Ear Infections in Children: When to Use Antibiotics, Tubes, or Watchful Waiting

When your child pulls at their ear, cries more than usual, or won’t sleep through the night, it’s easy to panic. Is it just a cold? Or is it an ear infection? And if it is, do they need antibiotics right away-or should you wait? These are the questions every parent faces when their child gets a middle ear infection. The truth is, most of the time, ear infections in children get better on their own. But knowing when to act-and when to hold off-is key to avoiding unnecessary antibiotics, reducing the risk of resistance, and preventing long-term hearing issues.

What Exactly Is an Ear Infection?

An acute ear infection, or acute otitis media (AOM), isn’t just fluid behind the eardrum. It’s an active infection with three clear signs: sudden onset of symptoms, fluid trapped in the middle ear (seen as a bulging or stiff eardrum), and inflammation-like redness, swelling, or pus. It’s not the same as swimmer’s ear (otitis externa), which affects the outer ear canal. AOM is most common in kids between 6 and 24 months old. By age 3, about 83% of children have had at least one. It’s the number one reason kids are given antibiotics in the U.S.-and that’s a problem.

Doctors don’t just guess. They look at the eardrum with an otoscope, check for movement, and ask about symptoms like fever, irritability, or trouble sleeping. If your child has a fever over 102.2°F (39°C), ear pain lasting more than 48 hours, or is acting very sick, it’s considered severe. Mild cases? They often clear up without drugs.

Antibiotics: When They Help-and When They Don’t

Antibiotics aren’t magic pills for ear pain. They kill bacteria, but most ear infections in kids are viral or start viral. Even when bacteria are involved, the body often handles it on its own. Studies show that 60% to 80% of ear infections improve within 24 to 48 hours without antibiotics.

So when do you actually need them?

• Children under 6 months: Always treat with antibiotics. Their immune systems aren’t strong enough to fight off infection safely.
• Children 6 to 23 months with bilateral infections: If both ears are infected, 95% benefit from antibiotics right away.
• Any child with otorrhea (pus draining from the ear): This means the eardrum has ruptured-antibiotics are necessary.
• Severe symptoms: High fever, intense pain lasting more than 48 hours, or a toxic appearance? Start antibiotics.

For kids over 2 years with mild, unilateral (one ear) infections, watchful waiting is the standard. That means no antibiotics right away. Instead, you manage the pain and watch for signs of worsening.

First-line antibiotic? High-dose amoxicillin-80 to 90 mg per kg of body weight per day, up to 3 grams daily. For kids allergic to penicillin, alternatives include cefdinir, ceftriaxone, or clindamycin. Treatment length depends on age: 10 days for under 2, 7 days for ages 2 to 5, and just 5 days for kids 6 and older with mild cases.

But here’s the catch: overuse is real. In 2022, 61% of ear infection cases still got antibiotics-down from 95% in 1995. That’s progress, but it’s still too high. Every unnecessary antibiotic increases the risk of resistant infections. The CDC estimates 2.8 million antibiotic-resistant infections happen each year in the U.S. because of overprescribing.

Watchful Waiting: The Smart, Safe Alternative

Watchful waiting isn’t ignoring the problem. It’s a planned, active approach. You give your child pain relief, monitor closely, and only use antibiotics if things don’t improve in 48 hours.

According to CDC guidelines, watchful waiting is safe for:

• Children 6 to 23 months with one infected ear and mild symptoms
• Children 24 months and older with one or both ears infected, as long as symptoms are mild

During this time, you should:

• Give acetaminophen or ibuprofen every 4 to 6 hours (as needed) to control pain and fever
• Keep your child hydrated
• Watch for worsening: fever over 102.2°F, pain lasting beyond 48 hours, or pus draining from the ear

Studies show that only about 33% of kids in watchful waiting programs end up needing antibiotics. Most feel better within two days. And crucially, there’s no increase in complications like hearing loss or serious infections.

Doctors often give a “safety-net” prescription-meaning you get the antibiotic, but you’re told to fill it only if symptoms don’t improve. This reduces pressure on parents and doctors alike. One study found that using safety-net prescriptions increased appropriate antibiotic use by 22%.

