To Treat Or Not To Treat?

Our beloved daughter Sydney is sick. Again. Sore throat, fever, weak, and woozy. Those of you who’ve read Gutbliss or The Microbiome Solution know that Sydney’s wellness journey has been an uphill battle, in large part due to the overly sterile circumstances of her birth: C-section; IV antibiotics right after delivery; nursed for only 6 weeks. The average American child receives a whopping 18 courses of antibiotics before their 18th birthday, but in Sydney’s case, all 18 courses were administered before she started pre-school.

Microbially disadvantaged from birth as a result of the trifecta of: 1) bypassing the vaginal canal where the founding species first colonize the newborn, 2) missing out on human milk oligosaccharides in breast milk that nurture microbes in the baby’s gut, 3) receiving massive amounts of antibiotics before the age of three when the microbiome is still developing – over a decade later Sydney’s immune system is still struggling. Frequent pharyngitis, sinus infections, colds and flus have been her constant companions.

It’s a terrible feeling when your child or loved one is sick. Most of us would gladly draw the illness out of them and into our own bodies (if only that sort of suffering by proxy were an option!). In our household, times like these often lead to conversations about bacterial infections like Strep throat (Group A Streptococcal or GAS pharyngitis), and what, if anything can be done to alleviate symptoms. My bias is clear – overuse of antibiotics is how Sydney got into this pickle so I have a very high bar for treatment. Most kids can weather an occasional course of antibiotics when they really need it, but in Sydney’s case, every additional dose weakens an already compromised immune system.

For those of you who find yourselves in similar circumstances, it’s worth reviewing the latest guidelines for treatment of strep throat:

Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America 

Three points in this guideline are worth noting:

“While treatment early in the course leads to a more rapid clinical cure in patients with acute GAS pharyngitis and decreases transmission of GAS to other children, the predominant rationale for treatment of this self-limited illness is to prevent suppurative and nonsuppurative complications. In particular, treatment within 9 days of the onset of illness is effective in preventing acute rheumatic fever (ARF)”

Fortunately, the incidence of ARF in the US these days is rare, with an annual incidence of approximately 0.04–0.06 cases per 1,000 children.

“It is important to note that streptococcal pharyngitis is usually a self-limited disease. Even without treatment, fever and symptoms commonly resolve within a few days of the onset of illness.”

A good reminder that a positive test for Strep doesn’t automatically mean antibiotics, although quarantining to prevent spread of infection is important.

“An even more challenging clinical circumstance is the person (usually a school-aged child or adolescent) who, within a period of months to years, experiences multiple episodes of acute pharyngitis for which culture and/or rapid antigen detection test (RADT) results identify GAS. It is likely that most of these patients are chronic streptococcal carriers who are experiencing repeated viral infections”.

Likely the case for Sydney.

Deciding whether or not to give your child an antibiotic when they’re sick can be a tough decision. My goal is not to influence you one way or the other but to remind you that medications are not without risk, and antibiotics can be a double-edged sword of swift relief but worsened long-term immunity, contributing to the development of autoimmune conditions like Crohn’s disease and ulcerative colitis.

By: Dr. Robynne Chutkan