Archive for the 'Antibiotics' Category

Not So Fast with Antibiotics, Updated Ear Infection Guidelines Advise

Recently, the American Academy of Pediatrics updated its otitis media guidelines for treating ear infections. This update further clarifies what health care providers should be doing when they see a child with an ear infection.

We know that most ear infections are self-limiting, meaning that no antibiotic treatment is required. The intent of this updated guideline is to further clarify when one should or should not treat with an antibiotic. At a high level, this further supports observation for most mild ear infections as first-line treatment and increases the awareness of caregivers that antibiotics are not always indicated. This has been my practice for the last few years.

For those who want more details:

  • The updated guideline starts with defining what acute otitis media is; a bulging ear drum from middle ear fluid or new onset of ear drainage from a ruptured ear drum.
  • When painful, pain medication should be used.
  • When there is severe otitis media (moderate to severe ear pain for at least 48 hours or fever more than 102F), antibiotics should be used.
  • For younger children aged 6 months through 23 months with mild bilateral ear infection, it should be treated. If it is just one side, observation or treatment can be considered.
  • For mild ear infections in older children, observation or treatment can be considered based on joint decision making with the caregivers.


The Bumpy Road to Adulthood

For most of my teen patients, acne is as inevitable as algebra as a fact of life. At puberty, hormones from the gonads and adrenal glands migrate and fundamentally change the nature of the sebaceous (oil) glands. These hormones passing through the body stimulate the oil glands to wake up and party, which can result in bumps of varying sizes and qualities on the skin. Some kids get by with just a sprinkling of the annoying skin irritation called acne, while those on the opposite extreme can experience painful and disfiguring nodules and cysts.

How do overactive oil glands lead to a lumpy landscape on the skin? When oil glands are behaving themselves, they produce just enough oil to properly lubricate the hair and skin. When the glands overproduce, they can create plugs of oil (also called sebum) and skin cells under the skin’s surface that sit there like unwelcome guests forming bumps called comedones. Blackheads are comedones that are open and exposed to the air—the air oxidizes the oil plug creating the dark color. Inflamed and pus-filled bumps or pimples arise when bacteria (called propionibacterium acnes) that live in the skin, chomp on the oil, causing irritation. Cysts, a more deeply planted and painful form of acne, happen in those individuals whose oil glands really don’t know when to stop. Some people only get acne on their face—others get it on other areas of the body, such as the neck, chest, and back.

For my patients with mild acne, the initial treatment I recommend is often familiar to the parents of these kids. Benzoyl peroxide—which comes in many forms and under many brand names over the counter—zaps bacteria, dries oil, and promotes the clearing of dead skin cells. Salicylic acid treatments work in a similar manner. Both treatments can be drying. Preparations containing benzoyl peroxide can bleach fabrics—you may want to have your teen use old or white towels and pillowcases if they use this treatment.

When the severity of the acne increases a little, there are a lot of other medications in my toolkit such as tretinoin (Retin-A is a brand name), topical antibiotics, and oral antibiotics.

I tell patients that the medications won’t work unless they’re used properly and regularly, and it can take some time—typically it will be quite a few weeks of use before they’ll notice a change. My experience is that if the acne bothers the parent more than the teenager the teen won’t use the medication, as it requires some motivation to use something for many weeks before getting a return on the investment.

I advise teens to try not to pick at pimples. This only ups the irritation and potential for scarring.  And there’s no need to scrub affected areas—acne is largely hereditary and hormonal. I generally advise patients to gently cleanse their skin with a mild soap and their hands or a soft washcloth.

When a patient has a more severe form of acne such as cystic acne, I recommend they see one of our specialists. My colleague Virginia Sybert, MD, is an expert in pediatric dermatology. Dr. Sybert sees patients for whom acne is not only a nuisance; it can cause severe physical pain and emotional scarring. Additionally, even though most general pediatricians or family practitioners can treat mild to moderate acne, sometimes seeing the specialist is beneficial to help teen patients stick to a treatment routine.

As Dr. Sybert says, “No one ever died from acne, but it can be a painful, debilitating, and scarring disease that deserves treatment.”

For those with severe, cystic acne, Dr. Sybert says the best treatment is Isotretinoin, which you may know as Accutane. She explains that this is a highly effective treatment, working for 60 to 65 percent of patients in the first course of treatment. She says that though the treatment has been surrounded by some controversy, it has been shown to be safe in studies when taken as prescribed. “Isotrentinoin is not a drug for mild acne, and each patient needs to weigh the risks and benefits of taking this route for treatment,” she explains.

Both Dr. Sybert and I find great satisfaction in helping teens with acne feel better both physically and emotionally. We know that there are many treatments and recommendations out there for fighting acne, and we’ve probably heard them all. Does eating chocolate and fatty foods lead to bumpy skin? Does light therapy help improve skin clarity? Studies don’t yet prove that they do, but for some teenagers, there clearly is a relationship. We recommend those treatments for which we have documented evidence of success, but we also know that individuals have found some relief with their own approaches.

Inaccurate Dosing and Kid’s Meds

Cold and Flu season is upon us which means lots of sick children. We all would like to think that the medications we give our children on occasion are safe and effective not to mention that the dosage is based on scientific evidence. Unfortunately that is not the case. There was an interesting article on MSNBC recently on this very topic.

The problem begins with parents not having detailed instructions and an accurate measuring device that is in line with the instructions. Was that one-teaspoon (tsp) or one-tablespoon (tbsp)? How big is that kitchen spoon really? Labeled instructions do not make it easy to do the right thing.

Next comes dosing, it has been based on science, right? Child dosing historically has often been calculated by extrapolating from the adult dose assuming that children are just little adults. Physiologically that is just not the case; children come in all shapes and sizes.

Now we get to effectiveness. Cold and cough medications for children under age 6 years are not recommended because they are not safe and not effective. Most preparations contained various combinations of antihistamines, decongestants, anti-tussives, and expectorants. The studies show they just do not work. Pediatricians are not holding out on a magic prescription medicine to relieve the symptoms either. I always get asked what I give my own kids when they are sick. Most of the time, we give absolutely nothing. When some intervention is necessary, we use saline water to irrigate their little noses so they can breath again. When there is a cough, we use a little honey water. If there is a fever and they are feeling bad from it, we will give a little fever reducer knowing full well that it will not make them get better any quicker. We spend time curled up on the couch with them, hold them a little closer and provide comfort and attention, and maybe a little cocoa until they smile through their tears and sniffles again.

Happy Holidays and wishing you Good Health in this New Year!

Do we have to treat strep throat?

After my most recent column,  a question was asked as to whether we had to treat strep throat. The answer is not as clear cut as one would think as it depends on how much risk, no matter how small, one wants to take.

Strep throat is self-limited and resolves within a few days, even without treatment.  The arguments  for treatment include faster resolution, prevention of complications such as a peritonsillar abscess, reduced time period of being contagious, and prevention of rare complications such as rheumatic fever.

 Antibiotics shorten symptom duration by about 16 hours.

Antibiotics do reduce the incidence of acute rheumatic fever. However, in industrialized nations like the US,  it has largely been controlled  It is estimated that 3,000 - 4,000 patients must be treated with antibiotics to prevent one case of rheumatic fever in developed nations.