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March 5, 2001
A Note from the Doctor

ast 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 mucus.

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 taking antibiotics.

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 crash course.

*Names and identifying characteristics have been changed to protect patient confidentiality.

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Lisa 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.