Overtesting and overtreatment-statement from the European Academy of Paediatrics (EAP)

Assessment of Medical Test Overuse and Its Impact on Pediatric Emergency Department Outcomes in Upper Respiratory Tract Infections in a University Hospital in Lithuania

Medical overuse poses potential risks to patients and contributes to increasing healthcare costs, pediatric emergency departments (PED) in particular. Often, upper respiratory tract infection (URTI) cases are viral-induced and self-limiting, and they do not require specific investigations or treatment. We conducted a retrospective study from 1 December 2021 to 31 January 2022, thereby aiming to identify the common tests and factors influencing specific diagnostic and treatment decisions for URTI in PED. In total, 307 (74.9%) URTI cases underwent complete blood count (CBC) tests, 312 (76.1%) were subjected to C-reactive protein (CRP) tests, and 110 (26.8%) received urinalysis tests. Patients with a longer duration of fever and a physician's suspicion of bacterial infection were more likely to receive CBC, CRP, and/or urinalysis tests (p < 0.05). Moreover, 75.1% of the cases were classified as viral URTIs, 9.8% were bacterial URTIs, and 15.1% were unspecified. Notably, 86 (20.1%) children received antibiotics and antibiotic prescription correlated with age, tonsillitis diagnosis, CRP values higher than 30 mg/L, and a CBC of p < 0.05. Patients triaged in the second or third categories were three times more likely to be observed for 24 h compared to patients with URTI and the fourth triage category (p < 0.05). This study highlights the need for interventions to improve the appropriateness of emergency service utilization, thereby emphasizing the importance of judicious decision making in managing pediatric URTIs.

Improving croup management at a pediatric emergency department

OBJECTIVES

Over-testing and over-treatment are common in children with croup at pediatric emergency departments (PED). The objective of the study was to improve care for children with croup.

METHODS

In this quality improvement (QI) initiative, all pediatric residents starting their rotation in the PED attended an informative presentation about croup and were provided reminders throughout their rotation. The primary outcome of this QI initiative was to reduce nebulized epinephrine (NE) use among children with mild croup by 50% over 7 months. The secondary outcome was to reduce X-rays by 50% over 7 months. Other outcomes included the administration of dexamethasone to all children with croup, reduction of antibiotics, laboratory tests, and revisits, and shortening the duration between physical examination to dexamethasone and NE treatments, and the length of stay (LOS) at the PED.

RESULTS

NE administration to patients with mild croup decreased from 80.2% to 36.3% (p < 0.001). The proportion of children with X-rays decreased from 37.4% to 17.1% (p < 0.001). There was a significant increase in dexamethasone administration, and significant decreases in laboratory blood tests, expanded viral PCR panel tests, and antibiotic prescription among all croup cases (p < 0.001). Revisit rates were not significantly different (p > 0.05). Time to dexamethasone and LOS shortened significantly (p < 0.001).

CONCLUSION

With this QI intervention, decreases in the rate of administration of NE to mild croup cases, antibiotic prescription, X-ray, laboratory blood and respiratory PCR panel tests in all croup cases were achieved without an increase in revisits. However, unnecessary NE, antibiotic, and X-ray rates are still high.

Changing patterns of routine laboratory testing over time at children's hospitals

BACKGROUND

Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time.

OBJECTIVES

To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes.

DESIGN, SETTINGS, AND PARTICIPANTS

We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database.

MAIN OUTCOMES AND MEASURES

We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index.

RESULTS

Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.

Antibiotic prescription for children with acute respiratory tract infections in rural primary healthcare in Guangdong province, China: a cross-sectional study

OBJECTIVES

The objective of this study is to understand the characteristics and patterns of the first antibiotic prescriptions for children with acute respiratory infections (ARIs) in rural primary healthcare (PHC) in Guangdong province, China.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

We used prescription data generated from the electronic medical record system of 37 township hospitals in two counties of Shaoguan City, Guangdong province. 46 699 first prescriptions for ARIs in children aged 0-18 years were screened from 444 979 outpatient prescriptions recorded between November 2017 and October 2018.

