"Max has been sick on and off since his sister started kindergarten," his dad says. Eighteen-month-old Max*, who didn't sleep all night, sits on his dad's lap, smiling, clear mucus dripping from his nose. As a pediatrician, I know that kids get sick on average six to 12 times a year in the first years of life, but now's not the time to remind this dad unless I've got Mary Poppins booked for a week and round-trip tickets to Hawaii for him and Max's mom.

I scroll through the chart notes. Since September, I've seen Max for a bad cold, a stomach flu, and most recently a nasty ear infection that oozed pus.

"His nose won't stop running, and he's up all night coughing," Dad says. Other parents at the daycare center have complained about Max's cough, and he's not allowed back without a doctor's note. Dad tells me in a hoarse voice that he can't miss any more days of work, and his wife has just started a new job. If they manage to keep their jobs, they won't be getting vacation days any time soon.

Dad remembers that Max got better the instant he took his first dose of antibiotics for the ear infection and wonders if he doesn't need them again.

The belief in antibiotics as cure-alls runs strong: According to studies quoted by William F. Pfeiffer, MD, in a 2005 article for Pediatrics in Review, 44 percent of people believe antibiotics cure viral infections despite the fact that antibiotics only work against bacteria. Dr. Pfeiffer's piece, "A Multicultural Approach to the Patient Who Has a Common Cold," estimates that 12 percent of all antibiotic prescriptions for children -- 6.5 million -- were squandered on a condition they can't cure.

Max chews on a stuffed kangaroo and smiles some more. I listen to his chest and check his ears and throat. If I find a bacterial infection that warrants antibiotics, I'll write a prescription, Max's dad will forgive him for the sleepless nights, and they'll live happily ever after.

But this may not be an appointment with a fairytale ending. I give Dad the good news: no pneumonia, no ear infection, and no sinus infection. Max, who sneezes clear mucus all over, does not need an antibiotic. I pass the box of tissues and dole out the facts: Viral infections respond best when we support the body's restorative powers. With rest and fluids, Max should improve in the next few days.

"Could you prescribe antibiotics just in case?" Max's dad asks.

I can't prescribe antibiotics when they aren't medically indicated for the specific disease a patient has. The overuse of antibiotics "just in case" -- as a sort of kitchen-sink assault on illness in general, or in the hopes of generating a placebo effect even in cases of viral infection -- is bad medicine. It can create drug-resistant superbacteria and cause countless adverse reactions and unpleasant side effects like diarrhea.

I tell the worried father we should save the magic of antibiotics for when Max really needs them.

Max and his dad could use a bit of magic: We all could when we're sick. By the time patients check with their doctors, their symptoms are usually at their worst, and they've had it with being sick. But most colds, coughs, and stomach bugs will gradually start to improve no matter what the patient does or doesn't do. Getting better, something statisticians call "regression to the mean," has been recognized by researchers for over a hundred years.

I go back to the chart notes. Max's family has called the office about a cough and a runny nose a few times, and each time, Dad admits, he got better without antibiotics.

Although I can't prescribe antibiotics merely in the hopes of generating a placebo effect, I know that the placebo effect can indeed be a powerful phenomenon. The term placebo comes from the Latin verb placare, to please, which also gives us placate. In 1955, Dr. Henry K. Beecher concluded in an article in the Journal of the American Medical Association that in blind studies of groups receiving either treatment or a placebo, 35 percent of patients felt improvement when given the placebo.

And while giving sugar pills or sham saline injections isn't ethical practice, there's no shortage of believing going on. In the 2001 review "Alternative Medicine and Common Errors of Reasoning" in Academic Medicine,Barry Beyerstein, PhD, quoted a 1997 survey that estimated Americans' out-of-pocket expenditures for alternative therapies at $27 billion. According to R. Barker Bausell, the author of Snake Oil Science (Oxford 2007), this money was spent on complementary and alternative treatments that have not been found effective in well-controlled experiments. Bausell understands the patient's desire to believe and feel better; he provides guidelines for pursuing effective care and lists things to consider for those who chose to use therapies that may involve the placebo effect.

But back to Max. I've taken a history, performed a physical examination, and made recommendations for his care without prescribing an antibiotic as a placebo.

"I'm actually relieved he doesn't need an antibiotic," says his dad. "It's a bugger getting him to take it." He asks what cough and cold medication works best, and I tell him that there's no medical evidence that cough and cold medicines work any better than placebos in young children. We talk about the 2007 advisory from the U.S. Food and Drug Administration that resulted in the recall of products marketed for children under 2 years of age. I suggest warm lemonade or tea with honey.

Max's dad sighs. Facing another sleepless night of waiting it out is tough.

I've seen doctors prescribe medications that are glorified combinations of over-the-counter ingredients, but I don't, because doing so violates rule number 13 from Samuel Shem's book The House of God, which states, tongue in cheek, that good medical care consists in doing as much nothing as possible.

I'm not a lazy, uncaring physician who enjoys holding back on the really good drugs. I want kids to get better, and I don't want to get in the way of the body's natural healing. I ask Max's dad what his own mother did when he was sick, and when he tells me she ran a vaporizer and made chicken soup, I tell him about a 2000 article in the journal Chest in which Barbara O. Rennard et al. found that chicken soup had an anti-inflammatory effect that helped fight upper respiratory tract infections.

Families all over the world have home remedies they pass down through the generations. There are soups, teas, and body treatments with compresses and oils. My favorite from Pfeiffer's article is the coconut oil massage practiced in the Micronesian state of Chuuk.

I joke about writing a prescription for a week in the islands and tell Max's dad that, theoretically, one of the reasons why kids may get fewer colds and flus in the tropics is because viral particles may be more likely to stick to the water droplets in humid, tropical air and drop to the ground where we are less likely to breathe them in and become infected. This research gem -- which happens to support the idea that vaporizers might help -- was published by Dr. Anice Lowen in the October 2007 issue of PLoS Pathogens.

I take out the magic wand I keep in the breast pocket of my white coat and wish Max's nose would stop running and he would never have another cold and win the Nobel Prize for research that cures the common cold and go on to live a long and healthy life.

Dad laughs and Max joins in. The desire for an antibiotic cure-all has passed. I tell Dad to watch for fever, a change in Max's breathing, or persistently colored mucus. If Max isn't better in a few days, he should call. He'll do that, he says, as Max wrestles me for the magic wand.

-- Lisa M. Asta, MD, FAAP is a board-certified pediatrician who practices in Walnut Creek.

*Names and identifying details have been changed to protect the privacy of individuals.

References

First published September 26, 2008
Copyright © 2008 Consumer Health Interactive