The Overuse of Antibiotics for Viral Infections in Children

“For every complex problem there is an answer that is clear, simple, and wrong.”

-H. L. Mencken

This approach is not endorsed by the American Academy of Pediatrics.

As I sit in an apartment full of unpacked boxes and grumpy children, only a few days removed from driving 1,600 miles to a 3rd floor walk-up and a better life just outside of Boston, I find the task of writing a post somewhat daunting. But I must admit that this new town is not without the potential for inspiring future musings. In fact, I find myself surrounded by irregular medicine of all shapes, sizes and dilutions.

Next door is a chiropractor who cures Tourette’s syndrome and, according to the pamphlet available outside the clinic entrance, only uses the in-house x-ray machine on select patients who truly need it. A few buildings down from me is an acupuncturist that treats athletic injuries with ear acupuncture and Kinesio-tape while liberally sprinkling references to his practice of “sports medicine” and “orthopedics” throughout the clinic’s promotional material. But at least I was reassured that acupuncture is completely harmless because it is a natural medicine. Finally, a block further down the road, completing my welcome committee of woo is a clinic that uses homeopathy to treat just about every real and fictional condition under the sun. I checked out their website and it’s a good thing that the walls are well insulated or my neighbors would have surely been forced to ignore the sound of my forehead pounding a wooden desk like a flagellant monk hoping for divine intervention.

So for the sake of time and sanity I am aiming at some pretty low-hanging fruit with this post. How low you ask? The inappropriate prescription of antibiotics for apparent viral infections is listed first on the American academy of Pediatrics contribution to the Choosing Wisely campaign. I’ve mentioned Choosing Wisely briefly in a prior post but it was explained in a little more detail in a discussion by SBM’s own science-based drugslinger Scott Gavura a little over a year ago. I of course mean that term in the cool, Roland of Gilead from The Dark Tower novels sense that I hope he appreciates.

Sadly it seems as if the campaign has been largely ignored since awareness of it appeared to peak in February when 17 groups, the AAP being one of them, contributed lists of clinical no-noes. And there has even been some backlash as well that frankly I find rather silly. Hopefully, there are plans in place to ramp up public and physician awareness in the near future.

One criticism that certainly isn’t valid is that the issues raised by the AAP aren’t pertinent to real world practice. The AAP went through lengthy process to determine their “Five Things Physicians and Patients Should Question”:

The American Academy of Pediatrics employed a three-stage process to develop its list. Using the Academy’s varied online, print and social media communication vehicles, the first stage invited leadership of the Academy’s 88 national clinical and health policy-driven committees, councils and sections to submit potential topics via an online survey. The Second stage involved expert review and evaluation of the management groups that oversee the functions of the committees, councils and sections. Based on a set of criteria (evidence to document unproven clinical benefit, potential to cause harm, over-prescribed and utilized, and within the purview of pediatrics) a list of more than 100 topics was narrowed down to five. Finally, the list was reviewed and approved by the Academy’s Board of Directors and Executive Committee.

So I am confident that they represent concerns that are important, require addressing urgently, and adequately represent the opinions of the vast majority of pediatricians. But are we just talking the talk?

Despite some decent evidence that overall prescriptions for antibiotics in pediatric populations have decreased over the past two decades, the trend appears to have plateaued and fairly widespread overuse is still occurring. This overuse primarily comes in the form of recommending antibiotics for what are in reality self-limited viral infections of the upper and lower respiratory tract and ear infections, which remain the number one diagnosis resulting in a prescription for antibiotics despite the majority of cases resolving without intervention other than TLC or chiropractic care. Misuse, if not overprescription, also comes in the form of writing for newer and broader agents when older and narrower antibiotics are equally, and often more effective, but that is a topic perhaps for another post.

Inappropriate use of antibiotics results in significant unnecessary medical costs, increasing rates of infections with resistant organisms and frequent adverse events ranging from fairly benign loose stools to life-threatening/altering skin conditions (Stevens-Johnson syndrome) and deadly allergic reactions. Antibiotics may have saved countless lives, and hopefully will continue to do so far into the future, but despite what many seem to believe they are not risk free.

