When your child is unwell, has ongoing symptoms, or needs specialist care, it is natural to wonder whether to use NHS paediatric services or see a private paediatrician. As a parent, you want your child to be assessed by the right doctor at the right time, with clear and reliable advice.
Both NHS and private paediatricians can provide high-quality care. The main differences are usually in how you access the service, how quickly appointments are available, how much time you have during the consultation, and how follow-up care is arranged. You may find these practical differences influence your decision.
NHS paediatric services are an essential part of the healthcare system and are designed to provide specialist care based on clinical need. Private paediatric care, on the other hand, often focuses on quicker access and more flexible appointment options. Both approaches can support your child’s health in different ways.
This guide explains the differences in a balanced and practical way. The aim is not to suggest that one option is better than the other, but to help you understand which pathway may be more suitable for your child’s needs at a particular time. It is about choosing the right care in the right situation.
What Is a Paediatrician?
A paediatrician is a doctor who specialises in the health of babies, children, and young people. They assess, diagnose, and treat a wide range of childhood health concerns, from common everyday symptoms to more complex medical conditions.
Children’s health is different from adult health, and symptoms can appear in different ways depending on age. A baby, toddler, school-age child, and teenager may all show similar issues differently, even when the underlying cause is the same.
A paediatrician takes a whole-child approach when assessing health. This may include reviewing growth, development, feeding, sleep, behaviour, family history, school life, and how symptoms are affecting daily routines. This broader view helps build a clearer understanding of your child’s overall wellbeing.
What Is an NHS Paediatrician?
An NHS paediatrician works within the National Health Service. Your child may see an NHS paediatrician through a hospital, community paediatric service, outpatient clinic, emergency department or specialist children’s service.
In most non-emergency situations, your child will usually need a referral from a GP or another NHS healthcare professional. The referral is then reviewed, and your child may be placed on a waiting list depending on urgency and local service availability.
NHS paediatric care is an essential part of children’s healthcare in the UK. It supports children with both common and complex medical needs, including urgent problems, long-term conditions, developmental concerns and specialist hospital care.
What Is a Private Paediatrician?
A private paediatrician is also a qualified doctor specialising in children’s health, but they see patients through private healthcare rather than routine NHS pathways. You may pay directly for the appointment or use private medical insurance if your policy covers paediatric care.
Private paediatric care is often chosen when parents want quicker access to a specialist, a longer appointment, a second opinion or more flexibility around appointment times. It can also be helpful when your child has symptoms that are not an emergency but are still causing concern.
A private paediatrician may assess your child, provide advice, arrange investigations where appropriate, recommend treatment and refer to other specialists if needed. Private care can also work alongside NHS care, depending on your child’s situation.
The Main Difference Is Access
One of the main differences between NHS and private paediatric care is how you access an appointment. With NHS care, you usually begin with your GP unless your child needs urgent or emergency attention. You may find this pathway helpful because it ensures children are assessed and referred based on clinical need.
Your GP will decide whether a referral to an NHS paediatrician is appropriate. If a referral is made, your child may then wait for an appointment depending on the nature of the concern, local waiting times, and clinical priority. This system is designed to prioritise the most urgent cases first.
With private care, you can often contact the clinic directly and book an appointment without waiting for a GP referral. However, some insurance providers may still require a referral, so it is always important to check your policy before booking. This difference in access is often one of the key reasons families choose private care.
NHS vs Private Paediatric Care at a Glance
| Feature | NHS Paediatric Care | Private Paediatric Care |
| Access | Usually requires GP referral (except emergencies) | Direct booking possible in most cases |
| Waiting times | Can vary depending on clinical urgency, local demand and service availability | Often available sooner, depending on clinic and consultant availability |
| Appointment length | Generally shorter, structured consultations | Often longer with more time for discussion |
| Cost | Free at the point of use | Paid consultation (or insurance-covered) |
| Continuity of care | May see different doctors depending on clinic availability | More likely to see the same paediatrician consistently |
| Investigations (tests) | Arranged through NHS pathways, prioritised by urgency | May be arranged faster, but usually paid separately |
| Follow-up care | Based on clinical need and service availability | Easier to book follow-ups with the same doctor |
| Urgent care role | Handles emergencies, hospital admissions, complex cases | Not suitable for emergencies; focuses on non-urgent specialist care |
| Communication | Clinic letters usually shared via GP | Direct written summaries provided to parents |
| Care pathway | Structured national healthcare system | Flexible, consultant-led private pathway |
Evidence Note:
Research on paediatric referrals and service access shows that waiting times, referral pathways and follow-up arrangements can affect how quickly children receive specialist assessment. For parents, this means the choice between NHS and private care is not about one system being “better”, but about choosing the route that is safest, most appropriate and most practical for your child’s current needs.
