Thinking About Medications: A Guide for Parents

As a specialist, I often prescribe medication to my patients.  I take this responsibility very seriously. I spend a lot of time in clinic discussing concerns about medications with patients and their families. Many patients are skeptical about using medications in their children. I’d like to explain my thinking about using them, and mention some common misconceptions I have come across in clinic.

My Guidelines for Using Medications

• The goal is effective treatment of symptoms at the minimum necessary dose. Sometimes that may mean more than one medication or medication at a higher dose than previously used. Sometimes that may mean stopping a medicine that a child has taken for years to see if symptoms reoccur or worsen. If you don’t stop a medication in a well patient, you may not know if he still needs it to stay well.
• Sometimes, trying a medication is the most effective way to make a diagnosis. There are many common conditions where the diagnosis is made primarily from history and physical examination. There may not be an effective test which is not invasive. Take the example of chronic cough in a child. Common causes may include sinusitis, asthma, or gastroesophageal reflux. Sometimes, I’m pretty sure of the cause. Other times, it is less clear. The way I make the diagnosis is that I try treatments for each in sequence. If an albuterol treatment like steroids or albuterol is effective, asthma is likely. If antibiotics fix the cough, sinusitis is probably the cause, etc. For the vast majority of medications, there is no risk for lasting harm to the child when used on a trial basis.
• Medication use is temporary until there is proven benefit. If I start a child on a medication I will usually see her back in 4-6 weeks to see if the medication is helping. The benefit should be clear-cut in that timeframe. If the parents are not sure they see improvement, I will stop the medication to see if the condition changes. Or, I will prescribe a different medication or dose.

Common Mistakes Parents Make in Thinking About Medication

I encourage my patients and their families to be informed consumers, and I have no difficulty with discussing risks and benefits of treatment.  I’m a parent and would be wary of my sons taking a daily medication too. However, I feel that that are mistakes which people sometimes make when thinking about the idea of using medication in their child.

• Assuming that the absence of treatment is better/less risky that treatment. Let’s say I see a little boy named John who has a nighttime cough and wheezes with exercise due to asthma. He has a little bit of difficulty keeping up with his friends in gym class. A daily inhaled steroid medication like fluticasone (brand name Flovent) may have effects on growth at higher doses. However, there is a cost to doing nothing in terms of sleep disruption, decreased athletic performance, and risk of an asthma flare. My response to families is to suggest trying the fluticasone and seeing if their son’s life is better with the medication. Usually, people notice such an improvement that they feel better about using it.
• Overestimating the likelihood of severe side effects. Fortunately, the nature of my practice is that I am generally not deploying medications with severe common side effects. A common example is montelukast (brand name Singulair). In 2008 the FDA investigated reports of psychiatric side effects including suicide. They were unclear if the medication actually caused these issues. They were not observed in the large medication trials leading to approval of the medication. A warning was added to the list of “adverse events” by the manufacturer. In my practice, montelukast is a useful medication for many patients and behavioral changes are very rare. (I take montelukast myself for allergic rhinitis and have not noticed any issues). Rarely, kids may get moody on the medication. I stop it, and that goes away. Should we take it seriously? Yes. How common is it? Pretty rare.
• Not applying the same level of scrutiny to alternative therapies as they do to medications. I have been frustrated at times with families who have refused well-accepted therapies (like the influenza vaccine) based on hearsay from disreputable sources.  In the same breath, they will acknowledge the use of chiropractors or homeopathic remedies. I have no issue with the use of alternative modalities in addition to appropriate medical therapy.   However, it is a fallacy to believe that such treatments are necessarily better, safer, or have fewer side effects. Side effects are identified as the result of large multicenter trials with thousands of patients in them; generally, such trials have not been performed to evaluate alternative therapies. If a provider tells you that they have a treatment which is perfectively effective and has no side effects whatsoever, I would be skeptical.

Obviously, no one wants their child on medications. However, some treatments can make your child healthier, improve his or her life, and avoid serious problems. Be a critical consumer of your child’s health care, but do not shy away from a trial of treatment. Make sure you understand the goal of the treatment, any side effects of therapy, and have a clear follow-up plan to help you make the ultimate decision.