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Ear pain in children may be a sign of an infection in the space behind the eardrum ( middle ear). Ear infections (otitis media) most commonly occur when cold symptoms, such as a runny or stuffy nose and a cough, have been present for a few days.
An ear infection may occur when the eustachian tube swells and closes and fluid accumulates in the middle ear. The combination of fluid and germs (from bacteria or viruses) creates a perfect environment for an infection. Swelling from the infection can cause pain from increased pressure on the eardrum. The pressure can cause the eardrum to rupture (perforate). A single eardrum rupture is not serious and does not cause hearing loss. Repeated ruptures may lead to hearing loss.
Middle ear infections are more common in children than in adults. Young children have short, soft, more horizontal eustachian tubes that are more easily blocked than those of older children and adults.
Ear infection is the most commonly diagnosed bacterial infection in children younger than age 7. Almost all children will have at least one ear infection by the time they are 7 years old. Most ear infections occur in babies between the ages of 6 months to 3 years. After age 7, ear problems may be related to inflammation, infection, or fluid buildup in the middle or external ear. Ear infections are more common in boys than in girls, and they most often occur in children who:
- Spend time in day care settings.
- Are bottle-fed.
- Use a pacifier.
- Live in households where parents or caregivers smoke.
- Have had a previous ear infection.
- Have problems present since birth (congenital abnormalities), such as cleft lip, cleft palate, or Down syndrome.
- Have allergies.
Fluid often remains in the middle ear (serous otitis, or middle ear effusion) after an ear infection. This may cause no symptoms, or it may cause a muffling of sound, decreased hearing, and mild discomfort. The body usually reabsorbs fluid behind the eardrum within 3 months, and hearing returns to normal. Recurrent ear infections and persistent effusion may occur in some children.
Even though ear infections are a common cause of ear pain, not all ear pain means an infection. Other common causes of apparent ear pain in young children include:
- A sore throat.
- An accumulation of earwax.
- An object in the ear.
- Air pressure changes, such as flying in an airplane.
- Fluid buildup without infection (serous otitis).
When evaluating ear pain in a child, remember that ear infections commonly occur after symptoms of a cold have been present for a few days. When other symptoms, such as fever, are present, ear pain or drainage may be less important than the other symptoms.
Ear problems caused by an injury to the ear can occur at any age. Common injuries include the following:
- A fall or a forceful, direct blow to the side of the head can burst the eardrum or damage the tiny bones in the inner ear that send sound to the brain.
- An injury during contact sports can cause an injury, such as "cauliflower" ear from wrestling.
- Loud noises or explosions can damage the eardrum (acoustic trauma).
- Atmospheric pressure changes (barotrauma) can cause problems with the eustachian tube and trap air in or keep air out of the middle ear. Middle ear problems can be severe (for example, the eardrum can burst or the middle ear can fill with blood or pus) or mild and only be felt as changes in pressure.
- Cuts or scrapes may injure the outside of the ear or ear canal. For more information, see the topic Ear Canal Problems (Swimmer's Ear).
- Cleaning the ear canal too often, too forcefully, or with a cotton swab, bobby pin, or sharp fingernail can cause irritation or injury.
- Burns or frostbite can cause ear injuries (thermal injuries).
- Objects placed in the ear can cause injury to the ear canal or the eardrum (tympanic membrane).
Check your child's symptoms to decide if and when your child should see a doctor.
Check Your Symptoms
The medical assessment of symptoms is based on the body parts you have.
- If you are transgender or nonbinary, choose the sex that matches the body parts (such as ovaries, testes, prostate, breasts, penis, or vagina) you now have in the area where you are having symptoms.
- If your symptoms aren’t related to those organs, you can choose the gender you identify with.
- If you have some organs of both sexes, you may need to go through this triage tool twice (once as "male" and once as "female"). This will make sure that the tool asks the right questions for you.
Many things can affect how your body responds to a symptom and what kind of care you may need. These include:
- Your age. Babies and older adults tend to get sicker quicker.
- Your overall health. If you have a condition such as diabetes, HIV, cancer, or heart disease, you may need to pay closer attention to certain symptoms and seek care sooner.
- Medicines you take. Certain medicines, herbal remedies, and supplements can cause symptoms or make them worse.
- Recent health events, such as surgery or injury. These kinds of events can cause symptoms afterwards or make them more serious.
- Your health habits and lifestyle, such as eating and exercise habits, smoking, alcohol or drug use, sexual history, and travel.
Try Home Treatment
You have answered all the questions. Based on your answers, you may be able to take care of this problem at home.
- Try home treatment to relieve the symptoms.
