HEALTH : Kids and Antibiotics : Parents, Doctors Worried Sick About Overuse of Wonder Drugs

Like many children, Jonathan Pike was 6 months old when he began suffering chronic ear infections. To control the problem, his pediatricians prescribed a constant dose of antibiotics for the boy for two years.

“I was very concerned that Jonathan was taking all those drugs,” said his mother, Sherry Gordon, who also worried about side effects such as the allergy Jonathan developed to penicillin, and whether, because of his constant early exposure to them, all antibiotics eventually would lose their effectiveness for her child.

Surgical Option

After Gordon consulted a specialist, Jonathan in December had tubes surgically placed in his ears to help drain fluid from them.

Since then, his health has greatly improved, and Jonathan, now 3, has required an antibiotic only once--for a bout with strep throat.

His mother, however, retains her concerns about children and antibiotics. She is not alone. Many parents, physicians and researchers worry about the drugs, which have become as common as a cold in many children’s lives.

Their prevalance, in part, is a sign of the times, experts said, noting the dramatic upswing in working-parent households and the resulting increases in the numbers of children in day care.

An Increasing Risk

“Putting a lot of kids together (in day care) increases the risk of common communicable diseases at an early age” and, of course, the need for antibiotics, said Dr. Jim McMahon, clinical assistant professor of pediatrics at Stanford University.

Indeed, because respiratory and ear infections seem so widespread among youngsters, some child-care center refrigerators resemble mini-pharmacies, jammed with dozens of children’s prescriptions for antibiotics.

Some parents, like Gordon, and some medical professionals wonder if doctors write too many antibiotic prescriptions.

“I think most pediatricians are very responsible. But there are some established practices prescribing antibiotics in cases where there is no scientific evidence” for their need, said Dr. Barbara Korsch, head of general pediatrics at Childrens Hospital in Los Angeles.

Other practitioners and researchers disagree. They complain that if physicians miss a diagnosis and fail to prescribe an antibiotic, they may find themselves involved in malpractice litigation.

Moreover, many doctors report that parents pressure them to hand out antibiotics every time a child has the sniffles.

“Parents say, ‘I have to go back to work; this child has to go back to school. Give him something,’ ” said Dr. William Luxford, an otologist (ear specialist) and researcher at Los Angeles’ House Ear Institute.

Antibiotic Therapy

So just how should parents determine when antibiotic therapy is indicated for their children? There are factors they may wish to take into account.

Experts, for example, said that parents too often fail to realize that antibiotics can cure bacterial infections but have no power to combat viruses. And about 70% of children arriving at a pediatrician’s office with a fever have viral illnesses that simply must run their course, said Dr. John Fricker, staff pediatrician at Kaiser Permanente Medical Center in Woodland Hills and a clinical pediatrics professor at UCLA’s medical school.

“We have built ourselves a trap trying to convince people we can do everything and cure everything and we can’t,” he said.

Physicians generally can determine that a child has a viral and not a bacterial infection via a diagnosis of exclusion. Though it is more difficult to do so with children under age 2 who may have a bacterial bloodstream infection, doctors figure that older children have viral infections if their throat cultures are negative, their ears look clear on examination and their chest areas, on listening, seem free of signs of pneumonia.

“If it’s a virus, I tell people to try the vaporizer, perhaps antihistamines and citrus drinks,” said Korsch of Childrens Hospital.

Korsch noted that viral infections may be stubborn, lasting several weeks and sometimes prompting renewed parental clamor for an antibiotics regimen. “The most common misconception is that if an illness goes on too long, or if it seems severe, or if the child doesn’t get over it by himself quickly, then an antibiotic is required, and that is not the case,” she said.

Real Lifesavers

But experts said that parents and physicians should not be excessively cautious in administering warranted antibiotics, which can be lifesavers whose dramatic effect on modern health care may be under-appreciated.

Before the advent of antibiotics, Fricker recalled, a 1930s study of four metropolitan hospitals showed a significant number of all deaths were due to complications from ear infections.

Even now, despite scientific advances, ear infections remain dangerous because it is possible for bacteria to cause even greater havoc by penetrating the mastoid bone and spreading to the brain’s lining.

More commonly, though, ear infections result in lifelong hearing impairment. Such infections, particularly when they occur in youngsters when they are most prone to them--at ages 1 to 6--also can hinder youngsters’ language development.

“Ear infections, even when getting better, can result in temporary hearing loss,” McMahon explained. “In this rapid learning phase, if children miss the ends of sentences or words, they are not picking up information they should and they may suffer developmentally.”

Not Taking Chances

To avert potential problems of this kind, “if I am unsure whether an ear infection is viral or bacterial, I will prescribe an antibiotic, because I don’t want to take a chance on hurting the child’s hearing in any way,” Korsch said.

Luxford noted that some kids also get runny ears whenever they get colds. Although most colds are viral, susceptible patients probably will develop secondary, bacterial infections, which may manifest as ear infections.

