Who’s Medication?

This 16 year-old boy hurt his knee playing basketball, banging it into another player’s knee. He was brought in limping by his mom. “Did you give him anything for pain?” I asked. “I gave him one of my prescription ibuprofens,” mom replied. I gave a little jerk inside: you did WHAT?  But I checked myself from berating her, because mom actually did right- ibuprofen is safe, good for her son’s injury pain, and he was big enough to tolerate that dose. She chose right, but I had instinctual alarm because some parents don’t.

Parents give their kids all kinds of medications- old prescriptions, over-the-counter (OTC) meds, herbal supplements. Using someone else’s prescription is fraught with danger. Those medications are available only by prescription for a reason; their misuse can harm. OTC medicines are typically safer; thus the FDA allows people to buy them without a doctor’s okay. But sometimes they can be dangerous if used improperly.

Among the safest, most effective, and most under-used medications are OTC fever and pain relievers. It’s hard to hurt kids with Ibuprofen and acetaminophen (Tylenol), and they work great. However, some parents are afraid to use them, or give enough. I’ll ask “how much Tylenol did you give?” Mom will indicate a tiny portion of the dropper, and I’ll say “no wonder her fever didn’t break, she didn’t get near enough!” Mom’ll look sheepish and say she was afraid to overdose her child. We laugh, and then have a conversation about effective dosing.

Sometimes parents worry these’ll make their child too sleepy, as if they’re narcotics. However, no one’s ever seen drug dealers pushing ibuprofen or Tylenol: “Psst, over here! This’ll get you high!”  Some kids do sleep after these medications, but not because of narcosis. It’s because their pain or fever’s relieved, and they can finally rest!

Other safe OTC medications include Peptobismol and Imodium for diarrhea, and laxatives for constipation. Except when parents give laxatives when they think their kid’s cramps are from constipation. If they’re actually from a stomach virus, the ensuing diarrhea from the virus plus the laxative is really bad!

Even doctors make mistakes with medications and their kids. During my residency, one of the pediatric oncologists rushed his toddler into the Emergency Department. He’d  been brushing his teeth at the bathroom sink, and looked down to see his boy sucking on a bottle of Visine eye drops. The doctor’s eyes bugged out, and he scooped up the toddler and zipped in. After several days in the Pediatric Intensive Care Unit, the boy’s heart rhythm quit hiccuping in scary ways, and he went home. I remember thinking: why did he buy Visine in the first place?  It’s not even good for eyes, much less exploring children.

Above we discussed safe and helpful over-the-counter (OTC) medications. Conversely, most OTC cold medicines are bad for children: they don’t work, and they’re not safe. They’re not deathly harmful, or the FDA wouldn’t allow their sale. They also get a pass from the FDA because they’ve been around for decades. But they’re not good: they can  make kids jittery and irritable. One time I gave a kid a prescription version of a cold medicine, the mom was so desperate for relief. The next time I saw her in the Emergency Department, she had dagger-eyes for me. I asked, what’s wrong?  She told me after giving her child that medicine, he screamed all night. That’s why we don’t  prescribe cold medicines. And they don’t relieve coughs and runny noses either.

Asprin is another OTC medicine kids shouldn’t get. In the 1970s they found that children who got Influenza or Chicken Pox viruses, and aspirin for their fevers, had liver damage. Thus for your child’s fever and pain, Tylenol and ibuprofen only. Beware, aspirin comes in forms you may not recognize as aspirin, like BC Powder or Goody”s.

Above we also mentioned not using old prescriptions. They’re available only by prescription for a reason- their potential harm. Certainly don’t give your kids old narcotics. If you get the dose wrong, they could stop breathing. Never give children old antibiotics either, since each antibiotic has a specific use and probably won’t work for this new illness.  Also, they have side effects like allergic reactions or yeast infections. Leave the prescribing to us!

Too Many Tests, Too Many Meds

I remember that first time- a parent insisting on antibiotics despite my advice.  The girl clearly had a virus- cough and runny nose for two days.  I explained to the father that antibiotics don’t kill viruses, she’ll get better regardless.  “I still want the antibiotic,” he answered.  No doctor likes to disappoint, but I didn’t give in.  Better to anger a parent than prescribe unnecessary medications; as I explained to him, medications have risks.

