Antibiotics: What are they, Who do they help, Where do they not work?

Antibiotics:  What are they, Who do they help, Where do they not work?

Antibiotics are a group of medicines that kill germs.

There are three types of germs that can make us ill:

1. Bacteria
2. Viruses
3. Parasites

There are plenty of medicines that kill bacteria and parasites, not so many that kill viruses.

Of course, it makes a big difference if a medicine works or not, so let's take a look at each of these types and whether antibiotics makes sense or not.

Bacteria

Bacteria are like us, living cells that eat food.  They are very small, always one-celled, and when the feed on us they make pus.  Antibiotics were invented to kill bacteria, and do a great job at it.

But, most of the infections we see in childhood, in fact the vast majority, are not caused by bacteria.

The most common infections bacteria cause are: ear infections (about 60% of them), pneumonia (about 20% of them in kids), strep throat, impetigo (a skin infection), and boils.  

Bacteria all have chemistries that are different from our cell's chemistries, so one could create a drug that blocks bacterial chemistry, but leaves our alone.  That's how the antibiotics are able to kill all the bacteria causing our infection, but leave our human cells alone.

If we know your child has an infection caused by bacteria, and the infection needs to go away, antibiotics are always available to kill essentially any bacteria.

Viruses

Viruses are an odd thing.  They are essentially a packet of information.  Every virus is a small snippet of genetic material (DNA or RNA) wrapped in a coat of protein designed to deliver the genes into our cells. Once in place, the genes only job is to force our cell to make more viruses, usually popping the cell in the process.  We get sick from all the cells infected with a virus that get destroyed.

Viruses have very little chemistry inside of them, so there are very, very few ways a drug can be taken to kill a virus.  There are a few antibiotics that kill viruses, but each only kill one very specific type of virus.  Tamiflu kills the influenza virus, but not any other virus, for example.

Viruses cause most of the infections now seen in childhood, and every person alive will have dozens of these infections, every person.

Infections caused be viruses include colds, flus, and stomach flus.

The usual antibiotics have no impact at all on any viral infections, and we have seen many children on antibiotics for a bacterial infection actually develop a viral infection, while on the antibiotic.

For the common cold and all stomach flus, medical science has not yet developed any drug or medicine that could kill or control that virus.

For influenza infections, there is Tamiflu, but this drug is very limited in its ability to help.  It has no impact on the course of the illness if taken 48 hours or more after it starts.  Further, in children, the impact on the course of a case of influenza virus infection is rather small, even if started at the start of the infection.

When it comes to nearly all viruses, antibiotics are ineffective, really very useless.

Parasites and fungi

Parasites are worms and small cellular creatures that cause infections.  This category is an unusual source of serious infection.  The yeast that babies in diapers get is a fungus, as is ringworm, but aside from occassional growths on the skin, fungi and parasites are very unusual sources of infection in American children.

As with bacteria, parasites and fungi can have chemistries that are different than ours, so again there are usually varieties of antibiotics that can kill them and are very useful.

Hazards of antibiotic use

One of the glories of antibiotics is that they do not kill human cells, even though they can kill vast swarms of bacteria completely.

But three hazards of use still exist:

1.  Allergic reaction.  Anyone can develop an allergy to any antibiotic anytime.  Sometimes these reactions can be quite severe, even dangerous.  So no one should take an antibiotic unless it is clear it will help and clearly needed.

2.  Disruption of "good" bacteria.  It turns out that 99%+ of all bacteria are actually helpful, even necessary, for our health and well-being.   It even turns out that for every one of us, we walk around with 10 times as many bacterial cells in and on us as there are human cells.  Antibiotics make no distinction between good and bad bacteria.  Thankfully they kill the bad ones, but unfortunately, they wipe out the good ones, especially in our gut, too.  So no one should take an antibiotic unless it is clear it will help and clearly needed.

