May 2008 Archives

For every cell in your body, you support 10 bacterial cells that make vitamins, trigger hormones, and may even influence how fat you are. Guess what happens to them when you pop penicillin?

Copyright Jessica Snyder Sachs, as first published in DISCOVER magazine

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ALAN HUDSON likes to tell a story about a soldier and his high school sweetheart. The young man returns from an overseas assignment for their wedding with a clean bill of health, having dutifully cleared up an infection of sexually transmitted chlamydia.

Image of Chlamydia by Judith Whittum Hudson

"Three weeks later, the wife has a screaming genital infection," Hudson recounts, "and I get a call from the small-town doctor who's trying to save their marriage." The soldier, with obvious double standard, has decided his wife must have been seeing other men, which she denies.

Hudson pauses for effect, stretching back in his seat and propping his feet on an open file drawer in a crowded corner of his microbiology laboratory at Wayne State Medical School in Detroit. "The doctor is convinced she's telling the truth," he continues, folding his hands behind a sweep of white, collar-length hair. "So I tell him, 'Send me a specimen from him and a cervical swab from her.' " This is done after the couple has completed a full course of antibiotic treatment and tested free of infection.

"I PCR 'em both," Hudson says, "and he is red hot."

PCR stands for polymerase chain reaction-a technique developed about 20 years ago that allows many copies of a DNA sequence to be made. It is often used at crime scenes, where very little DNA may be available. Hudson's use of the technique allowed him to find traces of chlamydia DNA in the soldier and his wife that traditional tests miss because the amount left after antibiotic treatment is small and asymptomatic.

Nonetheless, if a small number of inactive chlamydia cells passed from groom to bride, the infection could have became active in its new host.

Hudson tells the tale to illustrate how microbes that scientists once thought were easily eliminated by antibiotics can still thrive in the body. His findings and those of other researchers raise disturbing questions about the behavior of microbes in the human body and how they should be treated.

For example, Hudson has found that quiescent varieties of chlamydia may play a role in chronic ailments not traditionally thought to be related to this infectious agent. In the early 1990s, he found two types of chlamydia-Chlamydia trachomatis and Chlamydia pneumonia-in the joint tissue of patients with inflammatory arthritis. More famously, in 1996, he began fishing C. pneumonia out of the brain cells of Alzheimer's victims. Since then, other researchers have made headlines after reporting the genetic fingerprints of C. pneumonia, as well as several kinds of common mouth bacteria, in the arterial plaque of heart attack patients. Hidden infections are now thought to be the basis of still other stubbornly elusive ills like chronic fatigue syndrome, Gulf War syndrome, multiple sclerosis, lupus, Parkinson's disease, and types of cancer.

To counteract these killers, some physicians have turned to lengthy or lifelong courses of antibiotics. At the same time, other researchers are counterintuitively finding that bacteria we think are bad for us also ward off other diseases and keep us healthy. Using antibiotics to tamper with this complicated and little-understood population could irrevocably alter the microbial ecology in an individual and accelerate the spread of drug-resistant genes to the public at large.

THE TWO-FACED PUZZLE regarding the role of bacteria is as old as the study of microbiology itself. Even as Louis Pasteur became the first to show that bacteria can cause disease, he assumed that bacteria normally found in the body are essential to life. Yet his protege, Elie Metchnikoff, openly scoffed at the idea. Metchnikoff blamed indigenous bacteria for senility, atherosclerosis, and an altogether shortened life span-going even so far as to predict the day when surgeons would routinely remove the human colon simply to rid us of the "chronic poisoning" from its abundant flora.

Today we know that trillions of bacteria carpet not only our intestines but also our skin and much of our respiratory and urinary tracts. The vast majority of them seem to be innocuous, if not beneficial. And bacteria are everywhere, in abundance-they outnumber other cells in the human body by 10 to one. David Relman and his team at Stanford University and the VA Medical Center in Palo Alto, California, recently found the genetic fingerprints of several hundred new bacterial species in the mouths, stomachs, and intestines of healthy volunteers.

"What I hope," Relman says, "is that by starting with specimens from healthy people, the assumption would be that these microbes have probably been with us for some time relative to our stay on this planet and may, in fact, be important to our health."

