Don’t look for quick fixes for your cold! There’s no quick fix

We all have been sick and wish for a magic cure. Sometimes it seems we find the right fix, but it was just coincidental. I see many people who want antibiotics to fix a viral illness because “it always works” but I want to try to show why this isn’t usually the case. Using antibiotics for most colds and coughs isn’t necessary and can lead to problems.

My urgent care experience

This blog is generally about pediatric health, but sometimes the principles are similar in adult medicine, so I’m sharing a personal story.

I was visiting my parents out of town and came down with fever, chills, and a sore throat. Due to the fatigue and shaking chills, I wasn’t sure if I’d be able to drive the 4 hour trip home the following day. I decided to go to a walk in clinic to see if there was a treatment to help get me on my feet again.

Although it’s less common for adults to get Strep throat, I wanted to have my throat swabbed because I had been exposed to just about everything at work.

If it was just a viral illness, fine. I’d tough through it with fluids and a fever reducer for the body-shaking uncomfortable chills.

But a child had gagged and coughed in my face earlier that week when I was doing a throat swab – and he had Strep. If I had Strep (as I hoped), then an antibiotic would treat the cause and I’d be back in shape in no time.

I could technically call out an antibiotic for myself, but I didn’t want to do that. That is poor care and I would never recommend treating anyone with a prescription without a proper evaluation.

I followed my own advice and went to a walk in clinic since I was out of town. If I was at home, I would have gone to my primary care physician because I believe in the medical home.

The provider walked into the exam room looking at the nurse’s notes saying it sounded like I had a sinus infection. (I use the term provider because I don’t recall if he was a physician, NP, or PA.)

What?

He hadn’t even examined me or gotten any history from me other than answers to the cursory questions the nurse asked. Not to mention that my symptoms had just started within the past 24 hours and didn’t include any form of nasal congestion or drainage.

I’m a physician and know that sinusitis must have persistent symptoms for much longer than 24 hours. But I kept that thought to myself for the moment.

He did a quick exam and started writing a script to treat my sudden onset of fever without cough/congestion.

He literally started writing the script as he was telling me, once again, that I had a sinus infection.

Now I couldn’t stay quiet any longer.

antibiotics are not a quick fix for virusesI said I really just wanted a throat swab to see if it was Strep. I didn’t want an antibiotic if it wasn’t Strep throat.

He argued for a bit about the validity of rapid Strep testing.

I argued that I did not meet the criteria for a sinus infection and that the rapid strep tests are indeed fairly reliable (not perfect).

As a pediatrician I won that argument easily. In the end I was swabbed.

The test was negative. I most likely didn’t have Strep throat after all.

He still gave me a prescription for a commonly used antibiotic called a Z-pack, which I threw away.

avoid unnecessary antibiotics
Antibiotics are not a quick fix for viruses and carry risks.

Did I get better?

I felt better the next day, so if I had just taken the z-pack, I would have thought it worked.

Ironically, the Z-pack is not a very good antibiotic against Strep, the one reason I would have taken an antibiotic. Resistance rates are high in my area, so unless a person has other antibiotic allergies (which I do not) I would not choose it for Strep throat.

But my body fought off an unnamed virus all by itself. That’s what our immune system does. Pretty cool, right?

No. Not cool.

Well, yes… it is cool that we can get better with the help of our immune system and no antibiotics. But not cool that a less knowledgeable person would have taken the prescription without question.

Unfortunately, I think many people trust the medical care provider, even when he or she is wrong.  Even smart people don’t know how to diagnose and treat illnesses unless they’re experienced in healthcare, so anyone could be fooled. Especially since we’re vulnerable when we’re sick. Even more so when our kids are sick. We want to do anything to help them.

False security in an unnecessary treatment.

Many parents come into my clinic wanting an antibiotic for their child because the child has the same symptoms as they have and they’ve been diagnosed with a sinus infection, bronchitis, or whatever. They’re on an antibiotic and are getting better, so they presume their child needs the same.

Most of the time they both likely have a viral illness, and the natural progression is to get better without antibiotics, but it’s hard to get buy in to that when a parent’s worried about a child. Even harder when the parent is certain that their antibiotic is fixing their viral illness.

Confirmation bias.

Confirmation bias is the tendency to process information by looking for, or interpreting, information that is consistent with one’s existing beliefs.

