The most reliable signs of an infant ear infection are sudden fussiness or night waking after a cold, a fever of 100.4°F or higher, low appetite, and fluid draining from the ear. Ear-pulling alone is usually teething. A pediatrician's guide to spotting, treating, and knowing when watchful waiting is the right call.
Medically Reviewed by: Dr. Melissa Tribuzio, MD, Board-Certified Pediatrician
Last Reviewed: May 2026
In infants, the most common signs of an ear infection are sudden fussiness or night waking after a cold, a fever of 100.4°F or higher, ear-pulling combined with other symptoms, a drop in appetite, and sometimes fluid leaking from the ear. Ear-pulling alone is more often teething or self-soothing. A pediatrician's otoscope exam is what confirms the diagnosis.
The eustachian tube, which connects the middle ear to the back of the nose, is shorter and more horizontal in infants. Fluid and germs from the nose travel into the middle ear more easily during a cold. If germs multiply in fluid trapped behind the eardrum, you get acute otitis media (AOM).
Ear infections become more common after about 6 months and peak between 6 and 24 months. Daycare attendance, secondhand smoke, supine bottle feeding, and heavy pacifier use after 6 months raise the risk.
Babies cannot tell you their ear hurts. No single symptom is diagnostic — a cluster of symptoms after a recent cold is what raises the suspicion.
Common parent-observable signs include:
A study of 469 children aged 6–35 months whose parents suspected an ear infection found that ear-rubbing was not associated with actually having one. The authors concluded that an otoscope exam is essential because symptoms alone cannot predict it. Rule of thumb: ear-pulling on a happy, feeding, sleeping baby is almost always teething. Ear-pulling plus fever plus night waking after a recent cold is what should prompt a pediatrician's exam.
| Condition | Tells You It Might Be Ear Infection | Tells You It's Probably NOT | What to Do |
|---|---|---|---|
| Teething | Mild fussiness, drooling, ear-rubbing | No fever ≥100.4°F, no recent cold, no diarrhea | Comfort measures; recheck if symptoms escalate |
| Cold (viral URI) | Runny nose, cough, low-grade fever, mild fussiness | Symptoms peaking and improving by day 3–5 | Hydration, rest; call if worsening after day 3 |
| Colic | Intense crying episodes, often evenings, in babies <4 months | No fever, no recent cold, predictable pattern | Soothing techniques; talk to your pediatrician if new or escalating |
Not sure if it's an ear infection? Start a Blueberry virtual visit — our pediatricians can guide next steps 24/7.
Call your pediatrician today (or use a telehealth visit) if your baby has:
Go to the emergency department, or call 911, for:
A pediatrician confirms an ear infection by looking inside the ear canal with an otoscope. A healthy eardrum looks pearly gray and translucent and moves when a small puff of air is delivered. An infected eardrum is bulging outward, opaque or yellow-white, and doesn't move normally.
The current AAP guideline requires one of two findings to diagnose AOM: a moderately or severely bulging eardrum, or new fluid draining from the ear canal that is not from external otitis. Redness alone is not enough — that precise definition prevents over-diagnosis.
Not sure if it's an ear infection? Start a Blueberry virtual visit — our pediatricians can guide next steps 24/7.
Treatment depends on age, whether one or both ears are involved, and severity. The matrix below summarizes the AAP 2013 guideline (still current in 2026). It applies to babies 6 months and older. Infants under 6 months with possible AOM should always be seen in person.
| Baby's Situation | What the AAP Recommends | First-Line Antibiotic | Course Length |
|---|---|---|---|
| Under 6 months, suspected AOM | Always seen in person; antibiotics if AOM confirmed | High-dose amoxicillin (80–90 mg/kg/day) | 10 days |
| 6–23 months, one ear, mild symptoms | Antibiotics OR watchful waiting (48–72 hr) if AOM confirmed | High-dose amoxicillin if treating | 10 days |
| 6–23 months, both ears, severe, or with ear drainage | Antibiotics right away | High-dose amoxicillin (or amoxicillin-clavulanate if recent amoxicillin, pink-eye, or treatment failure) | 10 days |
Watchful waiting means delaying antibiotics for 48–72 hours while treating pain and fever at home, starting antibiotics only if your baby is not improving. It is not "do nothing" — it comes with a safety net (a scheduled re-check, or a "safety-net antibiotic prescription" to fill only if your baby isn't improving in 48–72 hours).
This is reasonable when all of these are true: your baby is at least 6 months old, only one ear is involved (or your baby is 24 months or older), symptoms are mild, there is no ear drainage, and your pediatrician can re-check within 48–72 hours. Research shows that most untreated ear infections improve on their own within 4 to 7 days.