So what is the deal with us pediatricians? Why can’t we keep our Hannah Montana brand non-latex examination mitts off of the prescriptions pad every time little Timmy has a runny nose or a cough? Why don’t we listen to the well-meaning experts from the AAP and our own inner voices? To put it bluntly, it’s because medicine is hard. It’s messy, it’s complicated, and it is practiced by humans beleaguered by the same propensity for bias and intellectual laziness as everyone else.

Pediatrics, in my biased opinion, is particularly difficult. Our patients can’t or won’t (teenagers) even talk to us most of the time so we must rely on second-hand accounts of symptoms. Our patients, I admit, don’t tend to get sick as seriously or as frequently as the average adult patient, but there is something fundamentally albeit subjectively different about a gravely ill or dead 9-year-old compared to a gravely ill or dead 90-year-old. Maybe that balances things out. Trust me it’s no picnic for any physician caring for the sick and/or dying, and of course it isn’t really a contest. But you never hear people say that it was just Timmy’s time and that he lived a good life, or that he did it to himself with lifestyle choices.

There is also something very different about dealing with a parent. Again, kids tend to be pretty healthy, and the most common ailments are usually self-limiting. Obviously there are many exceptions but children usually just get sick but not sick-sick, as the kids like to say. At least I think that they say that. I’m pretty sure some kids say that but I’ll need to re-watch season 3 of Good Luck Charlie to be certain. Very few of my patients watch Game of Thrones or even The Sopranos. This is the life I chose.

One of my favorite broken-record-quotes that rarely will fail to elicit groans of familiarity from the nurses during teaching rounds is that kids will usually get better despite what we do, not because of it. But parents often don’t see it that way. Many parents seem to interpret every sign or symptom as a distant but rapidly approaching death knell. Thus it can be considerably more difficult to explain why it is better to do nothing rather than something and to dispel the assumption that we are gambling with their child’s life. “Don’t just do something, stand there”, that’s another good one. “Masterly inactivity” is too. Somewhere a pediatric nurse I’ve worked with just rolled his eyes.

Then there are times when it seems as if our patients’ parents are evenly split between folks who present a list of demands and folks who refuse to end their cell phone conversations while you try to take a history or give treatment recommendations, but I admit that there is likely some selective recall bias at play here. Many parents are just scared and uncomfortable with a “wait and see” approach. But while I recognize the pressure that parents place on pediatricians and the reality that prescription writing patterns can be influenced by that pressure, I personally refuse to accept that it is a valid excuse for overprescription of antibiotics. One of many possible reasons perhaps, but not an excuse. Ultimately it is our signature on the pad, not the parent’s.

I hear a lot of talk about defensive medicine from my colleagues and the media but I don’t buy it as a major motivator either, at least not for the overprescription of antibiotics. More of a post hoc rationalization perhaps, but maybe that is a narrow perspective based on my own pediatric experience. There are far too many other more reasonable culprits in my opinion.

I doubt that any pediatricians set out to overprescribe antibiotics. Yet I personally am unaware of any pediatrician, including myself, that has never at some point in their career knowingly prescribed an antibiotic for what they were fairly confident was a viral process. I don’t believe that any of us is above reproach in this regard. I do know many pediatricians, however, that will pick their battles, recognizing when to just write for what the parent wants and when to stand their ground, with the latter being significantly more common.

As a hospitalist I tend to discontinue antibiotics as frequently as I start them and I’ve made many parents uncomfortable doing it. I’ve made my partners uncomfortable at times. But there have absolutely been occasions where, based on the specifics of the case and my interactions with the family, I have agreed to continue what I felt were unnecessary antibiotics.

Some pediatricians, unfortunately, drift towards the other end of the spectrum. There are bad pediatricians just as there are bad plumbers. The first pediatrician I shadowed during medical school had prefilled prescriptions for Augmentin (a broad spectrum antibiotic commonly prescribed for upper respiratory infections) that he gave out at almost every sick visit. I remember cringing at the intellectual contortions he worked himself into when coming up with reasons to hand that barely legible chicken scratch-covered piece of paper over to the caregiver with a smile. “Just in case” was his favorite excuse though. And in pediatrics, at least with new prescriptions, adherence appears to actually be pretty decent. Close to 90% of those antibiotics were probably taken, or at least started.

I think that extreme cases like this are an exception. We certainly don’t learn to treat viruses with intramuscular ceftriaxone in residency, often for fear of being taken to task by an attending or questioned into submission by a fellow resident or ambitious medical student. We learn good evidence-based practice and conserving antibiotics is a major part of our educations. So what goes wrong?

