These days, it seems every disease condition has its own day, week or even month. World Allergy Week runs from 22-28 April this year, and is dedicated to raising awareness about allergic diseases such as food allergy and anaphylaxis, allergic eczema, allergic rhinitis (hayfever), urticaria and allergic asthma.
It has long been recognised that allergic conditions are ‘diseases of civilisation’ – far more common in developed countries than in poorer nations, although differences in global prevalence appear to be narrowing. Within low-income countries, allergic disease is less common in rural parts than urban areas, even though allergic sensitisation may be common. English speaking nations including Australia have the highest rates of asthma, IgE-mediated sensitisation and allergic diseases.
‘Atopy’ – the tendency to develop allergic disease – is heritable. If both your parents are atopic (that is, they have a positive skin prick or RAST test), your risk of being atopic is 75%. If only one of your parents is atopic, your risk drops to 50%, and if neither parent is atopic you have only a 15% risk of developing allergic reactions.
However, it’s clear that the sharp increase in the prevalence of allergic disease has occurred over too brief a time-frame for genetic factors alone to be responsible – genes don’t change that quickly. As with virtually all disease conditions, genetics loads the gun but lifestyle and environment pull the trigger. Exposure to various risk factors increases the chance that genetically susceptible individuals will develop allergic disease.
- Changes in patterns of early-life microbial exposure due to smaller family sizes and hygiene practices;
- Diet, including breastfeeding patterns;
- Exercise;
- Housing design; and
- Exposure to pollutants.
What many of these factors have in common is that they cause disruption to the gut microbiome, leading to speculation that drugs that affect the microbiome may also impact on atopy. Now a new study confirms that early-life exposure to antibiotics and acid suppressing medications increases the risk of developing allergic disease in childhood.
The study involved almost 800 000 children from military families, who had a birth medical record in the Military Health System database between October 1, 2001, and September 30, 2013, and were continually enrolled (meaning that all of their medical care was provided by the military health system) from within 35 days of birth until at least 1 year of age. Data were available for a median of 4.6 years per child.
The researchers were seeking to determine whether the use of acid-suppressive medications (histamine-2 receptor antagonists [H2RAs] such as Pepcid, Tagamet and Zantac, and proton pump inhibitors [PPIs] such as Nexium, Prevacid and Somac) and antibiotics in the first 6 months of life was associated with the development of allergic diseases in early childhood.
The researchers compared the rate of allergic diseases – food allergy, anaphylaxis, asthma, atopic dermatitis, allergic rhinitis, allergic conjunctivitis, urticaria, contact dermatitis, medication allergy, and other allergy – in children who were prescribed acid suppressors and/or antibiotics, versus those who weren’t.
They found that in the first 6 months of life:
- 7.6% of the children were prescribed an H2RA,
- 1.7% were prescribed a PPI, and
- 16.6% were prescribed an antibiotic.
Compared to children who were not prescribed an acid suppressor in the first 6 months of life, those who were prescribed these medications had:
- Over twice the risk of developing food allergy (adjusted hazard ratios [aHR] of 2.18 for H2RAs and 2.59 for PPIs);
- Almost twice the risk of developing medication allergy (aHR 1.70 for H2RAs and 1.84 for PPIs);
- About half as much risk again of anaphylaxis (aHR 1.51 for H2RAs and 1.45 for PPIs);
- About half as much risk again of allergic rhinitis (aHR 1.50 for H2RAs and 1.44 for PPIs); and
- Substantially higher risk of asthma (aHR 1.25 for H2RAs and 1.41 for PPIs).
Children who received an antibiotic prescription in the first 6 months of life had:
- 2.09 the risk of asthma;
- 1.75 the risk of allergic rhinitis;
- 1.51 times the risk of anaphylaxis; and
- 1.42 times the risk of allergic conjunctivitis.
The authors concluded that
“Acid-suppressive medications and antibiotics should be used during infancy only in situations of clear clinical benefit.”
Unfortunately, I’ve seen far too many instances in my practice of unwise and unnecessary prescription of acid-suppressing drugs and antibiotics resulting in untold suffering. Many doctors appear to dole out prescriptions for these drugs on the most tenuous grounds; I’ve had several clients tell me that their doctor ‘diagnosed’ silent reflux in their hard-to-settle baby and prescribed an acid suppressor without any investigation whatsoever, while the rate of useless prescription of antibiotics for middle ear infections (otitis media) is truly alarming, despite clinical practice guidelines that clearly tell doctors to
“Avoid the routine use of antibiotic treatment for acute otitis media”
Drugs can be life-saving when used appropriately. If one of my children had bacterial meningitis, I wouldn’t hesitate to give them antibiotics – the risk-to-benefit ratio clearly favours use of antibiotics in cases of serious illness.
But runny noses, ear infections, coughs and colds don’t require antibiotics (and in most cases can’t possibly benefit from them, being viral rather than bacterial in origin), and reflux in a baby should be addressed first through dietary alteration (removing common culprits such as dairy products and caffeine from the mother’s diet if breastfeeding, or changing the baby’s formula), adjusting positioning before and after feeding, osteopathy and other low-risk measures.
I’ve seen way too many children who have scratched their own skin off due to the torture of eczema, adults who can’t step outside in spring without suffering hayfever, and people of all ages plagued with asthma, to have tolerance for doctors who complain that patients demand antibiotics even when they’re told they (or their child) won’t benefit from them. It’s the doctor’s role to educate, not to pander to ignorance.
Drugs should be reserved for serious illnesses and as the last resort in conditions that haven’t responded to diet and lifestyle change. If your doctor’s hand strays to the prescription pad as soon as you walk into the consulting room, it’s time to find a more enlightened practitioner who comprehends that all medical interventions carry risk and the patient (or parent) should be informed of that risk before giving consent to be treated.
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