3.  Resistance.   All bacteria are smart, so if they see a drug a bunch of times, they will figure out a way to resist being killed by that drug.   Only one bacteria, so far, has failed to find a way from being killed by an antibiotic:  every strep germ we know of is killed by penicillin, even after 70 years of being exposed to penicillin.  But in all other instances, bacteria have evolved to find the once deadly antibiotic harmless to them.  This almost never happens during a 10 day course of one antibiotic in a person.  It usually takes millions of doses across millions of people for the emergence of one resistant bacteria that then survives and spreads.   But the point is that if every doctor prescribes antibiotics for illnesses, such as colds, for which they do not good, then we do have a situation in which hundreds of millions of dosages are given that do go on to breed resistant strains.  This matters because once a strain of bacteria evolves that is resistant to an antibiotic, that antibiotic is then rendered useless against that bacteria.  Over time, even proper use of antibiotic will lead to all bacteria being resistant to all antibiotics, but overuse makes that process go a lot faster.

BOTTOM LINES

1.  There is no magic to the word antibiotic, these are simply the category of all drugs that kill germs.

2.  For the most common infections of childhood, such as colds, no antibiotic has any effect.  For two reasons, then, antibiotics should not be used for colds:  they do not work at all, and use of them greatly accelerates the emergence of deadly resistant bacteria.

3.  For bacterial illnesses that require treatment, there are antibiotics that will work, that will cure the infection.  The main risk from use of these drugs are allergic reactions and disruption of the natural and beneficial bacteria in our bodies.  

4.  The disruption caused by use of antibiotics can have unexpected effects, many of which are not understood.  The use of probiotics has been proven to help reduce this disruption and keep our useful bacteria in good balance.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Development- How to know if it is fine or a problem?

Development- How to know if it is fine or a problem?

Development is a very hot topic these days, and probably has gripped our attention for a very long time as well.

The reason it's so hot today, is that much is written to push parents to be worried that their infant and toddler is not developing well, might even be "delayed," and should receive "services" to avoid an unfortunate future.

So in this posting, we will take a look at development, some basics on how we develop, and some guideposts that will help you know if your child has a problem, or not.

Basics of Development

All of life develops, meaning that what a life form can do at one moment in time changes, often quite dramatically, over time.  This is quite case for all people.  Everyone of us starts off as a single cell, the fertilized egg, are born rather helpless, and over many years emerge as a fully grown person, capable of a staggering range of imaginative achievements ranging from the athletic, to the intellectual, to the artistic, to the enterprising, and beyond.

For most of us, we can see the transformations we call development starting at birth.  The newborn can see and hear, smell and touch, suck and swallow, cry and look and sleep, and can learn at a dramatic pace.  But a newborn cannot walk or talk, cannot sing or write a poem, cannot grab or smile.  The emergence of all these fabulous human abilities and more is what we mean by development.

There are three key aspects to all human development:

• The timeline.  No one is born able to do all that an adult can do, the emergence of these abilities always follows a timeline.  Time is a fundamental dimension of development.
• A rather predictable progression.  Consider walking, nearly everyone goes through this sequence in developing the ability to walk: can't walk at all, pulls to standing, walks holding on, takes a few steps, toddles in an early form of walking, develops more fluency and ease of walking, walks.  The point here is that everyone tends to follow a certain path to every commonly developed skill.
• There are highly individual patterns to development.  Despite nearly everyone learning to walk in the same sequence, the exact timing of each step, the enthusiasm or fear the progress generates, the age at which each step occurs vary wildly across a group of infants and toddlers.

A word on how misleading the average age is

Before we take a look at how to know when to worry, a word on one value can be potentially quite misleading, the average age any particular achievement in development occurs.

Consider sitting.   The average age infants learn to sit is 7 months old.  The vast majority of blogs, web pages, books, and magazine articles use this item as the key guide to know if everything is OK.  And that would seem to make sense, why not use the average age, after all, if your infant sits by 5 months of age, knowing the average age of attaining that skill is 7 months will prove to all your infant learned to sit in plenty of time- no problem.

The problem is that half of all humanity achieves any single developmental stage after the average age. That's what makes it the average age.  So if you base your sense of how things are going on the average age, you quickly find about half of all humanity being told there is a problem.

A much more helpful piece of reference information is the range of ages children achieve any particular developmental step.  

For sitting that can be anywhere from 4 to 9 months of age.

One last point in the basics:  when your infant or child achieves a milestone tends to have no relationship on how bright they are or how well they will perform in that arena.  

