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

Every year, over 5 million children in the U.S. get ear infections. It’s one of the most common reasons parents bring their kids to the doctor. But here’s the thing: ear infections in children don’t always need antibiotics. And sometimes, tubes aren’t the answer either. Knowing when to treat, when to wait, and when to intervene can make all the difference for your child’s health - and help fight antibiotic resistance.

What Exactly Is an Ear Infection?

An ear infection in kids, called acute otitis media (AOM), isn’t just an earache. It’s a sudden infection behind the eardrum, with fluid buildup and signs of inflammation - like a red, bulging eardrum or pus draining from the ear. It’s most common between 6 and 24 months old, and by age 3, 83% of kids have had at least one.

Not every ear pain means infection. Viruses often cause ear discomfort that clears up on its own. Doctors diagnose AOM only when three things are present: sudden onset of symptoms, fluid trapped behind the eardrum, and clear signs of inflammation. If your child has a fever, tugs at their ear, cries nonstop, or won’t lie down, it could be AOM. But symptoms alone aren’t enough - a doctor needs to look inside the ear with an otoscope to confirm.

When Antibiotics Are Necessary

Antibiotics aren’t always the right first step. But they’re essential in some cases. The American Academy of Pediatrics says children under 6 months old with an ear infection always need antibiotics. Their immune systems aren’t strong enough to fight it off alone.

For kids 6 to 23 months with infection in both ears, antibiotics are strongly recommended. Studies show 95% of these children benefit from treatment. Same goes for any child with a fever over 102.2°F, ear pain lasting more than 48 hours, or pus draining from the ear - these are signs of a severe infection.

The first-line antibiotic is high-dose amoxicillin: 80-90 mg per kilogram of body weight per day, split into two doses. For kids under 2, it’s a full 10-day course. For older kids with mild symptoms, it can be shortened to 5-7 days. If your child is allergic to penicillin, alternatives like cefdinir, ceftriaxone, or clindamycin are used.

But here’s the catch: antibiotics don’t work for every ear infection. About 60-80% of cases clear up on their own within a few days. That’s why watchful waiting is now standard for many kids.

Watchful Waiting: The Smart Alternative

Watchful waiting isn’t ignoring the problem - it’s a science-backed strategy. If your child is over 2 years old and has mild symptoms in one or both ears, you can wait 48 to 72 hours before starting antibiotics. During that time, focus on pain relief.

Acetaminophen or ibuprofen are the go-to options. Give acetaminophen at 10-15 mg per kg every 4-6 hours, or ibuprofen at 5-10 mg per kg every 6 hours for kids over 6 months. Studies show 69% of kids with ear infections have serious pain, but only 37% actually get proper pain meds. Don’t skip this step.

According to CDC data, only about one-third of kids who start with watchful waiting end up needing antibiotics. Most improve within 24-48 hours. Safety-net prescriptions are key: your doctor gives you the antibiotic script but tells you to fill it only if symptoms don’t improve or get worse. This reduces unnecessary use without risking complications.

Watchful waiting works best for children 6-23 months with mild, one-sided infections - and for any child over 24 months with mild symptoms, whether it’s one or both ears. But if your child gets worse, develops a high fever, or stops eating or sleeping, don’t wait. Call the doctor.

When Are Tubes the Answer?

Tympanostomy tubes - tiny plastic tubes inserted through the eardrum - are often thought of as a fix-all for recurring ear infections. But they’re not for every kid.

The guidelines say tubes are recommended only when a child has:

• Three or more ear infections in six months, or
• Four or more in a year, with at least one in the last six months.

There’s another important reason: persistent fluid behind the eardrum for three months or longer and documented hearing loss of 40 decibels or more. That’s the level where speech and learning can be affected. If your child is constantly pulling at their ears but hearing fine, tubes probably aren’t needed.

Each year, about 667,000 children in the U.S. get tubes. The procedure is quick, done under light anesthesia, and tubes usually fall out on their own in 6 to 18 months. They reduce infections by about half in the first six months after insertion. But after that, the benefit fades. And they don’t prevent all future infections.

Some experts warn tubes are overused. Dr. Charles Bluestone, a leading pediatric ear specialist, says many kids get tubes for simple recurrent infections without hearing loss - and that’s not what the evidence supports. Tubes are meant for kids whose hearing or development is at risk, not just those who get frequent infections.

Pain Management Is Non-Negotiable

No matter which path you choose - antibiotics, watchful waiting, or tubes - pain relief is the most important part of treatment. Ear infections hurt. A lot.

Studies show kids with AOM often have pain levels comparable to a broken bone. Yet, too many parents wait too long to give medicine. Don’t. Start acetaminophen or ibuprofen as soon as you suspect an infection. Keep giving it on schedule, even if your child seems better. Pain can linger even after the infection starts to clear.

And skip the decongestants and antihistamines. The CDC says they don’t help ear infections - and they can cause side effects like drowsiness, irritability, or even dangerous reactions in young kids. Same goes for home remedies like garlic oil or warm compresses alone. They might feel soothing, but they don’t treat the infection.

Why Overusing Antibiotics Matters

Every time antibiotics are used when they’re not needed, it increases the chance of antibiotic-resistant bacteria. In the U.S., inappropriate prescribing for ear infections contributes to nearly 3 million antibiotic-resistant infections every year.

That means next time your child gets sick - maybe with pneumonia, a sinus infection, or a urinary tract infection - the usual antibiotics might not work. That’s not theoretical. It’s happening right now.

Since 2000, watchful waiting has cut antibiotic use for ear infections by 35%. In 1995, 95% of ear infection visits led to an antibiotic prescription. By 2022, that number dropped to 61%. That’s progress. But in some states, it’s still over 80%. Why? Parental pressure, rushed appointments, and uncertainty about diagnosis.

Doctors who use decision aids, automated EHR reminders, and safety-net prescriptions see 22-29% fewer inappropriate antibiotic uses. If your doctor offers a wait-and-see script, take it. It’s not a delay - it’s a smarter approach.

What’s Changing in the Guidelines?

The current guidelines from the AAP (2013) are being updated, with new recommendations expected in 2024. The draft changes are tightening the rules even more:

• Tubes will only be recommended if there’s documented hearing loss - not just frequent infections.
• Watchful waiting may be expanded to include some children with bilateral infections if they’re over 2 years and have mild symptoms.
• Antibiotic duration for older kids may be shortened further.

And vaccines are helping. Since the pneumococcal vaccine (PCV13) became routine in 2010, ear infection rates have dropped 12%, and recurrent infections are down 20%. That’s a big win.

What Should You Do?

If your child has an ear infection, here’s your simple action plan:

1. Don’t panic. Most ear infections aren’t emergencies.
2. Give pain relief - acetaminophen or ibuprofen - right away.
3. Ask your doctor: Is this severe? Is it in one or both ears? How old is my child?
4. If symptoms are mild and your child is over 2, ask about watchful waiting with a safety-net antibiotic.
5. If your child is under 6 months, has a high fever, or has pus draining, antibiotics are needed.
6. If infections keep coming back, ask about hearing tests - not just tubes.

It’s okay to want to fix it fast. But sometimes, the best thing you can do is wait - and make your child comfortable while their body heals.