Evidence-Based Medicine—

How Applicable Is It To Children?

By Jeff Cersonsky, MD, FAAP

 

I hear that we shouldn’t be treating ear infections with antibiotics. Is that true?

My allergist has put my child on four medications for his asthma, including a steroid. Is that really necessary?

These two questions have arisen from our current climate of “evidence-based medicine.” The principle behind evidence-based medicine is a good one — we should be looking at good research studies to decide how we should treat different illnesses. In the past, illnesses have often been treated based on isolated case reports, or just because it’s “the way it’s done.” As a pediatric resident over 25 years ago, I was essentially taught to question, to look into published data, and to be critical of medical routines when there is no evidence to back it up.

However, as one of my old medical school professors used to say, medicine is not a science, but an art. We are not fixing washers, we are administering care to human beings. Not all human models are the same! What works for some may not work for others and our responsibility as physicians is to personalize the care we give to all our patients. We need to meld medicine based on good science with the unique needs of each of our patients.

Let me give you an example: I frequently inherit patients from other physicians, either because their families moved, or insurance changed, or for other reasons. Often, I will have a new patient with recurrent ear infections who has been on multiple antibiotics, and the parents feel that a certain antibiotic works best for their child. There is no evidentiary basis for using this antibiotic as each ear infection is new and, for the most part, each antibiotic has as much chance working in one child as the next. There is a terrific power in positive thinking, however, and, for that matter, negative thinking. If Amoxicillin didn’t work on this child’s ear infections in the past, but Cefazolin did, I’d be a poor physician to insist on trying Amoxicillin. The very fact that the parents and child do not believe it would work would make it less likely to work (there is evidence for that!).

Now, let’s get to the questions at the beginning of the article. The data that has led to the news stories that ear infections should be observed and treated only if they don’t resolve on their own. We know that if we misuse antibiotics, we run the danger of creating “super-bacteria” that are resistant to almost all antibiotics. However, the data neglects one important factor — the child’s comfort. Sure, the recommendations also state that pain can be managed with Tylenol or eardrops while we wait to see if the child gets better. Frankly, as many bleary-eyed parents can testify, these measures frequently don’t make the child comfortable, and a miserable child is not a thing that a parent or physician wants. It’s true that many of the ear infections will go away on their own without treatment, but what price success?

What is more important, in my opinion, is that the diagnosis be certain before antibiotics are started. Therefore, antibiotics should never be prescribed over the phone for ear infections! Good medical practice is always to examine the child before deciding on treatment. I see many children with serous (not ser-i-ous) otitis media (uninfected mucus behind the ear drum), or otitis media with effusion (fluid behind the ear drum with no infection), treated inappropriately with antibiotics when Tylenol would suffice until the condition clears on its own. Also, I see many children treated with a very powerful antibiotic when simpler Amoxicillin would do. In order to treat ear infections properly, a physician must examine the ears carefully and choose an antibiotic that will do the job with the least chance of breeding resistant organisms.

The second question has to do with asthma. Much of the literature sites evidence that treating asthma early with anti-inflammatory drugs such as steroids in moderate or severe cases decreases the risk of chronic lung disease. However, adding two anti-inflammatories (e.g., an inhaled steroid and Singular) to two other asthma medicines (e.g., Albuterol and Salbuterol) gets you a child with a full medicine cabinet! The child feels that he is sicker than he is just because of all the medicines that he has to take. Mistakes in administration are more common. Is all this really to the child’s benefit?

The problem lies with the definitions of asthma. There has been a move lately to classify asthmatics into cookbook categories, e.g,. “mild intermittent” or “chronic persistent.” Most children go from one group to another fairly frequently depending on the season, as well as their allergen or irritant exposure. So, since they are sometimes classified in the more severe groups, they may end up with too many medications when they don’t always need them. Don’t get me wrong, there are children who definitely need this poly-pharmacy, but many do not. It is again up to the pediatrician or pediatric allergist to use his/her experience and knowledge to individualize the treatment of the child. It is important that the pediatrician decide wisely on when to send the child to the specialist and that the two physicians communicate clearly with each other so that the child isn’t overmedicated.

Research is extremely important in determining which treatments are most effective, or least hazardous. However, medicine, especially pediatrics, is never going to be practiced out of a cookbook. Each child and each situation are different, requiring careful and direct examination coupled with a dose of common sense.