Common over treatments: 5 things your paediatrician should avoid

In a recent publication in Journal of Hospital Medicine ,  a diverse group of experts made a list of 5 common practices in paediatrics which they feel are of dubious value and often potentially harmful. These practices are common in any country with developed health care and are certainly very common here in Thailand. Indeed in some places they are so common that if your child is generally healthy but has been admitted to hospital in the past, you may have come across such over treatment without realising it.

“Do not order chest radiographs in children with asthma or bronchiolitis.”

In other words  don’t order chest X-rays in children with wheezing.

The diagnosis and evaluation of asthma can be done just by careful physical examination of the child. An X-ray rarely makes a difference on the treatment of asthma.

Much more common than asthma episodes are episodes of bronchiolitis, which is a little like the common cold but with wheezing and pronounced cough. Bronchiolitis is a very common childhood illness and it too can usually be diagnosed and evaluated without chest X-rays. The harm in X-ray is not just the tiny amount of irradiation but X-rays very frequently leads to a mistaken diagnosis of pneumonia, which then leads to unnecessary antibiotic prescribing and hospital stay.

“Do not use bronchodilators in children with bronchiolitis.”

Bronchodilators are used to treat asthma where their action is to help the airways expand by relaxing the musculature around the airways. Common bronchodilator medicines include Ventolin, Bricanyl, Meptin and numerous  generic brands. Because of the similar pathological process in asthma and bronchiolitis, many doctors use bronchodilators to treat bronchiolitis. Sadly bronchodilators have not been shown to either alleviate the symptoms of bronchiolitis, or prevent or reduce hospital stays for bronchiolitis, or indeed any benefit what so ever. Yet it is rare indeed for a child with bronchiolitis to not be prescribed a bronchodilator. In Thailand the situation is even more wasteful as bronchodilators are very commonly used as cough medicine and liberally prescribed to children when there isn’t even a vague theoretical rationale for  benefit, let alone research evidence of benefit. This practice is so common here that if your child has ever been prescribed a cough syrup, more likely than not it contains a bronchodilator. Although this class of medicine is not terribly toxic, significant side effects are common and include  palpitations, restlessness and nightmares.

Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection

Steroids when used judiciously can relieve many symptoms and conditions, even save lives but it is very much a double edged sword and the balance between risks and benefits is  precarious. Steroids are often prescribed when the doctor does not know what else to do and feels the need to be seen to do something. There are times when masterly inactivity is the best option but too few doctors understand this concept.

Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy.

Nearly all babies spit up, some do it a lot, some do it very little. Many people use the word “vomiting” which is misleading  because the mechanism is quite different. Vomiting is the forceful expulsion of stomach content commonly caused by an illness but can also be caused by extreme emotion. Spitting up milk in babies is commonly caused by reflux, which is a much gentler retrograde flow up the gullet caused by immature function of the gullet and the swallowing mechanism. The vast majority of babies with “reflux” are normal and healthy, and with few exceptions will stop refluxing and spitting up in time,  without need for any treatment.  Unfortunately some colicky, grumpy or demanding babies who also spit up are labelled as having “reflux” or even “acid reflux” just because no other cause can be found. For many people, parents and doctors, when there is a perceived health problem, taking positive steps may help alleviate anxiety. As often happens in medicine, unnecessary treatment and intervention are not only useless but can cause harm. Acid suppression in refluxing baby is a common treatment even though it does not work. Stomach acid has a vital job in preventing infection. The acid kills off most of the germs found in food. By suppressing stomach acid production this barrier to infection is negated. This has been shown to lead to increase risk of infection. In a baby who is gaining weight well, it really does not matter if he spits up with every feeds. Practical measures like keeping baby upright for a little longer after feeds, or more careful burping are often enough.

Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

Pulse oximetry is the measurement of the amount of oxygen in the blood using an oxygen saturation monitor. Special light sensors are used to painlessly measure blood oxygen level. This clever machine has made the treatment of many conditions in adult and children much easier. It is to be found in just about any ward in any hospital. It is so easy to use most doctors don’t even think it takes any skill or experience at all to use the machine, all you need to know is that 95% oxygen saturation is good, between 90 to 95% not so good, and under 90& definitely not good. Alas life is never that simple. Blood oxygen in children fluctuates, often for no apparent reason and many children with blood oxygen outside the “normal range” feel perfectly well. Some doctors, whether through inexperience or ignorance, come to rely so much on oxygen sat monitors that they ignore the patient’s condition as can be observed by traditional medical skills. They the keep giving patients oxygen supplement, other medicines like bronchodilators, and keep patients in hospital longer just to get the oxygen sat level up to “normal” range. I have come across kids who have had to undergo invasive tests, and kept in hospital long after they have largely recovered from common respiratory illnesses like the common cold or bronchiolitis, just because the machine says their blood oxygen levels were below normal.

These are just 5 things some doctors subject their patients to that cause more harm than good. There are many other things doctors do which are of no proven benefit, and when you do not benefit from a treatment, all you get from that treatment are the side effects, the discomfort, and the wasted expense. Most doctors are well-meaning and would do what they think is best for the patient. Some will do things of more dubious benefit if under pressure to “do something” and it is often easier and takes much less time to prescribe a pill than to explain why that pill is not needed. Parents too are often more comforted when the doctor seems to be more pro-active. Providing reassurance and comfort to patients and parents is an important part of the doctor’s job but in doing so it is not right to cause harm. Doctors need to always question the appropriateness of their own actions, and this is especially important for “experienced” doctors, who just might be making the same mistake over and over.