The longer I practice medicine, the more amazed I am at the reversal of long held medical dogmas. Since the common use of antibiotics began around World War II, the medical profession has seen the effectiveness of antibiotics as evidence that science can prevail over infections. However, we didn’t foresee the downside of that success — the current rise of antibiotic resistance by common bacterial organisms. A similar arena of surprise in the medical field has taken place in the realm of allergy and asthma. We have observed an alarming rise in allergic diseases in Western countries over the past few decades. There are different hypotheses as to the cause of this allergy epidemic, but an article in the May issue of Annals of Allergy Asthma and Immunology seems to shed new light on one potential root of the problem: antibiotics.
Consider this common scenario: A six-month-old infant with a high fever and extreme irritability is brought to the pediatrician. The doctor examines her and sees a red tympanic membrane with fluid. The mother is desperate to relieve her child’s pain and suffering. The pediatrician wants to help and doesn’t want to miss a possible bacterial infection, despite the likelihood that the infection is viral. More often than not, the parent leaves with an antibiotic prescription. In medical practice, we are constantly faced with balancing risks and benefits, as well as attempting to perfect the art of doing good while upholding the oath to “do no harm.” As we all know, this is a delicate balance. In order to maintain it, we have to keep ourselves constantly informed. The article cited above provides new and valuable information about the risks inherent in the above scenario. Here is the basic rundown …
Drs. Ong and Umetsu conducted a study on infants receiving antibiotics in the first year of life. The result: the antibiotic-receiving infants had double the incidence of asthma before three years of age. In addition, there appeared to be a dose-dependent relationship: the more antibiotic given, the more likely the child would develop asthma. Clearly, antibiotic usage in early infancy comes with risks. The explanation for the results lies in the alteration of the child’s microbiome. Antibiotic-induced biome alteration poses a concern for the development of atopy.
Where does this leave us in terms of treating infants with infections? As is so often the case, the key to the answer is patient/parent education. While effective for bacterial infections, antibiotics have no place in treating a child with viral infections — or allergic asthma. Doctors and parents need to be on the same page realizing that the best therapy for these young patients in the absence of definitive diagnosis of bacterial infection is close observation and supportive care. So many viral illnesses are self-limiting; a few days of rest and fluids go a long way. Powerful, broad-spectrum antibiotics are definitely not the answer to viral infection or allergic disease. Sometimes the parents just need an answer. While the febrile patient is clearly suffering from more than allergic disease, allergic inflammation sets up the ideal environment for infectious proliferation. The best thing you can do is definitively identify allergic children when they are not suffering from an acute infection.
Proper management of allergic disease, including avoidance where possible, appropriate medication use, and immunotherapy when indicated, can keep them well. A patient’s medical history is tremendously important in making the diagnosis of allergy, but a definitive IgE test is an equally important piece of the puzzle. If he or she has allergies or has asthma, if a parents smokes in the home, or if a pet lives in the house, allergies should be considered as the cause of the child’s problems. NIH guidelines indicate that all persistent asthmatics should be tested for allergic triggers and offered immunotherapy if indicated.
A new era in medicine is being ushered in, and the finding that antibiotic use in infancy increases the risk of asthma may be only the tip of the iceberg. Modern doctors must choose our treatments with care.
– Dr. Dean Mitchell