Pediatric Medical Overuse Persists

By Reuters Staff

February 22, 2019

NEW YORK (Reuters Health) - Evidence of pediatric medical overuse persists, but there are glimmers of progress, according to a new review.

The findings are based on research articles published in 2017. A 2016 analysis of commercial claims data found that 10% to 14% of children are exposed to one of 20 services that typically do not improve child health.

Dr. Eric R. Coon of the University of Utah School of Medicine, Primary Children's Hospital, in Salt Lake City, and colleagues aimed to update pediatricians on medical overuse and its mitigation. Their report, online February 18 in JAMA Pediatrics, describes 10 articles representing high-quality, original research from 2017.

As many as 8% of children who present to the emergency department with acute abdominal pain are diagnosed as having acute appendicitis, and most of these children undergo appendectomy, the researchers note. But two meta-analyses concluded that nonoperative treatment with antibiotics could be considered as the initial treatment strategy for children with uncomplicated appendicitis, thereby reducing risks associated with surgery and general anesthesia.

Featured articles showed that amitriptyline and topiramate, the two most commonly used preventive medications for pediatric migraine, are no more effective than placebo. And prophylactic antibiotics, while modestly effective in preventing recurrent urinary-tract infections, do not prevent renal scarring.

Broad-spectrum antibiotics are increasingly used for pediatric acute bacterial respiratory tract infections, based on theoretical benefits against emerging resistant pathogens, the researchers write. But one study found that these antibiotics do not confer additional treatment benefit and may be associated with more adverse events. Narrow-spectrum antibiotics should be the mainstays for treating these bacterial infections, the team says.

One multicenter retrospective study of nearly 24,000 childhood-cancer survivors showed that modifications made to therapeutic regimens over the years - in particular, decreased reliance on radiation therapy - have resulted in significant decreases in the subsequent risk of malignancy.

In a related demonstration of the benefits of less-intensive therapy, one systematic review and meta-analysis found that less-invasive surfactant administration for preterm infants (via a thin catheter without endotracheal intubation) was associated with better outcomes (less bronchopulmonary dysplasia and mechanical ventilation), with no difference in the risk of death.

Other articles featured in the review suggested that a large number of infants who undergo general anesthesia for minor surgery could be managed more safely with a laryngeal mask airway instead of a more invasive endotracheal tube; that tight glycemic control is not beneficial when treating children with critical illness and hyperglycemia and can increase the risk of severe hypoglycemia and healthcare-associated infections; and that higher doses of docosahexaenoic acid (DHA) supplementation for preterm infants not only does not reduce bronchopulmonary dysplasia, but may increase it.

"Two generalizable lessons emerge from this year's review of articles addressing medical overuse in pediatrics," the authors conclude. "First, all medical interventions, even those that are evidence based and lifesaving, have associated risks."

"The second lesson from this year's top pediatric overuse articles is that we should be cautious in adopting rational, seemingly common sense therapies that are unproven," they write.


JAMA Pediatr 2019.