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May 24, 1999
News this month
Parents, physicians and the use of antibiotics: a vicious cycle?
With increasing urgency, parents are being warning that antibiotics are being
overused in children. Overprescribing such medication has lead to an increased
drug resistance in certain illnesses in addition to wasting millions of health
care dollars.
96% of doctors said they received requests from parents for antibiotics, even when they were not needed.
The role of parental pressure
But are parents a part of the problem? Yes, according to a study in the February issue of Pediatrics. In the study, about 600 pediatricians from across the U.S. described how often they prescribed antibiotics, and what factors influenced their decisions to prescribe. Most of the physicians worked in busy group practices and saw about 114 patients per week. The doctors, surveyed by researchers from Boston Medical Center, were specifically asked if they ever felt pressured by parents to prescribe antibiotics, even when they were not medically necessary. Ninety-six percent of doctors said they received requests from parents for antibiotics, even when they were not needed.
- Half of the physicians said parents always, most of the time, or often pressured them to prescribe antibiotics when their children were ill.
- 40 percent of the physicians said parents had specifically requested antibiotics for their children at least 10 times.
- Parents frequently requested antibiotics over the phone.
- Some parents even gave their children antibiotics without consulting a doctor.
One third of these physicians acknowledged they went against their better judgment and prescribed an antibiotic when it was not medically necessary.
What parents really want
A study in the April issue of Pediatrics focused on what happened when physicians thought parents expected to receive an antibiotic for their child. In the UCLA study, parents of 306 children age two through 10 who were being seen for ear pain, throat pain, cough or congestion, were surveyed before and after the visit with the doctor. In addition, the 10 physicians who examined the children were surveyed after the visit.
Doctors acknowledged…it was often easier to write the prescription rather than take the time to explain the illness to the parent.
Changing the diagnosis to fit the treatment
Physicians were significantly more likely (62 percent versus 7 percent) to inappropriately prescribe antibiotics when physicians thought parents wanted an antibiotic compared with when they did not. In those cases, physicians were also more likely to give a bacterial diagnosis, which can be treated with an antibiotic (70 percent versus 31 percent).
In both studies, physicians reported that parental pressure was the strongest factor in overprescribing antibiotics. Doctors acknowledged that they were so pressured for time, it was often easier to write the prescription rather than take the time to explain the illness to the parent.
Call for action
Both research teams called for immediate action on the part of physicians to make a commitment to improve communication with parents in their practice. The UCLA group also suggested that their study be broadened to other regions to see if such practices held up in other areas of the country.
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Too much of a good thing
The introduction of antibiotics in the early part of this century was justifiably greeted as one of the major breakthroughs in modern medicine. No longer did major bacterial infections such as pneumonia mean certain death. But too much of a good thing, as you might expect, has consequences as well.
In 1980, about 900,000 prescriptions were written for cephalosporin antibiotics to treat acute otitis media (ear infection). In 1992, that number jumped to nearly 7 million, an increase of 687 percent. The use of amoxicillin went up nearly 200 percent during that same time period.
What has caused this jump? Several factors come into play.
- Recent improvements in recordkeeping of actual prescriptions being written.
- Incidence of real ear infections has gone up, as more children spend time in day care.
- Improved access to medical care, allowing more children to be treated for diseases.
But without a doubt, physicians are overprescribing antibiotics. Why?
“Antibiotics do not kill viruses and should not be used.”
Viruses versus bacteria
The majority of childhood illnesses are caused primarily by viruses. Viruses cause colds and a host of other upper respiratory tract infections and usually take a few days to a week or two to run their courses. Antibiotics do not kill viruses and should not be used. Infections caused by bacteria such as strep throat, however, can and should be treated with antibiotics.
The problem comes in when a parent brings to the doctor a child with a runny nose and cough or a stomach bug. The parent expects the doctor to "do something" to help the child feel better. That "something" too often means prescribe an antibiotic, even if the child has a virus.
A better way
Instead, the researchers recommend the following:
- Physicians should resist the urge to quickly write a prescription.
- Physician should allow enough time to explain what is causing the child's illness, how long it should last and any more serious symptoms for which they should watch.
But too often, this communication never takes place. Physicians may feel hurried or be overly eager to please the parent who could easily go to another physician more willing to prescribe an antibiotic. So the prescription is written, the child takes medication he or she never needed in the first place and the cycle continues.
Good information the key
What about those cases where the parent does not ask for antibiotics, but the physician assumes that's what the parent wants? As the second study pointed out, physicians were wrong more often than they were right about whether parents expected antibiotics in those cases when they did not directly ask for them. All those parents really wanted was good information about their child's condition. Those who received it were often extremely satisfied after the office visit.
What parents can do
Parents can also be part of the solution. If your child has a mild illness, consider following these guidelines:
- Call the doctor or nurse if you are concerned about your child's health. Sometimes a phone consultation is all that is necessary, instead of an office visit.
- Don't request antibiotics over the telephone and do not give your child antibiotics without consulting a physician.
- When you take your child to the doctor, think of the exam as a chance to rule out more serious illness, rather than always coming home with antibiotics.
- Make sure you understand why your child is sick and ask about more serious symptoms for which you should watch.
- If medication is prescribed, follow the directions carefully.
- Know that minor illnesses build up your child's immune system.
- Understand that overusing antibiotics can actually harm your child.
These steps will leave physicians and parents happier and their children healthier in the long run.
Dr. Shapiro is a specialist in pediatric infectious diseases at Yale-New Haven Children's Hospital and professor of pediatrics at Yale University School of Medicine.
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