Referral Pathways: NHS vs Private
NHS paediatric referrals follow structured pathways that are designed to prioritise children based on clinical need. You may find that more urgent cases are reviewed more quickly, while less urgent concerns are placed into routine pathways for outpatient assessment.
For example, a child with serious symptoms may be directed to urgent care, A&E, or a hospital paediatric team for immediate review. A child with non-urgent concerns, such as ongoing tummy pain or recurrent mild symptoms, may be referred for a routine specialist appointment and seen when availability allows.
Private paediatric care is usually more direct. You may be able to book an appointment without a referral, explain your child’s symptoms, and choose a suitable time based on clinic availability. This can make access to specialist advice feel more flexible, especially when you want quicker reassurance or guidance.
Waiting Times
Waiting time is often one of the main reasons parents consider private paediatric care. If your child has ongoing symptoms, delays can feel stressful, especially when the issue is affecting sleep, school, feeding, or daily family life.
NHS waiting times can vary depending on location, speciality, clinical urgency, and overall demand. Some children are seen quickly when symptoms require prompt attention, while others may wait longer for routine specialist appointments.
Private paediatric appointments are often available sooner, although this still depends on the clinic, consultant availability, and the nature of your child’s concern. For non-emergency issues, quicker access can help you gain clarity and reassurance earlier in the process.
Appointment Length
Appointment length is another key difference between NHS and private paediatric care. The amount of time you get with the doctor can affect how detailed the discussion is and how fully your concerns are addressed. This often influences parents when choosing between the two options.
- Shorter Structured NHS Consultations: NHS appointments are usually shorter due to high patient demand. They are designed to be efficient while still covering essential clinical concerns.
- Efficient Use of Time in NHS Care: Doctors focus on the most important symptoms and medical priorities during the visit. This helps ensure more children can be seen each day.
- Longer Private Consultations: Private appointments often allow more time for discussion and detailed assessment. This can be helpful when your child has multiple concerns.
- More Time for Questions in Private Care: Parents can ask more questions and fully understand the diagnosis and care plan. This can help reduce confusion and anxiety.
- In-Depth Explanation of Condition and Plan: Private paediatricians may spend more time explaining test results, treatment options, and next steps in detail.
A longer appointment can provide more clarity and reassurance for parents. However, both NHS and private care aim to deliver safe and appropriate medical advice within their available time.
Continuity of Care
Continuity of care means your child is seen by the same doctor, or a small consistent team, over time. This can be particularly helpful if your child has ongoing symptoms, a long-term condition or repeated health concerns that need regular review.
In the NHS, continuity can vary depending on the service. Your child may see the same consultant in some clinics, but in other settings they may be reviewed by different doctors within the same team. This is often based on availability and clinical scheduling.
In private care, continuity is often easier to maintain because you can usually book follow-up appointments with the same paediatrician. This allows the doctor to understand your child’s history in more detail over time and reduces the need for you to repeat information at each visit.
Investigations and Tests
Both NHS and private paediatricians can recommend investigations when they are clinically appropriate. These may include blood tests, urine tests, stool tests, allergy testing, imaging, or referrals to another specialist, depending on your child’s symptoms and needs.
In the NHS, tests are arranged through NHS services and prioritised based on clinical urgency. This can be particularly suitable for complex or serious conditions where hospital-based care and coordinated specialist input are required.
In private care, some investigations may be arranged more quickly depending on the clinic and available facilities. However, private testing can involve additional costs, so you should always ask what is included in the overall care plan and what may be charged separately before proceeding.
Follow-Up Appointments
Follow-up care is an important part of your child’s treatment, especially when they need review after tests, treatment, monitoring, or changes in symptoms. You may find that the approach to follow-up can differ between NHS and private care, depending on clinical need and service structure.
