Prescription for Trouble: Why Too Many Antibiotics Aren't Good for Kids
Every night for a week I set my alarm clock for 2 a.m. so I can wake my 3-year-old daughter, Devon, for yet another dose of her "icky" medicine. I sit on her, clamp her arms down, pinch her nose shut, and slowly squirt a teaspoon of thick, greenish-yellow liquid into her mouth. We repeat this wrestling match every six hours. I feel like the worst mommy in the world.
Unfortunately, there's no better option. Devon has a recurring urinary-tract infection (UTI) caused by bacteria that are resistant to most antibiotics. It only responds to one oral drug that's approved for kids a liquid with a taste, texture, and odor that cherry flavoring can't disguise. I worry what will happen if the bacteria eventually become resistant to that antibiotic too.
Before Devon got sick, I knew that misusing antibiotics could lead to the evolution of so-called superbugs, but I didn't really think about those germs striking my family. Now I know better. "Although we talk about antibiotic resistance as a public-health issue, it's an individual child who gets an infection," says Arjun Srinivasan, M.D., a medical epidemiologist at the Centers for Disease Control and Prevention (CDC).
A New Drug Problem
In fact, many everyday childhood illnesses are becoming increasingly hard to treat. You've probably heard about MRSA—methicillin-resistant Staphylococcus aureus, potentially deadly bacteria that don't respond to commonly used antibiotics. A new study analyzing data from more than 300 hospitals found that there's been an alarming increase in ear, sinus, and throat infections in children that were caused by MRSA.
However, the problem isn't limited to one superbug. Two-year-old Sloane Poth, of Charlotte, North Carolina, needed surgery last year for a skin infection caused by another strain of drug-resistant bacteria. On Monday, it looked like diaper rash. By Friday, she was in the hospital. "She's fine now, but it was very scary," says her father, Michael. "The surgeon said that he's now seeing two or three serious cases like hers every week."
Although most antibiotic-resistant infections aren't necessarily life-threatening, pediatricians who can't use their first-choice antibiotic may have to prescribe a drug that's not approved for children or simply isn't kid-friendly. "If medicine doesn't taste good, children won't swallow it, and then your only option is to give them a shot," says Mika Hiramatsu, M.D., a pediatrician in Castro Valley, California. For MRSA, however, there are no outpatient shots that work, so a child who won't take oral antibiotics will need to be hospitalized for IV antibiotics. "It's a huge ordeal for the types of infections that would have been very easy for us to cure 20 years ago," says Dr. Hiramatsu.
Treating a resistant infection is also costly in terms of both time and money not to mention anxiety and lost sleep. Karyn Bilezerian's 16-month-old son, Karson, suffered from a painful ear infection for nearly a month until his fourth antibiotic finally did the trick. "Every week, we were going back to the doctor and the pharmacy," says Bilezerian, who lives in Wrentham, Massachusetts. "Karson had never needed antibiotics before, so I was shocked when the first three didn't work. With the fourth one, we saw a difference very quickly—when it worked, it worked."
The Path of Most Resistance
Every child has colonies of helpful and harmful bacteria living in his body. Within those colonies, a few individual strains of bacteria may have a natural ability to resist certain antibiotics. So whenever your child takes an antibiotic, the germs that are susceptible to that drug die, leaving more room for the drug-resistant microbes to reproduce and become dominant. The same thing can happen when your child doesn't finish his whole course of antibiotics. Either way, the strong survive.
If your child develops a sizable population of resistant bacteria after taking an antibiotic, it doesn't necessarily mean she'll become ill. The new bugs may simply live in her body—in which case, she's said to be "colonized"—or they may disappear over time. Under the right circumstances, though, she could get sick with a tough-to-treat infection. One of the great mysteries of medical science is why bacterial infections develop in one case and not another; it probably depends on a variety of factors, such as the strength and number of bacteria, and the child's own immune system.
However, even if your child doesn't have any symptoms, she can still pass along those resistant bacteria to others. That's how a child who's never even taken antibiotics can become infected with drug-resistant bacteria. "Young kids in child-care centers share germs better than they share toys," says Sarah Long, M.D., a pediatric infectious-disease specialist at St. Christopher's Hospital for Children, in Philadelphia.
