Category: Choosing Wisely

Bonus Resource: The Dialogue Around Respiratory Illness Treatment (DART) program which is designed to support antibiotic stewardship

The Choosing Wisely Pediatric Emergency Medicine Recommendations

References

Gill, PJ, Richardson, SE, Ostrow O. Testing for respiratory viruses in children: to swab or not to swab. JAMA Pediatr. 2017;171(8):798-804

Noël KC, Fontela PS, Winters N, et al. The clinical utility of respiratory viral testing in hospitalized children: a meta-analysis. Hosp Pediatr. 2019;9(7):483-494

Parikh K, Hall M, Mittal V, et al. Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia. Pediatrics. 2014;134(3):555-562

Innis K, Hasson D, Bodilly L, et al. Do I need proof of the culprit? Decreasing respiratory viral testing in critically ill patients. Hosp Pediatr. 2021;11(1):e1-e5

Podcast: Play in new window | Download (Duration: 22:25 — 30.8MB)

Subscribe: Apple Podcasts | RSS

Tags choosing wisely, comprehensive viral panels, syndromic respiratory pcr, viral pcr

Constipation: Diagnosis, X-Rays, and more

Post author By bradsobo
Post date September 19, 2023
No Comments on Constipation: Diagnosis, X-Rays, and more

Where else is the poop going to be? Constipation is by and large a clinical diagnosis. This episode reviews how to make the diagnosis, red flags, and why X-Rays don’t necessarily help assess stool burden adequately in most children.

The Choosing Wisely recommendation: Do not obtain abdominal radiographs for suspected constipation

The Choosing Wisely Pediatric Emergency Medicine Recommendations

References

Anwar Ul Haq MM, Lyons H, Halim M. Pediatric Abdominal X-rays in the Acute Care Setting – Are We Overdiagnosing Constipation?. Cureus. 2020;12(3):e7283. Published 2020 Mar 15. doi:10.7759/cureus.7283

Beinvogl B, Sabharwal S, McSweeney M, Nurko S. Are We Using Abdominal Radiographs Appropriately in the Management of Pediatric Constipation?. J Pediatr. 2017;191:179-183. doi:10.1016/j.jpeds.2017.08.075

Berger MY, Tabbers MM, Kurver MJ, Boluyt N, Benninga MA. Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children: a systematic review. J Pediatr. 2012;161(1):44–50.e502. DOI: https://doi.org/10.1016/j.jpeds.2011.12.045

Freedman SB, Rodean J, Hall M, et al. Delayed diagnoses in children with constipation: multicenter retrospective cohort study. J Pediatr. 2017;186:87-94.e16. DOI: https://doi.org/10.1016/j.jpeds.2017.03.061

Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr. 2014;164(1):83-88.e2

Hoskins B, Marek S. Things We Do for No Reason^™: Obtaining an Abdominal X-ray to Assess for Constipation in Children. J Hosp Med. 2020;15(9):557-559. doi:10.12788/jhm.3387

Kearney R, Edwards T, Braford M, Klein E. Emergency provider use of plain radiographs in the evaluation of pediatric constipation. Pediatr Emerg Care. 2019;35(9):624-629. DOI: 10.1097/PEC.0000000000001549

McSweeney ME, Chan Yuen J, Meleedy-Rey P, Day K, Nurko S. A Quality Improvement Initiative to Reduce Abdominal X-ray use in Pediatric Patients Presenting with Constipation. J Pediatr. 2022;251:127-133. doi:10.1016/j.jpeds.2022.07.016

NICE. Constipation in children and young people: diagnosis and management. NICE. Clinical guideline [CG99] Published: 26 May 2010 Last updated: 13 July 2017. Available online at https://www.nice.org.uk/guidance/cg99

Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S. Lack of utility of abdominal x-rays in the evaluation of children with constipation: Comparison of different scoring methods. J Pediatr Gastroenterol Nutr. 2010;51(2):155-159. DOI: https://doi.org/10.1097/MPG.0b013e3181cb4309

Reuchlin-Vroklage LM, Bierma-Zeinstra S, Benninga MA, Berger MY. Diagnostic value of abdominal radiography in constipated children: a systematic review. Arch Pediatr Adolesc Med. 2005;159(7):671-678. doi:10.1001/archpedi.159.7.671

Rome IV Criteria: https://theromefoundation.org/rome-iv/rome-iv-criteria/

Rothrock SG, Green SM, Hummel CB. Plain abdominal radiography in the detection of major disease in children: a prospective analysis. Ann Emerg Med. 1992;21(12):1423-1429. doi:10.1016/s0196-0644(05)80053-8

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274. DOI: https://doi.org/10.1097/mpg.0000000000000266

Podcast: Play in new window | Download (Duration: 15:54 — 21.8MB)

Subscribe: Apple Podcasts | RSS

Tags abdominal x-ray, choosing wisely, constipation

Choosing Wisely Neurology

Do we need labs or a head CT after simple febrile or unprovoked seizures?

Post author By bradsobo
Post date September 12, 2023
No Comments on Do we need labs or a head CT after simple febrile or unprovoked seizures?

Labs or CT scans are not necessary to provide additional diagnostic information or reassurance for most children who recover completely following simple febrile seizures or unprovoked first time generalized seizures. The rate of abnormalities on these studies is very low, and the cost and downsides are too high to justify ordering them on a regular basis.

