There is no doubt that antibiotics are invaluable to the health and wellbeing of, well, the world. Before antibiotics, 90% of children with bacterial meningitis died. Strep throat was fatal. Ear infections would sometimes get so bad they’d spread to the brain! After decades of use, however, experts now see that you can have too much of a good thing.

“We are blessed with antibiotics,” says pediatrician Dr. Harvey Karp. “Unfortunately, we’re squandering them with overuse.” When antibiotics are used when they’re not needed—or when they’re taken incorrectly—they can place your child’s health at risk and put others’ health at risk by giving rise to those scary-sounding antibiotic resistant bugs that have been making the news. So, where’s the line between healthy antibiotic use and antibiotic overuse? Here’s everything you need to know about antibiotic resistance and how to use antibiotics the right way.

Antibiotic Resistance: The Danger of Antibiotic Overuse

While most of the microscopic bacteria that reside on our skin, in our gut, mouth, and throat are totally harmless or even beneficial, some bacteria can multiply and interfere with normal body processes causing illness. Enter: Antibiotics. These wonder drugs work by either killing the bacteria (yup, bacteria are living organisms) or making it super-hard for the bacteria to grow and multiply.

While antibiotics are great at killing harmful germs, taking antibiotics too often—or for the wrong reason—can also change bacteria so much that antibiotics simply stop working against them. This is called antibiotic resistance or bacterial resistance, and the Centers for Disease Control and Prevention (CDC) calls it one the most urgent threats to the public’s health. Dr. Harvey Karp explains it like this:

“When we use antibiotics, we kill 99% of bugs that are sensitive. But when some of the bugs are a little stronger and better able to survive a dose of antibiotics, they grow like crazy. When they get hit again by antibiotics, the strongest 10% of bugs survive.” When that’s done repeatedly, bacteria mutate and gets stronger and stronger. Not only do these “superbugs” become more resistant to antibiotics, they can pass on their resistant features…then spread.

That means, each time your child is given an antibiotic unnecessarily (or improperly), there’s an increased chance of developing antibiotic-resistant bacteria. So, it’s not that your child becomes personally resistant to a specific antibiotic. It’s that the bacteria becomes resistant to antibiotics.

Infections caused by antibiotic-resistant germs are very difficult, and sometimes impossible, to treat. For example, 5% of diarrhea-causing Shigella infections are now resistant to the five antibiotics most used to treat it. (Most of the roughly 450,000 cases of Shigella diagnosed in the U.S. each year occur in children under the age of 5.) And according to the World Health Organization (WHO), pneumonia and tuberculosis are among the growing number of infections becoming harder to treat as antibiotics become less effective.

Other Side Effects of Antibiotic Overuse

Antibiotics kill bad germs…but they can also get rid of good germs that protect the body against harmful infections. That means, when antibiotics are used unnecessarily or inappropriately, unintended icky side effects, like rashes, nausea, vomiting, abdominal pain, and diarrhea, can occur. For example, a large-scale 2022 study in JAMA Network Open found that children who received improper or non-recommended antibiotics for sore throat experienced a more than eightfold increased risk of a diarrhea-causing C difficile infection. And those who got non-guideline antibiotics for ear infections quadrupled their risk of severe allergic reaction. At the same time, other studies suggest early, frequent, and often inappropriate antibiotic exposure may play a role in developing issues like asthma and atopic dermatitis.

What Caused Antibiotic Resistance

There are a few reasons behind the rise of the resistance. Here’s a breakdown:

• Pediatricians are overprescribing for ear infections. Ear infections are one of the most common reasons antibiotics are prescribed to children, but many ear infections don’t require antibiotics for treatment (more on that in a bit).

• Docs are prescribing unnecessary meds for other common illnesses. Sore throats and upper respiratory tract infections, like the common cold, are among the illnesses that often receive unnecessary or inappropriate antibiotic treatments.

• Children’s hospitals are overprescribing. A 2020 report in the journal Clinical Infectious Diseases found that 1 in 4 children given antibiotics in U.S. children’s hospitals are prescribed the drugs inappropriately—the wrong types, or for too long, or when they’re not necessary.

• The pandemic increased unnecessary prescriptions. According to the Kaiser Family Foundation, “the impact of the pandemic on antibiotic use will be significant.” COVID-19 drove up the popularity of telemedicine visits, which meant children were getting antibiotic prescriptions without in-person exams. Meanwhile, when children were infected with COVID-19 and their symptoms pointed to a bacterial infection on top of COVID, doctors would sometimes prescribe antibiotics until tests rule out bacteria.

• Antibiotic use in animals. In some countries, roughly 80% of antibiotics are given to animals, not people. “These antibiotics are mostly given to healthy farm animals, like pigs and chickens, to help prevent disease and help them gain some extra weight,” says Dr. Karp. “Trouble is, these antibiotics are in the animal’s stools, which flow into huge pits of sewage…the perfect breeding ground for bacteria to develop resistance.” According to the WHO, the overuse and misuse of antibiotics in animals is contributing to the rising threat of antibiotic resistance.

How to Know When Antibiotics Are Really Needed

The number one thing families can do to fight antibiotic resistance is to become informed. Know that most illnesses your child will encounter—like colds, sore throats, and viruses—do not require an antibiotic. So, it's important to not expect your child’s doctor to automatically offer an antibiotic prescription for every sickness.

What do antibiotics treat?

There are two major types of germs that make people sick: bacteria and viruses. Antibiotics only treat certain bacterial infections, including:

• Strep throat

• Whooping cough

• Urinary tract infection (UTI)

• Sepsis

What don’t antibiotics treat?