OUTCOME MEASURES

Descriptive analyses were used to report sociodemographic characteristics and antibiotic prescribing profiles. χ2 analysis and binary logistic regression were used to analyse the factors associated with antibiotic prescriptions in children.

RESULTS

Of the 46 699 sampled cases, 83.00% (n=38 759) received at least one antibiotic as part of their first prescription. Of the 38 759 sampled cases treated with antibiotics, 40.76% (n=15 799), 56.15% (n=21 762) and 31.59% (n=12 244) received parenteral antibiotics, broad-spectrum antibiotics and two or more kinds of antibiotics, respectively. Multivariable analysis showed that children aged ≤5 years were less likely to be prescribed with antibiotics than those aged 16-18 years (OR 0.545, p<0.001). Those with health insurance were more likely to be prescribed with antibiotics than those without health insurance (OR 1.677, p<0.001).

CONCLUSIONS

Misuse and overuse of antibiotics were found in the prescriptions of children with ARIs in rural PHC. Antibiotic stewardship programme should be established to reduce the level of antibiotic prescriptions among children with ARIs in rural PHC, especially regarding the prescriptions of broad-spectrum antibiotics and parenteral antibiotics, tailored to different ages, sex and health insurance groups.

Use of antibiotics contrary to guidelines for children's lower respiratory tract infections in different health care settings

This study aimed to evaluate antibiotic prescriptions for children with lower respiratory tract infection (LRTI) in public and private primary care clinics and in a hospital's pediatric emergency department (PED) in 2012-2013 (pre-guideline) and in 2014-2015 (post-guideline). Special attention was paid to guideline compliance, especially regarding macrolide prescriptions, which the guidelines discourage. Retrospective data of 1431 children with LRTI in November-December 2012-2015 were collected from electronic registers and checked manually. Three diagnostic groups were analyzed: community-acquired pneumonia (CAP), wheezing bronchitis, and non-wheezing bronchitis. A comparison of the pre- and post-guideline periods revealed antibiotic prescription rates of 48.7% and 48.9% (p = 0.955) for all LRTIs, respectively, and 77.6% and 71.0% (p = 0.053) for non-wheezing bronchitis. The prescription rates for all LRTIs were 24.9% in PED and 45.9% in public (p < 0.001 vs. PED) and 75.4% in private clinics (p < 0.001 vs. PED and p < 0.001 vs. public clinics). During post-guideline periods, antibiotics were prescribed for CAP less often in private (56.3%) than in public clinics (84.6%; p = 0.037) or in PED (94.3%; p < 0.001 vs. private and p = 0.091 vs. public primary clinics). Macrolide prescriptions were highest in private clinics (42.8%), followed by public primary care clinics (28.5%; p < 0.05) and PED (0.8%; p < 0.05 vs. both public and private primary care). Amoxicillin was the predominant antibiotic in public primary care and PED and macrolides in private primary care.

CONCLUSION

 Antibiotic prescribing for children with LRTI differed significantly between healthcare providers. CAP was undertreated and bronchitis overtreated with antibiotics in primary care, especially in the private clinics.

WHAT IS KNOWN

• Clinical Treatment Guidelines tend to have modest effect on physicians' antibiotic prescribing habits. • Pediatric viral LRTIs are widely treated with unnecessary antibiotics.

WHAT IS NEW

• Remarkable differences in antibiotic prescriptions in pediatric LRTIs between Finnish private and public providers were observed. • Overuse of macrolides was common especially in private clinics.

