TORONTO - Acting on incorrect beliefs about the nature of upper respiratory infections (URIs) and antibiotic therapy, some child care center directors inappropriately suggest that children in their care receive antibiotics for URIs, according to a recent study. Such practices may contribute to the growing problem of antibiotic resistance.
Canadian researchers found that child care directors both directly suggest to parents that their child start antibiotic therapy, and indirectly encourage it by accepting children on antibiotics into the center who otherwise would have been excluded because of their illness, according to the Archives of Pediatric and Adolescent Medicine.
Eighteen percent of 34 child care providers required that antibiotic therapy be started before a child can return to the center. Lack of understanding about antibiotics and URIs was significantly more likely to be associated with requesting antibiotic therapy for sick children before allowing them to return, the study indicated.
"This article confirms that day care center directors do contribute to increased doctor visits and pressure for use of antibiotics based on a poor knowledge base about infections and the efficacy of antibiotics," said Elaine Wang, MD, CM, of the Hospital for Sick Children, Toronto, and the senior member of the study team.
"An estimated 3.9 million children younger than age 6 in the United States attend child care centers," said Jay M. Lieberman, MD, chief of pediatric infectious diseases at Miller Children's Hospital, Long Beach, Calif. "This puts them at increased risk for a variety of infectious diseases and increases the likelihood they will get antibiotics. Physicians sometimes get pressured by parents to prescribe antibiotics for their child. This report highlights a potential source of pressure on parents to have their child get antibiotics."
--- "Better education of child care workers could be implemented
through an educational requirement of day care workers as part of obtaining day
care licensure." - Elaine Wang, MD, CM
The researchers telephoned 36 licensed child care centers in Ontario. Directors were asked their reasons for excluding diapered children with URIs as well as their criteria for physician referral or antibiotic use. The directors were asked about the details of the most recent occasion of staff excluding a child with a URI. They were also asked questions on general knowledge and attitudes about URIs. Two centers did not give a case scenario.
Many directors (69%) allowed children to stay at the center if they had a prescription for antibiotics, even when they believed they needed home care. Sixty-two percent advised that the child visit a physician and 41% required a period of exclusion.
In response to questions about antibiotics, most directors accurately replied that drugs were necessary for streptococcal pharyngitis (97%), ear infection (94%) and sinus infection (83%). However, some believed they were necessary for bronchitis (83%), cough (39%), nonstreptococcal sore throat (33%), colds (19%) and "flu" (17%). Of 34 staff members, 38% believed that with a nonspecific URI, antibiotics were required to prevent bacterial infection, while 26% believed they would prevent the spread of infection and 21% thought they would speed recovery.
The study showed a stark contrast between child care center practices and official Canadian guidelines, which list only two types of children with URIs excludable by staff: those unable to participate in activities and those whose care would detract from the care of other children. All other exclusion decisions require a doctor's input.
There are, in fact, few URIs that require exclusion on the grounds that the child hasn't started antibiotic therapy, the study pointed out.
Sixty-nine percent of the 36 centers reported having a written policy for the management of children with URIs. The centers' criteria for excluding a sick child included inability to participate in center activities (92%), preventing the spread of infection (67%), or lack of staff to provide adequate care (61%). Ear pain, green or yellow nasal discharge and cough with phlegm were the URI symptoms that most often caused directors to exclude children (64%, 56% and 44%, respectively) or to advise physician referral. Eleven percent reported excluding children based on pressure from other parents. Neither having a written policy nor the size of the center were associated with differences in exclusion or referral practices.
The researchers called for education to correct these knowledge gaps, and more research of features of illness that would help child care workers in the management and referral of sick children.
"Better education of child care workers could be implemented through an educational requirement of day care workers as part of obtaining day care licensure. Such educational interventions should probably be studied in terms of their efficacy," Wang noted.
"As always, education is the key if we are to reduce inappropriate use of antibiotics," said Lieberman.
For more information:
- Skull SA, Ford-Jones EL, Kulin NA, et al. Child care center staff contribute to physician visits and pressure for antibiotic prescription. Arch Pediatr Adolesc Med. 2000;154:180-183.
- National Center for Education Statistics. Statistics in brief: child care and early education program participation of infants, toddlers, and preschoolers. NCES 95-824. October 1996.
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