- Call your doctor if symptoms get worse or you have any concerns (for example, if symptoms are not getting better as you would expect). You may need care sooner.
Temperature varies a little depending on how you measure it. For children up to 11 years old, here are the ranges for high, moderate, and mild according to how you took the temperature.
Oral (by mouth), ear, or rectal temperature
- High: 104° F (40° C) and higher
- Moderate: 100.4° F (38° C) to 103.9° F (39.9° C)
- Mild: 100.3° F (37.9° C) and lower
A forehead (temporal) scanner is usually 0.5° F (0.3° C) to 1° F (0.6° C) lower than an oral temperature.
Armpit (axillary) temperature
- High: 103° F (39.5° C) and higher
- Moderate: 99.4° F (37.4° C) to 102.9° F (39.4° C)
- Mild: 99.3° F (37.3° C) and lower
Note: For children under 5 years old, rectal temperatures are the most accurate.
A baby that is extremely sick:
- May be limp and floppy like a rag doll.
- May not respond at all to being held, touched, or talked to.
- May be hard to wake up.
A baby that is sick (but not extremely sick):
- May be sleepier than usual.
- May not eat or drink as much as usual.
If you're not sure if a child's fever is high, moderate, or mild, think about these issues:
With a high fever:
- The child feels very hot.
- It is likely one of the highest fevers the child has ever had.
With a moderate fever:
- The child feels warm or hot.
- You are sure the child has a fever.
With a mild fever:
- The child may feel a little warm.
- You think the child might have a fever, but you're not sure.
Certain health conditions and medicines weaken the immune system's ability to fight off infection and illness. Some examples in children are:
- Diseases such as diabetes, cystic fibrosis, sickle cell disease, and congenital heart disease.
- Steroid medicines, which are used to treat a variety of conditions.
- Medicines taken after organ transplant.
- Chemotherapy and radiation therapy for cancer.
- Not having a spleen.
Symptoms of an external ear infection may include:
- Moderate to severe pain in the outer ear.
- Pain with chewing.
- Redness and swelling of the ear, ear canal, or the skin around or behind the ear.
Vertigo is the feeling that you or your surroundings are moving when there is no actual movement. It may feel like spinning, whirling, or tilting. Vertigo may make you sick to your stomach, and you may have trouble standing, walking, or keeping your balance.
Pain in children under 3 years
It can be hard to tell how much pain a baby or toddler is in.
- Severe pain (8 to 10): The pain is so bad that the baby cannot sleep, cannot get comfortable, and cries constantly no matter what you do. The baby may kick, make fists, or grimace.
- Moderate pain (5 to 7): The baby is very fussy, clings to you a lot, and may have trouble sleeping but responds when you try to comfort him or her.
- Mild pain (1 to 4): The baby is a little fussy and clings to you a little but responds when you try to comfort him or her.
Pain in children 3 years and older
- Severe pain (8 to 10): The pain is so bad that the child can't stand it for more than a few hours, can't sleep, and can't do anything else except focus on the pain. No one can tolerate severe pain for more than a few hours.
- Moderate pain (5 to 7): The pain is bad enough to disrupt the child's normal activities and sleep, but the child can tolerate it for hours or days.
- Mild pain (1 to 4): The child notices and may complain of the pain, but it is not bad enough to disrupt his or her sleep or activities.
Seek Care Today
Based on your answers, you may need care soon. The problem probably will not get better without medical care.
- Call your doctor today to discuss the symptoms and arrange for care.
- If you cannot reach your doctor or you don't have one, seek care today.
- If it is evening, watch the symptoms and seek care in the morning.
- If the symptoms get worse, seek care sooner.
Call 911 Now
Based on your answers, you need emergency care.
Call 911 or other emergency services now.
Seek Care Now
Based on your answers, you may need care right away. The problem is likely to get worse without medical care.
- Call your doctor now to discuss the symptoms and arrange for care.
- If you cannot reach your doctor or you don't have one, seek care in the next hour.
- You do not need to call an ambulance unless:
- You cannot travel safely either by driving yourself or by having someone else drive you.
- You are in an area where heavy traffic or other problems may slow you down.
Make an Appointment
Based on your answers, the problem may not improve without medical care.
- Make an appointment to see your doctor in the next 1 to 2 weeks.
- If appropriate, try home treatment while you are waiting for the appointment.
- If symptoms get worse or you have any concerns, call your doctor. You may need care sooner.
When ear discomfort or pain is mild or comes and goes and occurs without other symptoms, home treatment may be all that is needed to relieve your child's discomfort. Home treatment measures include the following:
- Encourage your child to swallow more often. The discomfort may be caused by a blocked eustachian tube that can occur with mild irritation in the ear canal. Let a child younger than age 12 months drink from a bottle or cup to try to help open the eustachian tube.
