A review of 10 studies from 2021-’22 highlights what authors say are leading examples of medical overuse in pediatrics.
The studies call into question routine practices and demonstrate adverse effects of commonly overused pediatric interventions. They also suggest more judicious surgery referral.
Researchers selected the studies based on clinical significance and magnitude of potential harm to children, according to “2023 Update on Pediatric Medical Overuse” (Money NM, et al. Pediatrics. Sept. 25, 2023).
The publication marks their fifth annual or biannual medical overuse update since 2017.
“As health care systems struggle to meet increasing demands for services with limited resources, delivering value-based healthcare has become a priority,” the authors wrote.
About one in 10 children receive at least one low-value service each year, they added, “which contributes substantially to the $300 billion spent annually on pediatric health care costs in this country.”
To find the articles, researchers used selected journals’ tables of contents and a structured Medline review. They considered perceived impact on pediatric health care and historical volume of published overuse articles identified in prior reviews. Articles were scored on strength of methods, magnitude of potential harm and potential number harmed.
Researchers chose 201 articles on pediatric medical overuse, narrowing the list to 55 “top-scoring and impactful” articles. The top 10 were based on perceived impact on practice and included the following:
Routine temperature measurement at well-child visits may lead to unnecessary medical care and vaccine deferral. A five-year retrospective cohort study found temperatures were measured at 59% of well-child visits to a network of primary care clinics. Fever was detected at 0.2% (270 out of 155,527) of these clinic visits, where antibiotic prescribing was more common.
Routine dental X-rays may lead to unnecessary dental procedures in younger children. A small, randomized, controlled study of children ages 3-6 years concluded that radiographic examinations don’t provide benefit in caries management in this age group when compared with visual inspection alone.
Longer birth hospitalizations may not lead to better outcomes in newborns. An observational study of 202,385 infants during the COVID-19 pandemic found no readmissions within a week of discharge for short birth hospitalizations (less than two midnights for vaginal and less than three midnights for cesarean deliveries).
Longer antibiotic courses may not be necessary for children with nonsevere community-acquired pneumonia. A three-day course was noninferior to a five-day course of antibiotics, and a five-day course was noninferior to a 10-day course, according to a systematic review and meta-analysis of nine randomized clinical trials of 11,143 patients ages 2 months to 10 years.
Conventional care in an incubator is worse for infants with low birth weight than “kangaroo mother care.” A trial in five hospitals in Ghana, India, Malawi, Nigeria and Tanzania randomized 3,211 infants with birth weights of 1-1.8 kilograms to receive immediate kangaroo care (skin-to-skin contact, exclusive breastfeeding) or conventional care in an incubator/radiant warmer until they were stabilized. Those receiving kangaroo care had lower mortality (12.7%) in the first 28 days compared to infants receiving conventional care (15.7%). However, the results may not be generalizable to developed nations.
Gastrostomy tubes frequently are placed in children for whom the benefit is unclear and in those for whom home nasogastric tube feeding would be a superior option. These findings were based on a systematic review and meta-analysis of decision-making related to placement of gastrostomy tubes resulting in 17 recommendations reflecting four themes.
Tympanostomy tubes may not reduce the incidence of acute otitis media (AOM). A multicenter, randomized, controlled trial found that children who received tympanostomy tubes had a similar number of episodes of AOM per year as those receiving episodic medical management with 10 days of oral amoxicillin-clavulanate.
Postoperative tonsillectomy mortality highlights the importance of shared decision-making, particularly in children with medical complexity. A retrospective study of 504,262 patients under 21 years found the adjusted 30-day post-operative mortality rate was about 117 per 100,000 for children with chronic complex conditions and about four deaths per 100,000 for those without these conditions.
Proton pump inhibitor (PPI) use is associated with increased incidence of childhood asthma. Those were the findings of a retrospective study of 80,870 matched patients younger than 18 years. Other negative effects of PPI use in infancy can include fractures, decreased nutrient absorption and altered microbiome.
Over-the-counter cough and cold medications continue to cause pediatric deaths. Despite product labeling changes in 2008, children continue to die from exposure to these medications, according to a retrospective study of children younger than 12 years. Health care providers and public health professionals need to provide more education on this risk.
Resources
- A list of 201 articles with references and scores can be found in supplementary Table 1, with scores and rationale for the Top 10 in Table 2 at https://doi.org/10.1542/peds.2023-062650.
- Choosing Wisely, https://choosingwisely.org
