If you are in a hurry
- Acute otitis media (a middle ear infection) is common in children after a cold; the reason is that children’s eustachian tubes are shorter and closer to horizontal
- Touching the ear, fussiness, crying at night, and fluid draining from the ear are signs of a middle ear infection
- If the skin behind the ear is red and swollen, the ear sticks out, the face does not move normally, your child is limp, the neck is stiff, or your child cannot drink at all, see a doctor even at night. For a seizure lasting 5 minutes or more, call 119 (Japan’s emergency number)
Hello. I am Shunichi Gamo, MD, PhD, a board-certified pulmonologist and the director of Sendai Airport North Clinic.
From autumn into winter, more children catch colds. A few days after a cold, your child suddenly wakes in the middle of the night crying, “My ear hurts.” A baby who cannot say so keeps crying and will not settle, touching the ear. I imagine this is a familiar night scene for families raising young children.
Let me start with the conclusion: if your child has ear pain at night but settles and sleeps after a pain reliever, in most cases seeing a doctor the next day is fine. However, if the skin behind the ear is red and swollen, the face does not move normally, your child is limp, or the neck is stiff, see a doctor even at night.
This article covers acute otitis media, the middle ear infection that is common in children. Drawing on data from research papers, I explain why it tends to follow a cold, the signs you should not miss, what to do and where to go when your child has ear pain at night, and how to prevent it.
At our fever clinic, we give you the result of the PCR test (a test that copies the virus’s genetic material to detect it) on the same day.
Since October 4, 2026, our fever clinic is also open on Sundays and public holidays
10:00 to 15:00 (no lunch break). No appointment is needed; you are seen by checking in on the day. We give you the PCR test result on the same day. On Sundays and public holidays we run the fever clinic only, with no general outpatient care or IV drips. We are closed on Sunday, October 25, and from November we are in principle open every Sunday and public holiday. Announcement about the Sunday and public holiday fever clinic
Shunichi Gamo, MD, PhD
Director, Sendai International Airport North Clinic
Born and raised locally, he attended Yuriage Elementary School and Yuriage Junior High School in Natori City. After graduating from Tohoku University School of Medicine, he worked at Sendai Open Hospital and Kesennuma City Hospital, and then at Tohoku University Hospital. In April 2021, in the middle of the COVID-19 pandemic, he opened Sendai International Airport North Clinic. Holding to a fever clinic that never turns patients away, he cared for well over 20,000 patients with fever in the two years before COVID-19 was moved to Class 5 under Japan’s infectious disease law.
Society memberships and board certifications
Certified Member and Board Certified Fellow, Japanese Society of Internal Medicine
Board Certified Pulmonologist, Japanese Respiratory Society
Board Certified Allergist, Japanese Society of Allergology
Board Certified Specialist, Japanese Society of Anti-Aging Medicine
PhD in Medicine (Tohoku University)
Conclusion: for night-time ear pain in acute otitis media, the basic plan is “pain reliever, then a visit the next day”
For night-time pain from acute otitis media, I use roughly the following dividing lines.
- [See a doctor the next day]
Your child has ear pain but settles and sleeps after a pain reliever, is drinking fluids, and responds to your voice as usual - [Go to a clinic even at night]
The skin behind the ear is red and swollen, the ear sticks out sideways, or one side of the face does not move. Your child is limp and slow to respond, has a stiff neck or complains of pain when the neck is bent forward, or is unsteady and cannot walk. Your child cannot keep any fluids down, or has passed no urine for half a day or more. Your child keeps crying in pain even after a pain reliever - [Call 119 (Japan’s emergency number)]
A seizure lasts 5 minutes or more, your child does not respond when you call, or is struggling badly to breathe
If you are unsure, you can call the children’s medical consultation line (#8000, a phone line that advises on children’s illnesses). Also, if a baby under 3 months old has a fever of 38°C (100.4°F) or higher, see a doctor even at night, whatever the ear symptoms.
What is acute otitis media? Why it tends to follow a cold
Acute otitis media is an illness in which bacteria or viruses get into the “middle ear,” the space behind the eardrum, and cause inflammation. Pus collects in the middle ear and pushes on the eardrum from the inside, causing strong ear pain and fever.
The middle ear connects to the back of the nose through the eustachian tube (a narrow tube linking the ear and the back of the nose). A child’s eustachian tube is shorter than an adult’s, still immature, and closer to horizontal[1]. So bacteria and viruses that multiply at the back of the nose during a cold can easily travel through the tube into the middle ear. It is especially common from about 3 months to 3 years of age[1].