In NHS care, follow-up appointments are usually arranged based on medical need and availability within the service. Some children may be discharged back to their GP after a single visit if no ongoing specialist input is required, while others may continue under hospital care for longer-term conditions.
In private care, follow-up is often easier to arrange directly with the same paediatrician. This can feel reassuring when your child has ongoing concerns, as you may have a clearer idea of who to contact and what the next steps will be. Consistent follow-up can help you feel more supported throughout your child’s care.
Communication After the Appointment
After an NHS appointment, your GP usually receives a clinic letter outlining the assessment, diagnosis, and management plan. You may also be sent a copy, depending on the hospital or service, so you can stay informed about your child’s care.
Private paediatricians often provide a written summary or clinic letter after the consultation. This typically includes key findings, possible diagnosis, treatment advice, any medication plan, recommended tests, and follow-up instructions. You should be able to refer back to this information whenever you need clarity at home.
Clear written communication is valuable because it helps you remember what was discussed and what the next steps are. It also ensures that any other healthcare professionals involved in your child’s care have a clear and consistent understanding of the plan.
Cost Differences
NHS care is free at the point of use for eligible patients in the UK, which is one of its key advantages. You may find this especially reassuring when your child needs ongoing or urgent healthcare, as it removes financial pressure from decision-making.
Private care usually involves direct payment. You may need to consider costs for the initial consultation, follow-up visits, tests, prescriptions, reports, or referrals. These can vary depending on the clinic and the level of care required.
Before booking a private appointment, it is sensible to ask about fees in advance so you have a clear understanding of what to expect. If you are using private health insurance, you should also check whether consultations, investigations, and follow-up appointments are included in your cover.
Urgent and Emergency Care
If your child is seriously unwell, private routine care is not the right option. In these situations, NHS urgent and emergency services should always be used, as they are designed to manage serious or life-threatening conditions quickly and safely. You should not wait for a routine appointment if symptoms are concerning.
You should seek urgent medical help if your child has difficulty breathing, blue lips, a seizure, severe drowsiness, a non-blanching rash, signs of dehydration, severe pain, or if you feel that something is seriously wrong. Trusting your instincts is important when a child appears significantly unwell.
For life-threatening emergencies, you should call 999 or go to A&E immediately. If you are unsure what to do and the situation is not immediately life-threatening, NHS 111 can help guide you to the right level of care.
UK Safety-Net Note:
In the UK, routine private paediatric appointments should not replace urgent or emergency NHS care. If your child has severe breathing difficulty, blue lips, a seizure, a non-blanching rash, severe drowsiness, signs of dehydration, severe pain, a stiff neck or you feel something is seriously wrong, seek urgent help through 999, A&E or NHS 111.
When NHS Paediatric Care May Be More Appropriate
NHS paediatric care is often the best choice when your child has urgent, complex, or hospital-level medical needs. It gives you access to emergency services, specialist teams, and long-term care pathways when a higher level of care is needed.
- Emergency and Urgent Conditions: If your child has serious symptoms such as breathing difficulty, seizures, severe infections, or sudden deterioration, you should always seek NHS emergency care.
- Hospital-Based Specialist Support: NHS care is essential when your child needs hospital teams, specialist investigations, or multidisciplinary treatment.
- Long-Term Medical Conditions: Chronic conditions such as epilepsy, diabetes, or complex asthma are usually managed through NHS specialist services, where your child can receive ongoing care.
- Structured Care Pathways: NHS systems help ensure your child is referred, assessed, and managed based on clinical urgency and medical need.
- Access to Emergency Departments: A&E and urgent care services are available 24/7 when your child needs immediate medical attention.
NHS care remains essential for serious, urgent, and ongoing medical conditions. It helps ensure your child receives safe, structured treatment when higher-level care is required.
When Private Paediatric Care May Be Helpful
Private paediatric care can be helpful when your child has symptoms that are not emergencies but still need specialist attention. This may include recurring coughs, tummy pain, constipation, suspected allergies, feeding concerns, sleep issues, poor weight gain, headaches, or ongoing tiredness. You may find it useful when symptoms keep returning or are not improving as expected.
It can also be a good option if you want a second opinion, quicker access to a specialist, longer consultation time, or continuity with the same consultant. Many parents choose private care when they feel they need more space to talk through concerns and fully understand what is happening.