“The end result is, if I give an antibiotic early, I prevent having to give more medication over a longer period of time,” Luxford said, adding that in persistent cases, he may prescribe low-dose antibiotic therapy for two to three months. If that treatment fails, a child with persistent fluid in the ears and a hearing loss then may be a candidate for surgery.

But Luxford, like most physicians, tries to prescribe antibiotics carefully, in part because the drugs can lose their effectiveness if overused.

When bacterial strains are exposed to a particular antibiotic for long periods, they tend to become resistant to the drugs, noted Bob Poole, pharmacy director at Children’s Hospital at Stanford, who added, “Like humans, these bugs are trying to survive. They are able to alter their susceptibility by developing an enzyme that chews up the antibiotic. They change themselves so they aren’t destroyed by the drug.”

For example, haemophilius influenza, one of the most common microorganisms causing ear infections in infants and children, has developed a resistance in 20% to 60% of cases to ampicillin and amoxicillin, two penicillin derivatives, McMahon said. (In the Los Angeles area, Fricker noted, the microorganism has a 40% to 60% incidence of resistance to the two drugs.)

Targeting Microorganisms

To ensure the efficacy of their pharmacological arsenal, physicians, especially when dealing with children, generally try to narrowly target their prescribed drugs to specific microorganisms, rather than using broad-spectrum antibiotics.

If that first choice of a penicillin-like medication proves ineffective in two or three days, the next step might be to use erythromycin-sulfa or bactrim-sulfa combinations that have a somewhat broader range; or they might use the broadest range antibiotics--cephalosporins, such as Keflex.

“From a pure science point of view, you want to use a narrow-range drug whenever you can,” Poole said. “The problem with broad-spectrum drugs is you are exposing a lot of organisms to medication each time, and all of these organisms can develop resistance.”

Pediatricians sometimes use combinations like amoxicillin and clavulanate, an agent also known as Augmentin, which prevents the microorganism from breaking down the amoxicillin. But this agent is costly, about $45 for a standard prescription. Augmentin is considered a “second line” drug, pressed into service only when cheaper medication is ineffective.

Many doctors also try to protect antibiotics’ potency by rotating them, prescribing various kinds, Poole said.

Side Effects

Though they are wonder drugs, antibiotics also have side effects. They, for example, destroy natural, helpful bacteria in the gastrointestinal tract, which can lead to problems with diarrhea, vomiting and cramps. Their destruction of beneficial bacteria also can result in yeast infections in children, either with diaper rash, or, in the mouth, thrush.

The use of all antibiotics must be monitored carefully, physicians said.

More commonly, children exhibit allergic symptoms--rashes, bumps or swellings--from antibiotics; failure to discontinue them can cause life-threatening reactions.

Discretion Required

In the long term, however, Dr. John Bolton, a San Francisco pediatrician practicing for 20 years, noted that a key to the best handling of antibiotics involves discretion on the part of patients, parents and physicians.

As Bolton noted, some symptoms are beneficial and should not be medicated. Not every cough, for example, requires a prescription, he said, adding, “the best thing for a slight runny nose is Kleenex.”

Though parents often demand antibiotics because they want what is best for their child--as Bolton said, “The mark of being a good mom or dad is worry”--some adults, Korsch said, hold a misguided view that they do better by their youngster if they pay for the most expensive antibiotic for them, especially “if little Johnny next door is taking the same drug.”

But Korsch and Bolton, who practice 400 miles apart, both report increasing numbers of parents resisting antibiotics.

“Particularly with educated parents, who are more aware of health, nutrition, and consequences of strong drugs, I am finding more willing partners in holding off antibiotics,” Korsch said.

Bolton agreed: “I am seeing a real reversal. When I see a child with an ear infection who needs an antibiotic, the first thing a parent is likely to say is, ‘What happens if we don’t use the antibiotic?’ ” This is music to Bolton’s ears. “I love these kinds of questions.”

Experience Helps

When convincing parents that a child doesn’t need an antibiotic, a physician’s experience can be a benefit. “With my gray hair and pot belly, people are much more likely to trust my judgment than when I was a young intern,” Fricker said with a laugh.

Ultimately, though, it is confidence in physicians that helps parents over the hurdle.

“It takes more time for the doctor that a good physician is available to the family,” Korsch said. “I tell parents, ‘We won’t use an antibiotic because it may be harmful. But keep in touch. Call me tomorrow, or the next day, and if you are concerned, I will look at your child again.’ ”

WHEN TO CALL THE DOCTOR What’s the most reliable indicator of how ill children are? Often, it’s how they act, rather than how high their fevers may be.

“We must trust the parents’ judgment. They spend the vast majority of time with the child. If the parent is worried, the child should be seen,” said Dr. John Fricker, staff pediatrician at Kaiser Permanente Medical Center in Woodland Hills.

Pediatricians say that generally children should be checked if they have any of these symptoms:

Unconsolable crying or screaming spells

Tugging at the ear

A cough that sounds deep and wet

Uncharacteristic changes, such as non-sleeper volunteering for a nap