For some, I believe it is a path of least resistance that is taken after some time practicing in the real world. It is easier to do something rather than nothing. It is easier to write a prescription than to give reassurance and detailed instructions on expectant management. It is easier to treat than to learn how to accept, deal with and communicate uncertainty, skills which are not necessarily honed during medical training.

How long it takes an individual practitioner to fall into the unfortunate pattern of handing out antibiotic prescriptions for nasal drainage that looks “a little yellow” depends on many factors. Without more senior members in a practice that are supportive of antibiotic stewardship and science-based practice, for instance, it can be very difficult for recently graduated residents practicing without a safety net. Involvement with a local academic hospital, or with teaching students/residents, and constant effort to maintain one’s fund of knowledge and familiarity with current practice guidelines are all protective as well. But that takes a considerable amount of time and energy, things which many pediatricians have dwindling supplies of as they struggle to juggle work and family.

So while there are exceptions, I firmly believe that the most compelling and by far the most common reason why pediatricians write antibiotic prescriptions for viral infections is that they think that they are treating a bacterial infection. It is as simple as that. Naturally, the explanation for why we might think this is quite complex.

Sometimes it is impossible to tell the difference between viral and bacterial infections based on symptoms alone. Viral and bacterial pneumonia, for example, can present in a pretty similar manner in the average 15-month-old child: high fever, cough and infiltrates on a chest x-ray. Group A streptococcal infection of the throat (“strep throat”) is virtually indistinguishable from viral pharyngitis. 14 days of persistent runny nose and intermittent fever can be caused by acute bacterial sinusitis or back-to-back colds. These are just a few quick examples.

If the patient actually has strep throat or pneumococcal pneumonia rather than a viral mimic, the patient will generally get better more quickly, avoid potentially deadly complications and show up for the next well check if they are prescribed a course of an antibiotic. If it was a virus all along, the patient will also get better and no one will be the wiser for it. Either way, the parent will be happy with the care their child received.

The negative aspects of overprescription are unlikely to make a significant impact on the practice of an individual pediatrician. Parents have become conditioned over the decades to expect their child to have a little diarrhea or upset stomach while taking an antibiotic so it doesn’t really register as a reason to avoid antibiotics unless truly necessary. And despite the potential for serious complications when looking at large populations, the risks to any one child of a serious allergic reaction, an idiosyncratic process like Stevens-Johnson, or infection with Clostridium difficile remain pretty low. Resistance issues also don’t tend to affect the individual pediatrician in the office enough to serve as punishment for sloppy practice. They affect me in the hospital however.

So it is easy to see how a pediatrician can, over time, develop a nasty habit of handing out antibiotics carelessly. In order to avoid falling into the habit of prescription creep, a pediatrician can sometimes rely on the rational use of testing in certain clinical scenarios, such as the rapid detection of Group A streptococcal antigens. But more often than not determining the source of an infection comes down to historical variables and exam findings.

Pediatricians need to trust their clinical skills and be comfortable following evidence-based practice guidelines. They need high level critical thinking skills. They also need to be expert communicators and educators, with the ability to convince a distraught parent that antibiotics are not always the answer and that often watchful waiting is safe and appropriate. Not every pediatrician is capable of this but it doesn’t mean they can’t improve their skills and increase their prescriptive accuracy. There are many resources available to do just that.

There will always be some degree of overprescription of antibiotics. It isn’t realistic to expect us to get it just right, although people are working on it. There are many scenarios in pediatrics where a “shoot first, ask questions later” approach is justified. There is certainly room for much improvement and educating the public to question the use of antibiotics is probably the key to achieving this. If we can get parents to simply question why their child is being prescribed an antibiotic and if it is truly necessary it will make a big impact. Hopefully efforts like Choosing Wisely will gain more momentum.

So there you have it. A solution to a complex problem that is fuzzy, complicated, full of excuses and thus almost certainly correct…sort of.

Speaking of changing parental behavior, here is some good information from the AAP and Choosing Wisely on when kids need antibiotics for sore throat, cough, or runny nose and when they don’t.

Posted in: Medical Ethics, Science and Medicine

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26 thoughts on “The Overuse of Antibiotics for Viral Infections in Children

  1. Not sure this is of any value as my kids are now in 30’s and (gulp) 40’s, but it was the doctor who insisted on the antibiotics for sore throats (might be strep, why wait for the culture?) and ear “infections” (he could go deaf you know).

