The COVID-19 pandemic put great strains on health care professionals (HCPs) and health systems. Even though the clinical course of the COVID-19 disease is milder and prognosis is better for children than adults (1), children face specific risks, e.g., the pediatric inflammatory multisystem syndrome, which occurred in a small, but still significant number of children with a COVID-19 infection (2–4) and long-term complications are not foreseeable (5). Furthermore children, especially infants, are vulnerable and thus in close contact with pediatricians especially during their first year of life, e.g., taking up routine clinical examinations or vaccinations (6). In Germany, a great majority (90%) of the children <6 years of age is seen by a pediatrician (typically working in private practice), who is specifically prepared with a 5-year period of postgraduate pediatric training in certified hospitals and outpatient institutes. Thirteen routine clinical examinations are offered to children from birth to adolescence (7). Thus, the position of pediatricians providing outpatient care is unique within the German healthcare system, even more so during a pandemic.

During the course of the first year of the pandemic (2020), the majority of the German general population felt well informed about COVID-19 and displayed high levels of evidence-based knowledge, as a lot of information was available (8, 9). However, over half of the population at the same time felt confused due to the dramatic increase in availability of scientific evidence mixed with false information and was uncertain which information sources to trust (10). The World Health Organization (WHO) declared this an “infodemic” (11). It is a task of pediatricians to convey health-related information to parents in an understandable way, enabling them to act accordingly (12, 13). Thus, pediatricians had to stay up to date on the latest scientific evidence in order to be able to provide comprehensive care for their patients. Over the course of the pandemic, new information emerged that was relevant for parents, e.g., regarding infection protection measures, testing, vaccination of children, high infection rates within childcare institutions/schools (14–18). The basis for health-related decisions constantly changed, which sometimes made it difficult to stay informed even for medical experts (9, 19, 11, 20).

While pediatricians had to adapt to providing advice on COVID-19-related child health during the pandemic, pediatric encounters were also affected by hygiene and infection protection regulations. Pediatricians who provide outpatient care had to make considerable adjustments to the way their practice was set up in order to continue patient care (including testing for COVID-19) and consultations (including discussing COVID-19-related issues). To ensure safe patient care, they were required to implement hygiene and infection prevention/control measures in their practice (e.g., sneeze guards, wearing facial masks) and procedures (e.g., separation of sick and healthy patients) and communicate these to their patients (21, 22). Wearing face masks influenced pediatric encounters significantly, as it interrupted the ability of pediatricians to interact with the children (23, 22).

Moreover, HCPs had to deal with varying utilization of appointments over the course of the pandemic (24). Whereas patients with symptoms suggesting a COVID-19 infection had been advised not to visit medical practices in person, many patients with other serious symptoms were also afraid to visit their doctor, or did not attend preventive medical check-ups for fear of becoming infected with COVID-19 (25, 26). In pediatric practices emergency visits were significantly reduced, whereas developmental examinations remained mostly unchanged, compared to the previous year (27). Studies show, that vaccination uptake was affected during the pandemic, however could be resumed (28, 29). Additionally comprehensive provision of care was ensured also by introducing remote consultation via telephone/video during acute phases, e.g., lockdowns (20, 30).

In order to build resilient health systems, it is necessary to understand challenges and gain a deeper understanding how to cope with them (31). Several studies focus on experiences in primary and hospital care during the COVID-19 pandemic (32, 33). Pediatric outpatient care has specific challenges, e.g., providing care for very young patients who are not able to communicate with words, and it is thus necessary to specifically focus on this group of health care providers. Therefore, the aim of this study was to shed light on the challenges experienced by German pediatricians in providing outpatient care during the first year of the COVID-19 pandemic.

The interviews revealed that the pediatricians were confronted with four main challenges (cf. Table 2) during the pandemic.

