may include grommets.

Reducing the risk

• Vaccination: the pneumococcal vaccine, part of the NCIS, and the annual influenza vaccine both reduce ear infections.
• No tobacco smoke in the home or car. Smoke exposure is one of the strongest avoidable risk factors.
• Breastfeeding in the first months offers some protection.
• Feed babies upright, not lying flat with a bottle.
• Limit dummy (pacifier) use after 6 to 12 months of age.
• Hand washing and the ordinary measures that reduce colds, since most ear infections follow a cold. Attendance at large childcare groups increases exposure; this is a trade-off most families accept.

Swimmer’s ear is a different problem

Otitis externa, an infection of the ear canal itself, is common in Singapore’s swimming, humid climate. The ear is painful to touch or to pull, itchy, sometimes swollen and discharging, and the child is usually otherwise well without a cold. It is treated with antibiotic ear drops, keeping the ear dry, and pain relief, not with oral antibiotics. Do not use cotton buds inside the ear canal, which strip the protective wax and introduce infection.

Go to a children’s emergency department or call 995

• Swelling, redness or tenderness behind the ear, or the ear sticking out further than the other side (possible mastoiditis)
• A stiff neck, severe headache, repeated vomiting, or unusual drowsiness
• Weakness of one side of the face
• A high fever that is not settling with pain relief, in a child who looks very unwell
• A baby under 3 months with fever
• Sudden hearing loss, severe dizziness or unsteadiness

When to see a doctor

Come in if:

• Your child has ear pain with fever, or ear pain lasting more than 24 hours despite pain relief
• Your baby is under 6 months with symptoms that suggest an ear infection
• There is discharge from the ear
• Your child is no better after 2 to 3 days of watchful waiting, or gets worse at any point
• You have started a back-up antibiotic and things are not improving after 48 hours
• You are concerned about your child’s hearing, speech or attention, or a cold seems to have left them “not hearing properly” for more than a few weeks
• Your child has had 3 or more ear infections in 6 months
• Ear pain is triggered by swimming, or the ear is painful to touch

How we manage ear infections at our Punggol clinic

Children with ear pain are seen as walk-ins, Monday to Saturday, and can be booked online. At the visit:

• A proper look at both eardrums with an otoscope, and an examination of the throat, chest and glands to look for other causes of fever and distress. Where wax blocks the view, we clear it.
• A pain relief plan with doses written for your child’s weight, timed regularly for the first 48 hours.
• A shared decision on antibiotics: immediate, back-up, or none, based on your child’s age, how many ears are affected, discharge, and how unwell they are. If we give a back-up prescription, we explain exactly when to use it.
• A review if your child is not improving, and a hearing follow-up a few weeks after the infection in younger children or where glue ear is suspected.
• Referral to an ENT specialist for recurrent infections, persistent glue ear with hearing concerns, a perforation that has not healed, or any complication, with a letter that saves repeating the history.

Cross-links

• Colds, coughs and fevers in children: the illness that usually comes first
• Fever in children: comfort measures and dosing by weight
• Childhood vaccinations (NCIS): pneumococcal and influenza vaccines
• Minor procedures and ear care: ear wax removal at Punggol

Get in touch

Punggol: 658 Punggol East, #01-04, Singapore 820658 · Tel 6312 4589 · Walk-ins welcome Mon–Sat

Joo Chiat: 172 Joo Chiat Road, #01-01, Singapore 427443 · Tel 6920 1952 · By appointment

Email: admin@ktmc.sg

References

• National Institute for Health and Care Excellence (NICE). Otitis media (acute): antimicrobial prescribing. NICE guideline NG91. 2018, updated 2022. nice.org.uk
• National Institute for Health and Care Excellence (NICE). Otitis media with effusion in under 12s. NICE guideline NG233. 2023.
• Agency for Care Effectiveness (ACE). Upper respiratory tract infections: rational antimicrobial use. ACE Clinical Guideline, Ministry of Health, Singapore. May 2026.
• Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. American Academy of Pediatrics clinical practice guideline. Pediatrics. 2013;131(3):e964–e999.
• Venekamp RP, Sanders SL, Glasziou PP, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2023;(11):CD000219.
• HealthHub, Ministry of Health Singapore. Ear infections in children. healthhub.sg
• KK Women’s and Children’s Hospital (KKH). Otitis media and Glue ear, patient information. kkh.com.sg

This information is for general education only and is not a substitute for medical advice. Whether a child needs antibiotics depends on examination findings; please have your child seen. v1.0 · September 2026 · Review due September 2028.