The scary truth about antibiotic overuse in kids

Your kid has another ear infection. What should you do? As scientists unlock the connection between antibiotic use in kids and the increased risk of asthma, depression, obesity and other chronic diseases, parents are faced with a tough decision.

Illustrations by Olivia Mew

Jennifer Chrysler is a self-proclaimed hippie mom with a pretty chill parenting style. She makes baby slings out of hemp, embraces all things organic and, her son, Mitchell, at two and a half, already knows the words to Bob Marley’s “Everything’s Gonna Be Alright.” The only time Chrysler gets stressed is when Mitchell gets sick, which seems to happen with alarming frequency since he started school. What worries her the most is when that illness is accompanied by a fever.

Chrysler recalls the first time Mitchell had a fever just over a year ago. He woke up with a temperature of 102F. Cold cloths on his feet and forehead coupled with doses of pain medication every four hours didn’t make any difference. By the next morning, Chrysler was in a panic. “He was such a wee little thing and he was so sick, he couldn’t even lift his head. It was terrifying,” she says, and they headed right away to the doctor, who prescribed antibiotics for an ear infection. “I had to make a decision. I realized I had to get him on antibiotics because what I was doing wasn’t working.”

As medical marvels go, antibiotics top the list. Since the mid-1900s, they’ve prevented millions of deaths from pneumonia, tuberculosis and a host of other unpleasant infectious diseases. Before the advent of antibiotics, if children contracted bacterial meningitis there was a 90 percent chance they wouldn’t recover. Now, with a course of amoxicillin, toddlers like Mitchell recover almost instantly from bacterial infections and are back to their normal, busy selves in a day or two. However, scientists are realizing, this incredible success has come at a price.

The problem is that antibiotics are like indiscriminate weapons of mass destruction—yes, they wipe out the insurgent disease-causing bacteria that threaten our health, but they also obliterate the beneficial bacteria. Like bees in a hive, most of the tiny microbes that inhabit our bodies (as many as 1,500 species live in the gut alone) have important jobs to do, from digesting food and synthesizing vitamins to strengthening the immune system and fighting disease. And researchers are finding that when we mess with them, it can increase our risk for chronic illness.

All this creates a conundrum for parents like Chrysler: When your kid is sick and screaming with pain in the middle of the night, you want to fix it—fast. But is the answer always getting a prescription for antibiotics? Should you risk killing the good bacteria with the bad, which could increase their odds of developing asthma or allergies down the road, or hold out and hope things get better on their own? Of course, there are those nightmarish stories we hear about parents who chose not to administer antibiotics with terrible consequences. Last year, parents in Pennsylvania were criminally charged when their 18-month-old died from bacterial meningitis after they treated her with homeopathy; and a couple in rural Alberta were sentenced after treating their son’s bacterial meningitis with herbal remedies and “failing to provide the necessities of life.” It can feel a little like a lose-lose situation, where parents and doctors have to weigh the risks of treating versus not treating.

Too much of a good thing?
You’d be hard pressed to find a medical expert who’d contest the significant role antibiotics play in keeping kids healthy, but there are those, like Alexandra Zhernakova at the University of Groningen in the Netherlands, who worry that we’ve become overzealous in our approach to treating common illnesses. Zhernakova, who studies intestinal bacteria and the effects they have on disease, says children are especially vulnerable.

“Using antibiotics in children has a broader effect on health compared to adults, including long-term consequences,” Zhernakova says. She published a study last year that revealed just some of the ways, from diet to medication, we’re altering our gut microbiota—the population of micro-organisms that call our intestines home. A big concern is the extent to which antibiotic use in childhood messes with the trillions of bugs that live in the gut, wiping out everything, including the ones that might reduce a child’s risk of developing asthma, inflammatory bowel disease and even obesity later in life. “High diversity, or the presence of many different
bacteria, is good for gut health, whereas low diversity is associated with diseases,” Zhernakova says.

