Lack of Evidence

The Hospitalist. 2009 August;2009(08):

August 1, 2009 | The Hospitalist

Although the foster child population is relatively small (513,000 children in the U.S. were in foster care in 2005, according to the Department of Health and Human Services), the trend seen in this population is concerning. Medco Health Solutions’ 2007 survey of drug trends predicts that prescriptions for medications to treat ADHD will continue to increase at a rate of about 3% per year.3

Another concern is that the use of atypical antipsychotic medications to treat behavioral or bipolar disorders in children could result in weight gain (as it does in adults), which can trigger metabolic syndrome and increased risk of diabetes.

A Florida study that Dr. Zito co-authored demonstrated increased cardiovascular visits to the ED in Medicaid-insured children who had received stimulants.4 “It’s clear that we need to know more about safety and efficacy [of these medications in children],” Dr. Zito says.

A Dose of Education

What can hospitalists do to best treat and inform their patients? Education is key for both the parent and the physician. Parents need the best information possible to make good decisions for their children. Physicians need to stay up-to-date with the research and drug warnings, and dedicate themselves to communicating with families during stressful situations. Here are some suggestions from the experts:

Reinforce the wise use of antibiotics. “Our job is good antimicrobial stewardship, and whenever we talk with parents or consult in the ER, we can try and emphasize the appropriate utilization—and not overutilization—of antibiotics,” Dr. Percelay says.
Reassure and educate parents that such symptoms as fever and cough are the body’s natural defense mechanisms; that the symptoms usually are self-limited; and that there are harms to overmedicating their children, Dr. Shen says. One FDA resource that can be helpful for parents: www.fda.gov/cder/drug/advisory/cough_cold_2008.htm.
Don’t “overinform” families and then feel as if your job is done, Dr. Coghlin advises. “You cannot disseminate patient education information in the same way each time—even for the same people. You must constantly reassess your level of communication with the family and understand how the information is being absorbed.”
Partner with community pediatricians to bridge the knowledge gap, especially in the management of common viral diseases. “It’s really my responsibility,” Dr. Shen says, “to carry back to the community the research knowledge and national guidelines on common inpatient conditions.”
Listen to the concerns of the people—parents and providers—you’re serving, Dr. Coghlin says. If you have a difference of opinion regarding the institution of therapies, do not just arbitrarily announce your dissent; show respect for the provider’s level of expertise. Expressed with tact, your opinion is more likely to be respected. You must realize, however, that changing beliefs and mind-sets on prescription medicine will not occur overnight.—GH

The Parent Trap

Daniel Coghlin, MD, a general pediatrician for eight years and now a pediatric hospitalist at Hasbro Children’s Hospital in Providence, R.I., believes parents’ expectations of their physicians—and medications—often are too high. Many think the doctor should provide a solution to all of their children’s illnesses, and the expected solution often entails a prescription.

Does parental pressure influence prescribing patterns? One study showed that pediatricians would prescribe antimicrobials 62% of the time if they thought the parents wanted them—even for a presumed viral illness.5

Dr. Shah points out that physicians might misunderstand the parents’ expectations; he suggests having a frank discussion about efficacy of antibiotics. “Studies have also shown that if the physician explains that antibiotics won’t work against viruses, that there is no benefit but there is potential harm, [then] that’s an answer that’s acceptable to most parents,” he says.