    I’m sympathetic to the dilemmas faced by the medical profession and relieved that my kids are grown. I wonder if we can’t develop quick result tests to determine virus from bacteria? Apparently not.

    1. Clay Jones says:

      One of the links in the post was to some research on testing to do just that, but it is preliminary and imperfect. Definitely far from ready for prime time if it will ever be.

    2. Dr. Roy says:

      There are quick tests that doctors can and do use. These tests take 10 minutes, and are billable. Some document a viral infection (eg a quick flu test, mono test, or test for rotavirus) and some document a bacterial infection (eg quick strep test.) None are 100% accurate, but they’re all good, and they’re overall far more reliable than clinical judgment.

      However, often the results are ignored. I see kids all the time who went to urgent care, got a negative strep test, and were treated with antibiotics for strep “just in case.”

    3. cheshbitten says:

      I was about to say the same thing about doctors I dealt with as an adult. There have been a number of times when I went to the university campus doctors to get a medical certificate so that I could go back to bed knowing that I could worry about assignments when I didn’t feel like microwaved death. I could not convince the doctors to not perscribe me antibiotics for colds and just got into the habits of throwing the scripts out.

  2. Art Malernee dvm says:

    I have treated thousands of ear infections in dogs but never a viral ear infection. What % are viral? It must be tough to tell if ears are the only symptoms.

    1. Clay Jones says:

      In children, otitis media will resolve without antibiotics in the vast majority of cases. We recommend treating them in some populations or if particularly severe but there is a huge issue with pediatricians following the expert guidelines regarding this. There is still rampant treatment of soft call ear infections in older kids that really should be allowed to get better on their own. I personally am a big fan of a SNAP approach or Safety Net Antibiotic Prescription. You give the parent a script that is only good for a few days and discuss filling it if symptoms worsen or do not improve after 24-48 hours. Most of them aren’t filled.

      1. Nancy Brownlee says:

        Having suffered through many fiendishly painful inner-ear injections in my childhood, with perforated ear drums and midnight wakenings with pus-and-blood-soaked pillow, I have moderate hearing loss, and I was reluctant to subject my kids to the same ‘wait-and-see’ treatment. One of them seemed to have an almost continuous ear infection until he was 3 years old and little drainage tubes were inserted. The other child had mild/moderate asthma, and several viral pneumonias for which his allergist always prescribed prophylactic antibiotic, because the viral pneumonia set him up for a bacterial one.

        I do wonder, now, about the discouragement of antibiotic use in these common childhood ailments. Every pediatrician must surely see kids who’ve gone too long without treatment, as well as the kids whose parents insist on treatment for everything. What are the criteria?

      2. Now I think about it, this is what happened with my youngest (who is 18 years younger than my eldest). I don’t think I ever filled one of those short-term scripts.

      3. Alia says:

        When I was a kid, I used to suffer from otitis media a lot. It seems to me now as if every other cold enden in ear infection. At these times my mom used to warm a large swab of cotton wool with an iron and then I would hold it next to my poor, painful ear. I’m not sure if there is any science-based rationale to that but at least she felt she was doing something and I derived some comfort from that. And (which might have something to do with being a nurse on pulmonary ward – she knew what antibiotic-resistant tuberculosis looked like) she tried to avoid antibiotics as long as possible, so I didn’t get them often as a child.

        BTW, what would you say about a doctor who prescribes 500mg of azithromycinum (once a day for three days) for almost every respiratory infection? I know one, her patients love her but I’m not so sure.

        I’m also really sorry for the kids treated by the Augmentin doctor. I think I’ve already written here about it but one of the most miserable nights of my life was the one following a course of Augmentin (prescribed by a dental surgeon following an invasive wisdom tooth excision).

        1. Clay Jones says:

          Azithromycin use like that is a big red flag for either not keeping up with the evidence or simply not caring. The predominant organism that causes bacterial upper and lower respiratory infections is strep pneumoniae. Azithromycin has terrible coverage of it. It does not cover h flu. It does not cover anaerobes. There is even resistance with group a strep which famously is 100 percent sensitive to penicillin still. I use azithro for older children with classic signs and symptoms of atypical pneumonia and for cat scratch and I feel kinda dirty even doing that because both will probably get better without antibiotics.