The Choosing Wisely recommendation: Do not order laboratory testing or a CT scan of the head for a patient with an unprovoked, generalized seizure or a simple febrile seizure who has returned to baseline mental status

The Choosing Wisely Pediatric Emergency Medicine Recommendations

References

American Academy of Pediatrics, Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the children with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. DOI: https://doi.org/10.1542/peds.2010-3318

Brugman J, Solomons RS, Lombard C, Redfern A, Du Plessis AM. Risk-Stratification of Children Presenting to Ambulatory Paediatrics with First-Onset Seizures: Should We Order an Urgent CT Brain?. J Trop Pediatr. 2020;66(3):299-314. doi:10.1093/tropej/fmz071

Expert Panel on Pediatric Imaging, Trofimova A, Milla SS, et al. ACR Appropriateness Criteria® Seizures-Child. J Am Coll Radiol. 2021;18(5S):S199-S211. doi:10.1016/j.jacr.2021.02.020

Fine A, Wirrell EC. Seizures in Children. Pediatr Rev. 2020;41(7):321-347. doi:10.1542/pir.2019-0134

Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first nonfebrile seizure in children. Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000; 55(5):616-623. Reaffirmed October 17, 2020

Jaffe M, Bar-Joseph G, Tirosh E. Fever and convulsions: indications for laboratory investigations. Pediatrics. 1981;67(5):729 –731

Maytal J, Krauss JM, Novak G, Nagelberg J, Patel M. The role of brain computed tomography in evaluating children with new onset of seizures in the emergency department. Epilepsia. 2000;41(8):950-954. doi:10.1111/j.1528-1157.2000.tb00277.x

McKenzie KC, Hahn CD, Friedman JN; Canadian Paediatric Society, Acute Care Committee. Emergency management of the paediatric patient with convulsive status epilepticus. Paediatr Child Health. 2021;26(1):50-57

NICE. Epilepsies in children, young people and adults; Evidence reviews underpinning recommendations. NICE guideline NG217. 2022. Accessed online at https://www.nice.org.uk/guidance/ng217/evidence/b-computed-tomography-scan-performance-in-people-with-epilepsy-pdf-398366282811

NICE. Epilepsies in children, young people and adults. NICE guideline NG217. 2022. Accessed online at https://www.nice.org.uk/guidance/ng217

Reinus WR, Wippold FJ, 2nd, Erickson KK. Seizure patient selection for emergency computed tomography. Ann Emerg Med 1993;22:1298-303.

Riviello JJ Jr, Ashwal S, Hirtz D, et al; American Academy of Neurology Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2006;67(9):1542-1550

Royal Children’s Hospital Melbourne. Afebrile Seizures. 2020. Accessed online at https://www.rch.org.au/clinicalguide/guideline_index/afebrile_seizures/

Sawires R, Buttery J, Fahey M. A Review of Febrile Seizures: Recent Advances in Understanding of Febrile Seizure Pathophysiology and Commonly Implicated Viral Triggers. Front Pediatr. 2022;9:801321. Published 2022 Jan 13. doi:10.3389/fped.2021.801321

Shah SS, Alpern ER, Zwerling L, Reid JR, McGowan KL, Bell LM. Low Risk of Bacteremia in Children With Febrile Seizures. Arch Pediatr Adolesc Med. 2002;156(5):469–472. doi:10.1001/archpedi.156.5.469

Subcommittee on Febrile Seizures; American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. doi:10.1542/peds.2010-3318

Veerapandiyan A, Aravindhan A, Takahashi JH, Segal D, Pecor K, Ming X. Use of Head Computed Tomography (CT) in the Pediatric Emergency Department in Evaluation of Children With New-Onset Afebrile Seizure. J Child Neurol. 2018;33(11):708-712. doi:10.1177/0883073818786086

Young AC, Costanzi JB, Mohr PD, Forbes WS. Is routine computerised axial tomography in epilepsy worth while?. Lancet. 1982;2(8313):1446-1447. doi:10.1016/s0140-6736(82)91340-x
Yousefichaijan P, Dorreh F, Abbasian L, Pakniyat AG. Assessing the prevalence distribution of abnormal laboratory tests in patients with simple febrile seizure. J Pediatr Neurosci. 2015;10(2):93-97. doi:10.4103/1817-1745.159180

Podcast: Play in new window | Download (Duration: 16:28 — 22.6MB)

Subscribe: Apple Podcasts | RSS

Choosing Wisely Psychiatry

Do we need labs to medically clear a patient for psych admission?

Post author By bradsobo
Post date September 5, 2023
1 Comment on Do we need labs to medically clear a patient for psych admission?

For most children requiring admission to an inpatient psychiatric facility laboratory studies are generally not required. Many of the children and adolescents being admitted already have an established mental or behavioral diagnosis, and a reassuring history and exam. The heterogeneity of clinical settings makes it challenging to establish processes that account for the needs of our patients while limiting the use of unnecessary resources broadly.

The Choosing Wisely recommendation: Do not obtain screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission unless clinically indicated

The Choosing Wisely Pediatric Emergency Medicine Recommendations

References

Thrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e663.

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency

Berg JS, Payne AS, Wayra T, Morrison S, Patel SJ. Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients. Hosp Pediatr (2023) 13 (1): 66–71

Podcast: Play in new window | Download (Duration: 16:16 — 22.3MB)

Subscribe: Apple Podcasts | RSS

Tags choosing wisely, medical clearance, medically cleared, psych labs, psychiatry

Choosing Wisely Radiology Respiratory

Do children with bronchiolitis, croup, asthma, or first-time wheezing need a Chest X-Ray?

Post author By bradsobo
Post date August 29, 2023
1 Comment on Do children with bronchiolitis, croup, asthma, or first-time wheezing need a Chest X-Ray?

For most children with children with bronchiolitis, croup, asthma, or first-time wheezing chest X-Rays are not necessary. These X-Rays are often obtained due to the possibility of missing pneumonia. But, these radiographs are hard to interpret, increase length of stay and the cost of care, and expose children to excess radiation.

The Choosing Wisely recommendation: Do not obtain radiographs in children with bronchiolitis, croup, asthma, or first-time wheezing