Meanwhile, the behavior of even well-known bacterial inhabitants is challenging the old, straightforward view of infectious disease. In the 19th century, Robert Koch laid the foundation for medical microbiology, postulating: Any microorganism that causes a disease should be found in every case of the disease and always cause the disease when introduced into a new host. That view prevailed until the middle of this past century. Now we are more confused than ever. Take Helicobacter pylori. In the 1980s infection by the bacterium, not stress, was found to be the cause of most ulcers. Overnight, antibiotics became the standard treatment. Yet in the undeveloped world ulcers are rare, and H. pylori is pervasive.

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"This stuff drives the old-time microbiologists mad," says Hudson, "because Koch's postulates simply don't apply." With new technologies like PCR, researchers are turning up stealth infections everywhere, yet they cause problems only in some people sometimes, often many years after the infection.


Helicobacter pylori


These mysteries have nonetheless not stopped a free flow of prescriptions. Many rheumatologists, for example, now prescribe long-term-even lifelong-courses of antibiotics for inflammatory arthritis, even though it isn't known if the antibiotics actually clear away bacteria or reduce inflammatory arthritis in some other unknown manner.

Even more far-reaching is the use of antibiotics to treat heart disease, a trend that began in the early 1990s after studies associated C. pneumonia with the accumulation of plaque in arteries. In April of 2007, two large-scale studies reported that use of antibiotics does not reduce the incidence of heart attacks or eliminate C. pneumonia. But researchers left antibiotic-dosing cardiologists a strange option by admitting they do not know if stronger, longer courses of antibiotics or combined therapies would succeed.

MEANWHILE, MANY RESEARCHERS ARE ALARMED. Infectious-diseases specialist Curtis Donskey, of Case Western Reserve University in Cleveland, says: "Unfortunately, far too many physicians are still thinking of antibiotics as benign. We're just now beginning to understand how our normal microflora does such a good job of preventing our colonization by disease-causing microbes. And from an ecological point of view, we're just starting to understand the medical consequences of disturbing that with antibiotics."

Donskey has seen the problem firsthand at the Cleveland VA Medical Center, where he heads infection control. "Hospital patients get the broadest spectrum, most powerful antibiotics," he says, but they are also "in an environment where they get exposed to some of the nastiest, most drug-resistant pathogens." Powerful antibiotics can be dangerous in such a setting because they kill off harmless bacteria that create competition for drug-resistant colonizers, which can then proliferate. The result: Hospital-acquired infections have become a leading cause of death in critical-care units.

"We also see serious problems in the outside community," Donskey says, because of inappropriate antibiotic use.

The consequences of disrupting the body's bacterial ecosystem can be minor, such as a yeast infection, or they can be major, such as the overgrowth of a relatively common gut bacterium called Clostridium difficile. A particularly nasty strain of C. difficile has killed hundreds of hospital patients in Canada over the past two years. Some had checked in for simple, routine procedures. The same strain is moving into hospitals in the United States and the United Kingdom.

JEFFREY GORDON, a gastroenterologist turned full-time microbiologist, heads the spanking new Center for Genomic Studies at Washington University in Saint Louis. The expansive, sun-streaked laboratory sits above the university's renowned gene-sequencing center, which proved a major player in powering the Human Genome Project. "Now it's time to take a broader view of the human genome," says Gordon, "one that recognizes that the human body probably contains 100 times more microbial genes than human ones."

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Color-enhanced intestinal bacteria

Gordon supervises a lab of some 20 graduate students and postdocs with expertise in disciplines ranging from ecology to crystallography. Their collaborations revolve around studies of unusually successful colonies of genetically engineered germ-free mice and zebra fish.

Gordon's veteran mouse wranglers, Marie Karlsson and her husband David O'Donnell, manage the rearing of germ-free animals for comparison with genetically identical animals that are colonized with one or two select strains of normal flora. In a cavernous facility packed with rows of crib-size bubble chambers, Karlsson and O'Donnell handle their germ-free charges via bulbous black gloves that serve as airtight portals into the pressurized isolettes. They generously supplement sterilized mouse chow with vitamins and extra calories to replace or complement what is normally supplied by intestinal bacteria. "Except for their being on the skinny side, we've got them to the point where they live near-normal lives," says O'Donnell. Yet the animals' intestines remain thin and underdeveloped in places, bizarrely bloated in others. They also prove vulnerable to any stray pathogen that slips into their food, water, or air.

All Gordon's proteges share an interest in following the molecular cross talk among resident microbes and their host when they add back a component of an animal's normal microbiota. One of the most interesting players is Bacteroides thetaiotaomicron, or B. theta, the predominant bacterium of the human colon and a particularly bossy symbiont.