A false belief is reinforced when we think we get better due to an antibiotic. It doesn’t prove that the antibiotic worked, but our minds perceive it as such.

We want to believe something works, and when it appears to work, it affirms our false belief.

The wrong treatment plan.

In my example, not only did I not have a sinus infection, but if I did have a false negative Strep test and actually needed an antibiotic for Strep, the Z-pack wasn’t a good choice.

False negative tests mean that there is a disease, but the test failed to show it. False negative tests are the reason I usually do a back up throat culture if I really think it is Strep throat and not a virus.

If the wrong treatment is given, not only do you fail to treat the real cause, but you also take the risks associated with the treatment for no reason.

Doesn’t the doctor (or NP or PA) know the antibiotic won’t work?

Yes, they know (or should know) how antibiotics work and when they’re indicated. But unfortunately, there are other factors at work when quick fixes are chosen.

Top 3 reasons that lead to patients getting unnecessary prescriptions:

1. Time

One problem is that it’s much easier to give a prescription rather than taking time trying to teach why a prescription isn’t needed.

The faster they see a patient, the more patients they can see and the shorter the waiting time is, which makes people happy.

I see many unhappy parents who follow up with me because their child is still sick and the “last doctor” did nothing. I have previously blogged about the Evolution of Illness so will not go into it in depth here.

2. Experience

Sometimes it’s hard for physicians, NPs, and PAs to not try something to make a sick person better. After all, that’s why we do what we do, right? We want to help. We’ve all heard of patients who get progressively ill because an infection wasn’t treated quickly and we don’t want to “miss” something.

While missing a significant illness can happen, it’s not common. Common is common. Most upper respiratory tract infections are viral. It’s knowing how to recognize worrisome symptoms that comes from experience.

Physicians (MD, DO)

Physicians spend years of not only classroom training, but also clinical training to learn to recognize warning signs of illness. Even a brand new physician has at least 2 clinical years during the total 4 years of medical school. Then they spend at least 3 years of residency seeing patients in a supervised capacity before they can work independently. That’s at least 5 years of 60-80 hour work weeks.

The physicians in my office, including myself – now 18 years in practice – still ask for help if we feel it could be beneficial. Sometimes a second set of eyes or putting our heads together helps to put things into a clearer picture.

Trust that if we say it’s a virus, it’s a virus. We know that bodies can still be significantly sick if it’s Just A Virus, but most of the time you can manage symptoms at home. Listen to what we say are warning signs that indicate your child should be reassessed. Bring your child back if symptoms worsen or continue longer than typical. Symptoms can worsen, but taking an antibiotic does not prevent that progression in most cases.

Be sure to question if you do not understand or agree with an assessment or treatment plan, as I did in my example above. It is essential to have this type of communication for the best care.

Nurse Practitioners (NPs) and Physician Assistants (PAs)

I love the NPs in my office. They do a fantastic job and make patient access easier. They see a lot of sick kids and do a great job treating when needed and giving “just” advice when that is what is needed. (That’s usually harder, trust me.)

They are always able ask questions if they don’t know what to do or for a physician to see a patient if a parent wants a second opinion.

I do not want this to become an argument if NPs and PAs are good. They are needed in our healthcare system to help patients get seen in a timely fashion. I welcome and appreciate them as part of the healthcare team.

But I do want to acknowledge that the training and background can vary widely, and I think it’s important to know the experience of your provider. It is not as regulated to become an NP or PA as it is to become a physician.

Many NPs have years of work experience before returning to school to get their advanced degree. But newer online programs do not require much clinical experience. At all.

If they then begin working independently without much supervision, they learn as they go and may or may not learn well. I’m not saying they’re not smart, but I also know how lost I felt those first months as a new physician after many supervised hours, and I know they have a small fraction of those supervised hours. I can’t imagine doing that as a new grad!

This is why I think that all new practitioners should work with others who have more experience, so they can learn from the experience of others. I worry when inexperienced people work alone in clinics, with no one to bounce questions off of.

Learn more about the training of healthcare providers in What kind of doctor is your doctor?

Patient experience and the 6th sense as a parent

Experience as a parent (and patient) matters too.

