Side Effects Of Antibiotics In Children

Antibiotics are prescribed for treating some bacterial illnesses. They won't work on viral infections such as a cold or flu. Doctors need to be cautious when prescribing antibiotics as unnecessary usage is causing antibiotic resistance. Antibiotic resistance happens when the bacteria becomes immune to the antibiotic, so the antibiotic may not help you in the future when you need it. 

Antibiotics should be used when the infection can cause serious complications, when it  might not clear on its own or if it persists. Antibiotics come in the form of tablets, capsules, liquid, sprays, drops, lotions or injections. It is essential to take all doses on time, but double doses should never be taken to compensate for a missed dose. 

Importance of antibiotics in treating infections

The antibiotic revolution started in 1928 when Sir Alexander Fleming discovered penicillin. Penicillin G, a purified form of penicillin, was available for people outside the military in 1945. This led to the beginning of the antibiotic era. Several new antibiotics were discovered and modifications were made to existing ones. Infectious diseases were successfully treated which increased the life expectancy. Prior to the discovery of antibiotics, infectious diseases such as cholera, diphtheria, typhoid, smallpox, syphilis etc. were common. These were the leading causes of death in the beginning of the 20th century. Whereas now, non-communicable diseases such as cardiac arrest, stroke and different types of cancer are the leading causes of death. 

Antibiotic resistance, also known as antimicrobial resistance (AMR), is a significant issue due to unregulated use of antibiotics. Natural resistance occurs in some types of bacteria. However, misuse of antibiotics results in bacteria becoming increasingly resistant to them.¹ 

Types of antibiotics

There are numerous antibiotics available for different diseases, but they are grouped into six main categories:

Penicillins: This group includes penicillin, amoxicillin, co-amoxiclav, flucloxacillin and phenoxymethylpenicillin. 

• Amoxicillin: It is prescribed for dental abscess, chest infections such as pneumonia, bacterial infections and ear infections in children. Nausea and diarrhoea are the common side-effects observed
• Co-amoxiclav: It is a mixture of amoxicillin and clavulanic acid. This antibiotic is used to treat middle ear infections, sinus infections, dental infections, urinary tract infections, joint and bone infections. Side-effects can be diarrhoea, thrush or nausea
• Flucloxacillin: It is helpful in treating skin infections, bone infections and ear infections in children. Common side-effects are nausea and diarrhoea
• Phenoxymethylpenicillin: It is used to treat chest infections, ear infections or throat infections. It can also be prescribed to people with sickle cell disease, rheumatic fever or in cases of spleen removal to prevent infections. Side-effects are nausea and diarrhoea

Aminoglycosides: This group of antibiotics is administered in hospitals in the form of injections or drops as they have severe side-effects. They are used to treat sepsis. Side-effects can include hearing loss and kidney damage. Gentamicin and tobramycin are included in this group of antibiotics

Cephalosporins: Cefalexin belongs to this group of antibiotics. It is used to treat bacterial infections such as pneumonia, skin infections and urinary tract infections (UTIs). It can come in the form of tablets or liquids

Tetracyclines: This group of antibiotics include doxycycline, tetracycline and lymecyclin. 

• Doxycycline: It is used to treat chest infections, dental infections, skin infections such as rosacea and sexually transmitted infections (STIs). It is also prescribed as a prevention for malaria when travelling abroad. Side-effects can be nausea and thrush
• Lymecyclin: It is mostly used to treat acne. It can also be used for chest, sinus infections and STIs. Side-effects include nausea, diarrhoea, headaches and stomach pain

Macrolides: This includes antibiotics such as azithromycin, erythromycin and clarithromycin 

• Azithromycin: It is helpful in treating chest infections such as pneumonia, sinusitis, skin infections and STIs. It is also prescribed to people to prevent chest infection if they suffer frequently 
• Erythromycin: It is used to treat ear and chest infections in kids, skin infections and STIs. Side-effects include nausea, diarrhoea and stomach pain
• Clarithromycin: It is used to treat chest, ear and skin infections. It can be helpful in people who have an allergy to penicillin or its group of antibiotics 

Fluoroquinolones: This includes ciprofloxacin and levofloxacin.

• Ciprofloxacin: It is used to treat UTIs, STIs, chest infections, conjunctivitis, eye and ear infections 

Commonly prescribed antibiotics for children

Use of antibiotics  is common in paediatric patients, especially in the emergency department wards. A study was conducted in 2018 to identify the types of antibiotics prescribed in England. Data from The Health Improvement Network (THIN) was analysed for 2013-2015.² 

The table below summarises the number of patients per 1000 patients who were prescribed antibiotics according to their age group.

This table below summarises different antibiotics prescribed in the years 2013-2015 for all prescriptions.