Tympanostomy Tubes: For Recurrent or Persistent Cases

Some kids keep getting ear infections. If your child has had three infections in six months-or four in a year, with at least one in the last six months-your doctor might talk about tubes.

Tympanostomy tubes are tiny plastic or metal cylinders placed through the eardrum during a quick outpatient surgery. They let air into the middle ear, stop fluid from building up, and reduce infection risk. Tubes usually stay in for 6 to 18 months and fall out on their own.

They’re not for every kid who gets an ear infection. The American Academy of Pediatrics says tubes are only recommended when:

• Recurrent infections meet the above criteria
• Fluid stays in the ear for 3 months or longer and there’s documented hearing loss (at least 40 dB)

That last part is critical. Many parents think tubes are just for frequent infections. But if hearing isn’t affected, tubes may not help-and could even cause harm. A 2016 review warned that tubes are often overused in kids without hearing loss.

Studies show tubes cut infection rates in half during the first six months after placement. But after that, the benefit fades. And there are risks: scarring of the eardrum, persistent holes, or long-term drainage.

Over 667,000 tube surgeries are done each year in U.S. children under 15-costing around $5 billion. That’s a lot of procedures. And while they help kids with persistent fluid and hearing issues, they’re not a quick fix for every ear infection.

Pain Management: The Most Important Step

No matter what path you choose-antibiotics, tubes, or watchful waiting-pain control is non-negotiable.

Research shows 69% of children with ear infections have moderate to severe pain. Yet only 37% get proper pain relief.

Here’s what works:

• Acetaminophen: 10 to 15 mg per kg every 4 to 6 hours
• Ibuprofen: 5 to 10 mg per kg every 6 hours (only for kids over 6 months)

Don’t use decongestants or antihistamines. They don’t help ear infections-and they can cause drowsiness, upset stomach, or even dangerous side effects in young kids. The CDC says they offer no benefit and may do more harm than good.

Warm compresses, keeping the head elevated, and quiet rest also help. Pain relief isn’t optional. It’s the foundation of care.

Why Do So Many Doctors Still Prescribe Antibiotics?

If the guidelines are clear, why are 61% of kids still getting antibiotics?

Three big reasons:

• Parental pressure: 41% of doctors say parents expect antibiotics, even when they’re not needed.
• Time constraints: 68% of clinicians say they don’t have time to explain watchful waiting during a rushed visit.
• Diagnostic uncertainty: 33% of cases are hard to judge-especially if the child is crying, the ear looks red, but the eardrum movement is unclear.

Practices vary wildly. One study found antibiotic prescribing rates ranged from 52% in academic hospitals to 78% in private clinics-even when the same guidelines applied.

The fix? Better tools. Clinics that use electronic health record (EHR) prompts cut inappropriate prescribing by 29%. Those that use decision aids for parents see a 22% rise in correct antibiotic use. Safety-net prescriptions are now standard in 76% of watchful waiting cases.

What’s Changing? Vaccines, Guidelines, and the Future

Things are improving. Since the pneumococcal conjugate vaccine (PCV13) became routine in 2010, ear infections have dropped by 12%, and recurrent infections by 20%. That’s a huge win.

The 2013 AAP guidelines already made watchful waiting more widely accepted. The next update, expected in 2024, will likely tighten tube criteria even further-requiring documented hearing loss in all cases before surgery.

And the goal? Healthy People 2030 wants antibiotic prescribing for ear infections down to 50%. We’re at 61% now. We’re getting closer.

But the real win isn’t just fewer antibiotics. It’s fewer kids with hearing loss, fewer surgeries, fewer resistant infections, and more parents who feel confident making the right choice.

What Should You Do Next?

If your child has an ear infection:

1. Check for fever, pain, and how long it’s lasted.
2. Give acetaminophen or ibuprofen-right away.
3. Call your doctor if symptoms are severe or if your child is under 6 months.
4. If symptoms are mild and your child is over 2, ask about watchful waiting.
5. If infections keep coming back, ask about hearing tests before considering tubes.

You don’t need to rush to antibiotics. You don’t need to panic. You just need to know the facts-and what’s best for your child’s health, not just what’s fastest.