Understanding Middle Ear Infections in Children

Cross section of child's ear showing fluid in middle ear.

Middle ear infections are most common in children under age 5. Crankiness, a fever, and tugging at or rubbing the ear may all be signs that your child has a middle ear infection. This is especially true if your child has a cold or other viral illness. It's important to call your healthcare provider if you see these or any of the signs listed below.

Call your child's healthcare provider if you notice any signs of a middle ear infection.

What are middle ear infections?

Middle ear infections occur behind the eardrum. The eardrum is the thin sheet of tissue that passes sound waves between the outer and middle ear. These infections are usually caused by bacteria or viruses. These are often related to a recent cold or allergy problem.

A blocked tube

In young children, these bacteria or viruses likely reach the middle ear by traveling the short length of the eustachian tube from the back of the nose. Once in the middle ear, they multiply and spread. This irritates delicate tissues lining the middle ear and eustachian tube. If the tube lining swells enough to block off the tube, air pressure drops in the middle ear. This pulls the eardrum inward, making it stiffer and less able to transmit sound.

Fluid buildup causes pain

Once the eustachian tube swells shut, moisture can’t drain from the middle ear. Fluid that should flush out the infection builds up in the chamber. This may raise pressure behind the eardrum. This can decrease pain slightly. But if the infection spreads to this fluid, pressure behind the eardrum goes way up. The eardrum is forced outward. It becomes painful, and may break.

Chronic fluid affects hearing

If the eardrum doesn’t break and the tube remains blocked, the fluid becomes an ongoing (chronic) condition. As the immediate (acute) infection passes, the middle ear fluid thickens. It becomes sticky and takes up less space. Pressure drops in the middle ear once more. Inward suction stiffens the eardrum. This affects hearing. If the fluid is not removed, the eardrum may be stretched and damaged.

Signs of middle ear problems

  • A fever over 100.4°F (38.0°C) and cold symptoms

  • Severe ear pain

  • Any kind of discharge from the ear

  • Ear pain that gets worse or doesn’t go away after a few days

When to call your child's healthcare provider

Call your child's healthcare provider's office if your otherwise healthy child has any of the signs or symptoms described below:

  • Fever (see Fever and children, below)

  • Your child has had a seizure caused by the fever

  • Rapid breathing or shortness of breath

  • A stiff neck or headache

  • Trouble swallowing

  • Your child acts ill after the fever is gone

  • Persistent brown, green, or bloody mucus

  • Signs of dehydration. These include severe thirst, dark yellow urine, infrequent urination, dull or sunken eyes, dry skin, and dry or cracked lips.

  • Your child still doesn't look or act right to you, even after taking a non-aspirin pain reliever

Fever and children

Always use a digital thermometer to check your child’s temperature. Never use a mercury thermometer.

For infants and toddlers, be sure to use a rectal thermometer correctly. A rectal thermometer may accidentally poke a hole in (perforate) the rectum. It may also pass on germs from the stool. Always follow the product maker’s directions for proper use. If you don’t feel comfortable taking a rectal temperature, use another method. When you talk to your child’s healthcare provider, tell him or her which method you used to take your child’s temperature.

Here are guidelines for fever temperature. Ear temperatures aren’t accurate before 6 months of age. Don’t take an oral temperature until your child is at least 4 years old.

Infant under 3 months old:

  • Ask your child’s healthcare provider how you should take the temperature.

  • Rectal or forehead (temporal artery) temperature of 100.4°F (38°C) or higher, or as directed by the provider

  • Armpit temperature of 99°F (37.2°C) or higher, or as directed by the provider

Child age 3 to 36 months:

  • Rectal, forehead (temporal artery), or ear temperature of 102°F (38.9°C) or higher, or as directed by the provider

  • Armpit temperature of 101°F (38.3°C) or higher, or as directed by the provider

Child of any age:

  • Repeated temperature of 104°F (40°C) or higher, or as directed by the provider

  • Fever that lasts more than 24 hours in a child under 2 years old. Or a fever that lasts for 3 days in a child 2 years or older.