Vol 59: decemBeR • décemBRe 2013
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Canadian Family Physician•Le Médecin de famille canadien1261
Commentary
All I want for Christmas is amoxicillin
Sarah Reid
MD FRCPCI
work in a busy pediatric emergency department (ED) in Ottawa, Ont, which has 68 000 visits per year—with an average of 180 children per day. The 2012 holiday season was predictably busy, with an average of 225 children seen during each 24-hour period. As I worked over the holidays, I was struck by the number of children with classic viral symptoms (ie, cough, rhinorrhea, congestion) who either had been or were currently being treated with antibiot- ics. Fevers and other symptoms persisted, so parents came to the ED to find a cure for their children. Many parents seemed surprised by the suggestion that their children’s viral illness would resolve in time with sup- portive care alone. Where were their new antibiotic prescriptions?Most fevers in young, healthy, immunized children are due to viral illnesses.1 Here are some practical evidence-based approaches to common symptoms associated with febrile viral illnesses in children that can help clinicians reassure parents.
Sore throat
It is important to accurately diagnose and treat group A streptococcal pharyngitis to prevent both suppurative and nonsuppurative complications. However, a recent systematic review reminds us that symptoms and signs cannot be used to definitively diagnose or rule out strep throat in children aged 3 to 18 years.2 The same review looked at 15 studies assessing the accuracy of 5 prediction rules in children; none of the rules had a likelihood ratio that indicated it could be used to diagnose streptococcal pharyngitis (probability of group A streptococci > 85%).
Strep throat is rare in children younger than 3 years of age.3 Most children with upper respiratory tract infec- tions (URTIs) do not have sore throat, and their probabil- ity of having strep throat is only 4% (CI 3.37% to 4.78%).4 The American Academy of Pediatrics, American Heart Association, and Infectious Diseases Society of America all recommend testing (rapid test or throat culture) in suspected cases and avoidance of testing in children with symptoms clearly consistent with viral URTI (ie, cough, rhinorrhea, congestion). It is safe to await results before treatment, given that treatment is aimed at pre- vention of complications.
Sore ears
In 2009, the Canadian Paediatric Society published com- prehensive guidelines on the management of acute oti- tis media (AOM).5 Viruses have an important role to play
in the pathogenesis of AOM and are the likely cause of AOM when it spontaneously resolves. Although AOM is still a primarily bacterial infection, the treatment effect of antimicrobials is small. Approximately 15 children need to be treated to have 1 child experience resolution of symptoms at 48 hours.6 Eighty percent of children with AOM will likely be better within 3 days without antibiotic treatment.
Most young, healthy patients older than 6 months of age can be treated with a “watchful waiting” approach, which comprises symptom management (analgesia) and the use of antibiotics only if symptoms persist beyond 48 to 72 hours (deferred prescription). This approach decreases the incidence of complications associated with antibiotic therapy without leading to an important increase in complications of AOM. Most parents are satisfied with this approach and will follow physician instructions.
Cough and cold
There is no role for antibiotics in the treatment of pediat- ric URTI. Lower airway inflammation is usually related to an underlying viral infection, bronchiolitis, or asthma—
none of which requires antibiotic therapy.
In 2011, the Canadian Paediatric Society pub- lished a practice point on pneumonia.7 In young chil- dren, bacterial pneumonia is relatively rare. The most common causes of pneumonia in infants and preschool children are winter viruses like respiratory syncytial virus, influenza, parainfluenza, and human metapneumovirus.
Pneumonia should be suspected in children with fever (particularly with fever for more than 5 days or with a temperature persistently higher than 40oC), tachypnea, dyspnea, decreased oxygen saturation, persistent cough for more than 10 days, decreased air entry, or increased bronchial breath sounds. If pneu- monia is suspected, diagnosis should be made using a chest x-ray scan, as pneumonia is overdiagnosed in the absence of radiologic confirmation. The pres- ence of wheezing points to a diagnosis of bronchi- olitis or asthma; abnormalities on chest x-ray scans might reflect the atelectasis or mucus plugging asso- ciated with these conditions. The routine use of chest x-ray scan for bronchiolitis in infants leads to inappro- priate antibiotic use for this viral infection and is not recommended.8
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de décembre 2013 à la page e526.
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Canadian Family Physician•Le Médecin de famille canadien|
Vol 59: decemBeR • décemBRe 2013Commentary | All I want for Christmas is amoxicillin Fever phobia
Fever is a common reason that parents seek medical care for their children; this is often owing to a belief that fever is dangerous and indicates a serious infection that needs antibiotic therapy. Impart the following key mes- sages to parents of febrile children.
• Most fevers in healthy, well appearing, immunized children are caused by viruses.1
• History and physical examination are used to identify the source of the fever and to determine whether any further testing or treatment is required.
• Fever is a normal immune response (and thus not dangerous).9
• Only 2% to 5% of infants and young children will have benign febrile seizures and this does not increase the rate of epilepsy or neurologic issues later in life.10
• Most children look unwell when the temperature is elevated; it is reassuring if they are interacting nor- mally once their fever is treated and the temperature has decreased.1
We have the opportunity to empower parents and caregivers to care for febrile children at home, avoid- ing unnecessary overtreatment and further use of health care resources. Of course, parents must be coun- seled carefully regarding the reasons their child should be assessed by a physician (eg, any fever for infants younger than 3 months of age; persistent fever for more than 5 days; persistent fever with a temperature higher than 40oC; lethargy despite adequate fever control; and dehydration or respiratory distress).
Gift of consistency
Health care providers who treat children in their offices, walk-in clinics, EDs, or elsewhere should be
well versed in the treatment of pediatric febrile viral illness. Diagnostic tests like throat swabs and chest x-ray scans should be used appropriately to confirm diagnoses and initiate appropriate antibiotic therapy when required. Health care providers must be confident when counseling parents on supportive care that febrile children require. Parents need to hear a consistent mes- sage about fever and viral illness; let’s provide one that is evidence-based, sensible, and good for kids.
Dr Reid is a pediatric emergency physician at the Children’s Hospital of Eastern Ontario in Ottawa and Assistant Professor in the Department of Pediatrics and the Department of Emergency Medicine at the University of Ottawa.
competing interests None declared correspondence
Dr Sarah Reid, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1; telephone 613 737-7600, extension 3955; fax 613 738-4892;
e-mail reid_sa@cheo.on.ca
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
References
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J Pediatr 2012;160(3):487-493.e3. Epub 2011 Nov 1.
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6. Rosenfeld RM, Vertrees JE, Carr J, Cipolle RJ, Uden DL, Giebink GS, et al.
Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr 1994;124(3):355-67.
7. Le Saux N, Robinson J. Pneumonia in healthy Canadian children and youth:
practice points for management. Paediatr Child Health 2011;16(7):417-20.
8. Schuh S, Lalani A, Allen U, Manson D, Babyn P, Stephens D, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr 2007;150(4):429-33.
9. Sullivan JE, Farraf HC; Section on Clinical Pharmacology and Therapeutics:
Committee on Drugs. Fever and antipyretic use in children. Pediatrics 2011;127(3):580-7. Epub 2011 Feb 28.
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