Ear infections in children usually come in the middle of a cold, as sudden pain in the evening or at night, often with a fever. Pain relief is the most important thing in the first day or two. Under Swedish guidelines, children between one and twelve who otherwise feel well can wait two to three days without antibiotics, because most infections heal on their own. Children under one, children who are generally unwell and children with discharge from the ear should be assessed by a doctor.
Tuesday evening, day four of a cold. The one-year-old who fell asleep at seven wakes at eleven screaming in a way you don't recognise, can't be comforted, won't lie down. That is how ear infections usually show themselves in small children. It really hurts, but it is rarely dangerous, and there is a clear order for what you do. Here it is.
Signs of an ear infection
- Sudden worsening in the middle of a cold, often in the evening or at night. The child who was on the mend gets a new fever and becomes inconsolable.
- Pain. Older children point at the ear. Small children cry, pull at the ear, won't lie down, feed or drink less because sucking hurts.
- Fever, not always, but common.
- Discharge from the ear. That means the eardrum has burst from the pressure. It sounds bad but usually makes the pain let go, and it heals. Healthcare does want to take a look at it, though.
- Reduced hearing for a few weeks afterwards, from fluid left behind the eardrum. Your child doesn't hear when you call from the kitchen. It passes, but if it lasts more than three months it should be checked.
Pain relief first
On the first day it is the pain, not the infection, that is the problem. Painkillers for children are available over the counter. Follow the instructions on the packet for age and weight, and ask the pharmacy or 1177 (the national healthcare helpline) if you are unsure what suits your child. Give it well before bedtime, not when your child is already screaming. Raising the head end of the bed helps some, and many children want to sit up on your lap. Saline drops in the nose can ease the pressure by clearing the nose. Warmth against the ear, a lukewarm towel, feels soothing to some children but makes no difference to healing.
Antibiotics or not?
| Antibiotics usually recommended | Wait with pain relief, usually |
|---|---|
| Children under one | Children aged one to twelve who are fine between the peaks of pain |
| Discharge from the ear | No discharge, nothing running |
| Your child is generally unwell: lethargic, not drinking | Your child plays, drinks and sleeps with pain relief |
| Infection in both ears in small children | One ear |
| No improvement after two to three days | Clearly better after one to two days |
It can feel wrong to go home without a prescription when your child has screamed all night. But antibiotics shorten the pain by less than a day on average, often cause loose stools and contribute to resistance. What decides is your child's condition, not how much you slept. If your child is given antibiotics: give the whole course, even when your child is bright again after two days.
When to seek care
| Seek care | Wait at home with pain relief |
|---|---|
| A child under one with a suspected ear infection | A child over one with pain that is eased by painkillers |
| Discharge from the ear | No discharge |
| Lethargic, hard to engage, not drinking | Tired but bright between the peaks of pain |
| Red, swollen and tender behind the ear, or the ear sticking out: emergency | Pain only inside the ear |
| Stiff neck, high fever and a very unwell child: call 112 | Fever that responds to pain relief |
| No improvement after two to three days | Better on day two |
Förskola and everyday life afterwards
Ear infections are not contagious. Your child goes back to förskola (municipal preschool, from age one) once they are free of fever and up to joining in, which is often within a couple of days. Fluid behind the eardrum can mean your child hears less well for a few weeks, so speak close up and face your child. If there is discharge from the ear, hold off on baths and swimming lessons until it has stopped. After repeated infections, the vårdcentral (local health centre) can refer you to an ear specialist to assess grommets (tubes in the eardrum), which help many children who get a lot of infections.
One more thing about the nights: an ear infection hurts most when your child lies down, so expect the first nights to be short whatever you do. Take turns, bring your child onto the sofa in a half-sitting position and give pain relief as per the packet in good time before the next peak. It gets better, usually by the following night.
Can it be prevented?
- Breastfeeding for the first six months gives some protection.
- A smoke-free environment, including smoke-free clothes. Children in homes where someone smokes get more ear infections.
- The dummy in moderation. Heavy dummy use in the daytime after age one is linked to more infections.
- Saline in the nose with every cold, to keep the nose clear.
- Vaccinations according to the BVC schedule. The pneumococcal vaccine that is included protects against some of the bacteria that cause ear infections. BVC is the child health clinic every family is enrolled in.
How we do it with our families
Doaa looks after a one-year-old two evenings a week, and one evening in February she noticed that he, who always falls asleep easily, refused to lie down, pulled at his left ear and cried differently. She rang the parents straight away, comforted him sitting up and wrote the time and the signs on the note. The parents called 1177 and got advice on pain relief and an appointment for the next day. That is the point of a nanny who knows the child: she hears the difference between tired and in pain.
This text is general information and does not replace advice from BVC, your vårdcentral or 1177. If you are worried about your child, call 1177. In an emergency, call 112.
Would you like a nanny who knows your child, knows what is usual for them and notices when something is different? Book a free first meeting with the nanny at your home.
Read more: Colds in children · Fever in children · Laboured breathing while your child sleeps · FAQ
Frequently asked questions
How do we know our child has an ear infection?
Your child has a cold, suddenly gets worse, is in pain, cries at night and wants to lie on one side. Older children say their ear hurts; small children pull at the ear or are inconsolable. Fever is common. Sometimes there is discharge from the ear, which means the eardrum has burst, and that usually makes the pain let go.
Does my child have to have antibiotics?
Not always. Under Swedish recommendations, children between one and twelve with an uncomplicated ear infection and a good general condition can wait two to three days with pain relief, because most heal by themselves. Children under one, children with discharge from the ear and children who are generally unwell should be assessed by a doctor and are more often given antibiotics.
Can my child go to förskola?
Yes, once they are free of fever and up to taking part. The ear infection itself is not contagious; it is the cold that spreads. Many children feel fine the day after the pain has let go. Tell the staff that your child may hear less well for a few weeks, so they speak close up and face the child.
Can my child swim and fly?
Swimming is fine as long as the eardrum hasn't burst. If there is discharge from the ear, hold off on swimming until it has stopped. Flying can hurt when the pressure changes, and a recently healed ear infection is a reason to ask healthcare before a trip.
Why do some children get so many ear infections?
Small children's Eustachian tubes are short and lie horizontally, so fluid stays behind more easily. Children who started förskola early, have siblings or live in a home where someone smokes get more. Most grow out of it around three to four. With many infections in a short time, your child may need to be assessed for grommets.