In our study, we were able to gain insight into the changes and challenges in the routine care provided by German pediatricians during the first year of the COVID-19 pandemic. Generally, the interviewees in our sample felt able to keep themselves informed on COVID-19, infection prevention measures, regulations regarding COVID-19 and to convey COVID-19-related information to parents. However, they perceived this additional workload as a major burden as the high amount of COVID-19-related information and rapidly changing political recommendations required them to engage actively in time-consuming information retrieval and exchange with colleagues, in establishing new information channels and in extended consultations with parents. Most of these information-related tasks did not revolve around medical information on COVID-19 itself, but on how to implement political recommendations and how to deal with administrative challenges in family life and in the medical practice (setting). The physicians felt that political decision-making was detached from what they and their patients could realistically implement in their routine work as physicians and in family life, and moreover they felt as though they were not taken seriously by politicians and were insufficiently involved in political decisions. This feeling of being insufficiently involved in political decision-making and information flow became manifest for some pediatricians when they received the latest news on COVID-19 regulations from their patients instead of being updated via other professional channels.

Practices had to adjust to infection protection measures, appointments had to be restructured and all this had to be communicated to parents. Most of these changes posed an additional financial burden for the practice, but also placed pressure on staff. Some changes proved to be beneficial for some, e.g., the separation of appointments for acute infections from those focused on preventive measures may be kept on after the pandemic. Telephone and online consultations increased but were also perceived ambiguously. For some, this seems to be an option for the future when consulting on preventive measures, but generally the physical examination of children seems to be mandatory for pediatricians and parents alike, especially when children are in physical distress.

In a study on COVID-19 and pediatric health services in Australia and New Zealand with 468 participating physicians, 79.9% reported having good knowledge of where to find local information on how to manage patients. The majority felt well informed about current pediatric testing (71.1%) and infection control (75.2%) (44). This is in line with our findings, with all the pediatricians in our smaller, qualitative sample stating that they felt well informed, or at least able to access the required information, even though it was sometimes rather overwhelming, difficult to sort through and assess. As in our study, participants in another qualitative study on outpatient care in rural Germany describe the information exchange between colleagues in the management of pandemic information as important and helpful (45). Similarly, a quantitative study on the challenges of the first months of the pandemic in Germany showed that the workload of general practitioners (GPs) was highly increased because information had to be retrieved and corresponding measures implemented on a daily basis (20). These GPs, as well as the interviewees in our study, claimed that their professional experience was not considered in political planning processes, even though the government announced them as key points of contact for patients, and moreover politicians made promises that could not be fulfilled by the local GPs (20). An internet survey of pediatric practice owners and assistant health personnel from practices in Saarland, Germany confirmed, in keeping with the findings of our study, that pediatricians were able to retrieve sufficient information, but mentioned that cooperation with health authorities proved difficult at times (21).

A survey of pediatric clinicians in Israel supports our qualitative finding that an extensive use of face masks was a challenge for pediatric health professionals: Of 356 respondents in the study, the majority (82%) reported, that mask-wearing interrupted their ability to interact with children and that the children were more fearful (63%). The study also indicated that clinicians with more experience reported that, although things did get more difficult, the change was not as pronounced. As it is more common to wear masks in clinical encounters than in outpatient care, the difficulties might be greater in outpatient care (22). Similarly, the pediatricians in our sample reported that examining children was hampered significantly by the wearing of a mask. However, the lack of PPE was rarely mentioned by the pediatricians in our sample, whereas this was a greater problem for GPs, as the study on Germany's GPs during the pandemic concluded (20).

Other studies also describe a general decline in patient numbers in pediatric practices (15, 26, 46, 47). This differs slightly from the findings in our study and another study on pediatric primary care in Germany during the early COVID-19 pandemic, where almost all pediatricians stated that they were able to catch up with regular health check-ups (27). They saw the decline in patient numbers as being more strongly associated with the absence of acute infections due to social distancing and infection protection measures.

A study involving all 28 Italian pediatric scientific societies showed that the pediatricians had a positive view of telemedicine, especially for chronically ill patients. However, they also agreed that telemedicine could not replace in-person visits for acute patients (47). This supports our results, since the pediatricians in our sample described telemedicine as sometimes helpful, yet felt that face-to-face contact was essential for examining patients with acute conditions, especially small children who cannot verbalize their distress. In a qualitative study on the impact of the pandemic on pediatric health services in North of Scotland and North of England, pediatricians described rapid changes in communication with patients using new technologies, but also within the professional community. Participants in the study described improved collaboration between colleagues in different locations, which indicates that support for telemedicine is likely to grow in the future (48). However, the healthcare context in this study is specific and rather unique because generalist and pediatric services have to provide care in sparsely populated regions with underdeveloped infrastructure in the North of Scotland and England, which includes some remote islands. Thus, the context of these experiences differs from the context of our study.

