Ear Infection or Teething? How to Tell the Difference

Teething and ear infections share a frustrating number of symptoms in babies and toddlers, but a few reliable differences can help you sort one from the other. The overlap exists because both conditions peak during the same developmental window (roughly six months to three years), both cause irritability and sleep disruption, and both can involve ear pulling. The distinction matters because an ear infection sometimes needs medical treatment, while teething does not. Knowing which signs point where can save you an unnecessary trip to the pediatrician or, more critically, prevent you from dismissing an infection that needs attention.

Why These Two Get Confused So Often

Teething begins around six months and continues in waves until roughly age three, with new teeth breaking through the gums at irregular intervals throughout that stretch.¹ Acute otitis media, the most common type of ear infection in children, peaks during the same age range, largely because children’s eustachian tubes are shorter, more horizontal, and floppier than an adult’s, making it easier for fluid and bacteria to back up into the middle ear.² Because a child may be cutting a tooth and fighting an ear infection at literally the same time, parents understandably lump the symptoms together.

Surveys of parents consistently show that the vast majority believe teething causes a wide range of systemic symptoms. In one Australian survey, 70 to 85 percent of parents attributed fever, pain, irritability, sleep disturbance, drooling, and red cheeks to teething, while 35 to 55 percent also blamed ear pulling, runny nose, loose stools, and infections.³ A separate survey found that about 70 percent of mothers listed fever as a teething symptom and nearly 64 percent listed sleep disturbance.⁴ These beliefs are so entrenched that parents tend to diagnose “teething” based on the presence of symptoms they associate with teething rather than on actually seeing or feeling a tooth coming through.³ That circular reasoning is exactly how ear infections get missed.

What Teething Actually Looks Like

When researchers track babies day by day around tooth eruption, rather than relying on parents’ after-the-fact recall, the list of symptoms tied to teething shrinks considerably. The most reliably observed signs are drooling (found in about 92 percent of teething episodes in one clinical study), sleep disturbances (about 82 percent), and irritability (about 76 percent).⁵ Other common reports include swollen or reddened gums, increased biting or chewing on objects, mild appetite loss, and a slight rise in body temperature.⁶

That “slight rise in temperature” distinction is important. Teething can make a baby feel warm, but most pediatric research draws the line at a true fever. When a child’s temperature climbs above 38°C (about 100.4°F), the cause is more likely an infection than a tooth. Teething also tends to produce symptoms that are localized: the gum over the incoming tooth looks puffy and red, the baby gnaws on things, and drool may cause a rash around the mouth and chin. These local signs are the most useful clues that teething, rather than illness, is the culprit.

One carefully designed prospective study of infants found that even loose stools, commonly blamed on teething, were only weakly linked to eruption day itself. The association disappeared when researchers widened the window to the surrounding days.⁷ The takeaway is that many symptoms parents attribute to teething may simply reflect the fact that six-to-twelve-month-olds are constantly encountering new germs as their maternal antibodies fade, and these infections coincide with (but are not caused by) teething.

What an Ear Infection Actually Looks Like

Acute otitis media has its own signature, though it can be hard to read in a pre-verbal child. The hallmark is ear pain that comes on relatively suddenly, often during or just after a cold. A baby with an ear infection is typically more distressed than one who is merely teething. The crying tends to be intense and difficult to soothe, and it often worsens when the child lies flat, because that position increases pressure on the eardrum. Fever above 38°C is common and sometimes spikes to 39°C or higher, well beyond the mild warmth teething might produce.

Other signs that tilt toward ear infection include fluid draining from the ear, a noticeable change in hearing or responsiveness to sounds, and a child who has had cold symptoms (congestion, runny nose, cough) for several days before the fussiness escalated. The definitive diagnosis requires looking at the eardrum with an otoscope. Research on otoscopic signs has shown that a bulging eardrum is the most reliable indicator of a genuine bacterial infection that would benefit from antibiotics.⁸ Without that visual confirmation, even doctors can struggle to distinguish a real infection from fluid behind the eardrum that will resolve on its own.

The Ear-Pulling Problem

Of all the overlapping symptoms, ear pulling causes the most confusion. Parents naturally assume that a baby tugging at an ear has ear pain, and ear pain means ear infection. But teething babies also rub, tug, and pull at their ears, probably because the nerves serving the gums, jaw, and ear travel overlapping paths. In adults, pain felt in the ear that actually originates from somewhere else accounts for close to half of all ear-pain cases.⁹ In babies, the principle is the same: sore gums can produce a sensation that the child interprets as ear discomfort.

Ear pulling by itself, without other supporting signs, is not a reliable indicator of ear infection. If the pulling is accompanied by high fever, cold symptoms, intense crying when lying down, or fluid from the ear, an infection is more likely. If the pulling comes with drooling, gum chewing, and a visible swelling along the gum line, teething is the better explanation. And sometimes a baby just discovers their ears and finds them interesting to grab, with no pain involved at all.

A Quick Side-by-Side

Because the overlap is real and the stakes matter, here is how the two conditions compare on the symptoms that cause the most confusion:

• Fever: Teething may produce a mildly elevated temperature but rarely above 38°C. Ear infections commonly cause true fevers, sometimes 39°C or higher.
• Drooling: Heavy drooling is one of the most consistent teething signs and is not typically associated with ear infections on its own.
• Runny nose: A runny nose preceding the fussiness points toward a cold and potentially an ear infection. Teething does not cause nasal congestion.
• Ear pulling: Common in both conditions. Look at what else is happening to decide which is more likely.
• Timing of pain: Teething discomfort tends to wax and wane over days and often improves once the tooth breaks through. Ear infection pain tends to escalate over hours and gets worse at night or when lying flat.
• Gum appearance: Swollen, red gums with a visible bulge where a tooth is pressing through strongly suggests teething. Gums look normal during an ear infection.
• Duration: Teething irritability usually resolves within a few days of eruption. Ear infection symptoms persist or worsen until the infection is treated or clears on its own.