In fact, kids play a key role in the development of resistant bacteria—not only do they spread germs easily, but they take more antibiotics than adults do. While many of those prescriptions are crucial for their health, others are unnecessary. "Antibiotics are important for treating bacterial infections, but more than 90 percent of children's illnesses are actually viral infections that can't be cured with antibiotics," says Dr. Long. Asking for antibiotics when your child has a bad cold, for example, can wind up doing more harm than good.
Problems with Antibiotics
Part of the problem is that pediatricians sometimes prescribe antibiotics simply because parents want them to. In one CDC study, parents walked away with a prescription 65 percent of the time if the doctor thought they expected one, but only 12 percent of the time otherwise. "Although some physicians are getting the message, it's still a problem," says Lauri Hicks, D.O., medical director of the CDC program Get Smart: Know When Antibiotics Work. Earlier this year, the CDC also sent letters to several chain pharmacies expressing concern about their programs that were offering customers free generic antibiotics as the solution for colds and flu. Officials worried this would increase pressure on doctors to prescribe antibiotics inappropriately.
Let's face it: As parents, we typically put our child's immediate well-being—and sometimes our own need to get back to work—ahead of a remote concept like bacterial evolution. If there's a chance antibiotics will make our child feel better, we may be tempted to take it. However, antibiotic resistance is not a problem we can worry about tomorrow. Kids are already at risk when they get the following seemingly run-of-the-mill illnesses, so it's important to know when antibiotics don't make sense.
Most ear infections are caused by Streptococcus pneumoniae, a bacterium that can also cause meningitis, pneumonia, and other infections. Last year, a study identified a new strain of strep (dubbed 19A) that is resistant to all 18 antibiotics that are approved by the FDA for use in children. Kids in the study with those ear infections were successfully treated with an antibiotic meant only for adults, but one child suffered permanent hearing loss. Doctors also now realize that MRSA can cause ear infections as well as skin infections.
Drug-free treatment Since many mild ear infections clear up on their own, your doctor may recommend a wait-and-see approach for two to three days if your child is over age 2 and his infection isn't severe (based mostly on the appearance of his eardrum). You can get a prescription for an antibiotic to fill only if your child doesn't improve. "Most of my patients' parents never fill those prescriptions," says Dr. Hiramatsu.
Smart medicine For a more severe infection, your doctor will probably choose an antibiotic based on established guidelines (resistance varies regionally). "If your child is given two rounds of antibiotics within a month and still has an ear infection, there's a good chance the bacteria are resistant," says pediatrician Michael Pichichero, M.D., director of the Rochester General Hospital Research Institute, in New York. In that case, the American Academy of Pediatrics recommends an ear tap (tympanocentesis), which is the only way for a doctor to pinpoint the strain of bacteria and find out which antibiotic will kill it. Unfortunately, few pediatricians do the procedure, which involves putting a needle into a child's eardrum. "Tympanocentesis was very common when there were only a few antibiotics available, but pediatricians are no longer taught how to do it in medical school," says Dr. Pichichero. "I think that will change as more and more pediatricians are confronted with ear infections they can't cure with any antibiotic."
An ear tap can also be a form of treatment, since it drains infected pus from behind the eardrum. Karen Winters, of Hilton, New York, saw the results of an ear tap firsthand with her 2-year-old son, Anders, who's had several hard-to-treat ear infections. "He didn't like having us hold him down, but he felt better immediately afterward," she says.
If your doctor doesn't do the procedure, see if you can locate an ear, nose, and throat specialist who might. Otherwise, your doctor will keep trying different antibiotics and may eventually refer your child to have tubes placed in her ears to drain lingering fluid. Inserting tympanostomy tubes is now the most common surgical procedure performed on children; it's estimated that nearly 7 percent of kids have tubes in their ears by age 3.
Prevention strategies Make sure that your child is fully vaccinated. Ear infections have declined dramatically since the pneumococcal vaccine was first introduced in 2000. Encourage him to wash his hands frequently to avoid catching colds that can lead to ear infections.
