Several Pediatric Medical Practices Should Be Considered For Deimplementation

Several pediatric medical practices should be discouraged or considered for deimplementation, according to a systematic review of 2018 pediatric publications.

"In general, medicine helps people overcome illness and improves their lives," Dr. Nathan M. Money from Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, told Reuters Health by email. "But, occasionally, medical interventions lead to more harm than benefit. We worry that the harms of medical interventions are too often understudied and underappreciated."

Medical overuse is common, with as many as 40% of published studies contradicting established practice. Corticosteroids to treat viral-induced respiratory illnesses, screening for detection of neuroblastoma, and early tympanostomy tubes for persistent middle ear effusion are among numerous pediatric examples.

In the fourth annual update of current pediatric low-value practices, Dr. Money and colleagues chose 10 highly influential articles from 2018 based on their overall potential consequences for pediatric practice.

"This series is an effort to celebrate research that explores medical overuse, raises awareness for its prevalence, and increases the likelihood that patients receive the right amount of care," Dr. Money said.

Their review included one paper on misdiagnosis, three papers on overuse, and six papers on overtreatment.

A retrospective US-based study found that states with a September 1 cutoff for kindergarten enrollment had significantly higher rates of diagnosis of attention-deficit/hyperactivity disorder (ADHD) among children born in August than among those born in September, while states without a September 1 cutoff showed no differences in ADHD diagnosis rates between children born in August vs September.

These findings suggest misdiagnosis of ADHD and medicalization of childhood behaviors that likely represent normal variation in childhood behavioral development, according to the authors.

Surprising among the overuse papers was a study of nurse-led home visits after hospital discharge, which found that such visits were associated with higher 30-day urgent healthcare reuse without measurable improvement in patient outcomes.

About this finding, Dr. Money said, "Occasionally, well-meaning, intuitive practices are found to be unhelpful or even cause harm."

Other "overuse" studies found that preparticipation cardiac screening might be subjecting children to unnecessary medical diagnoses or interventions while missing those most at risk of sudden cardiac death and that rooming-in is associated with superior outcomes (compared with neonatal intensive care unit admission) for infants with neonatal abstinence syndrome.

Among the "overtreatment" studies in the online report in JAMA Pediatrics, two similar trials found no benefit of probiotics in children with acute gastroenteritis, and one study added troubling evidence of the over-prescription of opioids to children.

"Medical professionals should be deliberate in their efforts to question the status quo," Dr. Money said. "Practices based on tradition or intuitive appeal rather than evidence should be questioned and deimplemented if found to be unhelpful. Similarly, we should temper our enthusiasm for emerging practices that lack evidence supporting their use."

Dr. Michael Manos from the Cleveland Clinic Foundation, Cleveland, OH, who has reviewed the over/misdiagnosis and over/mistreatment of ADHD, told Reuters Health by email, "It is always disconcerting to read of evidence that providing medical care is problematic, as in the discussion of ADHD. Pathologizing normal development obviously creates problems for both children and parents."

"(As for) the implications for ADHD, it may be helpful to note that for young children, behavior therapy is recommended prior to pharmacotherapy by the American Academy of Pediatrics," he said. "This may prevent mistreatment."

His advice for pediatricians: "Stay current with evidence."

—Will Boggs MD

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