The bacterium is known for its role in breaking down otherwise indigestible plant matter, providing up to 15 percent of its host's calories. But Gordon's team has identified a suite of other, more surprising skills. Three years ago, they sequenced B. theta's entire genome, which enabled them to work with a gene chip that detects what proteins are being made at any given time. By tracking changes in the activity of these genes, the team has shown that B. theta helps guide the normal development and functioning of the intestines-including the growth of blood vessels, the proper turnover of epithelial cells, and the marshaling of components of the immune system needed to keep less well behaved bacteria at bay. B. theta also exerts hormonelike, long-range effects that may help the host weather times when food is scarce and ensure the bacterium's own survival.

Fredrik Backhed, a young postdoc who came to Gordon's laboratory from the Karolinska Institute in Stockholm, has caught B. theta sending biochemical messages to host cells in the abdomen, directing them to store fat. When he gave germ-free mice an infusion of gut bacteria from a conventionally raised mouse, they immediately put on an average of 50 percent more fat although they were consuming 30 percent less food than when they were germ-free. "It's as if B. theta is telling its host, 'save this-we may need it later,' " Gordon says.

Justin Sonnenburg, another postdoctoral fellow, has documented that B. theta turns to the host's body for food when the animal stops eating. He has found that when a lab mouse misses its daily ration, B. theta consumes the globs of sugary mucus made every day by some cells in the intestinal lining. The bacteria graze on these platforms, which the laboratory has dubbed Whovilles (after the dust-speck metropolis of Dr. Seuss's Horton Hears a Who!). When the host resumes eating, B. theta returns to feeding on the incoming material.

Gordon's team is also looking at the ecological dynamics that take place when combinations of normal intestinal bacteria are introduced into germ-free animals. And he plans to study the dynamics in people by analyzing bacteria in fecal samples.

Among the questions driving him: Can we begin to use our microbiota as a marker of health and disease? Does this "bacterial nation" shift in makeup when we become obese, try to lose weight, experience prolonged stress, or simply age? Do people in Asia or Siberia harbor the same organisms in the same proportions as those in North America or the Andes?

"We know that our environment affects our health to an enormous degree," Gordon says. "And our microbiota are our most intimate environment by far."

A COUPLE HUNDRED miles northeast of Gordon's laboratory, microbiologist Abigail Salyers at the University of Illinois at Urbana-Champaign has been exploring a more sinister feature of our bacteria and their role in antibiotic resistance. At the center of her research stands a room-size, walk-in artificial "gut" with the thermostat set at the human intestinal temperature of 100.2 degrees Fahrenheit. Racks of bacteria-laced test tubes line three walls, the sealed vials purged of oxygen to simulate the anaerobic conditions inside a colon. Her study results are alarming.

Salyers says her research shows that decades of antibiotic use have bred a frightening degree of drug resistance into our intestinal flora. The resistance is harmless as long as the bacteria remain confined to their normal habitat. But it can prove deadly when those bacteria contaminate an open wound or cause an infection after surgery.

"Having a highly antibiotic-resistant bacterial population makes a person a ticking time bomb," says Salyers, who studies the genus Bacteroides, a group that includes not only B. theta but also about a quarter of the bacteria in the human gut. She has tracked dramatic increases in the prevalence of several genes and suites of genes coding for drug resistance. She's particularly interested in tetQ, a DNA sequence that conveys resistance to tetracycline drugs.

When her team tested fecal samples taken in the 1970s, they found that less than 25 percent of human-based Bacteroides carried tetQ. By the 1990s, that rate had passed the 85 percent mark, even among strains isolated from healthy people who hadn't used antibiotics in years. The dramatic uptick quashed hopes of reducing widespread antibiotic resistance by simply withdrawing or reducing the use of a given drug.

Salyers's team also documented the spread of several Bacteroides genes conveying resistance to other antibiotics such as macrolides, which are widely used to treat skin, respiratory, genital, and blood infections.

As drug-resistant genes become common in bacteria in the gut, they are more likely to pass on their information to truly dangerous bugs that only move periodically through our bodies, says Salyers. Even distantly related bacteria can swap genes with one another using a variety of techniques, from direct cell-to-cell transfer, called conjugation, to transformation, in which a bacterium releases snippets of DNA that other bacteria pick up and use.

"Viewed in this way, the human colon is the bacterial equivalent of eBay," says Salyers. "Instead of creating a new gene the hard way-through mutation and natural selection-you can just stop by and obtain a resistance gene that has been created by some other bacterium."

