Pain management in acute otitis media: a qualitative study exploring GPs’ views and expectations parallel to a trial of an educational intervention

Treating symptoms instead of infection

All GPs stated that ear pain is a frequent reason for parents of children with AOM to consult a doctor. GPs considered AOM to be a very painful condition. A few GPs could even remember their own childhood AOM episode since it had been so painful. Others expressed that their own children had suffered from AOM-related ear pain. One commented:

'Well, an earache is incredibly painful. If you have ever had one yourself, you know enough. You’re ready to bang your head against the wall, that’s how much it hurts.' (P9)

However, one GP realised the severity of the ear pain caused by AOM through the internet-based training and felt that she had underestimated this condition thus far. She stated that clinicians are obligated to treat (ear) pain adequately. This was reflected by other GPs, who stated that the knowledge (whether pre-existing or kindled by the intervention) that childhood AOM is generally accompanied by considerable ear pain motivates them to provide adequate pain management; they felt that it warrants further action by the GP:

'Most important to me is that they take that earache seriously. A child with an earache, it just really hurts, so they [parents] have to give painkillers.' (P8)

GPs indicated that, prior to participating in the training, they mostly focused on whether or not to prescribe antibiotics, with analgesia considered less important.

The intervention provided new knowledge on analgesia and, as a result, GPs expressed that they made symptom relief central to their consultation by proactively discussing pain management with parents.

GPs indicated that the intervention led to a change in AOM pain management. GPs who tended to advise parents to administer paracetamol three times daily in a sufficient dosage did now prescribe ibuprofen as add-on therapy. GPs who irregularly advised on analgesics, or who took parents' response that they had already administered paracetamol to their child for granted, now tended to better explore the amount and dosage of paracetamol administration, and — where appropriate — advised parents to administer a higher dosage of paracetamol, or explicitly stressed the importance of administering paracetamol on a more regular basis:

'So, I started to shift, I think, from treating the infection specifically and pointing that out, to the pain aspect, which tends to be far more important to the parents.' (P5)

' ... but then I did actually state much more clearly that pain relief was important, that antibiotics weren’t useful here while analgesics were, the importance of a consistent pain medication level and, well, as a rule you can take paracetamol three times a day, and then there’s still ibuprofen on top of that.' (P1)

Several GPs did express that they prescribed fewer antibiotics to children with AOM due to the increased focus on pain management. Not all GPs shared this opinion though; some felt there was no difference in their number of antibiotic prescriptions for AOM, whereas others were unsure whether antibiotic prescribing changed. A subset of GPs indicated that the intervention led to fewer re-consultations and subsequently fewer antibiotic prescriptions. The interviewer asked if they had noticed that they had started to prescribe antibiotics more often, less often, or the same amount:

'I’m pretty reticent to do so anyway, I think. So if you ask me, not much has changed.' (P9)

'But what I do know is that, of the children I signed up for the study, I didn’t see any of them again. So, they were never given antibiotics, in any case.' (P3)

Empowerment of GPs through the intervention

Prior to the intervention, several GPs struggled with the idea of not being able to offer adequate treatment for AOM-related ear pain. Some parents had already provided paracetamol to their children before consulting the GP, and GPs therefore felt they could not offer these parents a solution for their child’s symptoms and did send those children home without additional analgesics. In the end, several of these children re-consulted their GP because of persisting symptoms, and were then prescribed antibiotics, even though the GP felt a clear indication was lacking.

The new knowledge on analgesia offered by the intervention might have changed their attitudes towards the management of these patients. It diminished GPs’ feeling of helplessness and increased their self-efficacy in managing these patients. GPs particularly valued the positive message that they could actually do something, and considered the intervention easily implementable:

'It is really annoying to have nothing to offer. Well, you do have something to offer: a sympathetic ear, an explanation, empathy. But sometimes it’s not enough and people want to have something. And then it’s nice to have something to give.' (P4)

'Yet I used to look only at the infection, and say: "Well, he does have an infection but it’ll pass, just give him some paracetamol." Whereas now, you’re drawing up an actual pain medication schedule. Which as a doctor, gives me more of a sense of doing something, as well as providing the parents with tools to help their child in pain, the one with persistent symptoms, to treat them.' (P5)

