Case Scenario

A woman brought her six-month-old daughter to our walk-in clinic. She said that the child had felt warm, had been irritable and had lacked an appetite. The child also had a runny nose, which her mother said she'd gotten from one of her older brothers or sisters. The mother finished explaining her daughter's symptoms by saying, “She needs an antibiotic.”

I offered to examine the child. “Maybe then we can decide what she needs,” I said. The child had a rectal temperature of 39.6°C (103.2°F) and cried vigorously, although she was consolable. Her ear canals were tiny, but I glimpsed red eardrums that were nonetheless mobile. She had copious discharge from her nose, but there were no retractions of her chest wall, and her lungs were clear. She did not appear to be dehydrated and had been gaining weight well. “Your child most likely has a virus,” I told the mother. “Antibiotics don't treat viruses. These things have to resolve on their own.” I explained under what circumstances she should bring the child back for re-evaluation and told her that I would call her in two days to find out how her daughter was doing.

While I was talking, I sensed the mother's extreme irritation with my decision. Although she did not argue and shook her head no when I asked her if she had any additional questions or concerns, I knew that she was not satisfied. I called her in two days as promised, and she told me: “I took her to the emergency department right after I saw you. She had an ear infection and they gave her an antibiotic.”

Commentary

I believe that the problem here could have been avoided by acknowledging the mother's concerns and answering them specifically and directly. A recent study performed in Atlanta indicated that 84 percent of parents would accept a physician's decision not to prescribe antibiotics for a febrile illness if the physician simply took the time to explain why he or she was not prescribing them. This experience has been validated by others,¹ and, in my experience, holds true for closer to 99 percent of parents.

When parents tell the physician that their child needs an antibiotic, the best way to show them that the physician is not merely “against antibiotics” would be to say something like this: “It's quite possible that you're right. Let's see if your child has an ear infection or some infection requiring an antibiotic.”

Telling the parent that the child “has a virus” is often an inadequate explanation. Parents want to know that their child is not seriously ill. So, first deal with their anxieties and tell them what their child does not have—for example: “I've examined your child, and I don't see any signs of strep throat, ear infection, pneumonia, sinusitis, dehydration or anything serious. She has a fever, but it's not too high for a child her age to handle easily.”

Next, tell the parents what their child does have: “Her findings are typical of a virus cold. She has a fever, her nose is runny, and her eardrums are a bit inflamed (or red), but they don't show anything more than slight blockage of the eustachian tubes, the ones running from her ears to the back of the throat. She's probably irritable because, in addition to having a stuffy nose, sleeping poorly, and maybe having a headache or sore throat, as do many of us during the first days of a virus cold, she feels pressure in her ears, like when you're up in the mountains or in an airplane and your ears keep popping. Her ears aren't infected, but that may be why she's poking at them.”

Third, tell the parents what to expect: “As with most colds in infants, I would expect her to have a fever of about 102°F to 103°F for a couple of days; it should then come down to about 100°F or 101°F for a couple more days, and then it should be gone by the fifth day. As she begins to feel better, her irritability and appetite should improve. Her runny nose will probably last for seven to 10 days, but her cough may continue for 10 days to two weeks.”

Then, explain to the parents how to treat the illness and, if the child goes to day care, tell the parents when the child can go back. For example: “For the fever and irritability give her children's Tylenol, Advil or Motrin every six to eight hours for the next day or two, then only as needed thereafter (specify dosage). It might help the runny nose and cough if you give her a cold medicine (specify name, dosage and schedule). Don't worry about her appetite, she'll eat when she's hungry, but let her have as much to drink as she wants and have fluids available so they're there when she wants them. She can go back to day care as soon as the fever's gone.”

Finally, tell the parents that the door is always open and tell them under what conditions they should bring their child back: “I would like to hear from you at any time if her fever doesn't follow the pattern I've described, if she seems to have increasing pain, if something new develops like vomiting or diarrhea, if her cough worsens or she has difficulty breathing, or even if she just plain looks ‘sicker’ to you and you're worried. If she's coughing for more than two weeks I'd also like you to give me a call.”

Although good data indicate that combination antihistamine-decongestant cold remedies are of little more value than placebo in the treatment of colds in children,² parents need to feel empowered. No parent can be expected to calmly sit and do nothing while their child appears to be suffering. Thus, I tell parents to use cold medicines in modest amounts. Whether through pharmacologic effect or placebo effect, this usually provides enough reassurance that “something is being done” to relieve their anxieties. Parenthetically, this also often displaces the demand for antibiotics. Furthermore, in 35 years of pediatric practice, I can remember only one child with a significant adverse reaction to a cold medicine, and it resolved after a few hours of observation.

Finally, it would be inappropriate not to acknowledge that there are a few parents or caregivers—very, very few to be sure—who, despite all efforts, can never, never, never be pleased. If they don't trust you with management of their child's cold, they will surely not trust you with a more serious condition. When real or perceived problems do occur, you will be held accountable to their uncle “the specialist in New York City,” their neighbor on the faculty of the local medical school, a cousin who practices alternative medicine, and their best friend, a lawyer. My advice is this: give them the antibiotics and ensure follow-up. But let them know that for further regular medical care they will need to find a physician in whom they have more confidence.