Upper respiratory tract infections in children — Why do parents seek medical consultation?
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* Elaine Wang

We know that antibiotics are too frequently prescribed for children with respiratory tract infections (RTIs).1,2 One of the factors that cause physicians to ignore guidelines3 is perceived parental pressure to prescribe.4 But is there really a pressure to prescribe? We know little about the care-seeking behaviour of parents with young children who have RTIs.

Saunders and colleagues5 (see page 25) followed 400 young children recruited from the practices of pediatricians in Toronto, Ont., to determine why parents take their children with RTIs to a physician. During the 6-month study an RTI developed in 275 of the children, and in just over half of the 251 for whom further data were available the parents sought a medical opinion either through a visit to their physician or an emergency department or walk-in clinic or over the telephone.

Many factors appeared to influence a parent's decision to seek medical care. Certainly a belief that the illness required treatment was important — and thus may have led to pressure on the physician to prescribe — but so was lower age of the child, high fever, earache or a parental interpretation that the illness was atypical in severity or duration or was getting worse.

Thus, the pressure on physicians is not entirely because parents think their child needs a prescription for antibiotics. There is some evidence that parents, at least in this middle-class group, are making the right triage decisions and are perhaps seeking reassurance more than specific treatment.

The study also showed that parents of children who attended day care or were looked after by a baby-sitter were not more likely to take their children with RTI symptoms to a physician. This finding is surprising and contrary to reports that day-care workers often refer children inappropriately for physician visits.6 However, again, this group of middle-class parents may not be typical of all parents.

Although parents are trying to make intelligent decisions about taking their children with RTI symptoms to a physician and are not necessarily seeking a prescription, unnecessary antibiotic use will not be eliminated. Non-illness factors such as imminent school examinations and day of the week (just before weekends or holidays) may play a role in the physician's decision to start antibiotic therapy.7

The results of this important and perhaps unique study of parental perceptions and behaviour when dealing with a child who has symptoms of an RTI should form the basis for anticipatory guidance in primary-care pediatrics and family practice. Physicians should describe to parents the clinical courses that may occur with an illness. This should reduce parental anxiety when the described events occur.

The results should also be useful in designing new interventions directed at the current crisis of inappropriate antibiotic prescribing. Studying the effect on the demand for antibiotics of parental education before the development of an RTI versus at the time of an RTI-prompted visit would inform us about the most effective way to reduce inappropriate antibiotic prescribing.

𝛃 See related article page [25](http://www.cmaj.ca/lookup/volpage/168/25?iss=1)

## Footnotes

*   *Competing interests:* None declared.

## References

1.  1. Wang EEL, Einarson TR, Kellner JD, Conly JM. Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections. Clin Infect Dis 1999;29:155-60.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2lkIjtzOjU6InJlc2lkIjtzOjg6IjI5LzEvMTU1IjtzOjQ6ImF0b20iO3M6MTk6Ii9jbWFqLzE2OC8xLzQzLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  2. McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA 1995;273:214-9.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/jama.1995.03520270048030&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7807660&link_type=MED&atom=%2Fcmaj%2F168%2F1%2F43.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1995QB23400025&link_type=ISI) 

3.  3. McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ 2000;163:811-5.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjMvNy84MTEiO3M6NDoiYXRvbSI7czoxOToiL2NtYWovMTY4LzEvNDMuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

4.  4. McDowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics 1998;101(Suppl):163-5.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1542/peds.101.1.S1.163&link_type=DOI) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000071331600001&link_type=ISI) 

5.  5. Saunders NR, Tennis O, Jacobson S, Gans M, Dick PT. Parents' responses to symptoms of respiratory tract infection in their children. CMAJ 2003;168 (1):25-30.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo4OiIxNjgvMS8yNSI7czo0OiJhdG9tIjtzOjE5OiIvY21hai8xNjgvMS80My5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

6.  6. Skull SA, Ford-Jones EL, Kulin NA, Einarson TR, Wang EEL. Child care center staff contribute to physician visits and pressure for antibiotic prescription. Arch Pediatr Adolesc Med 2000;154:180-3.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/archpedi.154.2.180&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10665606&link_type=MED&atom=%2Fcmaj%2F168%2F1%2F43.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000085193100011&link_type=ISI) 

7.  7. Howie JR. Clinical judgement and antibiotic use in general practice. BMJ 1976;2:1061-4.