March 5, 2001
Note from the Doctor
week, a patient I'll call Jody* came in with her mom. I'd seen this
little girl practically every other week throughout the winter.
First Jody had a cough. Then she caught a stomach virus and had
diarrhea for a week. Last week, Jody had a runny nose with green
Room to Grow
By Lisa M. Asta, M.D.
Jody's mom was at work when she called me. According to Jody's
child care provider, Jody didn't have a fever or a cough. She was
eating and drinking well, and her energy level was good. I told
Jody's mom it sounded like another cold and offered to write a note
for the day care center. Jody's mom explained that the day care
was very strict: Jody couldn't return unless she had seen a pediatrician.
I felt bad for Jody's mom. One day of green nasal discharge doesn't
usually indicate a need for a doctor's visit. Kids with colds usually
go through a period when they have green mucus. The mucus starts
clear, then changes to a cloudy white, then to yellow or green,
and back through white to clear again. A child whose nasal discharge
stays green or yellow for ten days or more may have a sinus infection
and require antibiotics, but these cases are definitely in the minority.
Jody's mother had to leave work, pick up her daughter, and come
to my office. Jody didn't have a fever, and her ears, throat, and
chest were clear. I recommended fluids and a decongestant. Jody's
mom said day care wouldn't take Jody back with a green runny nose
unless she was on antibiotics. We discussed the difference between
a cold and a sinus infection and agreed that Jody didn't need antibiotics.
I wrote a note for the day care center explaining that Jody's runny
nose with green mucus didn't require a prescription.
Although I hoped the note would do the trick, I learned years ago
that day care centers set their own policies for dealing with sick
children. And unfortunately, some child care providers don't have
the most accurate understanding of common illnesses. A study published
in the Archives of Pediatric and Adolescent Medicine in February
2000 found that 78 percent of child care workers surveyed believed
a child with green or yellow mucus should see a physician. More
than half of such workers wouldn't allow children with a green or
yellow runny nose to be in day care.
One quarter of child care workers questioned believed,
erroneously, that antibiotics were useful for common colds;
nearly as many believed that antibiotics sped recovery
from a cold.
More troubling than the tempest over colored mucus, however, were
the same child care workers' beliefs about antibiotics. One quarter
of those questioned believed, erroneously, that antibiotics were
useful for common colds; nearly as many believed that antibiotics
sped recovery from a cold. A full 69 percent reported that they
would allow a sick child back into the center if the child had begun
Parents inadvertently heap pressure on child care providers when
they complain that to a day care that their child is sick again.
Such parents blame their child's illness on the day care center,
and they're partially right - kids exposed to sick kids will get
sick. Children can be contagious for up to two days before showing
any signs of illness, so it's impossible to prevent most viral infections.
But parents who use up their own sick leave in caring for their
child's multiple colds can't afford to be philosophical about kids
and infections. Child care providers, in response to complaints,
may tighten their infection-control policy. Visits to the doctor,
like the one Jody and her mother made, become mandatory because
the day care wants to be able to assure other parents that the sick
child has seen a doctor. The result, however, is that parents lose
time away from work for additional doctors' visits, and antibiotics
can be overprescribed.
According to a study published in Pediatrics in January
2001, the solution to the overuse of antibiotics (and perhaps to
the green-mucus hysteria as well) lies in education. Specifically,
a group of researchers gave parents both verbal and printed information
about the alarming rise in bacterial resistance, and about the appropriate
use of antibiotics. As a result, these parents learned exactly when
antibiotics are appropriate. Compared with those who didn't receive
this information, the informed parents had realistic expectations
about the prescription of antibiotics.
Such studies show that there is work to be done both at home and
at child care centers. The American Academy of Pediatrics and the
Centers for Disease Control and Prevention have been educating the
public about viral infections, resistance, and the proper use of
antibiotics. Every parent and child care provider should take a
and identifying characteristics have been changed to protect patient
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M. Asta, MD, FAAP, is a board-certified pediatrician and a fellow
of the American Academy of Pediatrics. Dr. Asta graduated from the
Johns Hopkins University and Temple University School of Medicine.
She trained at St. Christopher's Hospital for Children in Philadelphia,
Pennsylvania. She is an assistant clinical professor of pediatrics
at the University of California San Francisco School of Medicine.
She practices in Walnut Creek, California.