          1. Dr. Roy says:

            Completely agree w/ Clay. Azith (when first released) was an excellent antibiotic, and so handy to use. Everyone loved it. Now it barely treats anything useful. As Clay said, atypical (sometimes called “walking” pneumonia), pertussis, some kinds of traveler’s diarrhea. That’s about it. It’s certainly not a good choice for otitis/sinusitis/strep pharyngitis/mystery URI.

          2. Alia says:

            Thanks for the answer about azithromycin, I will bear it in mind – and will probably choose another doctor the next time I get something more serious than a cold.

  3. mousethatroared says:

    Great article on the difficulties of dealing with pediatrics, antibiotics and Good Luck Charlie (if you think that’s bad, watch ICarly – urgh).

    Sorry, but I’m going to take a moment to gripe from a parent’s perspective. As a parent, sometimes I feel I can’t win when it comes to disappointing folks with the antibiotics my child do (or don’t) receive. My mother-in-law (retired nurse) puts on her “concerned” (actually disapproving) face every time I bring home a child from the pediatrician with the news that they’ve got a virus and we’ll just have to wait it out.

    Then the young pharmacist looks at me disapprovingly and inquires as to my son’s symptoms when I go in to fill my son’s script for antibiotics drops and oral medication for an ear infections. She is not aware that my son has some craniofacial differences that predispose him to ear infections and hearing loss. It would be nice if she reserved judgement until receiving all the relevant medical information.

    I’m happy that I seem to be on same page as our pediatrician (and pediatric ENT) as to antibiotic usage…but I wish everyone else would just trust us.

    1. calliarcale says:

      That’s an interesting perspective, on wanting to be trusted. I know where you’re coming from, but on the other hand . . . my perspective is in engineering. And, more specifically, configuration management in a high reliability organization. This has conditioned me to distrust anyone who implicitly trusts me, considering that to be a sign of poor judgement. ;-) In engineering, that is actually reasonable — W Edwards Deming famously said, “In God we trust, all others must bring data.”

      1. mousethatroared says:

        @CalliArcale – my comments today seem to be disappearing into the ether…I’ll try again. Apologies if there ends up being a double post.

        You make good points. But, I guess my problem is not so much with people questioning me and my doctor’s decisions, as a curious (or nosy) person I will often question folks about their medical conditions and care in a friendly way, as long as they seem open to the discussion. My problem was with the knee-jerk disapproval based on incomplete information. I feel that if a person either does not have access to all the relevant information or doesn’t have the time or energy to search it out, they should reserve judgement. I guess one could say “Trust me with my responsibilities, unless the data shows otherwise.” :)

        Not that I can’t stand-up to some disapproval, but I feel particularly uncomfortable with a pharmacist acting disapproving of a doctor’s recommendation to a parent without knowing the particulars of the case.

  4. kurt youngmann says:

    Clay states: “In children, otitis media will resolve without antibiotics in the vast majority of cases.”

    Isn’t the rate of resolution without intervention somewhere over 90%? That’s a great “out” for the quacks (like pediatric chiropractors) who claim to have huge success treating kids with ear infections. They’re guaranteed an automatic success rate right off the bat simply because most kids are going to get better no matter what!

    The danger, as I see it, is for the cases that don’t resolve on their own. These are the kids who, if they’re “treated” by chiros, have greater risk for permanent hearing impairment.

    Someone please correct me if I’m wrong.

    1. Carol Covill says:

      You are absolutely correct. That’s 10% that don’t get better, and why that decision has to be made by someone who knows when to hold them and when to fold them.

    2. Clay Jones says:

      Yep Kurt, pretty much anything can look like a cure for childhood ear infections. There are a host of potential complications when improperly managed and chiropractors are not trained to recognize them, and could not treat appropriately if one came up. The fact that so many sick visits in pediatrics are for conditions that resolve on their own or with minimal interference from us is a perfect set up for irregular medicine folks to look like they know what they are doing. I’m not surprised at all that they think they can serve as primary care docs for kids. They just don’t don’t what they don’t know.

  5. Dr. Roy says:

    Another, more odious incentive to over-prescribe antibiotics is financial.

