Three Things We Do for No Reason in Pediatrics

Christopher J. Chiu, MD; Justin L. Berk, MD, MPH, MBA


October 05, 2020

This transcript has been edited for clarity.

Christopher J. Chiu, MD: Welcome back. I'm Christopher Chiu and I'm with my colleague, Justin Berk.

Justin L. Berk, MD, MPH, MBA: We are The Cribsiders pediatric podcasts, bringing practice-changing knowledge and pearls to learners at all levels. We provide video recaps of previous podcast episodes here on Medscape.

Chiu: Today we're recapping our episode on "Things We Do for No Reason," with Drs Lenny Feldman and Carrie Herzke, both from Johns Hopkins Medicine.

Berk: "Things We Do for No Reason" is a series on high-value care published in the Journal of Hospital Medicine. It highlights common clinical practices we see in the outpatient or hospital settings that don't have a lot of evidence to support them but are still being practiced today.

Chiu: Our first pearl is about nebulizers and metered-dose inhalers (MDIs). In this discussion, we talked about the fact that MDIs are probably just as efficacious as nebulizers. And in fact, because most patients don't know how to use MDIs correctly, this is a good teaching point opportunity.

Berk: That's right. The hospital provides a great opportunity to teach patients how to use a portable inhaler for times when a nebulizer is not accessible. There is some clinical benefit to nebulizers, however, or at least fewer side effects. Nebulizers are associated with less tachycardia, less tremulousness, and even a shorter time in the emergency department.

Another item we discussed was the common 48-hour rule-out in a febrile infant. If a baby younger than 3 months comes in with a fever, the common practice is to watch the baby for 2 full days. But it turns out that this is something we do for no reason.

Chiu: It turns out that 97% of blood cultures will become positive by 36 hours. Because of this, maybe we don't have to wait 48 hours. Also, the number-needed-to-treat for stays of longer than 36 hours is nearly 2000 patients before you'd find one additional infection. This is another reason why we don't have to wait the full 48 hours.

Our last pearl is about asthmonia, a neologism combining asthma and pneumonia. Asthma and pneumonia are often co-diagnosed and co-treated. This may not be necessary.

Berk: Asthma and pneumonia are diagnoses that are often included in the same hospital encounter. But the research does not show that pneumonia necessarily causes asthma exacerbations. In a study that looked at patients with and without asthma exacerbations, it turned out the bacteria population was similar in both groups. One small exception was that some patients with asthma did have mycoplasma, but they also had a lot of other viruses that could cause a more likely viral pneumonia. Studies also show that treating mycoplasma pneumonia does not necessarily improve health outcomes all that much.

The bottom line is that most asthma exacerbations are likely not caused by pneumonia. We should clearly look out for pneumonia; we know what it looks like: focal findings on exam, fevers, kids looking pretty sick and not getting better. But the majority of patients with asthma exacerbations likely do not have pneumonia [and do not need antibiotics].

Chiu: I encourage our viewers to check out this episode with Drs Lenny Feldman and Carrie Herzke.

Berk: If you'd like to see our other episodes or check this out, go to our website or send us an email. Thanks for tuning in.

Chris Chiu, MD, is assistant professor at The Ohio State University, where he is also the physician lead at OSU's Outpatient Care East Clinic and serves as the assistant clinical director for the internal medicine residency. He is an Air Force veteran and a self-proclaimed gadget geek. Follow him on Twitter.

Justin Berk, MD, MPH, MBA, is assistant professor of medicine and pediatrics at the Warren Alpert School of Medicine at Brown University. He is a clinical educator active in ambulatory and inpatient care and pediatrics. He enjoys coffee, thinking about hiking, and being a generalist. Follow him on Twitter.

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