Alternative ways of providing consultation were also described in a qualitative study on outpatient care in rural areas of Germany (45). Telephone consultation was increased, as well as home visits and creative solutions such as consultations through windows, which was also described by some of our study participants, e.g., performing COVID-19 swabs and examining children in carparks.

In a narrative review of the impact of the pandemic on routine childhood vaccinations, it was concluded that there was a decline in vaccination coverage in many countries (28). In contrast, the pediatricians in our sample stated an overall decline in patient visits, but all of them reported that they managed to catch up with most preventive examinations. Vaccinations sometimes proved to be even easier to be administered on time as children suffered less from acute infections, which can otherwise cause a delay to immunization.

To the best of our knowledge, this is the first qualitative study with the aim of understanding the experience of the COVID-19 pandemic among German pediatricians. A strength of this study is that we succeeded in conducting detailed qualitative interviews with pediatricians, a target group that was hard to reach during the pandemic due to an increased workload. Our results cannot be generalized to all pediatricians. However, qualitative studies do not claim to generate statistically but theoretically representative data (34). Our interviews enabled us to gain an in-depth understanding of the daily working life of pediatricians during a pandemic. The interviewers (EMG and JvS) are experienced qualitative researchers who have conducted various interviews with different target groups on different topics and were thus able to ensure the professional conduct of the interviews and a rich outcome. All researchers involved in this study, have a great interest in health literacy, health care and health systems; none of them was a pediatrician or physician. Especially when conducting the interviews, this may have been an advantage, as the interviewed pediatricians elaborated more in detail on their daily work: they assumed that practice organization and procedures were unknown to the interviewers. JvS at the time of the interviews was mother of a child in kindergarten and a child in primary school, JC who supported the analysis of the data was at the time mother of a child in kindergarten. Thus, both were up-to date on the situation within those care institutions and affected in their work by the lack of childcare. This might have led to extended discussions on non-medical topics during the interviews as well as on putting a focus on those topics during the analysis. In conclusion, the interest in shedding light on pediatricians’ experiences during the COVID-19 pandemic was professional and personal.

We were able to recruit a broad sample of pediatricians in terms of location of practice (rural vs. urban), region (Bavaria/North-Rhine Westphalia), age and experience and different practice set-ups (individual vs. shared) and could thus capture a wide variety of different perspectives. We assume there are differences, e.g., in regard to socio-economic and ethnic backgrounds of families, depending on location and region of the practice. However, we did not collect data on the patients.

It might be considered a limitation that interviews were conducted via telephone. Observing facial expressions, gestures, or surroundings was not possible. However, recruitment was significantly facilitated by offering telephone interviews as interviews could be scheduled flexibly and there were no inhibiting technical requirements for the participants.

Another limitation of this study is the rapidly changing situation regarding COVID-19. The interviews were conducted from July 2020 to February 2021. During this time, changes occurred quickly, and some impressions and experiences might therefore have changed or developed in different ways after the interviews. This study can only provide insight into a certain time span during the pandemic, however, interviewing over the course of 8 months provides richer insights into the variety of challenges faced by pediatricians over time. Moreover, the study was conducted in Germany and can thus not be transferred to other countries as the health systems are set up differently and the pandemic was handled differently in other countries.

To our knowledge, this is the first qualitative study focusing in-depth on pediatricians’ experiences during the COVID-19 pandemic. By understanding the challenges and how pediatricians dealt with them, comprehensive pediatric care may be improved in “normal” times, as well as in future pandemic situations.

Pediatricians had to deal with various challenges in providing patient consultation and in organizing care throughout the pandemic. However, the study participants were committed to offering comprehensive support for children and families by providing information on health-related questions as well as on regulatory issues at all times. Positive experiences with reorganizing pediatric practices should be disseminated as “best practices” in order to improve future pediatric health services. Future research could explore whether some of the positive experiences in reorganizing care during the pandemic might be maintained by the pediatricians in the future, such as the separation of cases of acute infections and preventive appointments as well as the continuation of telephone and video consultations in some cases.