Association between neonatal phototherapy and sleep: The Japan Environment and Children's Study

This observational cohort study aimed to evaluate the association between the duration of neonatal phototherapy and sleep-and-wakefulness states at 1 month, 1.5 years, and 3 years of age. We analysed data from 77,876 infants using the Japan Environment and Children's Study, a nationwide birth cohort study. The participants were divided into three groups: no phototherapy, short phototherapy (1-24 h), and long phototherapy (>24 h). Multiple regression analysis was performed to assess the effect of phototherapy duration on infant sleep at each age after adjusting for potential risk factors. A longer duration of phototherapy was associated with a shorter sleep time over 24 h at 1 month of age (β, -0.62; SE, -0.77 to -0.47) when compared with a shorter duration of, or no, phototherapy, following the adjustment of confounding factors. Contrastingly, the short duration group, when compared with the no phototherapy group, was associated with later sleep onset (β, 0.04; SE, 0.00-0.08) and later sleep offset (β, 0.05; SE, 0.01-0.09) at 1.5 years of age. We concluded that the duration of phototherapy may be transiently associated with sleep duration in infants, as emphasised by the shortening of the total sleep time per 24 h at 1 month of age.

Do not do recommendations in different paediatric care settings

INTRODUCTION

There are many initiatives aimed at eliminating health care interventions of limited utility in clinical practice. The Committee on Care Quality and Patient Safety of the Spanish Association of Pediatrics (AEP) has proposed the development of "DO NOT DO" recommendations (DNDRs) to establish a series of practices to be avoided in the care of paediatric patients in primary, emergency, inpatient and home-based care.

MATERIAL AND METHODS

The project was carried out in 2 phases: a first phase in which possible DNDRs were proposed, and a second in which the final recommendations were established by consensus using the Delphi method. Recommendations were proposed and evaluated by members of the professional groups and paediatrics societies invited to participate in the project under the coordination of members of the Committee on Care Quality and Patient Safety.

RESULTS

A total of 164 DNDRs were proposed by the Spanish Society of Neonatology, the Spanish Association of Primary Care Paediatrics, the Spanish Society of Paediatric Emergency Medicine, the Spanish Society of Internal Hospital Paediatrics and the Medicines Committee of the AEP and the Spanish Group of Paediatric Pharmacy of the Spanish Society of Hospital Pharmacy. The initial set was limited to 42 DNDRs, and the selection over successive rounds yielded a final set of 25 DNDRs, with 5 DNDRs for each paediatrics group or society.

CONCLUSIONS

This project allowed the selection and establishment by consensus of a series of recommendations to avoid unsafe, inefficient or low-value practices in different areas of paediatric care, which may contribute to improving the safety and quality of paediatric clinical practice.

Watchful Waiting in Pediatric Acute Otitis Media: A Real Practice Approach or an Intangible Desideratum?

Acute otitis media (AOM) in children is one of the leading causes of health care visits and antibiotic prescriptions worldwide. The overall aim of the current study is twofold: 1. to analyze and discuss the antibiotic prescription patterns in AOM in children without complications or risk factors and 2. to assess to what extent the watchful-waiting approach is a real practice or a mere desideratum. We performed an electronic search in the PubMed and Embase databases from 2013 to 2023 to capture original research studies investigating antibiotic prescribing patterns for AOM in children. Among the 12 papers included in the analysis, the antibiotic prescription rate ranged from 44.8% to 98%. Our study reveals similarities regarding the use of amoxicillin as a first-line antibiotic in pediatric AOM, but also discrepancies in the watchful-waiting approach attitude and in the choice of second or third-line antimicrobial agents. The proportion of cases managed with the watchful-waiting approach ranged from 7.5% (Australia) to 55.2% (Finland). Denmark was the only country reporting penicillin V as a first-choice regimen for children with AOM, which fulfils the guidelines’ recommendations. The most unsatisfying rate of amoxicillin use was recorded in Japan, contrary to the recommendations of local guidelines. The use of quinolones was reported in two out of twelve studies, with the highest proportion in Japan, where tosufloxacin was used in 21.4% of the total number of cases. The duration of the antibiotic regimens was analyzed in three out of twelve papers. Since global antibiotic overuse contributes to the emergence of antibiotic resistant bacteria, new strategies are needed to increase the rate of watchful waiting and to promote the judicious use of antibiotics.

