Doctor uses stethoscope to check for infection in the lungs of baby

Many of the nearly 3 million kids under age 2 who went to an emergency room for bronchiolitis between 2007 and 2015 were prescribed unnecessary antibiotics, according to a new study published in the Journal of the Pediatric Infectious Diseases Society.

More on Antibiotics

In the first year of life, bronchiolitis is the leading cause of hospitalization for U.S. infants, with symptoms including a potentially long-lasting fever and trouble breathing. But because the condition is caused by a viral respiratory infection, antibiotics won’t help treat it.

One in 4 kids with bronchiolitis in the new study was prescribed antibiotics. In 70 percent of these cases, there was no accompanying bacterial infection that could justify their use. And in close to 40 percent of the cases, kids were prescribed antibiotics that are generally not recommended for children of that age.

Mistreating bronchiolitis with antibiotics is a “longstanding issue,” says Shawn Ralston, M.D., an associate professor of pediatrics at the Geisel School of Medicine at Dartmouth and the lead author of the American Academy of Pediatrics’ 2014 guidelines on the condition, who was not involved in the study. Bronchiolitis has been one of the main targets of campaigns by the AAP and others to reduce unnecessary antibiotic use.

“What is surprising is that in this context of multiple iterations of guidelines and a national campaign to reduce antibiotic prescribing, what we see is that actually there hasn’t been a reduction at all in the decade since the first release of those guidelines,” says Brett Burstein, M.D., Ph.D., one of the authors of the new study.

This misuse and overuse not only contributes to antibiotic resistance and drives up health care costs but also is dangerous for kids. Adverse reactions to antibiotics put nearly 70,000 kids in the ER every year. Antibiotics also can disrupt the natural bacteria that people need to stay healthy.

What the Study Found

Burstein and colleagues analyzed data from a nationally representative Centers of Disease Control and Prevention survey of emergency room visits to calculate that about a quarter of kids under 2 with bronchiolitis were given antibiotics.

They found that kids who visited nonpediatric emergency rooms and emergency rooms not connected to academic research centers were more likely to get antibiotics.

“Emergency departments are known to be very conservative,” says pediatrician Mark Sawyer, M.D., a member of the American Association of Pediatrics’ Committee on Infectious Diseases, who was not involved in the study. ER doctors—especially those who don’t regularly deal with children—may be prescribing antibiotics out of caution, he says. “I’m actually surprised it’s only 25 percent.”

Kids who got chest X-rays, which are not recommended for bronchiolitis, were also significantly more likely to be prescribed antibiotics.

“Viral illnesses in children result in a lot of abnormalities in chest X-rays,” Ralston says. But pediatricians, she says, tend to be very experienced with bronchiolitis and can diagnose it without an X-ray by observing a child and listening to his breathing.

The Dangers of Antibiotic Overuse

Curbing the spread of antibiotic resistance and untreatable “superbugs” is a good reason to use antibiotics only when needed, Burstein says. But there are more immediate implications of antibiotic overuse as well.

“I often tell parents that in the particular case of avoiding antibiotics in the case of something like bronchiolitis, you’re directly benefiting your child,” Ralston says.

Approximately 20 percent of kids will have some minor adverse reaction, such as diarrhea or gastrointestinal trouble, after taking antibiotics, Burstein says.

Young kids are also more likely to suffer an allergic reaction, according to previous CDC research, which in rare cases can be a life-threatening anaphylactic response. In other cases, Burstein says that adverse reactions in young kids are mistakenly identified as allergic, which can also have negative effects on their future medical care.

Experts are also concerned about the ways that antibiotic use affects the microbiome, the communities of bacteria that live in and on us and affect health in a number of ways. “Taking antibiotics kills off not just bad bacteria but good bacteria,” Ralston says.

That’s especially concerning when it comes to young kids. A growing body of research shows that exposure to antibiotics in the first two years of life is associated with later development of conditions such as asthma and allergies.

“The more we learn, the more important it is to reserve antibiotic use for when we actually need it,” Ralston says.

What Parents Should Know

Bronchiolitis can be scary for parents because kids can appear to be quite sick.

“It’s often the first significant febrile illness a child will suffer,” Ralston says. It almost always shows up in the winter and is usually caused by the very common respiratory syncytial virus (RSV), which first appears to have similar symptoms to a cold but can last longer, up to 14 days, she says. In addition to the fever and trouble breathing, children may have a runny nose and cough, and may be wheezing.

In general, parents should follow the AAP’s guidelines for a fever, calling their pediatrician if they believe their child appears very ill; if a child younger than 3 months has a fever of 100.4° F or higher; if any child has a fever over 104° F; or if a fever lasts longer than 24 hours in a child younger than 2 or longer than 72 hours for an older child.

Though some kids with bronchiolitis may need help breathing or staying hydrated, the only treatment most kids need is rest and supportive care. According to UpToDate, an online decision-making tool for doctors, a child needs urgent medical attention if she is grunting, tiring, or not breathing, or if skin is turning blue.

Even in the emergency room setting, it’s appropriate to ask whether a particular treatment is needed. “Ask the question, do I [or does my child] absolutely have to have this chest X-ray,” Ralston says. “Often, the physician’s default is to assume the patient wants these things.”

If the doctor does feel a test or antibiotic is necessary, he’ll say so.

Being diligent about hand-washing can help keep kids healthy, Sawyer says, even if they’re likely to encounter a common virus such as RSV at some point.

Remember to keep very sick kids home from day care and postpone visits to see young children if you are sick. 

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