We can’t see what your child experienced last night if we’re seeing them in the morning and symptoms changed. Many symptoms are worse overnight, which makes it difficult to assess during the day. Of course if symptoms are urgent at night, go to a 24 hour facility that can adequately evaluate the situation.

If you are able to wait until regular business hours, you must describe it so we can understand it.

If you feel uncomfortable with the treatment plan, talk to the provider. List your concerns and let them address them. That’s not the same thing as demanding a prescription or further testing. It means asking for more information about why they feel the current plan is the correct one.

3. Surveys

Many hospitals, clinics and insurance companies are surveying patients to see if “good care” was provided. These surveys are used to place providers on insurance contracts and decide payment and salaries.

People are happier and think care is better if something was done. A lab, x-ray, or prescription (whether needed or not) is “something” people can identify.

People do not feel that information about viral illnesses and what treatments can be done at home is as worthwhile as a tangible treatment, even if it’s the correct treatment. They see the prescription as making the cost and time taken for the office visit “worth it” even if it is bad care. Leaving empty handed (but with proper treatment) doesn’t satisfy.

And the surveys reflect that.

Sadly, the pressure felt by physicians and other medical providers to perform well on surveys has been shown to have many negative side effects. Healthcare costs rise from unnecessary tests and treatments. Side effects of unnecessary treatments occur. Hospitalization rates and death are even higher with high patient satisfaction scores.

Don’t look for a quick fix. Look for the right fix.

Antibiotics certainly have their place. They are very beneficial when used properly. For a fun read about being responsible with antibiotics, visit RESPECT ANTIBIOTICS: USE THEM JUDICIOUSLY TO ENSURE WE CAN STILL WAGE THE WAR AGAINST BACTERIA from Dr. Michelle Ramírez.

If we use antibiotics inappropriately, they cause more problems.



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All About Ear Infections – Treatments

Yesterday I wrote about what ear infections are, what they’re not, and what causes them. Many parents don’t care so much about the what’s and why’s – they want treatment. Now. Because ear infections hurt, and no one wants to watch their baby suffer. Today I’ll discuss treatments.

This is part 2 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

Treatments for Ear Infections

First manage the pain

Regardless of the cause of the earache or what the ultimate fix will be, you will want to first manage pain. It does not matter if it’s a real infection or if it’s even the ears that are causing problems, if your child is in pain, treat the pain.

Oral pain relievers

Ear pain can be managed with pain relievers, whether it’s a true infection or simply pain from the congestion that comes with a cold. You can begin pain relief at home whether or not the ear infection is confirmed with standard doses of either acetaminophen or ibuprofen.

Ear drops

Ear drops for pain work fast but the relief doesn’t last long, so I recommend also giving acetaminophen or ibuprofen per standard dosing recommendations in combination with drops. Ear drops can include both over the counter options and prescription options as long as the eardrum doesn’t have a hole or tube in it.

Do not put anything in the ear if you suspect a hole or know your child has a tube unless your doctor recommends it.

Olive oil works pretty well and most of us have that in our kitchen. Saturate a cotton ball with oil (not hot oil) and squeeze the cotton over the ear canal, putting 2-4 drops in the canal.

There are many over the counter ear drops for pain, but I find that the oil you already own is not only cheaper, but works just as well.

Prescription numbing drops are an option if your doctor thinks they are appropriate. These have been difficult to find in recent years for many factors. Be sure you’re using an approved product if you use prescription pain drops.

Positioning

If you’ve had an ear infection as an adult or watched your child refuse to sleep, you’ll know that ear infections can hurt more when lying down. Safely elevating the head can help the pain associated with the increased pressure lying down.

For young infants, elevate the head of the bed by putting risers under the legs of the bed or by wedging something under the mattress. Be sure it is stable, whichever you do. Never put an infant under 1 year of age on a pillow or other soft bedding.

For older children, propping up on several pillows is often helpful. Many toddlers and young children will not stay on pillows, so this is less effective.