In the past two decades, medicine has been touting “Antibiotic Stewardship.”  As more antibiotics are prescribed, bacteria develop resistance to them.  ”Super-bacteria” that resist all antibiotics sometimes infect patients.  Scientists worry that one day, bacteria will win the battle, they’ll all become resistant to all antibiotics.  The age of these miracle medicines will have passed, and a new medical dark age begun.

Antibiotics also are not entirely benign.  They can have side-effects.  Kids can get allergic reactions, sometimes just itchy hives, sometimes more severe.  Antibiotics can cause diarrhea and yeast infections.  Kids come to the Emergency Department for antibiotic reactions, and I sigh when the antibiotics were prescribed “for a cold.”  Unnecessary medications can lead to unnecessary ER visits.

Since the Antibiotic Stewardship campaign hasn’t really changed prescribing habits, there’s now a program called “Choosing Wisely.”  This new push is for doctors not only to prescribe medications carefully, but also stop unnecessary testing that can be potentially harmful, like unnecessary CT scans.  All the major medical academies, like the American Academy of Pediatrics, have Choosing Wisely goals for their specialties.

Why are campaigns like Choosing Wisely and Antibiotic Stewardship necessary?  Usage of medical testing and medication has skyrocketed, without improvement in health.  The most stark example is the opioid epidemic: more Americans are now dying of narcotic overdoses than from car accidents.  Part of the problem is consumer demand. We think that more is better, and that more tests, more medications, lead to better results.  Also, everyone knows a story of someone who suffered or died because the doctor didn’t order this test, or give that medication.  Then when their kid’s sick, they want it all.

Many people aren’t aware that tests can be harmful.  When I discuss the risks of CT scans, I sometimes talk about this experiment:  In August 1945, the Army Air Force dropped atomic bombs on two Japanese cities, Hiroshima and Nagasaki.  The physicists knew how much radiation the explosions would put out for each given distance from ground zero.  After the war, scientists followed the radiation effects in the victims.  From this data, we know from those that got a radiation dose equal to a CT scan, that dose increases your risk of cancer a small, but real, amount.

Besides radiation risk, CT scans can also cause other problems.  Often we need to give medical dye to “light up” inflammation for the scan, and that dye can cause allergic reactions.  Also, scans carry the risk of “too much information.”  Sometimes the scan shows not only what we’re interested in, like the appendix, but also shows other weird things we can’t explain.  Usually those weird things are normal, but sometimes we can’t be sure.  Then doctors are faced with a dilemma: do we spend more time and tests to prove that thing is cool, or do we just assume so and move on?

When people want more tests, like we discussed above, they’re often unaware that tests usually don’t declare the diagnosis, but only provide more clues.  What’s not well known to the public (and some doctors!), is that most diagnosis, as much as 85%, is made from the medical history alone.  The medical history is the “story” of the illness that doctors elicit from the patient.  Taking a thorough history if far more important than tests.  A good history also helps point to the best tests to do, or can eliminate the need for tests.

When the family wants a test or medication that the doctor is wary to order, there should be a clear conversation.  The doctor needs to explain why the risks outweigh the benefits, that the test or medication may harm the child more than help.  If the parents still insist, then the doctor either cedes to the parent’s request, if the harm is minimal, or must stand firm for the good of the child.  Sometimes we make parents angry, in order to Do No Harm.


Whaddya Mean “It’s Just A Virus?”

Some parents are disappointed with the diagnosis “virus” and not getting antibiotics. The only two times in my career a parent has outright yelled in my face were when I didn’t prescribe antibiotics. Today’s guest columnist, Dr. Seth Koster, explains viruses and when antibiotics are needed.  Dr. Koster is a resident at the University Hospital and Clinics here in Lafayette.

A lot of parents aren’t sure what to expect with their first child.  Did he just cough?  He sneezed twice, is that bad?  Do I need to go to the doctor?  Some things are common, yet seem complicated.  Let’s talk about some common conditions that are usually a virus that get better with a little TLC, and some “red flags,” things that need to be checked right away.

I think my kid is wheezing, should I bring her in?  Many parents hear baby make funny sounds, and call it wheezing.  Sometimes the sound they are trying to describe is the rattling of nose congestion.  True wheezing that we worry about is a whistling, gaspy tone in the lungs.  Either way you would be safe calling your doctor for a next day appointment if the wheezing doesn’t get better.  But if your child seems to be breathing fast or is having to pull in breaths, then he needs to be seen right away.