Private care is often considered when symptoms are affecting daily life but are not severe enough for urgent hospital treatment. It can help you gain clearer answers, understand possible causes, and decide on the next steps with more confidence.
Can Private and NHS Care Work Together?
Yes, private and NHS care can work together, but it helps to understand how the two systems interact. A private consultation may provide an assessment, advice, or diagnosis, while NHS services are still often needed for urgent treatment, hospital care, or long-term management. You may find that both pathways support different parts of your child’s healthcare.
However, private and NHS care are not always automatically linked. If a private paediatrician recommends an NHS referral or hospital review, your GP may need to help arrange the appropriate referral. This can sometimes take a bit of coordination, depending on your child’s situation.
It is also helpful to keep copies of all letters, test results, and reports. You may need to share these between private and NHS professionals to ensure everyone has the same information. This helps support clearer communication and more consistent care for your child.
Quality and Safety
Whether you choose NHS or private care, quality and safety should always come first. In the UK, you can check that a doctor is registered with the General Medical Council (GMC), which confirms they are licensed to practise and meet professional standards. This gives you an important level of reassurance.
If you are considering a private clinic, it can also be helpful to check whether the service is regulated by the Care Quality Commission (CQC), where applicable. The CQC regulates many healthcare services in England, including independent clinics, to ensure they meet required standards of safety and care.
Alongside official checks, you should also look at the paediatrician’s qualifications, specialist experience, and communication style. You may also want to see whether the clinic provides clear information about appointments, fees, and follow-up care, as these practical details often affect your overall experience.
Consultant-Led Care
Some private paediatric clinics offer consultant-led care. This means your child is assessed by a senior doctor who has completed specialist paediatric training and has significant experience in children’s health.
Consultant-led care can be reassuring when your child has ongoing symptoms, several possible causes or a concern that needs careful review. It can also be useful if you want a second opinion from a senior specialist.
NHS paediatric care can also be consultant-led, especially in hospital settings. The difference is usually not the doctor’s skill, but how you access the appointment and how quickly it can be arranged.
What About Prescriptions?
Both NHS and private paediatricians can recommend medication when it is appropriate for your child. However, the way prescriptions are issued and the cost involved can differ between the two systems. You may notice these differences depending on where your child is seen.
In NHS care, prescriptions are usually issued through NHS systems. In England, children under 16, and 16 to 18-year-olds in full-time education, are usually entitled to free NHS prescriptions. In private care, prescriptions are typically issued privately, which means the medication cost may vary and is usually paid separately.
Before your child starts any medication, it is important that you clearly understand its purpose, how to give it, how long it should be used for, and what side effects to watch for. A good paediatrician should explain all of this in a simple and reassuring way, whether your child is seen privately or through the NHS.
What About Referrals to Other Specialists?
Sometimes children need support from another specialist as part of their care. This could include an allergy specialist, dermatologist, ENT surgeon, dietitian, psychologist, physiotherapist, or another paediatric sub-specialist depending on their symptoms. You may be referred if your child needs more focused assessment or treatment in a specific area.
In NHS care, referrals usually follow established NHS pathways, which connect your child to the appropriate hospital or specialist service. In private care, referrals may be made to private specialists, or in some cases, back into NHS services through your GP. The exact route often depends on your child’s clinical needs, your family’s situation and whether NHS or private follow-up is most appropriate.
A good paediatrician should guide you clearly through this process so you understand what is happening at each stage. You should not feel uncertain about whether a referral is needed or which specialist is most appropriate. Clear direction helps you feel more confident about your child’s care.
What About Test Results?
Test results can often be one of the most stressful parts of your child’s healthcare journey. You may feel anxious about when they will arrive, who will explain them, and what the next steps might be once they are available. Having clear expectations can make this process feel easier to manage.
In NHS care, results are usually reviewed by the hospital team or sometimes your GP, depending on where the test was arranged. The timeframe can vary based on the type of test and how busy the service is, so it is not always immediate. You should be informed about how results will be communicated to you.
In private care, results are often returned directly to the paediatrician who requested the test. You may then have a follow-up discussion where the results are explained clearly and any next steps are recommended. Before agreeing to tests, it is always helpful to ask how and when you will receive the results so you know what to expect.
What If Your Child Has a Long-Term Condition?