Treat associated issues

When kids have ear pain, they often have a runny nose, cough, fever, and other symptoms. Each of these should be managed as discussed on previous blogs: fevergreen snotcoughgenerally sick. How long symptoms will last are discussed here.

treatment varies by age of the child and severity of the infection:

  • Pain relief for anyone with an ear infection is the first treatment. See above.
  • Monitor for the first 2-3 days without antibiotics in many instances, since most ear infections will self-resolve.
  • Antibiotics can be used if symptoms persist more than 2-3 days ~ earlier for children under 6 months of age, those with significant illness, those who had another ear infection within the past 30 days, or for those who have an increased risk of ear infection (such as immune deficiency or an atypical facial structure or chromosomal defect known to affect hearing or immune function).
  • If a child has tubes and develops an ear infection, pus will drain out of the tube. Antibiotic ear drops are the first choice for this type of infection. Antibiotics by mouth are not typically needed.
  • Prevent the next ear infection. See Part 3 tomorrow!

Why not use antibiotics for every ear infection?

Antibiotics don’t treat viruses

The large majority of ear infections are caused by a virus, for which antibiotics are ineffective. About 80% of ear infections self resolve without antibiotics.

Antibiotics can cause problems

Not only are antibiotics not needed, but they also carry risks. About 15% of kids who take antibiotics develop diarrhea or vomiting. Nearly 5% of children have an allergic reaction to antibiotics — this can be life threatening. So when you look at the benefits vs risks, you can see that most of the time antibiotics should not be used as a first treatment.

Superbugs

When bacteria are exposed to an antibiotic but don’t get completely killed, they learn to avoid not being killed the next time they see that same antibiotic. This is called bacterial resistance, also known as “superbugs”.

Superbugs can be shared from one child to another, which explains why some children who have never had antibiotics before have an infection that is not easily taken care of with the first (or second) round of antibiotics and why if a child needed several different antibiotics to clear an ear infection might get better with generic amoxicillin with the next.

It’s the bacteria in the ear that become resistant, not the child. The more we use antibiotics, the more resistance builds up and the less likely antibiotics will work for serious infections.

What are tubes and how do they work?

Tympanostomy tubes are small plastic tubes that are placed in a surgically made hole in the eardrum (tympanic membrane). They keep the hole in the eardrum open so that if pus develops in the middle ear it can drain out through the tube. This helps prevent the pain caused by the pus filling the middle ear area and pushing out on the eardrum. It also helps prevent the hearing loss that happens when the eardrum can’t move due to pus behind it.

photo from USAToday (Rosenfeld RM. A Parent’s Guide to Ear Tubes. Hamilton: BC Decker Inc., 2005)

Pus behind the eardrum causes many symptoms, which may include balance problems, poor school performance, hearing difficulties, behavioral problems, ear discomfort, sleep disturbance, and/or decreased appetite with poor weight gain. The benefits of tube placement for these children must be compared to the cost and risks of anesthesia and having an opening in the eardrum.

The majority of ear infections resolve completely without complication. The longer the pus remains behind the eardrum the less likely it will go away. If the pus is there longer than 3 months, it’s less likely to resolve without treatment.


When are tubes recommended?

Since placing tubes does involve risks, they are not recommended for everyone.
Guidelines recommend the following evaluation for tubes:
  • If pus or fluid has been in the middle ear for over 3 months (OME or OM that never clears), a hearing test should be done.
  • If the hearing test is failed, tubes should be considered.
  • If fluid has been there longer than 3 months but hearing is normal, recheck the hearing every 3-6 months until the fluid clears. If the hearing test is failed on rechecks, then tubes are warranted. (I know plenty of families who opt for tubes despite normal hearing due to quality of life despite this recommendation.)
  • Children with higher risk of speech issues or hearing loss may be considered for tubes earlier. This would include children with abnormal facial structures, such as cleft palate, or certain genetic conditions that predispose to developmental delays, hearing concerns, or immune problems.
 Dr. Deborah Burton is an Ear, Nose, and Throat (ENT) surgeon who answers common ear tube questions and discusses common tube complications in just a couple of her fantastic collection of blogs. She also gives tips on how to avoid ear infections to prevent the need for surgery!

What about recurrent ear infections?

I know parents get frustrated with recurrent ear infections, and I’ve seen many families who are happy that they got tubes for their child after recurrent ear infections, but studies show they aren’t really necessary. If each ear infection clears, that shows that the eustachian tube (the tube that drains the middle ear into the throat) can do its job. As long as the pus is there less than 3 months with each infection, the risk of tubes does not usually outweigh the benefits according to studies.
Again, quality of life can factor in here and I think that’s hard to measure in a study. If kids are missing out on sleep and not eating well due to ear pain, tubes might really help. Discuss this with your child’s doctor.