Say some kids walk starting at age 11 months, and others start at age 15 months. The ones who started at 15 months may turn out to be far more skillful track athletes than the ones who started at 11 months. Development is to a large extent the process of different processes in our brain coming together and activating.  When a light switch is turned on says nothing about how bright the light is.

How to Know if your Child's Development is OK or Needs Help

Human development is described in 4 categories:  gross motor (e.g., sitting, walking, and running), fine motor (e.g., grabbing, various grasps, drawing, writing), speech and language, and social.

In each instance, we get concerned if the child's progress establishes that they will struggle or be unable to attain a level of skill in any of these categories that would limit their ability to live their life successfully.

One approach would be to simply wait until development is completed and see what skills the child needs help improving.  The problem with this approach is that it waits a long time to help, and we do know that helping earlier leads to better results and less frustration.  

Another approach is to look carefully at your infant and toddler, and at the earliest sign of a problem with development, intervene to accelerate or improve their developmental progress.  The advantage of this approach is that you can perhaps change that child's developmental pace and outcome and prevent the impact of a limited ability in the area of concern.  There is one major disadvantage to this approach: inaccuracy.  When you try to identify whose development may be indicating trouble ahead, you cannot avoid the possible error that a child who is going to be fine is told there may be a problem.

Being Accurate

If we do accept the idea that looking carefully at our child to detect early signs of developmental concern, we must also accept the idea this sort of looking calls on us to be accurate.  By accurate we mean doing our best not to consider a child's development of concern unless there really are indications that the development will leave the child with a truly abnormal or limiting outcome.

The chief source of inaccuracy comes from not taking into account the normal variability in development, the third of the three key properties of development noted above.

One way to think about all this could be very helpful.  For any one developmental step, say talking for example, there are three phases of variability:

• Absolute uniformity- no one at this age or prior to it can do this skill, no one.  Everyone is the same.
• Maximal variability- big differences from person to person in the ability to do this skill are seen normally.
• Near uniformity- well after the age that people tend to develop a certain skill, nearly everyone can do that skill, nearly everyone is the same.

Now let's see how this works with talking, which starts with very early steps around 9 months of age and is well in place with most children by about 3 years of age.  So, the ages of 0-6 months are quite uniform- no young infant talks.  And also, well after 3 years of age, there is plenty of uniformity, essentially every healthy 5 year old talks, again lots of uniformity.

But look at a group of 2 year olds, there is no uniformity.  Many 2 year olds speak very well, some sound like grown-ups!  But many 2 year olds only speak in short phrases, and there are plenty of two year olds who will turn out fine who speak barely at all.

Picking out the problems

So the real challenge is picking out the child who needs help, and leaving the child who is going to turn out fine alone.  

Think about our group of 2 year olds.   Say we find 20 of them who aren't using many words yet, will all of them need help?  The answer is no.  Some of these children will turn out to have a problem, and could really use the help and benefit of good speech therapy.  Some of these children will simply be going along their developmental path in their own way and will reach the desired goal of normal speech without any help at all. Again, 50% of all people develop any skill after the average age everyone reaches it.

How to know when to act then?   We suggest some guidelines that can help you be reassured when no problem is present, and know when to act if a problem is present:

1. If the developmental step has not yet occurred, but if your child is still in the normal range of ages for gaining that skill, that is reassuring.   For example, the average age range for normal development of walking could be something like 8-18 months old.  That is, nearly all kids learn to walk by the time they are 18 months old and not many before 8 months of age.  So if your child is not walking yet, and is 14 months old, they are still at an age where normally developing children might not have learned to walk yet.   But, if your child is 26 months old and not walking, the chances of that being a sign that something is wrong is much greater.
2. Progress is reassuring.  If we think about developing the ability to walk again, consider someone who is not walking at 15 months of age.  If that child pulled herself to standing at 12 months, started walking holding on to furniture at 14 months of age, and seems tantalizingly close to letting go and taking a step now, that is more reassuring than the situation where the child can only sit at 15 months of age, cannot pull to standing.   If over several months there is no change noted towards the goal that is a sign worth being concerned about.
3. Losing a skill is always of concern.  Again, in the arena of walking, if someone was walking quite well at 13 months of age, but at 15 months of age cannot walk, that is very worrisome.  Losing a skill is very unusual and always requires evaluation.