Salyers has shown that Bacteroides probably picked up erythromycin-resistant genes from distantly related species of staphylococcus and streptococcus. Although neither bug colonizes the intestine, they are routinely inhaled and swallowed, providing a window of 24 to 48 hours in which they can commingle with intestinal flora before exiting. "That's more than long enough to pick up something interesting in the swinging singles bar of the human colon," she quips.

Most disturbing is Salyers's discovery that antibiotics like tetracycline actually stimulate Bacteroides to begin swapping its resistance genes. "If you think of the conjugative transfer of resistance genes as bacterial sex, you have to think of tetracycline as the aphrodisiac," she says. When Salyers exposes Bacteroides to other bacteria such as Escherichia coli under the disinhibiting influence of antibiotics, she has witnessed the step-by-step process by which the bacteria excise and transfer the tetQ gene from one species to another.

Nor is Bacteroides the only intestinal resident with such talents. "In June 2002, we passed a particularly frightening milestone," Salyers says. That summer, epidemiologists discovered hospital-bred strains of the gut bacterium enterococcus harboring a gene that made them impervious to vancomycin. The bacterium may have since passed the gene to the far more dangerous Staphylococcus aureus, the most common cause of fatal surgical and wound infections.

"I am completely mystified by the lack of public concern about this problem," she says.

With no simple solution in sight, Salyers continues to advise government agencies such as the Food and Drug Administration and the Department of Agriculture to reduce the use of antibiotics in livestock feed, a practice banned throughout the European Union. She supports the prescient efforts of Tufts University microbiologist Stuart Levy, founder of the Alliance for the Prudent Use of Antibiotics, which has been hectoring doctors to use antibiotics more judiciously.

Yet just when the message appears to be getting through-judging by a small but real reduction in antibiotic prescriptions-others are calling for an unprecedented increase in antibiotic use to clear the body of infections we never knew we had. Among them is William Mitchell, a Vanderbilt University chlamydia specialist. If antibiotics ever do prove effective for treating coronary artery disease, he says, the results would be "staggering. We're talking about the majority of the population being on long-term antibiotics, possibly multiple antibiotics."

Hudson cautions that before we set out to eradicate our bacterial fellow travelers, "we'd damn well better understand what they're doing in there." His interest centers on chlamydia, with its maddening ability to exist in inactive infections that flare into problems only for an unlucky few. Does the inactive form cause damage by secreting toxins or killing cells? Or is the real problem a disturbed immune response to them?

Lately Hudson has resorted to a device he once shunned in favor of DNA probes: a microscope, albeit an exotic $250,000 model. This instrument, which can magnify organisms an unprecedented 15,000 times, sits in the laboratory of Hudson's spouse, Judith Whittum-Hudson, a Wayne State immunologist who is working on a chlamydia vaccine. On a recent afternoon, Hudson marveled as a shimmering chlamydia cell was beginning to morph from its infectious stage into its mysterious and bizarre-looking persistent form. "One minute you have this perfectly normal, spherical bacterium and the next you have this big, goofy-looking doofus of a microbe," he says. He leans closer, focusing on a roiling spot of activity. "It's doing something. It's making something. It's saying something to its host.

|Science writer Jessica Snyder Sachs is the author of Good Germs, Bad Germs: Health and Survival in a Bacterial World (FSG/Hill&Wang) and Corpse: Nature, Forensics, and the Struggle to Pinpoint Time of Death (Perseus Books).

"Jessica Snyder Sachs successfully weaves story--telling, history, microbiology and evolution into an exciting account of the two aspects of microbes for humankind -- the good and the bad. The book is a wonderful read." --Stuart B. Levy, M.D., author of The Antibiotic Paradox: How the Misuse of Antibiotics Destroys their Curative Powers

 

It's hard not to get anxious about the superbugs in the news, from drug-resistant staph to the new strain of avian flu  -- especially when young children are so vulnerable to infections. But how can parents keep from getting paranoid? 

Copyright Jessica Snyder Sachs, as first published in Parenting

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Experts don't have all the information, they do have some clear and practical advice--some of it surprising. Here are their answers to parents' top questions about germs:

Q:  I've read about children who've died from drug-resistant supergerms. How can I protect my family?

ANSWER: The drug-resistant germs you've heard about are methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (often referred to as C. diff). We do encounter these bacteria on a regular basis, but the good news: Only rarely do they cause major harm.