A common infection in young kids, UTIs are often caused by Escherichia coli bacteria. In one recent study of kids with urinary infections, 27 percent had E. coli that didn't respond to the two most frequently used antibiotics. UTIs are most worrisome in babies and toddlers; if your child has a fever with no other symptoms, see your doctor right away.
Drug-free treatment Skipping antibiotics isn't a good option for a child under age 2 who has a UTI because an untreated infection can lead to serious kidney damage. That's why pediatricians usually recommend starting treatment immediately after diagnosis, rather than waiting to see whether a mild infection might resolve on its own.
Smart medicine It's important, though, to take the correct antibiotic. Most UTIs are diagnosed with an in-office urine test that confirms whether a child has an infection but does not identify the specific type of bacteria. If the result is positive, your pediatrician will prescribe an antibiotic to start while you're waiting for the culture results to come back from the lab. In a couple of days, the lab will identify the bacteria and send a list of effective antibiotics. If the drug your child has been taking isn't one of them, your doctor should give you a new prescription and decide whether your child should finish the initial one first.
Prevention strategies Encourage your child to drink plenty of fluids and use the bathroom frequently. That's the single best way to help prevent urinary-tract infections, explains Max Maizels, M.D., a pediatric urologist at Children's Memorial Hospital, in Chicago. Kids who hold in their urine are at higher risk for UTIs because any germs that reach the bladder have more time to grow before they're flushed away. Also be sure to teach your daughter to always wipe from front to back.
Many types of bacteria cause skin infections, but MRSA is making headlines because the multidrug-resistant bacteria can spread to the blood, joints, and lungs—and be fatal. Hospitalizations for MRSA nearly tripled between 2000 and 2005.
A child can get infected if he happens to have the bacteria on the surface of his skin and then he gets a bite, cut, or scrape. Infections can also develop in spots where there hasn't been a visible skin injury, like the diaper area. Although the bacteria can be spread by contaminated objects such as sports equipment, experts believe that they're usually transferred from person to person. "Studies show that between 2 and 10 percent of children carry the antibiotic-resistant germ in their nose, throat, armpits, or groin," says Rachel Orscheln, M.D., a pediatric infectious-disease specialist at St. Louis Children's Hospital who runs a clinic for children with recurrent MRSA infections.
Three of Tina Pickett's five children have been treated for MRSA, and she assumes that they probably passed it along to each other. Her 2-year-old daughter, Macy, needed surgery and IV antibiotics after a mosquito bite became infected, her 6-year-old son, Dominic, had an infection on his bottom, and her 13-year-old daughter, Brittney, needed surgery for a frighteningly infected spot on her leg. "It started out as a tiny flat red dot, and by the next day it had grown to more than six inches in diameter. The doctor told me that she was one day away from having her leg amputated or even dying," says Pickett, of Potosi, Missouri. "This can happen to anyone. My kids had hardly ever been sick before."
Drug-free treatment Depending on the severity of the infection, the cure may be as simple as having your doctor drain bacteria-containing fluid from the abscess.
Smart medicine Early detection is key. "Look out for a pimple-like lesion that's red, swollen, tender, and seems to get worse rather than better," says Dr. Srinivasan. Contact your doctor, especially if it's accompanied by a fever. Your pediatrician will probably send a sample of the bacteria to a lab to be identified, but if he suspects MRSA, he should prescribe an antibiotic. Kids with serious cases need oral antibiotics and may even need to be hospitalized for IV antibiotics or surgery.
Prevention strategies Teach your child to wash his hands frequently and to not share items like towels or bar soap.
Antibiotics are obviously important, lifesaving medications, but resistant bugs are evolving much faster than new drugs are being developed. Says Dr. Long, "I've been a doctor for more than 30 years, and it's only in the last five or six years that I've had to tell a family, 'There is no antibiotic for your child's infection.' " We have to use antibiotics wisely in order to help ensure that they'll continue to work when our children really need them.
Originally published in the May 2009 issue of Parents magazine.
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