Scientists really only started seriously investigating microbes in the last decade, so we still don’t know what role most of the bacteria in our bodies play. But links have been found between antibiotic use and an increased risk of everything from allergies to anxiety—last year, researchers at Tel Aviv University in Israel found treatment with just one course of antibiotics increases your risk of developing depression and anxiety, and that risk increases significantly with every prescription you fill. And the earlier you take antibiotics, the greater the implications. A study in JAMA Pediatrics in June found antibiotic use in breastfeeding babies could even reduce some of the long-term health benefits of nursing. And earlier this year, scientists at the University of Helsinki discovered that kids who receive antibiotics (especially macrolides like azithromycin, which are commonly used to treat upper respiratory tract infections) before age two are at an increased risk of asthma and obesity. That study also found that it can take children’s guts at least a year—sometimes two—to recover from one course of antibiotics.

Illustration: Olivia Mew
Illustration: Olivia Mew

Assessing the damage
This drastic change is what worries Brett Finlay, a professor of microbiology at the University of British Columbia. “What we’re seeing is that each time you take antibiotics, you screw up your gut microbiota,” he says. “You can get away with it once or twice, but if you do it repeatedly, you’ll shift your microbiota permanently—and not in a good direction.” This fall, Finlay co-wrote the thought-provoking book Let Them Eat Dirt: Saving Our Children from an Oversanitized World, which explores why keeping children’s gut bugs healthy is essential to their developing immune systems. 

The first three to five years are key, Finlay says, because that’s the time it takes for a child’s microbiota to become a fully formed community. We don’t yet know what all these bugs do, but we do know that one of their most important tasks is to help kick-start kids’ immune systems. Unfortunately, our squeaky-clean, bugs-be-gone way of life is putting kids at risk.

“We went on a major campaign to clean up the world with antibiotics and cleanliness and sanitizing everything,” Finlay says. It worked for infectious diseases, which plummeted in the last 50 years, but if you put them on the same curve as non-infectious diseases, Finlay says they go in the opposite direction. “When I was a kid, no one had asthma—there was one kid in the school. Now, up to 20 percent of kids have asthma. What has happened in that short time? It’s less than two generations, so we haven’t changed genetically, but something’s happened.”

Many scientists, including Emma Allen-Vercoe, an associate professor of molecular and cellular biology at the University of Guelph, believe that “something” may be the internal climate change we’ve inflicted on the microscopic ecosystems in our guts. Allen-Vercoe believes the complex relationship we have with that ecosystem may even be at the root of the increased incidence of autism spectrum disorder in the last decade. (Today, one in 68 children is diagnosed with ASD, compared to one in 150 in 2000.) “There may be a genetic predisposition, but I think the adage ‘genetics loads the gun, environment pulls the trigger’ is true in autism spectrum disorder,” she says.

Past studies have suggested a link between gut microbiota and the development of autism symptoms around age two, but what got Allen-Vercoe interested was anecdotal evidence from parents. “Many of these children seem to have gut issues—foul-smelling stool, constipation, diarrhea, bloating, discomfort—yet this aspect of their disease was largely ignored.” And many parents of autistic kids often say controlling their children’s diets plays a key role in managing their symptoms. “We’re trying to understand whether there is an abnormal metabolism in the guts of autistic kids, and whether interventions such as antibiotic use early in life, when a child’s microbiota is at its most vulnerable, may be the trigger to set the abnormal metabolism in place.”

As the idea of protecting good gut bacteria has spread, antibiotic use has become slightly more judicious. Between 2011 and 2013, the greatest reduction in antibiotic use in Canada was in children in the newborn to five-year age group, dropping from 1,003 to 872 prescriptions for every 1,000 children. Still, in 2013, antibiotics were recommended to a higher rate of children under age two than to adults aged 20 to 65—and Canada ranks 11th out of 29 countries based on total antimicrobial use overall. “Comparing the frequency of antibiotic use in different countries suggests that it can be reduced in a lot of cases,” says Zhernakova, pointing to how the Dutch use half as many antibiotics as Belgians.