MRSA generally produces hard-to-treat skin infections. Less often, it can cause severe pneumonia, typically on the heels of a chest cold or the flu, says John Bradley, M.D., director of infectious diseases at the Children's Hospital and Health Center in San Diego. Infection with the other bacterium, C. diff, is usually triggered by antibiotics and generally causes intestinal problems, such as diarrhea. But in rare cases C. diff can cause dangerous intestinal inflammation.

To protect against MRSA: Wash cuts and scratches thoroughly with soap and water, and keep them covered with a bandage until they've healed. Check the bandage every day or so, and don't ignore redness, swelling, or pus, as these can signal an infection. If the wound gets worse after a day, see a doctor and ask her about the possibility of MRSA. The same advice goes for a chest infection that takes a sudden turn for the worse.

For C. diff, the best prevention is to avoid taking antibiotics needlessly. Remember, they work only against bacterial infections, not viruses like colds and flu. When you or your child must take antibiotics, talk with your doctor about choosing the least gut-disruptive drug available and consider taking probiotics (beneficial bacteria that may help protect against drug-resistant germs). Sources of this good bacteria include Saccharomyces yeasts (in supplements), as well as yogurt and supplements containing lactobacillus. You can take probiotics after a course of antibiotics, or you can take probiotics regularly. Ask your doctor what's best for you.}]

Q:  My kids love snacking on fresh fruit and veggies on the way home from the market. Is this safe?

A: It's probably okay  -- and it's great that your kids are eager to snack on produce  -- but in very rare instances contaminated fruits and vegetables can lead to serious, even life-threatening food-borne illness. (Bad spinach, anyone?) The most common culprits include sprouts, lettuce, unpasteurized juice, melons, and tomatoes. But with the exception of sprouts (which can't be cleaned well and should never be served raw to children), a thorough rinsing under tap water decreases the risk for most fruits and vegetables  -- no soap or special sprays needed. So even though your kids may like to munch on grapes or apples on the way home from the grocery store, it's better to rinse off the produce before digging in.

Using public restrooms; the 5-second rule

 What can I do to make sure my kids don't pick up disease-causing germs in public rest rooms?

A: Let's start with the toilet: Unless the seat is wet or dirty (yuck), it probably harbors few germs. So you don't need to worry about layering it with tissue paper. What's more important is to turn your face away when you flush, says University of Arizona microbiologist Charles Gerba, Ph.D. (a.k.a. Dr. Germ, for his unprecedented studies of which germs lurk where). This is because the droplets that fly when you flush can be full of bacteria and viruses. ("That's another reason to put the lid down at home," says Gerba, whose research shows that in a typical home bathroom, toilet spray contaminates just about everything.)

Of course, be sure your kids wash their hands with soap and water when they're done. And during cold and flu season, it's a good idea to use a paper towel on the doorknob as they leave, since one-third of public-bathroom visitors don't wash their hands.}]

Q:  What about the "five-second rule"  -- that it's okay to pick up and eat a dropped cookie, say, if you get it off the floor quickly. Is there any harm in it?

A: That depends on where you drop the cookie. "Compared to your kitchen sink, a bare floor is quite safe," says Gerba, who practically shudders at all the germs he's catalogued in drain traps, dishcloths, and sponges. "So long as you clean the floor now and again, I wouldn't worry."

As for food that drops outside, Gerba suggests erring on the side of caution. "Toss it," he says, whether it's been on the ground for five seconds or five minutes. You don't know what got deposited on that spot before you arrived. Beach sand, for instance, is notorious for being contaminated with bird droppings, which can spread intestinal bugs. "Knowing what I know, I never eat off a bare picnic table," says Gerba. "Birds use it as their rest room while they're cleaning up the crumbs the last picnicker left behind."

Eating rare meat; avoiding avian flu

Q:  My husband likes to cook our burgers medium-rare and our eggs "sunny and runny," but what about the bacteria in these raw foods? Am I being a germophobe?

A: No. Much of the meat and eggs on our supermarket shelves is contaminated with disease-causing bacteria, and these bugs are more drug resistant than ever. Most of the time, the infections people get are run-of-the-mill food poisoning, but in a small fraction of cases, gastrointestinal infections can become a life-threatening problem. Infected babies and toddlers are among those at highest risk of death and serious complications.

To kill these germs, public-health experts recommend that you hard-cook eggs and use an instant-read thermometer to make sure burgers and egg dishes reach an internal temperature of at least 160 degrees Fahrenheit. Also, don't let raw meat or eggs contaminate other food in your kitchen; wash any plate, cutting board, counter, or silverware that's come in contact with the raw food before it touches any other food. For people who really want their eggs sunny-side up and runny, a growing number of supermarkets now carry pasteurized-in-the-shell eggs (such as Davidson's Safest Choice).

