Ear infections show up in nearly every family with young children. They cause real pain, wreck nights of sleep, and account for a huge slice of GP appointments and antibiotic prescriptions in the under-5s. The way we manage them has changed noticeably over the past 20 years as evidence has accumulated on which children genuinely benefit from antibiotics and which would do just as well with pain relief and a few days. The short version: most resolve on their own, pain control matters more than antibiotics, and a small but specific group of children need prompt treatment. For more on common childhood illnesses, visit Healthbooq.
What Otitis Media Is
Acute otitis media (AOM) is an infection of the middle ear — the small air-filled space behind the eardrum. It is almost always set off by a viral cold. The virus inflames the lining of the Eustachian tube, the tiny channel that connects the middle ear to the back of the throat. Drainage stalls, fluid collects behind the eardrum, and bacteria — typically Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis — move in.
Young children are especially prone because their Eustachian tubes are shorter, flatter, and floppier than in adults. Peak incidence sits between 6 and 24 months. The classic presentation is earache (often worse at night, when lying flat increases middle ear pressure), fever, and a child who has been off-colour for a couple of days after a cold. Pre-verbal children may pull at their ear, but on its own that sign is unreliable — plenty of babies handle their ears for entirely benign reasons.
Antibiotics: The Case for Watchful Waiting
The biggest shift in clinical guidance over the past two decades has been moving away from automatic antibiotics for AOM. The Cochrane systematic review by Venekamp and colleagues, drawing on multiple trials, found that in children over 2 with mild-to-moderate AOM most cases resolved without antibiotics, and that antibiotics shortened symptoms only modestly while clearly increasing side effects (diarrhoea, rash, vomiting). The number needed to treat to prevent one ongoing case at day 7 is around 20; the number needed to harm with side effects is much lower.
NICE guideline NG91 supports a watchful-waiting approach for most children with AOM: pain relief with paracetamol or ibuprofen for 2 to 3 days, with antibiotics added only if symptoms worsen or fail to improve. A delayed prescription — picked up at the pharmacy only if the child is not better after 48 to 72 hours — is the practical compromise many GPs use, and it cuts antibiotic use without worsening outcomes.
Antibiotics are recommended immediately for: children under 2 (especially with infection in both ears), any child with severe symptoms or high fever, any child with ear discharge (which signals a perforated eardrum), children who are systemically unwell, and any child not improving after 48 to 72 hours. Amoxicillin is the first-line choice; alternatives are used where there is a penicillin allergy.
Glue Ear (Otitis Media with Effusion)
Glue ear is a different condition. The middle ear fills with thick, sticky fluid, but it is not actively infected — there is no pain, no fever. Around 80% of children have at least one episode by age 4. The problem is hearing: sound cannot pass cleanly through a fluid-filled middle ear, producing a mild-to-moderate conductive hearing loss of around 25 to 30 dB — roughly what you experience with your fingers in your ears.
In a young child this matters because hearing drives speech and language acquisition. Persistent bilateral glue ear during the second and third year can cause language delay. Children with glue ear may seem to mishear, not respond when called from another room, turn the TV up, or speak unclearly.
Most glue ear resolves on its own — typically within 3 months for a single episode. NICE NG91 recommends a 3-month watchful-waiting period, with formal hearing testing, before considering surgery. Grommets — small ventilation tubes inserted in the eardrum under general anaesthetic — are recommended when glue ear is persistent, bilateral, and associated with significant hearing loss affecting speech, language, or quality of life. The TARGET trial run by Mark Haggard at the MRC Institute of Hearing Research provided much of the UK evidence base for who benefits from grommets and who does just as well with watchful waiting. Hearing aids are an alternative for children where surgery is not the right fit, decided in consultation with audiology and ENT.
When to Seek Urgent Care
Most ear infections can wait for a routine GP appointment. Seek same-day advice if your child is under 3 months with a fever of 38°C or above, has swelling or redness behind the ear (a possible sign of mastoiditis), is unusually drowsy, has a stiff neck or non-blanching rash, is breathing fast, or has had ear pain and fever for more than 72 hours without improvement.
Key Takeaways
Ear infections (otitis media) are among the most common infections in young children. Most cases of acute otitis media resolve without antibiotics — for children over 2 with mild-to-moderate illness, 48 to 72 hours of watchful waiting reduces antibiotic use without worsening outcomes. Antibiotics are recommended for under-2s, severe illness, or no improvement at 48 to 72 hours. Glue ear is a common cause of mild conductive hearing loss; most cases resolve within 3 months, and grommets are considered when it persists with significant hearing impact.