If your child has a long-term condition, NHS care often plays the main role in ongoing management. You may find this especially important when hospital services, emergency support, or multidisciplinary teams are involved. Conditions such as diabetes, epilepsy, complex asthma, inflammatory bowel disease, or significant developmental needs usually require structured specialist pathways.
Private paediatric care can still be useful in some situations. You may choose it for a second opinion, quicker review of non-urgent concerns, or extra reassurance when you want more clarity. It can sit alongside NHS care and help you feel more supported when questions come up.
However, it should not replace or disrupt established NHS care. If your child is already under a specialist NHS team, you should keep them informed before making changes. This helps maintain continuity and ensures everyone involved is working with the same information.
Which Option Gives More Reassurance?
Reassurance can come from both NHS and private care, and it often depends more on the quality of the consultation than the setting itself. You should feel that your child has been properly assessed and that you clearly understand the plan going forward.
Private care may feel more reassuring for some families because it can offer faster access, longer appointments and more direct follow-up, depending on the clinic and availability. You may find it easier to ask questions and get detailed explanations, which can help reduce anxiety and uncertainty.
For other families, NHS care feels more appropriate, especially when hospital services or wider specialist teams are needed. It can provide a strong safety net for complex or urgent conditions where coordinated care is important.
Ultimately, the right choice depends on your child’s symptoms, how urgent the situation is, their medical history, and what level of support you feel you need at that time. There is no single option that works for every family, and both pathways can provide good care when used appropriately.
How to Decide Which Route Is Right for Your Child
Start by thinking about how urgent your child’s symptoms are. If your child seems seriously unwell, it is safer to seek urgent NHS care rather than waiting for a private appointment. In these situations, acting quickly is the most important step.
If the concern is not urgent but has been ongoing, unclear, or is affecting daily life, private paediatric care may be helpful. You might find it useful when you want faster access to a specialist or a more detailed discussion about your child’s symptoms. This can give you clearer guidance and reassurance.
You should also think about practical factors such as budget, insurance cover, location, availability, and whether your child may still need NHS hospital services. The best choice is the one that fits your child’s medical needs safely while also working realistically for your family.
Choosing a Private Paediatrician in London
London offers many healthcare options, which can be helpful but also feel overwhelming when you are trying to choose the right paediatrician. When comparing private clinics, you should look for experience, clear communication, consultant-led care, and a child-friendly approach that makes both you and your child feel comfortable.
It is also worth checking practical details that can affect your overall experience. You may want to consider appointment availability, clinic location, follow-up arrangements, fees, and whether written reports are provided after consultations. These small details often make a big difference to how smooth and reassuring the process feels.
If you are looking for a paediatrician in London for private specialist child health support, choose a clinic where you feel listened to, informed, and supported. You should feel confident about your child’s care and clear about the next steps at every stage.
Myth vs Fact
| Myth | Fact |
| Private paediatric care is always better than NHS care. | Both NHS and private paediatricians can provide high-quality care. The right choice depends on your child’s symptoms, urgency and care needs. |
| Choosing private care means leaving the NHS completely. | Many families use both. Private care may help with non-urgent specialist advice, while NHS services remain essential for urgent, emergency and hospital-based care. |
| Private care means every test or treatment happens immediately. | Responsible paediatricians recommend tests and treatment only when clinically appropriate. |
| NHS care is only for emergencies. | NHS paediatric services also support routine referrals, long-term conditions, developmental concerns and specialist hospital pathways. |
| A private appointment can replace A&E. | Private routine appointments are not suitable for emergencies. Serious symptoms should always be managed through NHS urgent or emergency services. |
The Importance of Clear Communication
Clear communication is one of the most important parts of your child’s healthcare experience, whether you choose NHS or private care. You should always feel that you understand what the doctor thinks is going on, what has been ruled out, and what the next steps will be. This clarity can make decisions feel much easier.
Good communication also means your concerns are taken seriously. You should not feel rushed through the appointment, dismissed, or left confused about your child’s condition. You deserve time to ask questions and receive answers in a way that makes sense to you.
If anything is unclear, you should feel comfortable asking for it to be explained again. A good paediatrician will not mind repeating or simplifying information. In fact, they will want you to feel confident and reassured about the plan for your child’s care.
Key Takeaways
- NHS and private paediatricians can both provide high-quality care.
