imagesToday we continue our look at the “Things Physicians and Patients Should Question.” Yesterday we examined ten talking points for pediatricians and patients to consider as various medical treatments are discussed. Here are what some other medical specialty organizations are emphasizing with relevance to pediatric care:

 

American Academy of Allergy, Asthma and Immunology:

Don’t routinely avoid influenza vaccination in egg-allergic patients.

Of the vaccines that may contain egg protein (measles, mumps, rabies, influenza and yellow fever), measles, mumps and rabies vaccines have at most negligible egg protein; consequently no special precautions need to be followed in egg-allergic patients for these vaccines. Studies in egg-allergic patients receiving egg-based inactivated influenza vaccine have not reported reactions; consequently egg-allergic patients should be given either egg-free influenza vaccine or should receive egg-based influenza vaccine with a 30-minute post-vaccine observation period.

Don’t overuse non-beta lactam antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation.

While about 10 percent of the population reports a history of penicillin allergy, studies show that 90 percent on more of these patients are not allergic to penicillins and are able to take these antibiotics safely. The main reason for this observation is that penicillin allergy is often misdiagnosed and when present wanes over time in most (but not all) individuals. Patients labeled penicillin-allergic are more likely to be treated with alternative antibiotics (such as vancomycin and quinolones), have higher medical costs, experience longer hospital stays, and are more likely to develop complications…

 

American Academy of Family Physicians:

Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.

Don’t prescribe antibiotics for otitis media in children aged 2–12 years with non-severe symptoms where the observation option is reasonable.

The “observation option” refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief. The decision to observe or treat is based on the child’s age, diagnostic certainty and illness severity. To observe a child without initial antibacterial therapy, it is important that the parent or caregiver has a ready means of communicating with the clinician. There also must be a system in place that permits reevaluation of the child.

Don’t perform voiding cystourethrogram (VCUG) routinely in first febrile urinary tract infection (UTI) in children aged 2–24 months.

The risks associated with radiation (plus the discomfort and expense of the procedure) outweigh the risk of delaying the detection of the few children with correctable genitourinary abnormalities until their second UTI.

 

Here’s a resource explaining when a cold becomes an antibiotic-treatable sinus infection.  And The PediaBlog reviewed the most recent guidelines for the diagnosis and treatment of ear infections (otitis media) here.

 

American Academy of Ophthalmology:

Don’t order antibiotics for adenoviral conjunctivitis (pink eye).

Adenoviral conjunctivitis and bacterial conjunctivitis are different forms of infection that can be diagnosed by the ophthalmologist by clinical signs and symptoms, and if needed, by cultures. Antibiotics are useful for patients with bacterial conjunctivitis, particularly those with moderate to severe bacterial conjunctivitis. However, they are not useful for adenoviral conjunctivitis, and the overuse of antibiotics can lead to the emergence of bacteria that don’t respond readily to available treatments.

 

American Academy of Otolaryngology:

Don’t prescribe oral antibiotics for uncomplicated acute tympanostomy tube otorrhea.

Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.

Don’t prescribe oral antibiotics for uncomplicated acute external otitis.

Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.

 

Read about the guidelines for treating “drippy ears” here.

 

American Association of Pediatric Ophthalmology and Strabismus:

Don’t put asymptomatic children in weak reading glasses.

Low “farsightedness” is a normal finding in children. Children can easily focus to see at near, with their large accommodative reserve. If the reading glasses prescription is low (less than +2.00 diopters), their innate ability to focus can be used to see clearly at both distance and near. If the eyes are not crossed, prescription of weak glasses is generally not necessary.

Annual comprehensive eye exams are unnecessary for children who pass routine vision screening assessments.

Early childhood vision screening done as part of routine well-child care accurately identifies most children with significant eye problems that are otherwise asymptomatic. Annual comprehensive eye examinations increase financial costs, a child’s absence from school and parental time away from work, with no evidence that the comprehensive exam detects asymptomatic vision problems better than timely, methodical and recurrent screening efforts. Comprehensive eye exams are appropriate for children who do not pass a vision screening.

Don’t recommend vision therapy for patients with dyslexia.

Dyslexia is a language-based learning disorder in which a person has trouble understanding written words. This occurs because the brain has a problem distinguishing and separating the sounds in spoken words, called a phonological deficit. Dyslexia is not due to a vision disorder. Children with dyslexia do not have any more visual problems than children without dyslexia. Vision therapy does not work for this population because the eyes are not the problem.

Don’t order retinal imaging tests for children without symptoms or signs of eye disease.

Retinal imaging, such as taking a photograph or obtaining an Ocular Coherence Tomography (OCT) image of the back of a child’s eye, can be useful for documenting or following known retinal or optic nerve pathology. These imaging studies should not be obtained routinely for documentation of normal ocular anatomy in asymptomatic children.

 

American College of Emergency Physicians:

Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.

Skin and soft tissue infections are a frequent reason for visiting an emergency department. Some infections, called abscesses, become walled off and form pus under the skin. Opening and draining an abscess is the appropriate treatment; antibiotics offer no benefit. Even in abscesses caused by Methicillin-resistant Staphylococcus aureus (MRSA), appropriately selected antibiotics offer no benefit if the abscess has been adequately drained and the patient has a well-functioning immune system. Additionally, culture of the drainage is not needed as the result will not routinely change treatment.

Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children.

Many children who come to the emergency department with dehydration require fluid replacement. To avoid the pain and potential complications of an IV catheter, it is preferable to give these fluids by mouth. Giving a medication for nausea may allow patients with nausea and vomiting to accept fluid replenishment orally. This strategy can eliminate the need for an IV. It is best to give these medications early during the ED visit, rather than later, in order to allow time for them to work optimally.

 

Emergency physicians also concur with the AAP regarding CT scans and head injuries:

Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules.

Minor head injury is a common reason for visiting an emergency department. The majority of minor head injuries do not lead to injuries such as skull fractures or bleeding in the brain that need to be diagnosed by a CT scan. As CT scans expose patients to ionizing radiation, increasing patients’ lifetime risk of cancer, they should only be performed on patients at risk for significant injuries. Physicians can safely identify patients with minor head injury in whom it is safe to not perform an immediate head CT by performing a thorough history and physical examination following evidence-based guidelines. This approach has been proven safe and effective at reducing the use of CT scans in large clinical trials. In children, clinical observation in the emergency department is recommended for some patients with minor head injury prior to deciding whether to perform a CT scan.

 

Medical care — especially in pediatrics — has gotten very fragmented, with children being treated by non-pediatricians in adult emergency rooms and “Doc-in-the-Boxes.”  It’s nice to see physician organizations getting on the same page with consistent information and messages.

See some more lists here— especially from those organizations that may pertain to your own health.

 

(Google Images/fairview.org)