The vast majority of colds and coughs are viral.  Even with true wheezing, this is usually a virus and not pneumonia, and antibiotics won’t help.  Hundreds of viruses cause coughs and runny noses and wheezing: adenoviruses, rhinoviruses, enteroviruses, and many more.  Antibiotics do not kill viruses.  What kids with these need is supportive care, meaning fluids and fever and pain medicine.  If they get really sick with wheezing and shortness of breath, they may need IV fluids, breathing treatments, and observation in the hospital.

My child is pulling at his ears.  Does she need antibiotics?  Most of the time “ear pulling” is not from ear infection.  Kids pull on their ears when they are stuffy from congestion, if they have a headache, or some kids just play with their ears.  If the child is not fussy and doesn’t have fever, they don’t have to see the doctor.

What if she has fever-rush her to the Emergency Department?  No.  Ear infections may hurt, but that can be controlled with ibuprofen or acetaminophen (Tylenol) for fever and pain.  Over 70% of ear infections are viral and don’t need antibiotics.  That being said, if your child is having ear pain and fever, see your doctor.  After an exam the doctor can decide if antibiotics or pain drops will help.  But ear pain is rarely an emergency that can’t wait until tomorrow.

My child is vomiting, what to do?  Whether vomiting needs to be checked out by the doctor depends on how much and how long.  Some kids are brought in to the ER when they vomit only once or twice, or only for a few hours. However, that is not enough time for a child to get dehydrated, and most will quit vomiting soon after.

A simple “stomach virus” is usually not serious and will resolve in 1-3 days.  If the child vomits, wait an hour for his stomach to settle, then start clear liquids (gatorade, dilute juice, pedialyte), sipping slowly.  After the child has stopped vomiting for about 6 hours, you can start bland foods.  No fast food.  If your child has a fever, ibuprofen or acetaminophen will help with that. For most stomach illnesses antibiotics will not help, and even make vomiting and diarrhea worse.

So when does your child need to be seen?  If she is having worsening belly pain, that is worrisome.  If your child is vomiting all day or is vomiting blood or dark green, bring them in.  If your kid is having diarrhea for more than a week, that is one of the few times an antibiotic may help, since that may be a bacterial illness and not a virus.

Your child will get sick, there’s no avoiding it.  You usually don’t need antibiotics to treat them.  Most of the time your kid just needs rest, fluids, ibuprofen, and TLC.




A Difficult Case of C. Difficile

I took care of a teenager this past year who suffered from too many antibiotics.  Her doctor originally thought she had a skin infection and put her on the first antibiotic course.  The skin did not improve, so he put her on a second course.  When the skin was still no better, he sent her to the Emergency Department.  Here she was put on a third, even more powerful antibiotic.  Her skin still did not improve, but she developed diarrhea, fever, loss of appetite, and terrible cramps. 

Her diarrhea and cramps lasted almost three weeks before we figured out that she had a bowel infection called “C. Difficile.”  C. Difficile is a bacteria that lives in your colon, in harmony with the other kinds of bacteria there.  If you get too many antibiotics though, the antibiotics wipe out many of the other bacteria that compete with C. Difficile, and the C. Difficile takes over.  When it takes over, you get the painful and unpleasant symptoms of our teen above.  After two more rounds of antibiotics aimed at the C. Difficile, the girl finally got better.  Except for her skin, which probably wasn’t infected in the first place. 

Antibiotic overuse is a big problem in modern medicine.  Antibiotics are prescribed too often for conditions they can’t help.  People are most often infected by viruses, which antibiotics do not kill.  Viruses cause the vast majority of coughs and runny noses, fevers, sore throats, and even most sinus and ear infections.  There is no cure for viruses except for time; waiting the three or four days it will take for the patient’s immune system to clean out the virus.  However, patients or patients’ families often pressure doctors to prescribe the unnecessary antibiotics: “You’ve got to do something!” 

In turn, doctors feel that pressure and write the prescription.  What can it hurt?, we think.  What if it really is a bacterial infection, which antibiotics do cure, and we are late in prescribing the antibiotic and the patient gets sicker?  This is what we doctors often say to ourselves to make it easier on our consciences when we over-prescribe antibiotics. 

