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A SPOONFUL OF NOTHING

The Baltimore Sun

Yara Cheikh expected her pediatrician to diagnose the sickly rattle in her infant son's chest as a bacterial infection. "I went in looking for antibiotics," said the Towson mother of four.

The pediatrician made a different call: Nine-month-old Hugh DeBrabander's illness was viral, an infection antibiotics are powerless against. Cheikh accepted the explanation and was happy to spare her son an unnecessary dose of medication.

Not all young children are so fortunate. Many receive ineffective or even dangerous drugs for common illnesses such as colds, flu, sore throats and earaches.

Parents spoon out over-the-counter cold medicines despite evidence that they don't work and have even been linked to children's deaths. Doctors prescribe antibiotics for conditions they can't improve, driving today's proliferation of dangerous, drug-resistant infections.

Medical professionals and parents alike are growing more aware of the problems - especially overused antibiotics. But experts say the practice persists, in part reflecting an understandable desire by parents and doctors to ease a child's suffering. In other cases, impatience plays a role, as busy parents struggle with an irritable child, or busy doctors appease demanding parents.

For many common childhood ailments, the best medicine is often no medicine. Yet strong medicine is what our culture has come to expect.

"We have to somehow educate ourselves and patients that we should not always rely on medications to make us well," said Dr. Caroline B. Hall, a professor of pediatrics at the University of Rochester School of Medicine and Dentistry.

She conceded, however, that the message is difficult to convey when faced with a suffering child. "You look at a child who's wheezing and their chest is retracting," she said, "it's hard to say, 'I'm going to do nothing.'"

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Dr. Joshua Sharfstein, Baltimore's health commissioner, said the nurturing instinct makes parents vulnerable to pitches from the makers of ineffective over-the-counter medications.

"Some of the marketing preys on parents' guilt," Sharfstein said. "I think the marketing creates an expectation that a medication is necessary for treatment."

Sharfstein argues that many common cough and cold remedies, some linked to the deaths of several children in recent years, are ineffective and unsafe for children younger than 6.

Although drug industry representatives argue that the medicines are clearly labeled for use by adults and that adverse reactions are the result of misuse, Sharfstein and other experts have asked the Food and Drug Administration to restrict marketing of the drugs for use in young children.

In the case of antibiotics, many parents think they're a panacea. In fact, antibiotics target bacterial infections and are useless for killing viruses - including the bugs responsible for the common cold.

Resistance to drugs

In recent years, nearly every significant type of bacterial infection worldwide has developed resistance to antibiotics that were once effective at killing them, according to the Centers for Disease Control and Prevention. This is largely the result of doctors overprescribing the strong drugs, and a misconception among patients that antibiotics are effective against viruses.

A 2003 study by University of Tennessee Health Science Center researchers found that out of 2,076 office visits, pediatricians around the country misprescribed antibiotics in 883 cases, or 42 percent.

Pediatricians will prescribe antibiotics 65 percent of the time if they perceive parents expect the drugs, but only 12 percent of the time if they perceive parents don't expect them, according to the CDC.

"A lot of parents come with the expectation that they are going to get something when they leave," said Dr. Marion Hare, a pediatrics professor and the lead author of the 2003 study. "If the physician doesn't prescribe antibiotics, patients don't want to see that physician any longer."

Doctors report that some parents will shop around for a pediatrician willing to prescribe antibiotics, even within the same medical practice.

In some cases, Hare said, busy doctors prescribe the drugs to get demanding parents out of their hair. "If you've been in a pediatrician's office in the winter time," she said, "you know how many children they are seeing."

Her research, however, suggests it takes a doctor about the same amount of time to explain why antibiotics aren't appropriate than to write a prescription and explain what it is.

"It may take a little longer to explain the first time a pediatrician meets a parent," she said, "but if you do that on the front end, then they don't come in with that expectation later."

Respiratory infections

Another reason children get drugs they don't need is confusion over their diagnoses and controversy over a respiratory infection known as bronchiolitis.