    It is much quicker to prescribe than explain why you don’t think a prescription is necessary. And worse than that: antibiotic prescriptions, in a sense, are addictive. Parents who grow to expect them are trained to go to the doctor for every sore throat and runny nose, to get their prescriptions. More encounters, more income. And these encounters are quick, and end with a satisfied customer that will fill out a positive review for the bean counters and many physician-tracking sites.

    All of us practicing peds know the doc in town who sees 60+ kids a day, puts them all on antibiotics– and has legions of happy customers referring more business to him.

    Teaching parents when they don’t need antibiotics– and, in a way, don’t need to come to the doctor– ends up costing the physician money. Who’s got the guts to address this reality?

    1. Carol Covill says:

      Not only that, the patient then goes next door and gets the Rx, and tells his or her friends that all you did was “talk”. But we have to keep trying.

    2. mousethatroared says:

      I have to question whether this dire scenario is accurate, at least in my region. My children’s peditrician and the others I’ve seen in the practice have diagnosed viral infections and instructed me to use comfort measures only, numerous times. They appear to have a thriving practice. Their onlines reviews are excellent. Not only this, but I’ve never heard a local parent complain about a pediatrician, in terms of not “treating” an “infecton” and I’ve never seen a friend who is a parent on FB gripe about a doctor not “treating” an illness…although I do see many “oh no, we’ve all got a virus” complaint. I occassionally see a guilty – “I feel so bad, “Alice” has been sick for several days and I only just now took her to the doctor and found out she had strep.”

      This is not to say that some parents don’t push for antibiotics. I’m sure they do. But, our pediatrician(s) approach seems very similar to what Clay Jones and Choose Wisely advocates and they seem to be doing fine pulling in patients.

      1. Dr. Roy says:

        I’m glad to hear that, mouse. This may be a regional thing, or reflect the expectations in some neighborhoods.

        Ironically, the best overall prescribing data is probably that collected by the pharmaceutical firms for use by their reps to influence doctor behavior. But I don’t see them using their data to help identify and address areas or doctors who over-prescribe.

      2. Clay Jones says:

        Well there are regional differences. My experience with local pedi’s in Baton Rouge was considerably worse than in Nashville for instance. Also there is a big problem with urgent care and adult emergency department practice in regard to pediatrics.

  6. In my 27 years as a pharmacist, rampant over-prescribing of ABs has been a pet peeve. Much as I love our single-payor government healthcare system here in Canada, it does allow people who are so inclined to doctor-shop, so if their PCP doesn’t give them an AB, they go doctor to doctor until they get the Ceclor they feel their child “always needs” when they get an upper respiratory tract infection.

    And don’t get me started on walk-in clinics, which are basically antibiotic prescription mills, their waiting rooms filled with people queuing up for AB rxs for their self-limiting viral infections.

    I can understand the messiness of trying to discern between viral and bacterial infections. But many doctors don’t even seem to try, just giving ABs to all comers.

    1. Clay Jones says:

      I purposefully left urgent care and emergency room care of children out of this post. It was already overlong and that is a hefty topic, but I have serious concerns myself.

  7. Birdy says:

    Paediatricians have my sympathy and admiration for what they put up with. As a mom who tends to prefer watchful waiting, I get chewed out by friends and family for it. Not that I have anything against antibiotics when needed but for my kids, the side effects are often erm… crappy much longer than the illness would be, so we avoid them if possible.

    I recall once hearing a mother shouting quite loudly at a clinician in a walk-in clinic that her child ‘always gets a prescription from Dr D when he has a cold!’ I was in the waiting room and I could hear her. I have also, however, had doctors give me incredulous looks when I refused ‘just in case’ prescriptions for antibiotics for colds/sniffles/coughs that happened to be going on at the time of a well visit.

    It’s things like that which make me a little nervous about my intentions to go into medicine myself. I imagine it has to be very tiring to deal with a lot of parents who insist on treatment that can’t – or likely won’t – help, knowing they may just go somewhere else to get it if you don’t give it to them, and dealing with other doctors who may be set in their ways about their prescribing processes.

    My son’s paediatrician is incredible, though, I must say. She has really made patient/parent education a priority and will even take time to discuss the research so I’m confident about my decisions. I really like her (and I think she reads SBM. Hi Dr B!) I’m doubting that sort of detail is feasible for most paediatricians though, given time constraints, but it’s very helpful as a parent.

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