Q:  I heard that avian flu could arrive any time with migrating birds. Is it safe to let my child feed ducks at the park or seagulls at the beach?

A: Even if the dangerous avian-influenza virus (technically referred to as highly pathogenic H5N1) turns up in North American birds, the chance of transmission from birds to humans is low. In Asia, the people who have gotten this flu were almost exclusively those who regularly handle chickens and ducks. The greater risk, then, is that this virus will mutate, or change, so that it can be transmitted easily from one person to another. Thankfully, that hasn't happened yet.

Still, you and your child shouldn't get too close to wild birds, says Paul Slota, branch chief of the U.S.G.S. National Wildlife Health Center. Feeding wild birds encourages their crowding  -- which is bad for the birds as well as for people (bird droppings can spread germs).

If your child does touch a wild bird or its droppings, be sure to wash her hands with soap and water before letting her touch her face, eat, or drink. If you're not near a sink, a dollop of alcohol hand gel will do the trick.

Antibacterial soaps; puppy kisses

Q:  The supermarket is filled with soaps and household cleaning products labeled "antibacterial." Are they better than regular cleaning products?

A: No. Antibacterial soaps and cleaning products aren't any more effective in preventing the spread of disease-causing germs. (Alcohol-based hand gels, on the other hand, have been shown to cut down on the spread of infections.) What's more, the chemicals in antibacterial products work like antibiotics  -- by interfering with bacterial growth  -- and you've no doubt heard there's concern (not yet proven) that these chemicals may promote the rise of drug-resistant bacteria. "If they don't provide any benefit, why take the risk?" says Tufts University microbiologist Stuart Levy, M.D. When you want to disinfect surfaces, he and other experts recommend cleaning products that contain bleach or alcohol.

Q:  Our new puppy loves to give playful kisses. Is it okay to let him lick our child's face?

A: "The odds are in your favor that the occasional face lick is okay," says Gerba. "Just ask yourself, what was the last thing your dog licked?" Dogs can pick up intestinal parasites from infected canine buddies or if they drink from streams and lakes frequented by wildlife  -- and these infections show up in stool. So if your dog has just licked himself down there, that may not be the best time for a kiss. But if your dog doesn't show signs of illness, you should generally feel safe letting him give your child friendly licks from time to time.

Parenting contributing editor Jessica Snyder Sachs is the author of Good Germs, Bad Germs: Health and Survival in a Bacterial World (Hill&Wang/FSG).

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Winter is the season of the cough, the wheeze, the whoop, the bark, and the rattle, sniffle, and honk.

Copyright Jessica Snyder Sachs, as first published in PARENTING magazine

We spend so much more time indoors, where it's easier for respiratory infections to spread from person to person. Children, with more immature immune systems, get colds and the flu more often than grown-ups. And they have their very own diseases, like croup.

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That's why millions of moms (and dads) will be awake tonight, trying to figure out how to relieve their kids' coughing and congestion and fretting over whether to call the doctor or even make a midnight run to the emergency room.

Most of the time, all our kids need is a little symptom relief and comforting -- even when they sound terrible. Sometimes, a parent's wisdom lies in not giving her child medication. But some symptoms do warrant immediate medical attention, while others linger long enough to make you wonder if they signal asthma.

Art by Courtney

What you need to know:

The very common cold
Babies and kids get six to eight colds a year, but sometimes they sound sicker than they are. "What parents usually hear are the random snorts and sniffles of air passing through mucus and secretions in the nose and throat," says pediatric pulmonologist Peter Scott, M.D., of Children's Healthcare of Atlanta. There's no need to worry as long as your child seems reasonably comfortable and active, continues to eat and drink, and starts to get better after a few days. In the meantime:

Try saline drops to loosen nasal congestion. They're especially helpful for babies too young to blow their noses. Use three or four times a day.

To relieve a nighttime cough, elevate your child's head with a wedge beneath the mattress.

Offer liquids to lubricate an irritated, cough-prone throat. For babies, nurse or bottle-feed more frequently. For children, give water or diluted juice (semi-frozen if you want, for its pain-soothing chill). "But there's no need to push fluids -- normal intake is fine," says Dr. Scott.