Choosing Wisely in pediatric healthcare: A narrative review

Background

It has been estimated that 20% of the tests and therapies currently prescribed in North America are likely unnecessary, add no value, and may even cause harm. The Choosing Wisely (CW) campaign was launched in 2012 in the US and Canada to limit the overuse of medical procedures in adult and pediatric healthcare, to avoid overdiagnosis and overtreatment.

Methods

In this narrative review, we describe the birth and spread of the CW campaign all over the world, with emphasis on CW in pediatric healthcare.

Results

To date, CW has spread to more than 25 countries and 80 organizations, with 700 recommendations published. The awareness of medication overuse also made its way into pediatrics. One year after the launch of the CW campaign, the American Academy of Pediatrics and the pediatric section of the Society of Hospital Medicine provided the first recommendations specifically aimed at pediatricians. Thereafter, many European pediatric societies also became active in the CW campaign and published specific top-5 recommendations, although there is not yet a common set of CW recommendations in Europe.

Discussion

We reviewed the main pediatric CW recommendations in medical and surgical fields and discussed how the recommendations have been produced, published, and disseminated. We also analyzed whether and how the CW recommendations impacted pediatric medical practice. Furthermore, we highlighted the common obstacles in applying CW recommendations, such as pressure from patients and families, diagnostic uncertainty, and worries about legal problems. Finally, we highlighted the necessity to foster the CW culture, develop an implementation plan, and measure the results in terms of overuse decline.

Outpatient Antibiotic Prescribing for 357,390 Children With Otitis Media

AIM

This study aimed to evaluate antibiotic prescriptions for children with otitis media (OM) in a large nationwide network of private clinics between 2014 and 2020. Special focus was paid to amoxicillin and amoxicillin-clavulanic acid prescriptions, which the national guidelines recommend for first-line drugs. We also focused on macrolides, which are commonly prescribed for respiratory tract infections in children but are not appropriate for OM cases.

METHODS

The data were obtained from the electronic health records of about 250,000 annual visits in <18 years old children. The collected variables were all diagnoses, age, visit year, doctor's specialty, and prescribed antibiotics. Children with OM and upper respiratory tract infections were included, but those with lower respiratory tract infections were excluded.

RESULTS

The number of children with OM was 357,390 (55.2% boys). Antibiotics were prescribed in 44.8% of cases, with the lowest proportion (44.1%) being in <2 years old children. The overall prescription rate decreased from 48.3% in 2014 to 41.4% in 2020. The rates were 19.3% and 18.1% for amoxicillin and 12.6% and 13.2% for amoxicillin-clavulanic acid, respectively. Macrolide prescriptions were reduced from 7.5% to 3.5%. Pediatricians prescribed antibiotics for 38.8%, general practitioners for 54.0% and ear, nose and throat physicians for 39.8% of children with OM.

CONCLUSION

The selection of antibiotics for OM, when prescribed, was according to the recommendations (amoxicillin or amoxicillin-clavulanic acid) in 80.1% of pediatricians, 67.0% of general practitioners and 55.1% of ear, nose and throat physicians.

Local healthcare professionals need to work together to implement bronchiolitis guidelines that stop unnecessary tests and treatments

AIM

This mini review summarised studies published over a 10-year period on the impact of guidelines for diagnosing and managing bronchiolitis in children, with a special focus on interventions that enhanced adherence during implementation.

METHODS

PubMed was searched from 1 December 2011 to 31 November 2021 for papers published in English that used the terms bronchiolitis, child or infant, guidelines and either implementation or impact. After the exclusion criteria had been applied, 27 articles were reviewed in more detail. Eight described protocols without any comparisons and were excluded. Ten of the 19 remaining studies evaluated the impact of bronchiolitis guidelines, and 9 examined the effects of interventions linked to their publication.

RESULTS

Just releasing evidence-based guidelines had a poor impact, but this improved when local tailored current care, clinical practice or best-practice guidelines were issued. Even better results were achieved when all the staff treating bronchiolitis patients participated in the preparation and implementation of local guidelines. Adherence to the guidelines was as high as 85% when multidisciplinary, and multifaceted interventions were used to complement the publication of guidelines.