Illustration by Olivia Mew
Illustration: Olivia Mew

A prescription for the problem
Do some doctors still over-prescribe antibiotics for non-serious infections? Do some parents still insist on leaving the nearest walk-in with a prescription, even if their child’s runny nose is caused by a virus and not bacteria? Yes, on both counts, says Joan Robinson, chair of the Canadian Paediatric Society’s Infectious Diseases and Immunization Committee in Edmonton. Yet, she cautions that even though we know there has been a big change in our gut bacteria, a lot of the research is based on correlations, which means an exact cause-and-effect relationship still needs to be teased out. “Is the problem antibiotics, or is it something else?” Even so, she says paediatricians recognize over-prescribing antibiotics has a negative effect, from disrupting our microbiomes to creating antibiotic resistance. As a result, doctors are getting better at “more rational prescribing.”

Robinson says it’s also up to parents to ensure there’s a really good reason their child is getting a prescription. “When parents understand the risks, they can say to their doctors: ‘We don’t want antibiotics unless you think they’re completely necessary.’” Antibiotics need to be reserved for serious infections, she says, adding that for all the ear infections that get treated, only between 10 to 20 percent of patients need antibiotics. “We’re realizing that maybe it’s not reasonable to give 10 children antibiotics just to benefit one.” Most doctors now recommend parents wait 24 hours before filling a prescription, to see if the symptoms disappear on their own. It may feel like a long wait, but Robinson says it’s worth it. “If you give children Advil or Tylenol for the pain, odds are they’ll get better just as quickly as they would on an antibiotic.” 

Even the doctors who study the havoc antibiotics can wreak on our internal bug populations aren’t saying “don’t do drugs” altogether. Antibiotics, if prescribed correctly, are necessary, says Allen-Vercoe. Her daughters, now 10 and 17, have both been on antibiotics—the eldest for strep throat when she was a toddler and the youngest for a urinary tract infection. “Get a second opinion if you’re concerned, but remember that antibiotics, when used judiciously, save lives.”

Chrysler’s son, Mitchell, has already been on antibiotics five times, usually for ear infections. “My paediatrician is amazing and she’s not a drug pusher,” Chrysler says. “When it’s just a cold or the infection isn’t severe, she tells me to just let it run its course.” But in those five cases when Mitchell didn’t seem to be getting better on his own, she feels the prescription was warranted.

In an attempt to counteract the effect of the antibiotics Mitchell had after being sick for several weeks last spring, she started giving him chewable probiotics every day—and ensures his diet is full of fruit and vegetables to strengthen his immune system naturally. She says she’s also trying to resist the urge to douse her son in antibacterial gel after every interaction with the outside world—although a recent mouth-on-a-shopping-cart-handle incident did freak her out. “I’m trying to be less of a germophobe, but that was really gross.”

And yet when Mitchell gets an ear infection that doesn’t improve after the “watch and wait” period, she puts her concerns about antibiotics aside. “I’ve gotten to the point where if rest doesn’t bring down his fever and I know the prescription is the only thing that will fix it, I don’t argue, I just fill the script.”

Can we make better antibiotics?

There’s a promising discovery that bacteria in the human body may be effective when it comes to fighting specific infections. Antibiotics are typically derived from bacteria found in soil, but a recent study published in Nature found microbes that live in people’s noses can create an antibiotic that not only kills the bacteria that cause meningitis and bronchitis, but also defeats the hospital superbug MRSA.

Another potential treatment on the horizon: targeted probiotics. Currently, probiotics consist of a few select microbes that aren’t chosen for what they do, but because they can be grown easily out of things like milk (Lactobacillus, for example). They typically contain only a single strain, so their impact is minimal. They’re also not designed to stick around in your gut (which is why you have to take billions every day to get any real benefit). But microbiologist Brett Finlay says work is underway to create better probiotics—ones that contain more strains of microbes that the body produces naturally, thus offering bigger health benefits and increasing the chance the microbes will colonize in the gut. They’ll also be streamlined to target different health issues. “With probiotics 2.0, we’ll be able to say, ‘We know these specific microbes are needed to prevent asthma, so let’s actually get these into kids,’ which will be a big regulatory task, but it will come.”

Read more:
Ask Dr. Dina: Should you finish the entire bottle of antibiotics?
Why your baby’s gut bacteria is so important
New study: Antibiotic use during pregnancy may affect baby’s gut health

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