Go easy on cold preparations. Never give babies under 6 months decongestants or cough suppressants, says Dr. Scott. Some decongestants can act as stimulants and keep an older child (and you) awake if taken within four hours of bedtime. Some moms find that over-the-counter cough suppressants help their kids, although studies haven't shown them to be effective. If coughing interferes with your child's sleep for four or five nights, talk to your doctor, who may prescribe a stronger prescription cough suppressant.

See the doctor if your baby is under 3 months and has a fever over 100.5 degrees. And call if a child of any age has symptoms -- cough, congestion, mild sore throat -- that linger for longer than a week.

 

RSV: a risk for infants

Respiratory syncytial virus (RSV) is either a minor nuisance or an emergency. Most kids get it by age 1, but parents usually think it's just a cold. But around 2 percent of the time, the virus causes bronchiolitis, an inflammation of the small tubes of the lungs. Even this condition is not usually life-threatening, but it can be in some babies under 6 months, and in preemies up to 1 year.

Maribelle Lewis, a medical technologist in Palisades Park, New Jersey, suspected RSV when her 3-month-old daughter, Aiyannah, developed a persistent wheezy cough but no fever. "Her extreme lethargy tipped me off," says Lewis.

Aiyannah's pediatrician gave her an inhaler with medication to open her airways. But over the next two days, Aiyannah stopped nursing and became even more listless. When Lewis took her baby back, the pediatrician sent her to the hospital, where Aiyannah received intravenous fluids and intensive respiratory therapy (inhaled steroids). Today Aiyannah is a healthy, happy 3-year-old.

Some babies with severe RSV do spike a high fever, but others never get hot at all. Always call your pediatrician if your child's wheezing or coughing makes it difficult to breathe, or if there's a loss of appetite and unusual lethargy.

Flu fears

Anxiety over avian flu may be dominating the news, but even the old-fashioned kind can prove severe, with symptoms that often begin like a cold but become more debilitating and long-lasting.

It often hits more abruptly, with a sudden high fever, dry cough, and a headache. There can also be muscle aches, sore throat, and a runny nose. Kids -- but rarely adults -- sometimes also have stomach problems, like diarrhea or belly pain.

For most babies (6 months and up) and children, treat flu-related cough and congestion much like those of a cold (with acetaminophen or ibuprofen, but never aspirin). Just expect more lethargy and feverishness. One exception: If you suspect flu in an infant under 2 months, go to the doctor right away; from 3 to 6 months, call.

And for a child of any age, watch out for that sore throat. If it's severe, there's a fever over 101, and it lasts more than a day, see the doctor to rule out strep. Also bring your kid in if his ear hurts (flu can cause ear infections), if a fever doesn't go away in three or four days, or if a cough persists more than a week. But it's fine to call earlier.

Sinusitis and pneumonia

Sinusitis
Around 10 percent of the time, a child's cold or flu will progress to sinus inflammation, or sinusitis, which may include a wet, or phlegmy, cough, bad breath, and thick yellow or green mucus. Sinusitis may also bring headache and fever.

The underlying cause is a bacterial infection, so it always warrants a trip to the doctor, who will likely prescribe antibiotics to clear it. Once you're back home, you can help your child breathe better by letting her inhale steam over a hot (but no longer boiling) pot or cup of water.

Pneumonia
"We were a bit too sanguine," admits Marina Budhos, a mom in Maplewood, New Jersey. Last February, her son Sasha, 4, had been coughing for nearly two weeks, though he never had a fever. Then, in the middle of one night, he woke up crying inconsolably. His breathing was labored, and he looked exhausted. "We brought him in the next morning, and the nurse took one look at him and said, 'He's a mess.'"

Sasha had pneumonia, which occurs when a respiratory virus settles into the chest and causes an inflammation of the lung's air sacs. Sometimes the cause is bacterial, typically as a secondary infection after a cold or flu.

Unfortunately, figuring out whether a child's congestion is in the lungs is maddeningly difficult, even for doctors. "That's why we spend so much time with our stethoscopes on your child's chest," says Joshua Needleman, M.D., a pediatric pulmonologist at Children's Hospital at Montefiore, in New York City. Three red flags:

Coughing that lasts two weeks or more

Coughing plus fast breathing and a high, persistent fever

Coughing that returns a few days after a cold appears to go away

Pneumonia can come on quickly, with fever, shaking, and chest pain, or slowly, with fatigue, weakness, and headache. See your pediatrician, who'll examine your child and most likely have her chest x-rayed. If he sends you home, treat symptoms with rest, fluids, and children's pain relievers (but not cough suppressants, which may interfere with your child's ability to clear congestion out of the lungs). But don't be surprised if the doctor hospitalizes your child to make sure she's getting enough oxygen and to bring the infection under control.