In fact, quite a few children get a middle ear infection after a cold. In a US study that followed 294 healthy children aged 6 months to 3 years for a year, there were 1,295 colds in total, and 37% of colds were followed by acute otitis media[2]. The younger the child, the more likely it was.
In another US study (615 children aged 6 to 36 months), 23% of children had at least one episode of acute otitis media by age 1, and 60% by age 3[3]. Some parents worry, “Why does only my child get it again and again?”, but for small children this illness is that common.
What are the signs of acute otitis media? Touching the ear, fussiness, crying at night
The signs of acute otitis media include ways of behaving other than words, such as touching the ear, fussiness, and crying at night. A child old enough to talk will tell you, “My ear hurts.” But babies and children who do not yet say much cannot explain the pain well. If you notice the following, suspect a middle ear infection.
- Keeps touching, pulling, or rubbing the ear
- More fussy than usual and cannot be soothed
- Wakes crying many times in the night, or has trouble falling asleep
- Fever returns after cold symptoms (runny nose, cough)
- Yellowish fluid or pus comes out of the ear (ear discharge)
- Slow to respond when called, or seems to have trouble hearing
In babies, the only sign may be fussing and not sleeping. In toddlers, nausea, vomiting, and diarrhea often come along with the fever[1]. Touching the ear alone does not prove a middle ear infection, but if these signs pile up after a cold, be alert.
If fluid drains from the ear
Ear discharge is often pus from the middle ear that has come out through a small hole in the eardrum. Once the pus drains, the pressure is released and the pain may suddenly ease.
Even if the pain eases, the middle ear infection has not gone away. Wipe away only what has come out at the opening of the ear with soft gauze or similar, do not push a cotton swab deep into the ear, and see a doctor the next day.
What to do when your child has ear pain at night: what you can do at home
Even if your child has ear pain in the middle of the night, there is no need to panic. Please follow these steps in order.
- [First, check how your child looks]
Check whether any of the “signs that call for a visit even at night” below apply - [Give a pain reliever]
The pain reliever most often used for children is acetaminophen. A child’s dose is set by body weight, so use any prescribed medicine (including suppositories) in the amount and at the intervals you were told. For over-the-counter children’s medicines, always follow the age range and dose on the label - [Let your child rest in a comfortable position]
Let your child rest in whatever position is most calming, such as being held - [Give fluids]
If there is a fever, give barley tea or oral rehydration solution in small, frequent sips - [Take notes]
Write down when the pain began, how the fever has changed, when you gave the pain reliever, and whether there is ear discharge. This helps at the next day’s visit
Please do not use adult over-the-counter medicines or a sibling’s medicine. For a baby under 3 months old, do not decide on your own to give medicine; go to a clinic first.
Relieving pain is one of the key pillars of treating a middle ear infection[1]. There is a systematic review (a study that gathers studies on the same topic by a set method, leaving none out, and summarizes them). It analyzed data from 3 comparison trials covering a total of 327 children with acute otitis media[4].
In the data comparing acetaminophen with a placebo (a dummy medicine with no active ingredient), the share of children still in pain after 48 hours was 10% with acetaminophen and 25% with the placebo[4]. The relative risk (how many times more likely it is than with the placebo) was 0.38, meaning that children with lingering pain were about 4 in 10 of the placebo group[4]. The 95% confidence interval (the range that the true value very likely falls within) was 0.17 to 0.85[4].
In this trial, all the children were also taking antibiotics (medicines that kill bacteria) when compared[4]. In other words, the basic approach is to get treatment and also control the pain well with a pain reliever. The quality of the data is said to be not yet high, but on a night when pain keeps your child awake, please do not hesitate to use a pain reliever.
Which signs mean going to a clinic even at night with acute otitis media? When to call 119
The signs that call for a visit even at night are swelling behind the ear, abnormal movement of the face, limpness, and a stiff neck. Rarely, acute otitis media lets the inflammation spread around the ear or into the head. Examples are mastoiditis (infection of the bone behind the ear) and meningitis (inflammation of the membranes that cover the brain)[1]. If even one of the following applies, go to a clinic without waiting for morning, even at night or on a holiday.
- The skin behind the ear is red and swollen, or your child complains of pain when you press it
- The ear looks pushed outward and sticks out
- One side of the face does not move (the eye does not close easily, water spills from one corner of the mouth, the face twists when your child smiles)
- Your child is limp and slow to respond (if your child will not wake up or does not respond when you call, call 119)
- Stiff neck, pain when the neck is bent forward, vomiting that will not stop, or severe headache
- Unsteady and cannot walk straight, or complains of severe dizziness
- Cannot keep any fluids down, or has passed no urine for half a day or more
- Keeps crying in pain even after a pain reliever and cannot sleep at all
- Under 3 months old with a fever of 38°C (100.4°F) or higher (go to a clinic even if the baby looks well)
Swelling behind the ear and an ear that sticks out are signs of mastoiditis. They can appear days to weeks after the middle ear infection starts[1]. If your child is already being treated for a middle ear infection and the skin behind the ear begins to swell, go to a clinic right away.