- Some babies and children who have ear pain are more comfortable in an upright position. Allow the child to rest in the position that is most comfortable.
- To relieve moderate to severe ear pain while waiting to see your doctor, or to relieve a red, swollen external ear:
- Apply heat to the ear to ease pain. Use a warm washcloth. Be careful not to burn the skin around the ear. There may be some drainage when the heat melts earwax.
- Encourage your child to rest as much as possible.
Try a nonprescription medicine to help treat your child's fever or pain:
Talk to your child's doctor before switching back and forth between doses of acetaminophen and ibuprofen. When you switch between two medicines, there is a chance your child will get too much medicine.
Be sure to follow these safety tips when you use a nonprescription medicine:
Symptoms to watch for during home treatment
Call your child's doctor if any of the following occur during home treatment:
- Your child's pain gets worse.
- Your child develops a new fever.
- New or different drainage from the ear develops.
- Your child's symptoms become more severe or more frequent.
There are many steps you can take to help prevent ear problems and injuries.
- Breastfeed your baby. Breastfed babies may have fewer ear infections.
- Avoid exposing children to cigarette smoke. Children exposed to secondhand smoke have more frequent ear infections. If you smoke and are unable to stop, smoke outside, away from your child.
- Do not put your baby to bed with a bottle.
- Do not allow your baby to hold his or her own bottle.
- When your toddler is using a bottle or sippy cup, have him or her stay seated. This can help prevent injuries that might occur if your child were to fall while walking and holding a bottle or a cup.
- Feed babies in an upright position to prevent milk from getting into the area around the eustachian tubes. Do not allow infants to fall asleep with a bottle. (Nursing babies may fall asleep at the breast.)
- Being in day care increases your child's chance of getting an ear infection, so:
- Choose a day care setting with 6 or fewer children.
- Make sure that day care workers wash their hands before and after each diaper change.
- Have day care workers wash toys often.
- Limit the use of a pacifier after age 6 months to moments when your child is falling asleep. Babies who use pacifiers after 12 months of age are more likely to get ear infections.
- Teach your children to blow their noses gently. This is a good idea for adults too. Wash your hands and teach your child to wash his or her hands after blowing. This helps prevent the spread of germs that can cause infection.
- Wash your hands before and after every diaper change and teach your child to wash his or her hands after using the toilet.
- When possible, limit your child's contact with other children who have colds.
- Try to keep soap and shampoo out of the ear canal. Soap and shampoo can cause itching, which can be mistaken for ear pain if the child is scratching or pulling at his or her ears.
- If your child has tubes in his or her ears, try to keep water from getting in the ear when your child takes a bath or a shower or goes swimming. The ear could get infected if any germs in the water get into the ear. If your doctor says it's okay, your child may use earplugs. Or your doctor may have other advice for you. He or she can tell you when the hole in the eardrum has healed and when it's okay to go back to regular water activities.
- The Haemophilus influenzae type b (Hib) vaccine prevents ear infections caused by this bacteria. Pneumococcal vaccine also prevents some ear infections in children. For more information, see the childhood immunization schedule.
- Do not insert anything, such as a cotton swab or a bobby pin, into the ear. Gently cleanse the outside of your child's ear with a warm washcloth.
Preparing For Your Appointment
To prepare for your appointment, see the topic Making the Most of Your Appointment.
If you have made an appointment with your child's doctor, you can help your doctor diagnose and treat your child's condition by being prepared to answer the following questions:
- Did your child have an injury to the ear? If so, describe when and how the injury occurred.
- When did the pain start?
- Has the pain been constant or does it come and go?
- Does anything make the pain better or worse?
- What symptoms make you think your child is having ear pain?
- Has your child ever been treated for an ear infection in the past? If so:
- How long ago was he or she treated?
- What medicine did you use?
- Did your child finish all of the medicine?
- Did you have a follow-up checkup after the medicine was finished?
- Does your child have ear tubes in place?
- Does your child have other symptoms, such as fever, a runny nose, a cough, or congestion? If so, how long have these symptoms been present?
- What immunizations has your child had?
- What home treatment measures have you used? Be sure to include nonprescription medicines you have given your child.
- Do you suspect a hearing problem? Describe the hearing problems you have noticed. How did your child respond to sounds before and after you noticed the problem?
- Does your child wear hearing aids?
- Does your child have any health risks?
Current as ofSeptember 23, 2018
Author: Healthwise Staff
Medical Review: William H. Blahd Jr. MD, FACEP - Emergency Medicine
Kathleen Romito MD - Family Medicine
Adam Husney MD - Family Medicine