CONCLUSION

Healthcare professionals need to work together to avoid children receiving bronchiolitis management that is unnecessary and not based on evidence.

Antibiotic prescriptions for children with lower respiratory tract infections fell from 2014 to 2020, but misuse was still an issue

AIM

We evaluated main trends in antibiotic prescriptions for children with lower respiratory tract infection (LRTI) by Terveystalo, Finland's largest private healthcare company.

METHODS

The study comprised of 89,359 children aged 0-17 years (57.2% boys) who visited Terveystalo primary care clinics from 2014 to 2020 with LRTI. The data were assessed by age, study year, location, the doctor's speciality and whether the diagnosis was bronchitis or community-acquired pneumonia (CAP).

RESULTS

There were gradual decreases in overall antibiotic prescription rates during the study period (37.0% in 2014 vs. 20.1% in 2020) and in prescribed macrolides (16.8% vs. 7.5%). Altogether, 31.3% of 72,737 children with bronchitis and 22.5% of those 16,622 with CAP-received antibiotics. Macrolides were the most frequently prescribed antibiotics for bronchitis, at more than 40%, without any substantial relative decrease during the study. Costs of antibiotics increased from 2014 to 2016 and then decreased in line with the reduction in prescriptions. However, there was still a marked overuse of antibiotics, especially macrolides, for children with bronchitis. The relative use of amoxicillin for CAP increased from 41.4% to 65.4% between 2016 and 2020, in line with current guidelines.

CONCLUSION

Despite an overall reduction in prescribed antibiotics, some antibiotics were still overused, particularly macrolides for bronchitis.

Antibiotic Use and Vaccine Antibody Levels

BACKGROUND

The majority of children are prescribed antibiotics in the first 2 years of life while vaccine-induced immunity develops. Researchers have suggested a negative association of antibiotic use with vaccine-induced immunity in adults, but data are lacking in children.

METHODS

From 2006 to 2016, children aged 6 to 24 months were observed in a cohort study. A retrospective, unplanned secondary analysis of the medical record regarding antibiotic prescriptions and vaccine antibody measurements was undertaken concurrently. Antibody measurements relative to diphtheria-tetanus-acellular pertussis (DTaP), inactivated polio (IPV), Haemophilus influenzae type b (Hib), and pneumococcal conjugate (PCV) vaccines were made.

RESULTS

In total, 560 children were compared (342 with and 218 without antibiotic prescriptions). Vaccine-induced antibody levels to several DTaP and PCV antigens were lower (P < .05) in children given antibiotics. A higher frequency of vaccine-induced antibodies below protective levels in children given antibiotics occurred at 9 and 12 months of age (P < .05). Antibiotic courses over time was negatively associated with vaccine-induced antibody levels. For each antibiotic course the child received, prebooster antibody levels to DTaP antigens were reduced by 5.8%, Hib by 6.8%, IPV by 11.3%, and PCV by 10.4% (all P ≤ .05), and postbooster antibody levels to DTaP antigens were reduced by 18.1%, Hib by 21.3%, IPV by 18.9%, and PCV by 12.2% (all P < .05).

CONCLUSIONS

Antibiotic use in children <2 years of age is associated with lower vaccine-induced antibody levels to several vaccines.

Antibiotic stewardship programmes had a low impact on prescribing for acute respiratory tract infections in children

Aim

This mini review summarises the available data on antibiotic stewardship programmes (ASP) for acute respiratory tract infections (ARTI) in paediatric outpatients, particularly the implementation and impact of programmes.

Methods

PubMed was searched from 1 January 2012 to 31 December 2021 for papers with abstracts that used the terms respiratory tract infection, antibiotic, child and guideline. We then saw how many of these included the individual terms impact, implementation or stewardship. After exclusions, we included 10 papers that were published in English on children treated as outpatients for ARTIs. All of these included data on implementing and assessing the impact of ASPs.