Most GPs indicated they extended their history taking by asking parents whether they had provided analgesics to their child and, if so, which type, how frequent, and at which dosage. This communication technique, exploration, was specifically addressed in the internet-based training to optimise pain management. One GP commented:

'These days, I do, in fact, ask people much more frequently how they fight it. Your study really was a wake-up call for me, so to speak. That idea of asking: what are they doing now, how often are they giving it, and what, specifically, do they give. And are they administering that thing preventively or not. So in that regard, I do find the study appealing, because you take a different approach than in the past.' (P3)

Furthermore, GPs were very positive about the parent information leaflet. All GPs stated that they used the leaflet specifically to illustrate the specific dose per weight recommendations of paracetamol and ibuprofen, but not to inform parents about AOM or analgesics in general. Several GPs also used the leaflet for children who did not participate in the trial or who consulted them because of other painful conditions. Some even used the leaflet, or copies thereof, during their out-of-hours service:

'Well, I even took it with me to the after-hours clinic; I put it in my bag, and then I just grab it, indicate the level, and then calculate [the dose]. People typically ask me for written instructions on how much they’re supposed to take.' (P1)

'Yes. It always adds a certain panache, of course, when a doctor prescribes something. I felt even more — because I did use that card you gave me with that dosage — even more like "This doctor knows exactly how much it has to be, because she has worked it out very precisely." That would provide motivation, whether it was prescribed or not.' (P10)

The intervention asked GPs to prescribe, rather than recommend, analgesics according to current guidelines. In the Netherlands, both paracetamol and ibuprofen are available OTC and therefore a prescription is not formally required. In general, GPs valued prescribing analgesics (in particular ibuprofen), as they felt that a prescription increased the trustworthiness of drugs and might lead to better compliance, and improved medical documentation for themselves and colleagues:

'Why I make that distinction? Good question. I guess also because it’s a little more familiar and the parents feel that a prescription is more effective, I think, than me just telling them to go to a drugstore and pick up some OTC syrup.' (P10)

In everyday practice, however, GPs usually decided to provide a prescription for ibuprofen, but not for paracetamol, since they assumed most parents are more familiar with it and would have paracetamol at home. Some GPs were unfamiliar with the OTC availability of Nurofen (liquid ibuprofen) and therefore chose to specifically prescribe this, yet other GPs thought a prescription might provide parents with explicit instructions on ibuprofen usage, assuming parents were unfamiliar with administering ibuprofen to their children, in addition to the information provided in the booklet.

Balancing potential beneficial and harmful effects of prescribing ibuprofen to children

None of the GPs were familiar with prescribing ibuprofen to children suffering from pain. There was a general lack of knowledge about the possibility of prescribing ibuprofen at a young age (≥1 year). Ibuprofen for children was regarded as a neglected subject in Dutch primary care and GP training, and some GPs felt they had insufficient knowledge and experience to safely prescribe ibuprofen in children prior to the intervention. Once presented with this information, some GPs indicated they were inclined to prescribe ibuprofen and were eager to have a tangible additional management option of potential benefit for their patient:

' ... and indeed, the addition of ibuprofen. […] Because I didn’t know that it was appropriate for children this young.' (P1)

'That’s really the most important message, I think, to keep in mind: that there’s nothing wrong with three days of ibuprofen use.' (P4)

'And the thing I like is, [it shows] that you have certain preconceived notions. My own understanding, for sure, was that ibuprofen was unacceptable for children. And it was entirely unfounded. It’s not like that idea was promoted in medical school, that you shouldn’t [use it] with children. In fact, it’s something that was never really touched upon.' (P6)

On the other hand, some GPs already knew ibuprofen could be administered to young children, but felt reluctant to prescribe this drug since none of their colleagues did so. Other GPs felt reluctant since non-steroidal anti-inflammatory drugs such as ibuprofen have received negative media attention in recent years. Over the past decade, awareness of ibuprofen-related adverse effects has increased and clinicians are explicitly recommended to be cautious when prescribing ibuprofen to older people. Children are considered even more susceptible and vulnerable to adverse effects than older people, and GPs therefore refrain from prescribing ibuprofen.

These GPs, however, now consider prescribing ibuprofen if the child suffers from pain and has already received an optimal dosage of paracetamol. It seems the need for better pain management overcomes their hesitation to prescribe ibuprofen:

'Well, in any case, what I took away is what I learned from the introductory videos, about the low barriers to use ibuprofen in children.' (P7)