- NHS paediatric care is usually best for urgent, emergency, complex or hospital-based needs.
- Private paediatric care can be helpful for faster access, longer consultations, second opinions and non-emergency specialist advice.
- NHS care is free at the point of use, while private care usually involves self-pay or insurance costs.
- Private care can work alongside NHS care, but communication between professionals is important.
- Tests should only be recommended when there is a clear clinical reason.
- If your child seems seriously unwell, seek urgent NHS care rather than waiting for a private appointment.
Frequently Asked Questions:
1. What is the main difference between private and NHS paediatricians?
Both NHS and private paediatricians are fully qualified doctors. The main differences are usually access, timing and appointment flexibility. NHS care is free and usually involves GP referral and waiting times, while private care may allow faster appointments, direct booking, and often longer consultations.
2. Do private paediatricians provide better care than NHS paediatricians?
Not necessarily. The standard of medical care can be high in both NHS and private settings, and many doctors work across both. The difference is usually in appointment speed, time spent with the doctor, and flexibility rather than clinical expertise.
3. Is a GP referral needed to see a private paediatrician?
In most cases, no. You can usually book a private paediatric appointment directly. However, some insurance policies may require a GP referral, so it’s important to check your cover beforehand.
4. Why are NHS paediatric waiting times longer?
NHS services prioritise patients based on clinical urgency and manage high demand across the system. This can mean longer waiting times for non-urgent conditions compared with private care.
5. Can private paediatricians order the same tests as NHS doctors?
Yes, private paediatricians can request many common investigations, such as blood tests, urine tests, allergy testing and imaging, when clinically appropriate. The main difference is how quickly tests are arranged and whether they are included in private fees.
6. What conditions are better suited for private paediatric care?
Private care is often chosen for non-emergency but ongoing concerns like recurrent infections, asthma symptoms, tummy pain, constipation, allergies, feeding issues or developmental worries where faster review is preferred.
7. When should NHS care be chosen instead of private care?
You should choose NHS or emergency care for serious symptoms such as breathing difficulty, seizures, severe dehydration, blue lips, or serious or high-risk infections. NHS services are also essential for urgent hospital treatment.
8. Can NHS and private paediatricians be used together?
Yes, many families use both. Private paediatricians can provide assessment and advice, while NHS services handle emergency care, hospital treatment and long-term conditions. Good communication between both is important.
9. Do private paediatricians provide follow-up care?
Yes, most private paediatricians offer follow-up appointments, review test results, and adjust treatment plans if needed. Follow-up is often easier to arrange with the same doctor compared with NHS pathways.
10. How is the decision made between NHS and private paediatric care?
It depends on your child’s symptoms, how urgent the situation is, and what type of support your child needs. NHS care is best for urgent or complex hospital needs, while private care can be useful for faster access, detailed consultation, and ongoing but non-emergency concerns.
Final Thoughts: Choosing the Right Path for Your Child’s Care
Both NHS and private paediatric care play an important role in supporting children’s health, and neither is “better” in every situation. The right choice depends on your child’s symptoms, how urgent the concern is, and whether you need faster access, more time in consultation, or ongoing specialist input. Understanding how each system works can help you make more confident and informed decisions when your child is unwell or needs reassurance.
What matters most is that your child receives timely, appropriate care and that you feel supported throughout the process. Whether through NHS services or private consultations, a clear diagnosis, effective communication and a practical care plan are key to good outcomes. If your child needs to see a specialist paediatrician in London, you can contact us at London Paediatric Clinic for support.
References:
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- Nilsson, S. et al. (2023) Parental access to healthcare following paediatric surgery, Children. Available at: https://www.mdpi.com/2227-9067/10/9/1578
- Harding, K.E., Camden, C. and Lewis, A.K. (2022) Service redesign interventions to reduce waiting time for paediatric therapy services, Health and Social Care in the Community. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10084082/
- Conlon, C. et al. (2020) Factors influencing general practitioners’ decisions to refer paediatric patients to emergency care, BMC Family Practice. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC7568398/
- Thompson, E., Todd, P. and Ní Bhrolcháin, C. (2013) The epidemiology of general paediatric outpatients referrals, Child: Care, Health and Development. Available at: https://pubmed.ncbi.nlm.nih.gov/22118410/