No single symptom in isolation clinches the diagnosis either way. The pattern matters more than any individual sign.

Why Teething Gets Blamed for Ear Infections

There is a well-documented tendency among caregivers to attribute a wide range of childhood illnesses to teething. Researchers have called this “teething diagnosis,” and it can be genuinely dangerous. One study noted that in 120 babies observed during eruption of lower front teeth, only 39 percent showed any symptoms at all, and those symptoms resolved on or within a day of the tooth appearing.¹⁰ Yet parents frequently report teething episodes lasting a week or more, which suggests that other illnesses occurring in that window are being folded into the teething narrative.

The biological plausibility is thin for most of the dramatic symptoms blamed on teething. Researchers have found elevated levels of inflammatory markers in the gum tissue around erupting teeth, which could explain local pain, swelling, and perhaps the mild temperature increase.¹¹ But these localized inflammatory signals are not strong enough to produce high fevers, vomiting, or diarrhea. When a teething-age baby has those more severe symptoms, something else is usually going on, and an ear infection is one of the more common culprits.

The risk of the “it’s just teething” reflex is that a treatable infection goes unaddressed. This does not mean you need to rush to the doctor every time your baby is cranky and chewing on a fist. But if the crankiness is accompanied by a fever that keeps climbing, symptoms that last more than a few days, or a dramatic change in your child’s behavior, it is worth having the ears checked.

Managing Pain at Home

Whether you are dealing with teething pain, ear pain, or both at once, the first-line approaches overlap. Over-the-counter acetaminophen and ibuprofen (the latter for children over six months) are effective for both. A Cochrane review of pain relief for children with acute ear infections found that both medications outperformed placebo in reducing short-term ear pain, though neither was clearly better than the other.¹² For teething specifically, chilled (not frozen) teething rings, gentle gum massage with a clean finger, and hyaluronic-acid-based gum gels have all shown some benefit.¹³

What to avoid matters just as much. Topical numbing agents containing benzocaine or lidocaine have fallen out of favor because they wash away quickly with drool, can be swallowed, and in rare cases have been linked to a dangerous blood condition in infants. Amber teething necklaces carry a choking and strangulation hazard with no demonstrated benefit. And for ear infections, over-the-counter decongestants and antihistamines have not been shown to help children’s ear pain or speed recovery.

When Both Happen at the Same Time

Because teething and ear infections hit the same age group during the same season-heavy months, you will sometimes face both at once. A child cutting a molar while also battling a cold that turns into an ear infection is not rare. When symptoms stack up, the question shifts from “which one is it?” to “is an ear infection also happening?”

The practical approach is to treat what you can see and flag what you cannot. Swollen gums and drooling you can address at home with teething comfort measures. But if the baby also has a climbing fever, worsening fussiness despite pain relief, or a cold that seems to be getting worse after initially improving, those are signals to get the ears examined. Only an otoscope can confirm whether the eardrum is bulging or infected.⁸

It is also worth knowing that not every ear infection requires antibiotics. Many pediatric guidelines now recommend a “watch and wait” period of 48 to 72 hours for older toddlers with mild ear infections, during which pain management alone is appropriate. Antibiotics are more clearly warranted for children under six months, for children with high fevers or severe symptoms, or when the infection involves both ears. Your pediatrician can help make that call based on what the eardrum looks like.

Why Children Outgrow Both Problems

Teething ends once all twenty primary teeth are in, usually by age three. Ear infections also become less frequent as children grow, and the anatomy explains why. As the skull and face develop, the eustachian tube lengthens, steepens in angle, and becomes firmer, all of which make it harder for fluid to pool in the middle ear.² Research into the evolutionary basis for this vulnerability suggests that human infants are born with particularly immature eustachian tubes compared to other primates, a trade-off linked to changes in facial structure that allowed for speech development.¹⁴ In practical terms, this means the ear infection years and the teething years end around the same time, and the overlap that made them so confusing gradually resolves on its own.

The maturing immune system plays a role too. By age two or three, children have encountered enough common respiratory viruses to build partial immunity, so they get fewer colds, which means fewer colds progressing to ear infections. The combination of better plumbing and better defenses is why a four-year-old rarely has the same ear trouble as a nine-month-old, even though plenty of other childhood ailments remain.

Teething Symptoms That Should Always Prompt a Doctor Visit

Because the “just teething” label can mask real illness, there are a few red lines worth keeping in mind. A rectal temperature above 38.3°C (about 101°F) in a baby under three months always warrants a call, regardless of whether teeth seem to be coming in. Persistent vomiting, bloody diarrhea, a rash that does not blanch when pressed, or lethargy that goes beyond normal tiredness are not teething symptoms. Similarly, if a child refuses fluids for more than a few hours or seems to be in pain that does not improve with age-appropriate pain relief, something beyond a tooth is probably going on.

The evidence consistently shows that true teething discomfort is self-limiting and mild.⁷ A child who seems seriously unwell deserves a proper evaluation rather than a reassuring “it’s just a tooth.” Keeping that principle in mind is probably the most useful thing you can take away from the research: teething is common, uncomfortable, and harmless, but the symptoms that get pinned on it are not always so benign.