Reducing antibiotic prescriptions for children with coughs: who to target?

head shot  By Christie Cabral

Do parents want antibiotics when a child has a cough?  I’ve spoken to a lot of parents over the past five years and pretty well all of them say they would really rather not give their child any kind of drug treatment.  Yet the belief that parent demand for antibiotics is an important driver of antibiotic over-prescription is very persistent among clinicians and policy makers.

Over-prescription of antibiotics is a serious issue as it contributes to the problem of rising drug-resistant infections.  Considerable effort is going into trying to reduce over-prescription of antibiotics.  However, figuring out where best to target that effort is not always that straightforward.  The TARGET research programme and related Conker project investigated what influences antibiotic prescribing for children with coughs.

The parents we talked to in our study worry about the impact of any kind of medication on their child.  Many express fears around overdosing with child paracetamol and ibuprofen and believe that antibiotics should only be given if really needed.  All of this supports a general preference for not giving children any pharmaceutical treatment at all.

So that sounds like good news – parents don’t want antibiotics, problem solved; right?  Well of course the reality is messier than that.  Parents do want antibiotic treatment if they think it’s going to make a difference, to help their child to get better or to suffer less.   The key influence on parental expectation of antibiotic treatment is experience of antibiotics being prescribed for something similar in the past.  Often when antibiotics are prescribed, there is little explanation of the reasons, leaving parents to develop their own ideas about what symptoms indicate a need for antibiotic treatment.  These ideas are shared and reproduced within communities.  We have created an animation which shows how this happens.

The animation also illustrates a doctor’s point of view.  The doctor’s main concern is making sure they don’t miss a child with a potentially life threatening infection.  I think we would all agree that this is a good top priority.  However, because there is currently no definitive way of identifying children who may develop a serious illness from those who are poorly but will get better, doctors have to use their judgement to decide which ones to treat.  Most of the time, clinicians are able to judge confidently, but in a minority of cases there remains some uncertainty.   This is where the problem lies.  Faced with clinical uncertainty, many doctors will prescribe antibiotics in the belief that not only is it safer for the child in front of them but it also protects the doctor from the potentially serious medico-legal consequences of ‘missing a sick child’.

Reducing over-prescription of antibiotics for children with a cough is a challenging problem. Our research found that current antibiotic prescribing practices by doctors are a key influence on parental expectations (rather than the other way around).  Enabling doctors to change their practice will be a key part of the solution.  There is a need for basic science to help reduce clinical uncertainty, but we are still a long way from eliminating this.  In the meantime, there is a role for social science research in understanding how clinicians deal with uncertainty and how a different balance might be struck between the immediate risks to the patient and doctor and the wider risks to all of us from drug resistant infections.

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