Side-effects of antibiotics

Antibiotics can be very beneficial in treating bacterial infections, but its use should be carefully decided. 160 observational studies were analysed for various side-effects observed after antibiotics usage.³^,⁴

• Atopic dermatitis: Atopic dermatitis or atopic eczema causes itchy, dry and cracked skin. It is common in children. 17% of children exposed to antibiotics developed atopic dermatitis compared to 14% of children who were not exposed to antibiotics
• Food allergies: 2.5% of children exposed to antibiotics had food allergies compared to 2.4% of children not exposed to antibiotics. The chances of getting food allergies are higher in children who are exposed to antibiotics in their first year of life compared to their second and third year
• Allergic rhinoconjunctivitis: Allergic rhinoconjunctivitis is the allergy of the eyes and nose. 30% of children exposed to antibiotics were affected by allergic rhinoconjunctivitis compared to 28% of children not exposed to antibiotics
• Wheezing: Wheezing is a high pitched sound during breathing when the airways get narrow. 17% of children exposed to antibiotics suffered from wheezing compared to 9% of children not exposed to antibiotics
• Asthma: Asthma is a condition where people face difficulty in breathing. Symptoms mostly start in childhood. 13% of children exposed to antibiotics developed asthma compared to 10% of children who were not
• Infantile colic: Around 22% of newborns exposed to antibiotics in their first week of life developed infantile colic compared to 14% of newborns who were not exposed to antibiotics
• Inflammatory bowel disease (IBD): Inflammatory bowel disease causes severe tummy pain and diarrhoea. Around 0.06% of children exposed to antibiotics developed IBD compared to 0.08% of children not exposed to antibiotics
• Obesity: Around 14% of children exposed to antibiotics developed obesity compared to 12% of children not exposed to antibiotics
• Psoriasis: Psoriasis is a skin condition characterised by flaky skin. Around 10% of children exposed to antibiotics developed psoriasis compared to 6% of children not exposed to antibiotics 
• Autism spectrum disorders: Autism affects people in how they interact and communicate with others. 1.3% of children exposed to antibiotics developed autism spectrum disorders compared to 1.1% of children not exposed to antibiotics
• Child growth: Studies have shown that antibiotics exposure in the neonatal phase causes increased body mass index (BMI). Antibiotics exposure in the neonatal phase also altered the gut microbiota

Management of side-effects

Antibiotics can have adverse health effects if not used with caution. Around 10% of patients are suspected to have an antibiotic allergy and sometimes patients are incorrectly marked as ‘allergic’. In such cases, it becomes challenging for healthcare professionals to handle the situation with an alternative to antibiotics. There are two approaches that can be taken:⁵

• Making a correct diagnosis: The first step includes classifying the type of adverse drug reaction. Type A reactions are the possible side-effects which can be dose dependent. Type B reactions are unpredictable and not dependent on the dosage. In children, most cases are type-B reactions. Type-B reactions can be anaphylaxis, urticaria, contact eczema, severe cutaneous adverse reactions (SCARs) or toxic epidermal necrolysis (TENs). Antibiotic allergy testing programmes or penicillin skin tests can be helpful in determining allergy
• Finding an efficient alternative: Most of the antibiotic reactions are noted with beta lactam  (BL) antibiotics. In most cases, penicillin is the first choice of antibiotic. But if allergy is suspected, patients are given third generation cephalosporins (with some exceptions). Skin tests should be performed to determine the allergy. Unfortunately, there is not much current research for non beta lactam antibiotics. 

Antibiotics guidelines

Let's take a look at the guidelines for proper usage of antibiotics. The Global Alliance for Infections in Surgery has established guidelines for effective use of antibiotics to tackle the issues of antimicrobial resistance (AMR):⁶

• To improve infection prevention and control
• To prescribe antibiotics only when required
• To prescribe antibiotics at the right time
• To administer antibiotics in required dose via correct route 
• To start targeted treatment if required after culture and susceptibility testing
• To use antibiotics only for the required amount of time
• To identify and eliminate the source of infection
• To monitor antibiotic usage by surveillance of AMR
• To raise awareness among staff
• To improve collaboration in different disciplines of healthcare professionals 

Healthcare professionals should strive to strike the right balance when prescribing antibiotics. They should aim for maximising the benefits, while minimising the adverse reactions. 

Summary

Antibiotics are essential in some cases when the usual medications won't work or might take time to work. Antibiotics can treat some bacterial illnesses, but not viral illnesses. However, the dark side of antibiotics is antimicrobial resistance (AMR). Both children and adults can develop AMR when they are over-prescribed antibiotics they don’t necessarily need or take for a long duration. 

There are side-effects of antibiotics in children such as wheezing, asthma, food allergies, obesity, psoriasis etc. Healthcare professionals should try to maximise the benefits of antibiotics and minimise their side-effects, especially when prescribing them to children.