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Child Care Center Staff Contribute to Physician Visits and Pressure for Antibiotic Prescription
Susan A. Skull, MBBS, FRACP, MAppEpid;
E. Lee Ford-Jones, MD, FRCPC;
Natalie A. Kulin, MSc;
Thomas R. Einarson, MS, MEd, PhD;
Elaine E. L. Wang, MD, CM, FRCPC
Arch Pediatr Adolesc Med. 2000;154:180-183.
Objective To determine whether child care center (CCC) providers contribute to unnecessary physician referrals and antibiotic prescriptions in young children with upper respiratory tract infections.
Design A survey using a structured telephone questionnaire between May 3, 1998, and July 27, 1998.
Participants Child care center providers from randomly selected licensed Ontario CCCs accepting diapered children.
Main Outcome Measures Knowledge, attitudes, and practices concerning physician referral; exclusion; and antibiotic use for children with upper respiratory tract infections. Indications for exclusion were compared with published Canadian guidelines.
Results Contact was made with 42 eligible CCCs to obtain the requisite number of 36 participants (participation rate, 86%). Of the 36 centers, staff reported advising that children visit a physician for colored nasal discharge in 28 (78%), for productive cough in 23 (64%), and for unusual behavior in 9 (25%). Also of the 36 centers, staff reported excluding children for colored nasal discharge in 20 (56%), for productive cough in 16 (44%), and for unusual behavior in 15 (42%). Antibiotics were thought useful for nonspecific upper respiratory tract infections to prevent the spread of infection in 9 (26%), to speed up recovery in 7 (21%), and to prevent bacterial infection in 13 (38%) of 34 centers. In the previous 6 months, 25 (69%) of 36 staff members reported making an exception to exclusion because a child had an antibiotic prescription.
Conclusions Many children are referred by CCC staff to physicians contrary to established guidelines. As staff must act on behalf of parents, a low threshold for referral is not unreasonable. However, this survey confirms that CCC staff recommend children to receive antibiotics and exclude children inappropriately. These practices are based on incomplete knowledge. Research on appropriate management of upper respiratory tract infections by CCC staff is needed. Education to correct specific knowledge deficits should be initiated.
From the Department of Pediatrics, The Hospital for Sick Children (Drs Skull, Ford-Jones, and Wang); and the Department of Pediatrics (Drs Skull, Ford-Jones, and Wang), the Faculty of Pharmacy (Ms Kulin and Dr Einarson), and the Program in Clinical Epidemiology and Health Care Research (Dr Wang), University of Toronto, Toronto, Ontario. Dr Wang is now with the Department of Clinical and Medical Affairs, Pasteur Merieux Connaught, Toronto.
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