Saturday, 9 April 2016

The Best Medicine

We all want to give the best medicine. If you are not part of that ideology, please stop reading. This is not for you.

Prescribing for children is tricky.  Sometimes dosing is about weight, sometimes age and sometimes it's not that simple such as when giving bronchodilators.  The choice of treatment is also difficult. I try to practice evidence based medicine but there is often a lack of good quality research on which to base my decisions.

In the brave new world of guideline driven medicine, there is one factor that I don't often consider and that's a shame because it can make all the difference.  That factor is the acceptability of the treatment to the child.

In our desire to make a child better (or at least feel better) it may be wise to consider what the child wants. I know, that's crazy talk.  But the best medicine may just be the one that the child will take.

Let's talk about a few examples.

What is the best corticosteroid for treating croup?

I recently ran through the management of croup.  In that I addressed a question that I am often asked by my GP colleagues: "Should we be giving dexamethasone or prednisolone?"  The evidence comes down gently in the favour of dexamethasone. However,  prednisolone is often cheaper and more readily available.  

But what would the child choose?  I have prescribed each of these steroids enough times that I've got a strong suspicion that a consumer survey would say dexamethasone is the customer's favourite.  This is based on the number of pens I have worn out writing that prednisolone can be re-administered since the first dose is now fluorescent decoration on a parent's clothes.  This is a lot easier to sort out while the child is sat near me in the ED.  It's less easy to resolve if they've picked up their medicine from a pharmacy and are at home when they vomit back their steroid.

I don't have the facts on how many children spit out or vomit back prednisolone versus dexamethasone.  It would be good to know so that I could offer more than a belief when someone asks the dex/ pred question.  In the absence of hard facts, I will continue to point to the dex bottle and mouth, "This one!" in a way that allows plausible deniability.

What is the best oral antibiotic for bacterial tonsillitis in children?

I recently read with interest an article in the Archives of Disease in Childhood about another treatment choice that would affect even more children.  This article had the bravery to question the well established practice of giving ten days of phenoxymethylpenicillin  to children with suspected or proven streptococcal tonsillitis.  Apparently the old thing about a high proportion of cases of Epstein-Barr virus (EBV) infection having florid rashes when prescribed amoxicillin is a myth.  Well, technically it is a misunderstanding (or mythunderstanding perhaps?) since the reaction described originally was to ampicillin.  The latest evidence is that there is no increased occurrence of rash when amoxicillin is given and EBV is present.  Can I trust no one?

The article goes on to mention (casually, as if to avoid hate mail) that since amoxicillin is better tolerated by children, perhaps we should prescribe this instead of phenoxymethylpenicillin.  Bonkers.

Now before anyone changes their practice, there is another consideration: antibiotic guardianship.  Amoxicillin has a broader spectrum of antimicrobial activity and with rising bacterial resistance we should be using broad spectrum antibiotics as infrequently as possible.  What is exciting to me is that someone has questioned our long-continued routine.  Better still, they have as good as involved the child in the discussion that should rightly follow.

Is phenoxymethypenicillin that bad?  Parents frequently tell me that the phenoxymethylpenicillin prescribed to their child has transformed them from a nice child with a febrile illness into some sort of rabid beast undergoing an exorcism.  It seems entirely reasonable therefore to ask that the writers of guidelines consider whether the evidence and stewardship of phenoxymethylpenicillin outweighs the acceptability of amoxicillin.  How many additional completed completed antibiotic courses would it take to allow amoxicillin to win in a straight fight?

I would not be me if I didn't mention the other option for the child who has a deep loathing for their antibiotic.  There are ten good reasons to make stopping the antibiotic the best way forward. There is only really one reason to change to something like amoxicillin: the child needs the antibiotic.

Edward Snelson
Medical mythologist

Disclaimer: Trust no one


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