If a seizure lasts 5 minutes or more, your child does not respond when you call, or is struggling badly to breathe, call 119 without hesitation. If you are unsure, call #8000.
Where should you take a child with acute otitis media? Ear, nose and throat doctors specialize in looking at the eardrum
For acute otitis media, the basic choice is an ear, nose and throat (ENT) clinic, where the eardrum can be examined closely. Whether it is acute otitis media is decided by looking directly at the eardrum. In Japan, three societies, including the Japan Otological Society, produce clinical practice guidelines for acute otitis media in children (a guideline is a set of recommendations for care compiled by medical societies), and the latest is the 2024 edition (5th edition)[5].
The previous edition (2018) is also available as an English summary, and it covers children under 15[5]. It sorts severity into mild, moderate, and severe by age, symptoms, and eardrum findings, and chooses treatment to match the severity[5]. It states that an accurate look at the eardrum is essential for judging severity[5]. The 2024 edition also lays out the flow of treatment for mild, moderate, and severe cases[5].
An examination that looks closely at the eardrum is the specialty of ENT doctors. If ear pain or ear discharge is the main problem, I recommend seeing an ENT clinic first the next day.
If cold symptoms are also strong, such as a high fever, cough, runny nose, or limpness, it is also fine to have a pediatrician, your family doctor, or a fever clinic check your whole body first. When you go, it helps to tell the doctor the following.
- Since when, and in which ear, your child has had pain
- How the fever has changed, and when you gave a pain reliever
- Whether there is ear discharge (its color and amount)
- Since when cold symptoms (runny nose, cough) have been present
- Whether your child attends nursery or kindergarten, and whether your child has had a middle ear infection before
What matters in treating acute otitis media? Finish the antibiotics
The doctor decides treatment for acute otitis media from the eardrum findings and the severity[5]. For acute otitis media in a baby under 6 months old, treatment with antibiotics is considered appropriate[1]. If antibiotics are prescribed, please keep to the following.
- Take the prescribed antibiotics in the amount and number of doses you were told, until they are finished
- Even if the pain and fever go away, do not stop partway on your own
- Do not use leftover antibiotics from before or a sibling’s medicine
- If your child has trouble taking the medicine, do not stop on your own; ask the doctor or pharmacist how to give it
- On the follow-up day you were given, go even if there are no symptoms, so the eardrum can be checked
If pain or fever continues despite the medicine, or the ear discharge increases, go to a clinic without waiting for the follow-up day. If any of the “signs that call for a visit even at night” above appear, go to a clinic at night even during treatment.
Dr. GamoIt is truly worrying when your child cries with ear pain in the middle of the night. At the next day’s visit, please tell the doctor anything that concerns you, without holding back.
How can you prevent acute otitis media? Secondhand smoke and vaccines
To prevent acute otitis media, it is important to avoid secondhand smoke (breathing in other people’s tobacco smoke) and to get the pneumococcal vaccine on schedule.
Keep tobacco smoke away at home
Tobacco smoke is linked to middle ear disease in children. There is a report that pooled 61 studies in a meta-analysis (a method that statistically combines the results of several studies)[6].
According to it, children in homes where someone in the family smoked had an odds ratio (a ratio comparing how likely something is to happen) of 1.37 (95% confidence interval 1.25 to 1.50) for middle ear disease[6]. Roughly, that is about 1.4 times as likely[6]. When the mother smoked after the birth, it was higher still, at 1.62 (95% confidence interval 1.33 to 1.97)[6].
Even if someone smokes under the range hood or on the balcony, the smoke clings to hair and clothes and is carried into the house. Please take this chance to think about quitting as a family.
Get the pneumococcal vaccine on schedule
In Japan, the children’s pneumococcal vaccine is part of the routine vaccination program and starts at 2 months of age[7]. Since October 2024, the 20-valent vaccine (PCV20) is in principle the one used, and the 15-valent vaccine (PCV15) can also be used[7]. The Ministry of Health, Labour and Welfare also explains that pneumococcus can cause serious complications (another illness that follows the first one) such as pneumonia, middle ear infection, and meningitis[7].
There is a systematic review of comparison trials of pneumococcal vaccines (11 trials, 60,733 people in total)[8]. In the trials that vaccinated in infancy, middle ear infections caused by pneumococcus fell by 20% to 53%, depending on the type of vaccine[8].
