Annals of Family Medicine Research

Misconceptions About Antibiotics for Children's ARIs Persist

April 04, 2017 09:00 am Chris Crawford

Children typically experience four to 12 acute respiratory infections (ARIs) a year, and many times, they are prescribed antibiotics despite evidence that, at best, the drugs provide only marginal benefits and, at worst, they may actually cause harm.

This led researchers in Australia to explore parents' expectations for and experiences with the use of antibiotics for pediatric ARIs. Their findings appear in a study( in the March/April issue of Annals of Family Medicine.

Researchers conducted an extensive telephone survey between May and July 2014, reaching 401 parents of at least one child between 1 and 12 years of age. The questionnaire used addressed three ARIs: acute otitis media, sore throat and acute bronchitis.

Questions asked parents about their

  • knowledge of and expectations for antibiotic benefits and harms and other treatments;
  • recall of their last medical visit with their child for one of these ARIs (including discussion about antibiotic benefits or harms);
  • experience with shared decision-making; and
  • physician's offer of delayed prescribing (receipt of a prescription with the stipulation that it not be filled immediately).
Story highlights
  • An Australian study explored parents' expectations and experiences using antibiotics for acute respiratory infections (ARIs) in children, with findings published in the Annals of Family Medicine.
  • Researchers developed a questionnaire that addressed three ARIs: acute otitis media, sore throat and acute bronchitis, and conducted an Australia-wide telephone survey reaching 401 parents of at least one child ages 1-12 between May and July 2014.
  • The authors' principal findings were that most parents think antibiotics are needed for their children's common ARIs (particularly acute otitis media), and parents have a number of misperceptions about perceived benefit and need.  

The authors' principal findings were that most parents think antibiotics are needed for their children's common ARIs (particularly acute otitis media) and that they have a number of misconceptions about perceived benefit and need.

"Parents grossly overestimated antibiotic benefits on illness duration, which largely matched the minimally important effect of antibiotics that parents nominated as required for antibiotics to be worth using," the study said. "Nevertheless, many were aware of potential harms from antibiotics, with some inaccuracies in knowledge identified."

Study Findings

The authors found most parents thought antibiotics provide benefits for common ARIs -- specifically, for acute otitis media (92 percent), sore throat (70 percent) and cough (55 percent) -- most commonly saying the drugs treated the infection and killed bacteria.

On the other hand, some parents thought that not using antibiotics, at least sometimes, was an option, particularly for cough (99 percent) and sore throat (97 percent), but less so for acute otitis media (61 percent).

For parents who thought antibiotics were necessary to treat these acute conditions, the most common reason they gave for that belief was that the illness wouldn't resolve without treatment.

Regarding the minimum reduction in duration of illness parents would want before considering antibiotic use, the answers they gave actually exceeded evidence-based estimates by a staggering five to 10 times.

A large majority (78 percent) of parents recognized antibiotics may do harm, including by contributing to antibiotic resistance (49 percent); however, some incorrectly defined exactly what "resistance" meant.

Importantly, fewer than half of those interviewed (44 percent) recalled discussing why an antibiotic might be used with their physician during their most recent visit for a child with an ARI, 72 percent recalled little or no discussion about why antibiotics might not be used, and 78 percent did not remember any discussion about possible antibiotic harms. Nearly all (93 percent) respondents wanted to be involved in future decisions about antibiotic use.

Finally, almost 60 percent of parents recalled being given an antibiotic prescription but being instructed not to have it filled immediately (delayed prescribing). Of these parents, 21 percent filled the prescription, of whom only 18 percent gave the antibiotic to their child.

Importance of Shared Decision-making

Study co-author Tammy Hoffmann, Ph.D., professor of clinical epidemiology at the Center for Research in Evidence-Based Practice, Bond University, Queensland, Australia, told AAFP News she thinks shared decision-making might help bridge the knowledge gap between family physicians and their patients.

"For clinicians, it's about combining their skills in evidence-based medicine with their skills in communication," Hoffmann said, suggesting physicians review an article( she co-authored on this topic in the Oct. 1, 2014, issue of JAMA. "There is reasonable evidence that patients can hear the evidence and understand it well enough to make better informed decisions with the information."

Additionally, she said, evidence shows that successful shared decision-making doesn't require more effort than that expended during a normal office visit.

"And even more important, for acute respiratory infections, there is evidence that (shared decision-making) reduces antibiotic prescribing, and that patient satisfaction with the consultant isn't affected by this," Hoffmann said, referencing a systematic review of trials( published online Nov. 11, 2015, as part of the Cochrane Database of Systematic Reviews.

In another recent research project(, Hoffmann said her team tested patient decision aids (about antibiotic use for ARIs) in a randomized trial.

"Participants who received (the decision aids) had an increase in their knowledge about these issues, as well as an increase in the number who made an 'informed choice,'" she said.

Family Physician's Perspective

Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that when caring for children with ARIs, it's an ongoing challenge to balance parents' desire to help their kids feel better with evidence-based decisions.

"As hard as it can be to say 'no,' family physicians need to remember that by prescribing antibiotics for what is most likely a viral infection, we are putting our patients at risk," she said. "We can't give them a full lesson on microbiology, but we can still try to help them understand in simple terms."

Frost said it's important to validate parents' concerns about their children, letting them know that as their physician, you care about their perceptions and aren't just dismissing them. She recommended explaining that there are different types of organisms that cause infections; antibiotics can help with many infections caused by bacteria, but they don't do anything for infections caused by viruses.

Tell parents and their children antibiotics won't make someone feel better faster, they may have side effects that make them feel worse, and as a family physician, you want to make sure antibiotics still work when the child really needs them, she said.

"Keep it simple and let them know that you care about their child's health, both now and in the future," Frost said. "Give them tips on what they can do to help manage the symptoms until the virus resolves. And reassure them that it will resolve."

Not all parents will be satisfied with this explanation, and some may leave angry; they may even go in search of a physician who will give them antibiotics, she said.

"But we need to move on and repeat to ourselves, 'Do no harm,'" Frost concluded.

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