Usually caused by a virus, it is the leading cause of infant hospitalization in the United States and has grown in recent years to account for 100,000 admissions each year. It can cause wheezing, coughing and, in severe cases, a blue tint to a child's skin from lack of oxygen.

As with other viral infections, antibiotics are ineffective, but often prescribed anyway. A 2006 study by Hare found they were prescribed for 54 percent of bronchiolitis cases nationally between 1993 and 2003.

Some doctors use corticosteroid asthma medications to treat the infections, arguing that some cases of bronchiolitis are actually early cases of asthma.

But in guidelines issued last fall, the American Academy of Pediatricians recommended such drugs should be avoided in the routine management of bronchiolitis.

A study in the New England Journal of Medicine in July found that dexamethasone, a commonly used corticosteroid, did little, if anything, to help children to recover from the infections.

"These are medications that like all medications have down sides," said Rochester's Hall, who helped develop the AAP guidelines. "And this study says they don't help."

Yet she doubts physicians will stop prescribing the drugs. "It's part of our culture," she said. "I'm a little skeptical that our guidelines are going to change human behavior."

'The right care'

Hall and other doctors agreed that keeping useless and dangerous drugs out of children's bodies could be avoided by better communication between medical experts and parents.

In addition to making parents more aware of the potential dangers of over-the-counter drugs, doctors need to explain the dangers of the misuse of antibiotics and other prescription drugs, they said.

"Because you're not giving medication doesn't mean you are not giving care and not giving the right care," Hall said. "That message has to be communicated."

With that in mind, some doctors now place pamphlets in their office waiting rooms explaining the appropriate use of antibiotics.

Doctors' confidence diagnosing infections and communicating with parents improves with experience, said Dr. Jay Gopal, the chief of pediatrics at Union Memorial Hospital and Yara Cheikh's pediatrician.

Earlier in his career, he said, he acquiesced more often to parents' demands for medication. For example, he would prescribe nasal decongestants containing pseudoephedrine (sold commonly under the brand name Sudafed) for children with colds and allergies if their parents requested them. With several deaths now linked to cough and cold medicines containing the compound, he refuses to prescribe them today.

He said "comfort measures," such as air humidifiers, saline nasal spray and over-the-counter pain medications such ibuprofen and acetaminophen, are usually adequate for colds and flu. For allergies, he advises long-acting antihistamines such as loratadine, which is sold as Alavert, Claritin and Lomilan, in formulations free of pseudoephedrine.

Gopal also assures worried parents he will be available if their child's illness worsens. If parents know their doctor is competent and available in case their child's illness worsens, he said, they are less likely to expect ill-advised remedies.

Science and art

"Medicine is a science," he said, "but it's also an art. It all depends on the experience of the doctor and how long the patients have been involved with the doctor."

Cheikh said she's found seeking Gopal's advice helps her avoid giving her children drugs when they don't need them. Sometimes, however, medicine is the answer.

A week after her son Hugh was diagnosed with a viral infection, the rest of the family fell ill while on vacation in Cape May, N.J. "I was sure we'd all gotten a viral infection," she said. She put off seeing a doctor because she thought antibiotics would do no good.

When they got back, Gopal diagnosed the family with strep throat, a bacterial infection, and prescribed an antibiotic. Lamenting her delay in seeking treatment, Cheikh said, "We were all miserable for a week and for no reason."

chris.emery@baltsun.com

Dangerous medicine

Some recent statistics related to treating children with drugs:

In 2004 and 2005, an estimated 1,500 children younger than 2 years were treated in U.S. emergency departments for adverse events associated with cough and cold medications.

In 2005, medical examiners or coroners determined the deaths of three infants younger than 6 months were caused by cough and cold medications.

Pediatricians will prescribe children antibiotics 65 percent of the time if they perceive parents expect the drugs, but only 12 percent of the time if they perceive parents don't expect them.

Last year, 282 children younger than 5 died from antibiotic-resistant pneumonia in the United States, a disease in part resulting from the overuse of antibiotics.

Source: Centers for Disease Control and Prevention

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