Sunday, January 9, 2011

Drug: Resistance

For a generation that grew up with Nancy Reagan’s “Just Say No” campaign, it is interesting that the biggest obstacle between us and the drugs many of us crave is the American Academy of Pediatrics.

But, as we head into the lion of winter, noses dripping, coughs hacking, and our little ones sharing germs more freely than they do their toys, there is a noticeable grumbling among some parents who have finally cracked and asked, as only a Kleenex-hoarding, humidifier-using, orange juice-buying parent can: “What do we have to do to get some antibiotics around here?”

Amoxicillin, cefdinir, amoxicillin/clavulanate-- any one of the cephalosporin antibiotics that are more precious than gold for the parent whose main concern is the health of her child and the sanity of the family and not the “emerging resistance of the common pathogens” and that nitpicky distinction between viral and bacterial infection. Ah, science, that realm of specifics.

Although it’s true that many of us sit in the examination room with our children and pediatrician wondering what it would take to get her to pull out a prescription pad, to say we’re on opposite sides of the situation is not actually the case. It just often feels that way.

Dr. Robert M. Siegel, in a January 2010 article in PEDIATRICS, (Acute Otitis Media Guidelines, Antibiotic Use, and Shared Medical Decision-Making) describes the medical community’s response to the 2004 guidelines set forth by the American Academy of Family Physicians and the American Academy of Pediatrics for the treatment of the most common problem sending kids under five and their parents to the doctor: ear infections, or more specifically, acute otitis media or AOM.

The guidelines advised practitioners to be more careful in diagnosis, select narrow-spectrum antibiotics, use analgesics such as acetaminophen, ibuprofen and Auralgan instead of antibiotics unless the infection failed to clear, and endorsed an observation option. Siegel cites a study that showed a decrease in antibiotic use for AOM from 1994-2000 (before the new guidelines) which he credits to better accuracy in diagnosis, as well as another study that looked at behavior after the guidelines, showing an increase in the use of analgesics and the narrow-spectrum antibiotic amoxicillin (the type recommended in the guidelines.)

Still, the endorsed practice of “watchful waiting” and observation of the infection translates to one thing for parents: no drugs. Not the kind we think we want, anyway.

A fact that Siegel says requires more parental involvement and input, not less.

“Several groups have examined watchful waiting for AOM with a rescue or safety-net antibiotic prescription if the symptoms do not resolve. In office and emergency department settings, more than 60% of parents chose not to fill an antibiotic prescription when the child was given adequate pain control. ”

The choice not to fill the prescription is part of a larger agenda to educate parents on the risks and benefits of antibiotics and he writes, “If the use of antibiotics is to be decreased when treating AOM, physicians must immediately address the main concern and reason for the visit: ear pain.”

If you’re typically respectful of your doctor’s opinion, and the greater mission of the AAP and their guidelines, then it takes a leap of confidence or desperate anguish to finally say, “What do I have to do to get some antibiotics around here?” Especially when you have not been given the safety-net option, or when AOM is not the issue.

One reader found herself in such a position. Never, she said, in her multiple visits over the years to doctors in both New York and New Jersey, would a pediatrician prescribe an antibiotic. Finally, she sent her husband to the pediatrician with her young daughter instead of going herself.

“He’s got an MD and a Ph.D in neurobiology. We were pretty confident he could get a prescription.”

Her doctor, a brilliant and well respected practitioner, who like many in his field has stickers of farm animals on his stethoscope and does magic tricks with tongue depressors, is not so avuncular when it comes to parents’ desires for antibiotics. Did sending in Dad, a heavy-weight who can pronounce and spell Streptococcus pneumoniae and Haemophilus influenzae with the best of them, do the trick?

No dice.

The only time the reader has gotten a prescription was after failing to get one from her primary pediatrician and taking her sick child across the country to visit her family. They went to an urgent care clinic in a strip mall somewhere in Montana.

“We got an antibiotic. The improvement in her child’s condition was, “dramatic.”

I found myself in a similar situation over the Christmas holiday when my daughter was on day 28 of a sickness that had vacillated in intensity but included: five days of fever, two days of bloody ears, a fortnight of grumpiness and at least a lunar cycle of runny nose. The illness had, essentially, followed our Advent calendar in terms of length, but had given us far fewer chocolate surprises.

I’d taken her to the doctor three times that month, called twice with follow up questions, and then, before heading in for my fourth visit in as many weeks, was able to speak with the doctor on the phone once more.

“Here’s the thing,” I said, getting my courage, “you’re going to check her ears and find nothing. But, I want an antibiotic.”

I brought her in. He examined her. He asked her about sinus pressure. (She’s two and a half—it was an interesting exchange.) He looked at her throat. He double checked her chart—a long, well documented history of the last month.

The risk, he explained, reaching for his prescription tablet, was that we would give her medicine and it wouldn’t help. It could still be viral.

That risk, a large bottle of amoxicillin in all its bubble-gum flavored glory, was one we were more than willing to take.

Whether we needed 31 days to beat a viral infection, or the medicine combated what was in fact a bacterial one, I guess I don’t know. And, I admit, the fact that we are given antibiotics so rarely is the thing that makes them so effective whenever we are.


Tim Morrissey said...

Another excellently-written "universal parenting issue" post, Sarah. My wife and I had to do battles with urgent-care doctors for a decade, because our strep-throat-prone son did not "present the classic symptoms" immediately.

But his mother always knew. And she was always right.

And, finally, after years of battles, and when medical records became computerized, the urgent-care doctors stopped fighing her.

Liz said...

Hmm, good timing on the watchful waiting advice for me as my 4 yr had some ear pain Sat that then disappeared, but he now is stuffy and not hearing me and clearly has pink eye. We are snowed in, but I have some drops from the last pink eye episode, so we're good there. (and I think those 3 years of ophtho residency qualify me to diagnose and dispense). Hopefully the ear thing goes away on it's own...

It's always hard to choose between the individual and society and it's not easy being the dr trying to do the right thing for everybody.

parenting ad absurdum said...

This is a great article about a balance between respecting your pediatrician's knowledge and your own awareness of your children's health and needs. Really well done, Sarah.