Are there kids who should be considered tube candidates earlier?

Some kids are more sensitive to the problems associated with OME. These kids might have sensory, physical, cognitive, or behavioral issues that increase his or her risk of speech, language, or learning problems from pus in the middle ear. Children with known craniofacial abnormalities or chromosomal abnormalities who are at higher risk for speech and hearing impairment will also be considered for tubes more liberally. These kids might benefit from tubes even if they don’t have pus for 3 months in the middle ear or hearing loss.

What are complications and risks of tubes?

Tube placement requires anesthesia, which is overall safe, but not without risk.
Tubes keep a hole in the eardrum, which can allow water and bacteria to get into the middle ear, leading to infection. This leads to pus draining out of the ear canal, called otorrhea. This pus can be treated with antibiotic ear drops initially, and oral antibiotics if it last more than a month.

Some ENTs recommend earplugs when kids with tubes swim, but studies do not show that they are needed in most cases. If kids get recurrent otorrhea, they might be candidates for earplugs when swimming. Kids who swim in lake water or do deep water diving might also benefit from earplugs.

NEXT UP: Prevention

So now that you know what ear infections are and how to treat them, check in tomorrow for Part 3: how to prevent them.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines

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How long will a cough or cold last?

How long will a cough or cold last?

I get this question all the time.

Most people want it gone now. (Or more likely, last week.)

Unfortunately despite our medical advancements over the years, we still have no cure for colds and coughs. Viruses do not get killed by antibiotics, and most colds and coughs are caused by viruses.

cough and colds last weeksI don’t hold back on advice when I see kids with disturbing colds and coughs. I sympathize with the child and parents. I’ve been there: both as a person with a bad cold and as a parent watching my kids struggle with colds. But I still can’t make them better faster.

We have our standard instructions:

  • Fluids (water)
  • Rest
  • Saline washes to the nose
  • Blow the mucus out. If a child’s too young to blow his nose well, parents can suck the snot right out.
  • Honey for children over 12 months of age
  • Prop the head up during sleep
  • Prevent spread
But then we still have the original question: How long will a cough or cold last?
One of my favorite graphs depicting the timeline of a typical upper respiratory infection is from research done in the 1960’s, but since we don’t have any better treatment now than we did back then, I find it to hold true to what I experience when I get a cold and what I see in the office.
how long will cold and flu symptoms last
Days of Illness

Notice how the symptoms are most severe during the first 1-5 days, but still persist for at least 14 days. And at 14 days 20% of people still have a cough, 10% still have a runny nose. And the lines aren’t going down fast at that point, they both seem to linger.

A more recent review of medical studies showed that the many symptoms of illness linger for much longer than parents want to accept. From this study:
earache, sore throat, croup, bronchiolitis, cough, common cold
* Earache range 7-8 days, Sore throat 2-7 days

Bear in mind that children tend to get about 8 colds per year, often in the fall/winter months, so a second virus might start developing symptoms right as the first cold is finally going away.

There’s an important distinction between back to back illnesses versus a sinus infection requiring antibiotics. This is why doctors and nurses ask (and re-ask) about symptoms. The history and timeline of symptoms are very important in a proper diagnosis.

It isn’t the color of the mucus (really!) We don’t want people to unnecessarily take antibiotics. That leads to bacterial resistance, side effects of medicine, and increased cost to families.

So if you’re struggling with cough and cold symptoms in your house, follow these instructions.

To help determine when your child needs to be seen:

Urgently or emergently:

If your child is breathing more than 60 times in a minute, ribs are going in and out with breaths, or the belly is sucking in and out with each breath, your child needs to be seen in the office, at urgent care or an ER (preferably one that specializes in children), depending on time of day and your location. Another complication that kids must be seen for is dehydration. Dehydration may be present when the child is unable to take in enough fluids to make urine at least 4 times a day for infants, twice a day for older children.

Routine office visits:

If your child has ear pain, trouble sleeping, or general fussiness but is otherwise breathing comfortably and well hydrated, he should be seen during regular office hours. If the cold is worsening after 10-14 days, bring your child in during regular office hours.

To help determine where your child should be seen, check out my old blogs on What to do After Hours and Urgent Cares for Routine Illnesses.

More reading:

Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years

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