5 reasons your paediatrician might not order tests or write prescriptions

Question:

I feel that when I take my child to the doctor, the doctor doesn’t perform enough tests to properly diagnose. And sometimes, I leave without a prescription. Should I speak up during appointments?

Answer:

Of course, you should always voice any concern with your doctor. However, it is reported that Canadians have over one million potentially unnecessary medical tests and treatments each year. In a publicly funded health care system, unnecessary tests can lead to a waste of health system resources that could be better spent on other services for patients. The “Choosing Wisely” campaign has been launched to help clinicians and patients engage in discussions about investigations and make smarter choices. Many low-risk patients are getting tests that are not needed. Sometimes this testing even leads to further tests that are inconvenient, expensive and have risks or side effects. There are now over 230 “Choosing Wisely” recommendations. In pediatrics, specifically, here are five of the ones currently in place.

1. Don’t prescribe antibiotics to children with bronchiolitis
Respiratory distress or wheezing from bronchospasm (ie. bronchiolitis) is common in children. This infection is almost always caused by a virus, not bacteria. Inappropriate administration of antibiotics can lead to unnecessary risks (allergies, rashes, diarrhea and other adverse side-effects) and also increases overall antibiotic resistance.

2. Don’t order CT head scans in children with minor head injuries
Minor head injuries are common. Children with minor falls who cry right away with no loss of consciousness, recurrent vomiting, or change in behaviour, who return to their normal way of interacting and behaving and do not score on validated clinical decision rules (eg. CATCH or PECARN) are at a very low risk of having a brain injury. CT scans can expose children to unnecessary ionizing radiation that has the potential to increase a patient’s’ lifetime risk of cancer. They also increase length of stay and misdiagnosis.

3. Don’t use antibiotics in children with uncomplicated acute otitis media
Children over the age of two years who seem well with mild ear pain and fever should have a watch-and-wait approach using analgesia only for 48 hours. If there is no improvement, or worsening of symptoms (infections in both ears, discharge from ear, persistent fever) then a reevaluation for antibiotics can be done. Inappropriate immediate use of medicine can expose patients to unnecessary risks (allergies, rashes, diarrhea, side effects).

4. Don’t use antibiotics in children with uncomplicated sore throats
Children frequently present with sore throats. The vast majority are caused by self-limiting viral infections, not bacterial infections and therefore don’t respond to antibiotics. If the physical examination and subsequent clinical scores show features of a bacterial infection (pus/exudate, red pinpoint spots, fever, no cough), then a throat swab should be done before starting antibiotics. If the throat swab is positive and shows Group A Streptococcus (GAS), then antibiotics should be started. All too often children are given an antibiotic without a documented positive throat culture, which then leads to a rash and a referral to an allergy specialist for penicillin allergy testing – which is costly and uncomfortable and more than often negative and therefore unnecessary.

5. Don’t order ankle and/or foot X-rays in children with a negative physical examination with respect to type of injury and fracture risk
Foot and ankle injuries are common in children and following the validated Ottawa Ankle Rules (OAR) for children greater than two years old has been shown to reduce the number of x-rays performed without adversely affecting patient outcome. If the risk is low on the OAR, then the likelihood of a fracture needed casting is very low and the x-ray is not needed. It only exposes the child to unnecessary ionizing radiation, extending health care visit with associated costs without providing additional value.

Originally published in ParentsCanada magazine, Fall 2017.