As the predominant symptom of an acute middle ear infection (acute otitis media; AOM), ear pain is central to families’ experience of the illness. Most clinical guidelines on AOM, therefore, include recommendations on the use of pain medication. Usually, this includes paracetamol and, in case of insufficient pain relief, either switch to ibuprofen, or give ibuprofen on top of paracetamol. In a busy clinic, however, doctors may fail to give parents detailed advice on how best to manage ear pain. As a result children might suffer unnecessarily. This could lead to parents consulting their doctor more often, and requesting antibiotics even though AOM can often be treated without them.

GP training
In his PhD research, Rick van Uum (Julius Center, UMC Utrecht) developed a training aimed at educating general practitioners (GPs) about pain management in children with AOM. The training included an online training module and a face-to-face visit by the study physician. GPs were trained to discuss pain management with parents in detail using an information leaflet and to give a prescription for pain medication rather than suggest to parents to buy it over the counter. The training emphasized the importance of regular and weight-appropriate dosing of paracetamol and suggested to prescribe ibuprofen in addition to paracetamol when needed.

Between 2015 and 2018, he studied the potential benefit of this intervention over care as usual in 224 children with AOM and ear pain in a randomized controlled trial in 18 GP practices across the Netherlands. Parents in the intervention group reported to have given their child more pain medication during the first three days than parents in the control group. They gave paracetamol more frequently, for more days and in slightly higher dosages, and ibuprofen was given more frequently: about one out of two children in the intervention group were given ibuprofen, compared to one out of six in the control group. Remarkably, despite having received advice on pain medication, parents gave paracetamol and ibuprofen in lower doses than recommended in the GP training.

No difference
Surprisingly, parents in the intervention group did not report lower ear pain scores over time or fewer days with ear pain and fever. Children in the intervention group received fewer antibiotic prescriptions at the initial GP consultation, but over the total follow-up period of 28 days, the number of antibiotic prescriptions per child was the same in both groups. Children in the intervention group re-visited the GP more often in the follow-up period re-consultations than children in the control group.

Rick van Uum concludes: “Our training aimed at educating GPs about pain management in children with AOM resulted in parents giving their child more pain medication, in particular ibuprofen, but did not affect average ear pain scores over the first three days. Future research should focus on parents’ barriers to giving paracetamol in high dosage, as well as the effectiveness of other types of pain medication for children with AOM, such as analgesic ear drops.”

Acute otitis media
Worldwide AOM affects about 11% of people a year (about 325 to 710 million cases). Half the cases involve children less than five years of age and it is more common among boys.

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