Croup

Croup, an infection of the larynx (the voice box) is a rite of early childhood for millions of families. When Jennifer Lopez's son Noah, 3, woke up barking one night, she turned on the hot shower and sat with him upright on her lap in the steamy bathroom. "He was coughing so deep in his chest, we could just feel his pain," says the Gainesville, Florida, mom. When Noah's breathing became more labored -- his nostrils flaring and his belly and chest heaving -- his parents called the pediatrician, who sent them to the emergency room. There, Noah got an injection of steroids -- a standard treatment that's safe in kids as young as 3 months -- and was given an inhaler with medication to help open his airways. He went home three hours later.

"The family did everything right," says pediatrician Ari Brown, M.D., author of Baby 411. They elevated their child's head and headed for a steamy bathroom. (The opposite -- going out into the cool night air -- can also ease croup for many children.) Even more important, the Lopezes sought immediate medical care when they saw signs that Noah was struggling for breath.

Another sign of extreme airway narrowing is when croup's classic bark turns into a high-pitched squeal, called "stridor." If a steamy bathroom or a whiff of chilly air doesn't make the squeal disappear in 20 minutes, head to the emergency room, says Dr. Brown.

 

Whooping cough

Sandy Knight thought she knew what to expect when her 3-month-old son Luke got his third cold: "It always started the same, with a runny nose. Then toward the end, he'd get a nighttime cough."

But this cough sounded different. Instead of a little "cough-cough," Luke would hack on and on and then pause, as if gagging. "My husband and I would sit there on edge, just waiting for Luke to take a breath." Somewhat sheepishly, Knight, of Austin, Texas, took Luke to his pediatrician the next morning. "I'm probably being a silly mom," she began. Far from it, given what Knight described -- prolonged coughing followed by a gag or gasp. The doctor swabbed Luke's nose and throat for analysis. The diagnosis: pertussis, a.k.a. whooping cough, a serious bacterial infection that can lead to pneumonia, seizures, even death. Luke and both of his parents got a five-day course of antibiotics, and everyone was fine.

This highly contagious disease has been making a disturbing comeback across North America. It's the only vaccine-preventable disease that's on the increase, with more than 18,000 reported cases in 2004, up from around 10,000 in 2003. Babies are especially vulnerable until they get the third of four diphtheria-tetanus-pertussis (DtP) vaccinations, usually at 6 months. Those under 3 months are at special risk of pertussis-related apnea, in which they stop breathing altogether and need emergency help.

Pertussis starts like a common cold, with a runny nose, sneezing, and cough, with or without fever. After a week or two, the cough tends to worsen, with severe and prolonged coughing jags punctuated by gags and gasps and, occasionally, vomiting. In spite of its name, babies under 1 rarely "whoop." Nor do adults (kids do). Any suspected case of pertussis warrants a trip to the doctor, as antibiotics may be needed.

The best prevention: Stay on schedule with baby shots and remain vigilant for signs of pertussis until full protection kicks in around 6 months. Though your baby's first DtP shot may produce a spike in temperature, studies have shown it does not cause lasting harm -- and certainly nothing to compare with the disease's dangerous symptoms.

By the time your child becomes a teenager, though, his immunity will start to wane. That's why the Centers for Disease Control and Prevention now recommends that all kids at age 11 or 12 get the new Food and Drug Administration- approved Tdap vaccine (Boostrix), which adds pertussis to the tetanus-diphtheria booster -- and that adults get it every ten years (sooner if you're around an infant). This should help curb the spread of whooping cough to young children.

Coughs and congestion may always be a part of early childhood. They'll become less frequent as our kids strengthen their immunity through regular vaccinations and, inevitably, a touch of actual sickness. In the meantime, your watchful vigilance protects them from serious dangers, and your TLC eases these rites of passage.

When to call 911
Pneumonia, croup, whooping cough (pertussis), RSV, and asthma can each make a baby or child struggle to breathe. This is an emergency. Call 911 if your child:

pauses more than 10 seconds between breaths

breathes very rapidly for more than a minute

turns gray or blue

Or if:

his nostrils are flaring

the muscles between or below the ribs (or the chin) are moving inward, a phenomenon called retraction

PARENTING contributing editor Jessica Snyder Sachs is the author of Good Germs, Bad Germs: Health and Survival in a Bacterial World (Hill&Wang/FSG)

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