COMMENTARY

Three More Things We Do for No Reason in Pediatrics

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

Disclosures

April 30, 2021

This transcript has been edited for clarity.

Christopher J. Chiu, MD: Welcome back to The Cribsiders on Medscape. We are the pediatric medicine podcast, and on these videos we recap our interviews with leading experts in the field to bring you clinical pearls, practice-changing knowledge, and answers to nagging questions about core topics in pediatric medicine.

Justin L. Berk, MD, MPH, MBA: One of our latest and most popular episodes is "Things We Do for No Reason in Pediatrics." Our recurring guests, Dr Lenny Feldman and Dr Carrie Herzke, spoke with us about high-value care. We discussed some of the common practices in pediatrics that might not actually have that much evidence to support them.

The first topic was blood cultures in the diagnosis of community-acquired pneumonia. Say you have a kid with probable bacterial pneumonia. Should you get a blood culture on children who aren't that sick? The answer is actually "no." The blood culture positivity rate in community-acquired pneumonia is only about 2.5%, while the contamination rate is closer to 3%. You are more likely to find a contaminant than anything that's helpful. This is especially important because community-acquired pneumonia is likely to be viral — Streptococcus pneumoniae or Mycoplasma. The blood culture is not going to help. It's an unnecessary order and often just causes a lot of confusion.

Chiu: I totally agree. My favorite pearl from the episode is one that I've talked about quite a bit. It's about constipation, and how the evidence isn't really there for using x-rays to diagnose constipation in children. In fact, it just increases admissions for bowel clean-outs.

Berk: This is a great pearl. We did abdominal x-rays all the time just to see if there was any stool. And often, there was, but that didn't mean the child was constipated. It just means that the bowel was working the way it's supposed to.

Chiu: Did you have any other pearls from this episode?

Berk: Our third topic was very high-yield as well. We talked about cellulitis and how nonpurulent cellulitis or nondraining cellulitis is often overtreated. The pathogen is often Streptococcus. So, the treatment is really simple: a second-generation cephalosporin. It's when we encounter purulent cellulitis that we need Staphylococcus and methicillin-resistant Staphylococcus aureus (MRSA) coverage. Once again, no blood culture is needed. How to effectively treat cellulitis in pediatrics was a great topic.

Chiu: Why is there a difference in treatment between purulent and nonpurulent cellulitis?

Berk: The big difference between purulent and nonpurulent cellulitis the most common pathogen. With nonpurulent cellulitis, Streptococcus is the most common pathogen, while with purulent cellulitis, it's more often Staphylococcus or MRSA. MRSA coverage is important only for purulent cellulitis.

Chiu: It makes a lot of sense. Thanks for joining us for another Medscape video recap of a Curbsiders pediatric podcast. You can download the full episode "Things We Do For No Reason in Pediatrics" on any podcast player or check our website.

Justin L. 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 patient care on Medicine and Pediatrics. He enjoys coffee, thinking about hiking, and being a generalist. Follow him on Twitter

Christopher J. 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 assistant clinical director for the Internal Medicine Residency. He is an Air Force veteran and a self-proclaimed gadget geek. Follow him on Twitter

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