Almost every visit to the pediatrician results in the prescription of one or more medications. As a parent, you'd like to trust that the medications your doctor prescribes for your child are selected based on careful reflection, and are not only effective, but safe. Unfortunately that's not always the case. As a board-certified pediatrician of sixteen years I regret to confess that many of the treatments we provide are ineffective, while others can cause grave harm. Too often, we doctors stray from accepted standards of care as a matter of expediency, the result of habit, or to satisfy perceived parental expectations. Nowhere is this so apparent as when a pediatrician prescribes a medication that experts agree should never be used by primary care doctors.
A medication that is shunned by pediatricians typically possesses one or more of the following features: it is not safe; it is not effective; its use has been supplanted by newer, better choices; pediatricians do not have the expertise required to prescribe the drug. Using these criteria, let us examine 7 medications that your pediatrician should never prescribe under any circumstance.
Promethazine:
Pediatricians commonly use this medication for the treatment of nausea and vomiting that often accompany viral intestinal infections. Unfortunately, it doesn't work very well and it frequently produces drowsiness, dizziness and confusion: symptoms we'd like to avoid in a child whose mental status must be monitored as an indicator of dehydration. The intra-venous use of this medication has resulted in tragic events requiring the amputation of limbs due to the caustic nature of the drug, and is now prohibited in many hospitals. Fortunately, we have a much more effective medication at our disposal with a far better safety profile; which makes one wonder why some doctors still cling to Promethazine.
Cough suppressants:
The common cold is the most common ailment in childhood. It is natural to want to provide some relief to a child whose cough is keeping her from sleeping. Unfortunately, the cough medications we have at our disposal have not been shown to be effective in children and may cause unacceptable side-effects. Over the counter cough medicines almost universally include the active ingredient, Dextromethorphan (DM), whereas prescription versions may employ Codeine. Both these drugs are derivatives of opiates. Respiratory depression and behavioral problems have been observed in children taking these products, and in infants, overdoses have resulted in deaths.
In October 2007, the American Academy of Pediatrics proposed to the Food and Drug Administration that the following warning be included on the labeling of cough medications:
"This product has been shown to be ineffective in the treatment of cough and cold in children under six years of age. Serious adverse reactions, including but not limited to death have been reported with the use, misuse and abuse of this product." Inexplicably, many pediatricians continue to routinely prescribe these medications even to infants.
Dexamethasone eye drops:
This is an example of a medication that can be extremely efficacious, but which pediatricians should not prescribe because they lack the requisite expertise to use it safely. Dexamethasone is a steroid that is utilized for its anti-inflammatory properties. These eye drops are a powerful tool for a variety of conditions but require a careful eye exam by an ophthalmologist prior to their use. If applied in the midst of some eye infections, Dexamethasone-containing drops can exacerbate the infection and lead to irreparable eye injury. This medication is best left to the eye specialists.
Nystatin with Triamcinolone Combination Cream:
Sometimes the sum of the parts is less than the individual parts. Nystatin is a useful topical antifungal, routinely used to treat diaper rashes that have an overgrowth of yeast. Triamcinolone is a potent steroid cream that is effective in treating a variety of inflammatory conditions of the skin, including eczema. The problem arises when these two medications are combined. Doctors, wanting to add some anti-inflammatory effect in the treatment of a yeast rash, or uncertain as to whether the rash is the result of a fungal infection or due to plain inflammation, mistakenly instruct parents to use this product in the diaper area. The potency of all steroid creams is multiplied when applied to skin that is occluded by dressings, plastic wraps, or diapers. When applied under cover of a diaper, Triamcinolone can lead to ulcerations of the skin, which often intensify as a well-meaning parent continues to apply ever more cream in a frantic but futile attempt to alleviate the worsening rash. Only thin applications of far weaker steroid creams might be applied to this extremely delicate area of the body, and only after the careful consideration of potential risks and benefits.
Cefaclor:
A few decades ago, Cefaclor was one of the only oral preparations of a family of antibiotics known as the Cephalosporins, which are commonly used to treat a variety of childhood infections. This particular medication, however, has a much higher rate of allergic reactions compared to other drugs in its class, including a particularly severe complication known as Serum Sickness-Like Reaction, in which children develop rash, fever, swollen, painful joints, and other troubling symptoms. Furthermore, many bacteria have become resistant to this drug. In a large study published in 2003, out of 19 antibiotics tested, Cefaclor was the least likely to kill the most common bacterium implicated in ear infections, sinus infections and pneumonia. Academic medical centers have stopped using this medication some 20 years ago, but some doctors in the community just can't break the habit.
Albuterol Oral Syrup:
Albuterol by inhalation, either in an aerosol or inhaler form, remains the most important rescue medicine for the treatment of asthma attacks. When the medication is inhaled, it travels directly to receptors located on the walls of the respiratory airways, signaling muscle fibers to relax, thereby reducing bronchial constriction and improving the flow of air in and out of the lungs. The inhaled route maximizes the amount of medication delivered to its intended target and mitigates common side-effects, such as jitteriness and an accelerated heart rate, that are produced when the drug enters the bloodstream. When the oral formulation is used, the medication must first be absorbed from the intestinal tract into the circulation, by which it then travels throughout the body, with just a fraction of the ingested dose eventually finding its way onto the receptors of the airways. This is a highly ineffective delivery system that magnifies the side-effects while minimizing effectiveness. Albuterol oral syrup is often used not for asthma, but as a type of ersatz cough medicine; a practice that is a relic of the past.
Anti-Diarrhea Compounds:
Diarrhea is a common occurrence in childhood, most often the result of a viral gastroenteritis; what is commonly referred to as the "stomach flu". At times, it can be the result of bacterial dysentery. The key to the treatment of this usually self-limited but bothersome condition is to provide hydration and nutrition. Guidelines from the American Academy of Pediatrics and the Center for Disease Control and Prevention discourage the use of anti-diarrhea compounds due to their lack of efficacy and the potential for serious side-effects, including severe cramping, and temporary paralysis of the gut, which can lead to a concentration of bacteria and their toxins in the setting of dysentery. Unfortunately, many pediatricians are either unaware of, or choose to ignore these recommendations.
At its best, the practice of pediatrics incorporates scientific evidence, critical thinking, best practices, and accepted standards of care, while embracing humility and a deep compassion; ever cognizant of each child's unique constitution and the cultural values of his family. Too often, we doctors fall far short of this objective, particularly when we are rushed, when we don't take the time to listen patiently or examine carefully, or when we fall into the ruts of habit, not questioning what we think we know.
Sir William Osler, a renowned 19th century physician who practiced at a time where many of the treatments were ineffective and fraught with hazards, wrote, "One of the first duties of the physician is to educate the masses not to take medicine": an admonition that retains a clear ring of truth even in the 21st century. All medications have potential side-effects and, particularly in children, a wise philosophy is to use the fewest medications with the most favorable safety profile for the least amount of time.
Many childhood illnesses are self-resolving conditions that doctors should manage by providing comfort to the child and by counseling parents, rather than blithely dispensing prescriptions designed to subdue symptoms without a conscientious attempt at identifying the true nature of the underlying condition. We doctors must do better. The best parents can do is to become informed consumers of health-care, and never hesitate to question their doctor.