On the flip side, antibiotics are not designed to treat viruses…our immune system is! Unlike bacteria, viruses are not alive. Instead, they grow and reproduce only after they’ve invaded other living cells. That means our body’s immune system can fight off some viruses before they make us sick. And others—like the common colds—simply need to run their course.

Antibiotics do NOT treat:

• Colds and runny noses, even if the mucus is thick, yellow, or green

• Most sore throats (except strep throat)

• Influenza

• Most chest colds (including bronchitis)

• Many sinus infections

• Some ear infections 

Antibiotics are sometimes needed to treat ear infection and sinus infections, but not often. According to the CDC, some ear infections and many sinus infections get better on their own, without the use of antibiotics.

Do antibiotics treat ear infections?

Only sometimes. Many ear infections are caused by viruses, not bacteria, which means antibiotics won’t do a thing to combat the infection. At least half of all ear infections—regardless of cause—go away without antibiotics. But it’s not surprising that many parents believe antibiotics are necessary to treat ear infections. Despite the American Academy of Pediatrics’ (AAP) recommendation to wait two to three days before jumping into antibiotic treatment, nearly 78% of ear infections are immediately treated with antibiotics, according to a 2022 report in The Journal of Pediatrics.

When a pediatrician adopts the recommended “watch and wait” protocol, they observe your baby or big kid for two to three days after diagnosis and then determine if antibiotics are needed. While you wait for the infection to run its course—or to see if antibiotics are truly needed—the focus should squarely be on helping your kiddo feel better with pediatrician-approved pain medicine, such as Acetaminophen or ibuprofen (ear drops may also help relieve pain). In most cases, the pain and fever will improve within the first two days. (Learn more about the best pain-relievers for babies.)

After the recommended pause, doctors may still choose antibiotic treatment if your child has a higher fever, has severe ear pain, or if the infection is present in both eardrums. Of note: Among the doctors who “watched and waited” in the 2020 report above, only a very small percentage wound up prescribing antibiotics in the end.

What Parents Can Do About Antibiotic Resistance

To further help prevent antibiotic overuse and to lower the risk of antibiotic resistance, adopt the following habits:

• Ask questions! Don’t be afraid to ask your child’s doctor if your child’s illness is bacterial or viral, and inquire about the risks and benefits of opting for antibiotics.

• Consider visiting this doc for ear issues. Research shows that Ear Nose and Throat doctors (ENTs or otolaryngologists) were less likely to prescribe antibiotics for ear infections and far more likely to adopt a “watch and wait” approach to ear infections than pediatricians.

• Forget the mucus “rule.” Yellow or green mucus in the nose does not automatically mean antibiotics are needed.

• Follow antibiotic directions carefully. If your child receives an antibiotic, give it exactly as prescribed. That means it’s important to have your child finish the entire prescription, otherwise, the infection may come back. (PS: The safest way to dispose of unused, unwanted, and expired antibiotics is through a take-back program at a local pharmacy. To find one near you, use this tool.)

• Never use leftover antibiotics. And don’t save extra antibiotics “for next time,” either.

• Wash hands regularly. Keeping hands clean is one of the best ways to sidestep infections and prevent spreading germs. (Here’s how to teach kids to wash their hands the right way.)

• Stay up to date on vaccines. Vaccines are an important step to prevent infections, including resistant infections. (Learn more about your child’s immunization schedule.)

Soothing Symptoms Without Antibiotics

• Tummyache Treatments and Relief
• How to Treat Ear Infections
• Cold, Flu, and RSV Relief for Babies
• Dr. Harvey Karp’s Tips on Treating Newborn Colds  

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REFERENCES

• American Academy of Pediatrics (AAP): The History of Antibiotics
• Centers for Disease Control and Prevention (CDC): Antibiotic Use Questions and Answers
• The Nemours Foundation, KidsHealth: The Danger of Antibiotic Overuse
• Kaiser Health Network: Children’s Hospitals Are Partly to Blame as Superbugs Increasingly Attack Kids
• Johns Hopkins Medicine: Antibiotics
• CDC: Antimicrobial Resistance Questions and Answers
• CDC: Increase in Extensively Drug-Resistant Shigellosis in the United States
• CDC: Shigella—Shigellosis: Questions & Answers
• World Health Organization (WHO): Antibiotic resistance
• CDC: Your Risk of C. diff
• Association of Inappropriate Outpatient Pediatric Antibiotic Prescriptions With Adverse Drug Events and Health Care Expenditures. JAMA Network Open. May 2022
• Antibiotic exposure and adverse long-term health outcomes in children: A systematic review and meta-analysis. Journal of Infection. September 2022
• Association of Infant Antibiotic Exposure With Childhood Health Outcomes. Mayo Clinic Proceedings. January 2021
• The Pew Charitable Trusts: Study Shows That Inappropriate Antibiotic Prescribing for Children Leads to Increased Costs, Complications
• Appropriateness of Antibiotic Prescribing in United States Children’s Hospitals: A National Point Prevalence Survey. Clinical Infectious Diseases. October 2020
• WHO: Stop using antibiotics in healthy animals to prevent the spread of antibiotic resistance
• AAP: Antibiotics for Children: 10 Common Questions Answered
• The Diagnosis and Management of Acute Otitis Media. Pediatrics. March 2013
• AAP otitis-media watchful-waiting recommendations not followed. The Journal of Pediatrics. December 2022
• Food and Drug Administration (FDA): Where and How to Dispose of Unused Medicines

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Disclaimer: The information on our site is NOT medical advice for any specific person or condition. It is only meant as general information. If you have any medical questions and concerns about your child or yourself, please contact your health provider.