So how can antibiotics be bad?  Just ask our teenager in the case I just described.  Antibiotics are drugs, just like adrenalin or steroids or heart medicines.  They can be helpful when used properly, but they also have side effects.  People develop allergic reactions to antibiotics, occasionally severe and life-threatening reactions.  Antibiotics can also change the healthy balance of bacteria in a person’s bowels (like our teenager), or in the mouth, leading to painful consequences. 

Even worse, too many antibiotics in a person, or in the environment as a whole, lead to bacteria developing resistance to the antibiotics.  Bacteria are living things, and their populations are constantly evolving.  One of their evolutionary abilities is to develop and share resistance to chemicals that can harm them, like antibiotics.  Some bacteria populations, like Enterococcus or Staph Aureus, have developed resistance to so many antibiotics that people infected with them have a hard time being cured.  There are only a few antibiotics left that can wipe out those bugs, and those antibiotics are so strong that they really have some nasty side effects, and can only be given in the hospital through an IV catheter in a vein. 

Doctors and scientists worry that there might come a day when all bacteria become resistant to all antibiotics, and we will be back to the days before antibiotics.  In those olden days, people died of pneumonia and strep throat.  Ear and sinus infections sometimes caused terrible complications where the infections ate into the brain cavity.  Just about all doctors’ professional organizations, like the American Academy of Pediatrics, have campaigns to encourage doctors and patients to be more judicious in their use of antibiotics, so that antibiotic resistance does not get out of control. 

So join doctors and scientists in advocating the proper use of antibiotics.  Do your part to prevent antibiotic resistance by not insisting on an antibiotic if your doctor says it is not necessary.  That is not only better for us all in the long run, it is just plain better medicine.

Give Me Antibiotics! No?

Every pediatrician has come to know The Look.  The parent’s face falls.  They are obviously disappointed, sometimes angry.  It happens when the parent came in expecting that the doctor will prescribe an antibiotic for their child’s illness, only to be told an antibiotic will not help.  There are only two times in my 17 year career that I have been yelled at and insulted to my face by a parent.  Were they at times of terrible stress and tragedy, a diagnosis of cancer or a death?  No, they were both when I diagnosed a viral illness in a smiling, obviously not very sick child and told the parent that an antibiotic was not necessary.

This October the national Center for Disease Control (CDC) is declaring a Get Smart About Antibiotics week.  From October 5 to 11 they will be having a media campaign to promote better public knowledge about when patients need antibiotics, and when they don’t.  October is a good time for this, given that child illnesses will be rising as kids swap germs at school, and the flu season starts (as if it already hasn’t!).  Many kids will get sick and their parents will be hoping for something to make them better.

Most of those illnesses will be caused by a virus, and antibiotics don’t kill viruses.  Viruses are those bugs that cause runny noses (even green runny noses), coughs, vomiting and diarrhea, most sore throats, and most fevers.  These illnesses get better on their own in 3 to 4 days.  Their treatment is to ease the symptoms with vaporizers, fluids, fever and pain medicine, and such.  For more information on these, see the Categories column on the right side of this page.

Antibiotics are for treating infections caused by bacteria.  These are the bugs that cause some ear infections, skin infections and boils, Strep throat, certain pneumonias, and bladder infections. 

So many parents wonder “why not just give an antibiotic, just in case?  What’s the harm?”  Many doctors hate to disappoint parents, give in to this argument, and prescribe unnecessary antibiotics when pressured by families.  Well, here is the harm:  antibiotics are not entirely safe drugs.  Patients can have allergic reactions to antibiotics, sometimes severe reactions.  Sometimes if a patient gets an antibiotic and then stays sick, the antibiotic can negate the ability of later tests to tell the diagnosis. 

The biggest reason not to give antibiotics is the risk of bacteria developing resistance to antibiotics.  This has been happening for decades and has given rise to bacteria resistant to multiple antibiotics.   Some patients get very sick with these super-resistant bugs like MRSA and VRE.  The newer antibiotics to attack those infections are so strong that the patient can get sick from the antibiotic too. 

Experts worry that the day may come when all bacteria develop resistance to all antibiotics.  This is why the CDC, the American Academy of Pediatrics, and other expert groups are anxious to get doctors to stop prescribing unnecessary antibiotics; and to get parents to stop pressuring their doctors for them.

Next time your doctor says your child has a virus, be patient.  Give it a few days of fever medicine, vaporizers and throat sprays, chicken soup and honey.  If your child is not better then, it is fair then to call your doctor about getting another look.

Feel free to comment about your experiences with viruses and antibiotic disappointments!