BOTTOM LINES

1. Development are the changes that happen to all people that allow them to do certain skills that they could not possibly do earlier in life.
2. All human development follows a timeline, follows a regular pattern of change, but carries with it lots of individual variation.
3. Around the average age people gain any particular skill, there is lots of variability.   So the range of normal ages for gaining a skill says loads more than the actual average age about who to be worried about.
4. If you are in the range of normal ages for gaining a skill and making good progress, there is usually less to be worried about than if that is otherwise.
5. When a variation in development is noted, but all indications are that your child is still progressing along normally and will likely gain that skill and do well, there is less need for help.
6. When a variation in development is noted, and the indications are that progress towards the goal is not so likely, or has actually reversed, help is a very good idea.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Hand washing- how does it help, does it help?

Hand washing- How does it help, Does it help?

Washing your hands is a time-honored bit of advice we have heard from our parents and grandparents for a long time, probably since soap was invented.  As a bit of advice, it belongs to other such honored items as, "Wear a hat when it's cold, or you'll get sick," "Don't cross your eyes or they'll get stuck," and ""Clean your plate, don't leave food on it."

But, does washing your hands really do anything?  The answer is yes, it really does have an impact on the spread of germs, but of course that impact all depends on where you are- at home, in the hospital, in the operating room, for example.

The germs hand-washing might stop from spreading

Before we get into just what hand washing does, a word on what sort of infections it might prevent.   In the United States, nearly all the infections we encounter in daily life are either from germs called viruses or germs called bacteria.  They are quite different.  Viruses are the germs that cause infections such as colds, flus, stomach flus, mono, viral pneumonia, chickenpox, and warts.  Bacteria are the germs that create pus, such as ear infections, bacterial pneumonia, strep throat, abscesses, and impetigo.  Viruses are very contagious, bacteria less so.  Viruses turn out to be bits of DNA that land on you and make you make more copies of that viral DNA, essentially causing an information cycle that just happens to irritate the cells forced to participate.  Bacteria are more like us, they are cells that land on us and eat our cells, just like we eat. Antibiotics kill bacteria, but have no effect on viruses.

What does handwashing do in the home?

With all that in mind, let's look at what hand-washing can do in the home.   It turns out at home and in school, the vast majority of infections that spread around are from viruses.  With the exception of strep throat there are no very common infections that are spread by bacteria.  So, if hand washing is going to make a difference at home, it would have to stop the spread of common viruses seen in the home or school.  Those viruses split into two main types- those that infect the nose, throat, eye, and lung (colds and flus), and those that infect the stomach and gut (stomach flus).    The respiratory viruses tend to spread in the air, and the gut viruses by hand contact.  You might see now that if you wash your hands it has no impact on what happens if you sneeze or cough, or even just breath.  You can even have your hands soaking in disinfectant, and if you sneeze, the virus will spread just fine.  But it is the case that if you are very careful about hand washing, you an decrease the spread of stomach flus which need a handshake to go from one person to another.  So, it turns out that hand washing has very little impact on the spread of colds and flus, but can make a difference on the spread of stomach flus.

What about in the hospital?

The hospital is a special place for germs.  There is a very unfortunate irony that the more we gather sick, really sick people, into one building, the more nasty bacteria will be in that building.  And this is clearly the case for hospitals.  There are loads of studies that prove that hospitals are unique places for the number and concentration of really dangerous bacteria.  And we also know that perhaps the #1 way dangerous bacteria travel from person to person in a hospital is on hands.  And so it comes as no surprise that it has been proven that if everyone washed their hands after touching anyone, anytime, in a hospital, many lives would be saved by preventing the spread of dangerous bacteria.  

BOTTOM LINE

• If visiting anyone in a hospital, even the newborn nursery section, wash your hands, a lot!  Everytime you enter a room, after shaking a hand, holding the baby, wash your hands.
• At home, handwashing is a really good idea if stomach flu is circulating, and not a bad thing to do to stay clean, but has little impact on the spread of respiratory infections like colds and regular flus.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.