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Use of Antibiotics in Children Is Down, but Enough? July 23, 2002 By LAURIE TARKAN When Dr. Bonnie Fass-Offit joined a pediatric practice in suburban Philadelphia 12 years ago, she tried to follow her conviction that children should not take antibiotics or over-the-counter medications unless they were necessary. She explained to parents that antibiotics did not cure viral infections and why she thought limiting over-the-counter drugs was a wise course for their sick children. Sometimes, though, a parent would get a child's prescription from another doctor. "The patients were used to one style of medicine, and didn't appreciate my approach," Dr. Fass-Offit said. "I was occasionally blamed for missing things." Today, however, more pediatricians are following the same guidelines. A study by the Centers for Disease Control and Prevention, published last month in The Journal of the American Medical Association, found that from 1989 to 2000, the number of antibiotic prescriptions written for children at doctors' offices declined 40 percent. Despite this, experts at the centers say they believe that most pediatricians still prescribe drugs too liberally. More than 40 percent of antibiotics prescribed in doctors' offices are for viral ailments, which antibiotics do not cure. Most upper respiratory illnesses - colds, bronchitis, ear infections, sore throats - are viral, not bacterial. "I think our paper does present good news, but there is much work to be done," said Dr. Richard E. Besser, an author of the study and the director of the C.D.C.'s Campaign for Appropriate Antibiotic Use. Excessive use of antibiotics has contributed to the emergence of drug-resistant bacteria. Because of this and other concerns, the American Academy of Pediatrics, other medical associations and public health groups have published guidelines and policies calling for fewer antibiotics and fewer over-the-counter drugs like decongestants and cough medicines. Doctors have been slow to adopt the recommendations. Indeed, an unintended consequence of the decline in antibiotics usage may be a rise in the use of over-the-counter remedies, as doctors try to treat symptoms because they cannot treat the infection. The obstacles facing doctors are as much social, cultural and legal as they are medical. To start with, distinguishing untreatable viral illnesses from treatable bacterial infections is difficult. This is compounded by parents' pressure to prescribe drugs. And some physicians, eager to do something to help, respond. Still others are reluctant to change habits, distrust guidelines and fear losing patients or being sued for not treating illnesses that turn worse. The pediatric academy and the C.D.C. have published separate guidelines to help doctors diagnose and treat upper respiratory ailments in children. The agency has also begun educational campaigns for physicians, medical schools and the public. The academy has issued policy statements on the use of over-the-counter drugs as well. One statement says that no good studies support the use of cough medicines in children. Another says that the safety, dose and effectiveness of decongestants have not been well studied in children. Although the risks associated with over-the-counter drugs in children are small, they do exist, especially when used incorrectly, the statement says. On pseudoephedrine, the only over-the-counter decongestant, the American Academy of Family Physicians has recently reported that the range between a therapeutic dose and toxic dose is very narrow. The doctors concluded that decongestants should be given to young children "with extreme care, if at all." Still, in many cases, doctors do not seem to be passing this information to parents and continue to recommend over-the-counter drugs. Sales of children's cold remedies totaled $277.6 million in 2001. "There is a knee-jerk response in medicine: we want to help," said Dr. Susan L. Montauk, a professor of clinical family medicine at the University of Cincinnati College of Medicine and co-author of the family physician group's report. "It's not uncommon for doctors to say among themselves, such and such doesn't do any good, but it doesn't do any harm, and parents feel like they need to do something," she said. Most physicians have been trained to use antibiotics and to recommend cough and cold medicine and fever reducers, said Dr. Janet Serwint, medical director of the Harriet Lane Primary Care Clinic at the Johns Hopkins Children's Center in Baltimore. "It takes a lot to rethink that," she said. But clearly, the uncertainty of diagnoses can affect prescribing practices. Viral and bacterial infections can look similar: a viral cough can closely resemble bacterial bronchitis; a viral ear infection can look like a bacterial one; and a sore throat can appear to be strep throat. Because there are no simple diagnostic tests, with the exception of the strep culture, doctors tend to be cautious, medically and legally, and order antibiotics. An ear infection, for example, is the single biggest condition for which antibiotics are prescribed, but it is tricky to diagnose. It is often difficult to get a clear look into a child's ear, especially a screaming toddler's, and some doctors do not use highly sophisticated otoscopes. In some cases, doctors have improved their diagnosing skills: they wrote eight million fewer prescriptions for ear infection in 2000 than they did in 1989. The pediatrics academy and the C.D.C. guidelines, if followed, will help clear up some confusion, said Dr. Rita Mangione-Smith, an assistant professor of pediatrics at the University of California at Los Angeles. But physicians do not always pay attention to practice guidelines, she said. One report published in 1999 in The Journal of the American Medical Association identified 5,658 studies that described reasons that doctors did not stick to guidelines. "It has been shown pretty conclusively that practicing physicians don't care about guidelines or evidence-based reviews. What they care about is what they think works," Dr. Mangione-Smith said. The C.D.C. is trying to crack this resistance by offering physicians tools to cut back on prescribing, like a viral prescription pad that has a checklist of actions parents can take when their child has a virus. "We need to do direct interventions," Dr. Besser said. "We published principles and guidelines for appropriate prescribing in 1998, but that's not enough." One tactic some doctors have used to deal with parental pressure is to give the parents a prescription on the condition that they wait 24 to 48 hours before filling it and fill it only if the symptoms worsen. Studies show this approach cuts down on the number of prescriptions filled. The parents themselves often feel the pressures of a child's illness and expect results from a doctor. Working parents feel pressure to get their children healthy and back in day care or school. Parents from certain cultures are more likely to pressure doctors to prescribe antibiotics because of their beliefs that the drugs are cure-alls, said Dr. Mangione-Smith. Many, though, genuinely worry that their child has a bacterial infection, but much of this anxiety is caused by misconceptions. For instance, many patients, and some doctors, believe that green mucus indicates a bacterial infection, in part because many doctors routinely ask about the color of the mucus. "There's no data that shows that green is any more common in a bacterial infection than a viral infection," Dr. Besser said. "A common cold will go from clear to yellow to green back to yellow to clear to gone." Also contrary to popular belief, high fever is no more likely to be caused by bacterial infection than by viral infection. And the corollary, a high fever alone is not dangerous to a child, though many parents fear a high fever. Studies consistently show that this pressure has a huge influence on how doctors practice. Dr. Mangione-Smith, presenting a study at the annual meeting of the Pediatric Academic Societies in Baltimore in May, said that doctors prescribed antibiotics 65 percent of the time if they perceived that parents expected them, and only 12 percent of the time if they felt parents did not expect them. In this competitive medical market, some doctors fear they will lose patients if they do not get what they want. But the research shows that when physicians take time to explain to parents why they are not ordering medications, parents tend to feel satisfied. Dr. Paul A. Offit, chief of Infectious Disease at the Children's Hospital of Philadelphia, and others say that while such discussions are time-consuming, they can take place during the child's routine visits. When the child does get sick and has to be squeezed into a doctor's schedule, the doctor will not have to explain the approach again. 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