However, middle ear infections can also be caused by bacteria and viruses other than pneumococcus. So how much middle ear infection overall falls differs from study to study, and some points remain unclear[8]. Also, the vaccines used in these trials were 7-valent to 11-valent, which are different from the vaccines used in Japan’s routine program today[8].
Even so, pneumococcus causes serious illnesses such as meningitis, not only middle ear infection. Please check your Maternal and Child Health Handbook and get the vaccine on schedule.
Avoid catching colds, and keep colds from getting worse
As I mentioned earlier, a middle ear infection tends to follow a cold[2]. Everyday steps help too: making colds less likely with hand washing, and wiping or suctioning the nose often when there is a lot of runny nose.
About our fever clinic
Our clinic does not see patients at night. We are also closed on Thursdays. If dangerous signs appear during the night, please use #8000, a night and holiday clinic, or an emergency department.
If your child has ear pain but also seems miserable with fever or cough, you can also consult our fever clinic. Our policy is not to turn anyone away from the fever clinic (depending on the symptoms, we may direct you to a more suitable medical institution).
| Day | Hours |
|---|---|
| Mon, Tue, Wed, Fri, Sat | 9:00-12:00 / 14:00-18:00 |
| Sundays and public holidays (from October 4, 2026) | 10:00-15:00 (no lunch break, fever clinic only) |
| Thursday | Closed |
On Sundays and public holidays, we are closed on Sunday, October 25, and from November we are in principle open every Sunday and public holiday. For details, see the announcement about the Sunday and public holiday fever clinic.
How a visit works (no appointment needed)
- Pre-visit questionnaire (optional) → check in on the day using the QR code (a square pattern read with a smartphone camera) at the fever clinic entrance (required) → wait in your car → we call you by SMS (a mobile text message) or by phone
- On Sundays and public holidays, after check-in your insurance card (My Number insurance card, certificate of eligibility, and so on) is checked at the general outpatient entrance
- For detailed steps, see About the fever clinic pre-visit questionnaire and same-day check-in
Please note that on Sundays and public holidays we run the fever clinic only, with no general outpatient care or IV drips.
Frequently asked questions
- My child is crying with ear pain in the middle of the night. Should I go to the emergency department right away?
-
If your child settles and can sleep after a pain reliever (acetaminophen), in most cases seeing a doctor the next day is fine. However, if the skin behind the ear is red and swollen, one side of the face does not move, your child is limp, the neck is stiff, or your child cannot drink at all, see a doctor even at night. If you are unsure, you can call #8000.
- If fluid drains from the ear, should we see a doctor right away?
-
Ear discharge is often pus from the middle ear coming out through a small hole in the eardrum, and the pain may suddenly ease. If there are no other danger signs, wipe away only what has come out and see a doctor the next day. Even if the pain eases, it does not mean the infection has healed.
- For a child’s ear pain, should we see a pediatrician or an ENT doctor?
-
An examination that looks closely at the eardrum is the specialty of ENT doctors, so if ear pain or ear discharge is the main problem, I recommend an ENT clinic first. If cold symptoms such as a high fever or cough are also strong, it is fine to have a pediatrician, your family doctor, or a fever clinic check your whole body first.
- The pain went away after 2 days on antibiotics. Can we stop now?
-
No. Do not stop on your own; finish all of the medicine you were given. Even when symptoms settle, inflammation can remain in the middle ear. On the follow-up day you were given, go so the eardrum can be checked.
- Can a middle ear infection be prevented?
-
It cannot be prevented completely, but there are things you can do: keep tobacco smoke away at home and get the pneumococcal vaccine on schedule. Because it tends to follow a cold, I also recommend making colds less likely with hand washing and wiping your child’s runny nose often.
- Can I bring a child with ear pain to the fever clinic on a Sunday or public holiday?
-
Yes. The Sunday and public holiday fever clinic runs from 10:00 to 15:00. It is closed on Sunday, October 25, and from November it is in principle open every Sunday and public holiday. No appointment is needed; you are seen just by checking in on the day. On Sundays and public holidays we run the fever clinic only, with no general outpatient care or IV drips. Because looking closely at the eardrum is the specialty of ENT doctors, if ear pain or ear discharge is the main problem, please also consider seeing an ENT clinic the next day.