Antibiotics are recommended right away for babies 6–23 months with both ears infected, any baby with fluid draining from the ear (an infection has ruptured the eardrum), any baby with severe symptoms (moderate-to-severe pain, pain lasting 48 hours or longer, or fever of 102.2°F or higher), and any infant under 6 months with a confirmed ear infection.
The first-line antibiotic is high-dose amoxicillin (typically 80–90 mg/kg/day, split into two doses). For babies under 2 and for severe infections at any age, the course is 10 days. Amoxicillin-clavulanate (Augmentin) is used if your baby took amoxicillin in the past 30 days, has pink-eye, or didn't respond to a recent course. For penicillin allergy, your pediatrician will choose cefdinir, cefuroxime, cefpodoxime, or a ceftriaxone shot.
The AAP tells pediatricians to assess and treat pain in every ear infection, whether or not antibiotics are prescribed.
With or without antibiotics, most babies feel meaningfully better within 2–3 days. By days 4–7, the large majority of untreated infections have also improved. Antibiotics could speed recovery for the babies who would otherwise stay sick longer. Fluid behind the eardrum can linger for weeks after the infection clears — this is otitis media with effusion (OME) and usually doesn't need treatment. Call back if your baby is not noticeably better after 48–72 hours, develops a higher fever, becomes more lethargic, or has new drainage.
Recurrent ear infections are formally defined as 3 or more well-documented episodes in 6 months, or 4 or more in 12 months with at least one in the last 6. If your baby meets that bar, your pediatrician may refer you to an ENT to discuss tympanostomy tubes. The current ENT guideline (AAO-HNS 2022) does NOT recommend tubes for babies who meet the recurrent count but whose ears are dry at the visit. Tubes are more strongly considered when there is also persistent fluid for 3 months or more with hearing loss, or in babies with cleft palate, Down syndrome, or developmental delay.
A general virtual visit can take a focused history, assess severity, triage urgency, spot red flags like mastoiditis, counsel on pain and fever management, refer for in-person otoscopy when confirmation would change management, and follow up after a diagnosis is made.
Most virtual visits cannot confirm an ear infection without a view of the eardrum, and the AAP discourages sight-unseen prescribing on symptoms alone. Blueberry Pediatrics is the exception: our membership includes a home exam kit, so your pediatrician can examine the eardrum during the video visit and only prescribes antibiotics after a confirmed diagnosis.
Not sure if it's an ear infection? Start a Blueberry virtual visit — our pediatricians can guide next steps 24/7.
Treatment depends on age and severity. The AAP recommends antibiotics — most often amoxicillin — for babies under 2 with both ears infected, severe symptoms, or ear drainage. For some milder cases, watchful waiting with pain control and a 48-to-72-hour follow-up is appropriate. Acetaminophen (or ibuprofen for babies 6 months and older) helps with pain and fever.
You can manage pain and fever with acetaminophen, or ibuprofen if your baby is 6 months or older. But ear infections in infants should always be evaluated by a pediatrician. Avoid OTC oral benzocaine teething gels in children under 2 (per FDA), benzocaine-containing ear drops at any age, and decongestants or antihistamines in babies and toddlers.
On an otoscope exam, an acute ear infection shows an eardrum that is bulging outward and looks opaque or yellow-white. New drainage in the ear canal is another diagnostic sign. The eardrum doesn't move normally when a small puff of air is applied.
Ear infections are uncommon in the first weeks of life but become more frequent after about 6 months and peak between 6 and 24 months. Any fever in a baby under 3 months needs urgent in-person evaluation.
Teething can cause mild fussiness, drooling, gum-rubbing, and even ear-rubbing. But teething does NOT cause fever of 100.4°F or higher, diarrhea, or significant respiratory symptoms — an explicit AAP position. If your baby is pulling at the ear AND has a fever or recent cold, don't blame teething.
A general virtual visit can take a focused history, assess severity, identify red flags, counsel on pain and fever management, and guide whether your baby needs in-person care now. Diagnosis requires a direct look at the eardrum, so most virtual visits alone can't confirm an ear infection. Blueberry Pediatrics is different: our membership includes a home exam kit, so your pediatrician can examine the eardrum during the video visit and triage or refer for in-person care when needed.
This article was written by the Blueberry Pediatrics content team and medically reviewed by Dr. Melissa Tribuzio, MD, Board-Certified Pediatrician. It draws on current AAP and AAO-HNS guidelines, peer-reviewed Cochrane reviews, CDC vaccine schedules, and the FDA. It is for general education only and is not a substitute for evaluation by your child's pediatrician.
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