Summary: for night-time ear pain, “pain reliever, then a visit the next day”; go even at night if there are danger signs
- Acute otitis media is common in children after a cold; the reason is that children’s eustachian tubes are shorter and closer to horizontal
- Touching the ear, fussiness, crying at night, and fluid draining from the ear are signs of a middle ear infection
- If your child has pain at night, ease it with acetaminophen; if your child settles and sleeps, seeing a doctor the next day is fine
- If the skin behind the ear is red and swollen, the ear sticks out, the face does not move normally, your child is limp, the neck is stiff, or your child cannot drink at all, see a doctor even at night. For a seizure lasting 5 minutes or more, call 119
- Examining the eardrum is the specialty of ENT doctors. If antibiotics are prescribed, finish them even after symptoms settle
- For prevention, keep tobacco smoke away and get the pneumococcal vaccine on schedule
Watching your child in ear pain in the middle of the night is hard on you, too. If you remember just two things, “if a pain reliever settles the pain, see a doctor the next day” and “the signs that call for a visit even at night,” you will be fine. Once you get through the night, leave the examination and treatment that follow to us.
That’s all.
Disclaimer
This article is intended to provide general medical information and does not replace an examination, diagnosis, or treatment by a doctor. The content is based on medical knowledge at the time of publication, but the right response differs from person to person. If you are worried about your symptoms, please consult a medical institution.
References
- MSD Manual Professional Edition. Otitis media, acute (last updated July 2024) (in Japanese). https://www.msdmanuals.com/ja-jp/professional/16-%E8%80%B3%E9%BC%BB%E5%92%BD%E5%96%89%E7%96%BE%E6%82%A3/%E4%B8%AD%E8%80%B3%E3%81%8A%E3%82%88%E3%81%B3%E9%BC%93%E8%86%9C%E7%96%BE%E6%82%A3/%E4%B8%AD%E8%80%B3%E7%82%8E-%E6%80%A5%E6%80%A7 / Mastoiditis (last updated January 2024) (in Japanese). https://www.msdmanuals.com/ja-jp/professional/16-%E8%80%B3%E9%BC%BB%E5%92%BD%E5%96%89%E7%96%BE%E6%82%A3/%E4%B8%AD%E8%80%B3%E3%81%8A%E3%82%88%E3%81%B3%E9%BC%93%E8%86%9C%E7%96%BE%E6%82%A3/%E4%B9%B3%E6%A7%98%E7%AA%81%E8%B5%B7%E7%82%8E
- Chonmaitree T, Revai K, Grady JJ, Clos A, Patel JA, Nair S, et al. Viral upper respiratory tract infection and otitis media complication in young children. Clin Infect Dis. 2008 Mar;46(6):815-23. doi:10.1086/528685 PMID: 18279042
- Kaur R, Morris M, Pichichero ME. Epidemiology of Acute Otitis Media in the Postpneumococcal Conjugate Vaccine Era. Pediatrics. 2017 Sep;140(3):e20170181. doi:10.1542/peds.2017-0181 PMID: 28784702
- Sjoukes A, Venekamp RP, van de Pol AC, Hay AD, Little P, Schilder AG, et al. Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in acute otitis media in children. Cochrane Database Syst Rev. 2016 Dec;12(12):CD011534. doi:10.1002/14651858.CD011534.pub2 PMID: 27977844
- Hayashi T, Kitamura K, Hashimoto S, Hotomi M, Kojima H, Kudo F, et al. Clinical practice guidelines for the diagnosis and management of acute otitis media in children-2018 update. Auris Nasus Larynx. 2020 Aug;47(4):493-526. doi:10.1016/j.anl.2020.05.019 PMID: 32576390
- Jones LL, Hassanien A, Cook DG, Britton J, Leonardi-Bee J. Parental smoking and the risk of middle ear disease in children: a systematic review and meta-analysis. Arch Pediatr Adolesc Med. 2012 Jan;166(1):18-27. doi:10.1001/archpediatrics.2011.158 PMID: 21893640
- Ministry of Health, Labour and Welfare. Pneumococcal vaccine for children (in Japanese). Ministry of Health, Labour and Welfare website. Accessed October 2026. https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/kenkou/kekkaku-kansenshou/yobou-sesshu/vaccine/pneumococcus-child/index.html
- Fortanier AC, Venekamp RP, Boonacker CW, Hak E, Schilder AG, Sanders EA, et al. Pneumococcal conjugate vaccines for preventing acute otitis media in children. Cochrane Database Syst Rev. 2019 May;5(5):CD001480. doi:10.1002/14651858.CD001480.pub5 PMID: 31135969
More articles to read about fever
For the Sunday and public holiday fever clinic, see the announcement about the Sunday and public holiday fever clinic; for how to come in, see About the fever clinic pre-visit questionnaire and same-day check-in. If your child is vomiting and cannot keep fluids down, please also see our article on children who cannot drink because of fever and vomiting.