Results

The primary care data were mainly from the United States. The ASP programmes did not influence antibiotic prescription rates, but broad‐spectrum antibiotics decreased by 43–48%. The emergency department data were mainly from France and the antibiotic prescription rate decreased by 31–35% and the rate for broad‐spectrum antibiotics by 63–71%. A nationwide register‐based study from France confirmed these results.

Conclusion

ASPs had a low impact on overall antibiotic prescription rates and a modest impact on prescribing broad‐spectrum antibiotics. The implementation of ASP protocols needs further development, and more research is necessary on barriers to complying with ASPs.

Assessment of Machine Learning-Based Medical Directives to Expedite Care in Pediatric Emergency Medicine

IMPORTANCE

Increased wait times and long lengths of stay in emergency departments (EDs) are associated with poor patient outcomes. Systems to improve ED efficiency would be useful. Specifically, minimizing the time to diagnosis by developing novel workflows that expedite test ordering can help accelerate clinical decision-making.

OBJECTIVE

To explore the use of machine learning-based medical directives (MLMDs) to automate diagnostic testing at triage for patients with common pediatric ED diagnoses.

DESIGN, SETTING, AND PARTICIPANTS

Machine learning models trained on retrospective electronic health record data were evaluated in a decision analytical model study conducted at the ED of the Hospital for Sick Children Toronto, Canada. Data were collected on all patients aged 0 to 18 years presenting to the ED from July 1, 2018, to June 30, 2019 (77 219 total patient visits).

EXPOSURE

Machine learning models were trained to predict the need for urinary dipstick testing, electrocardiogram, abdominal ultrasonography, testicular ultrasonography, bilirubin level testing, and forearm radiographs.

MAIN OUTCOMES AND MEASURES

Models were evaluated using area under the receiver operator curve, true-positive rate, false-positive rate, and positive predictive values. Model decision thresholds were determined to limit the total number of false-positive results and achieve high positive predictive values. The time difference between patient triage completion and test ordering was assessed for each use of MLMD. Error rates were analyzed to assess model bias. In addition, model explainability was determined using Shapley Additive Explanations values.

RESULTS

There was a total of 42 238 boys (54.7%) included in model development; mean (SD) age of the children was 5.4 (4.8) years. Models obtained high area under the receiver operator curve (0.89-0.99) and positive predictive values (0.77-0.94) across each of the use cases. The proposed implementation of MLMDs would streamline care for 22.3% of all patient visits and make test results available earlier by 165 minutes (weighted mean) per affected patient. Model explainability for each MLMD demonstrated clinically relevant features having the most influence on model predictions. Models also performed with minimal to no sex bias.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest the potential for clinical automation using MLMDs. When integrated into clinical workflows, MLMDs may have the potential to autonomously order common ED tests early in a patient's visit with explainability provided to patients and clinicians.

A Self-criticism of Diagnostic and Therapeutic Decision Making in Children Admitted With Acute Lower Respiratory Infection at a Single Pediatric Emergency Department

OBJECTIVES

Acute bronchiolitis and community-acquired pneumonia are the most common acute lower respiratory infections (LRIs) leading to emergency admission and hospitalization in children. The aim of this study is to investigate clinical, laboratory, and radiology findings; diagnostic and therapeutic decisions; and the relationships between them in patients younger than 2 years of age, hospitalized for LRI.

METHODS

Patients hospitalized for acute LRI (aged 28 days to 24 months) between November 1, 2017, and March 31, 2018, at a referral hospital were included. Patients' characteristics, clinical, laboratory, and radiologic findings and diagnostic and therapeutic decisions, along with reason for hospitalization, were recorded retrospectively. Chest x-rays were reinterpreted by the pediatric radiologist. Associations of these data with the radiologic signs and treatment modalities including antibiotics, bronchodilators, and high-flow oxygen therapy (HFOT) were assessed.

RESULTS

One hundred eighty-two patients were included. One hundred sixty (87.9%) had at least one of the following criteria for hospitalization: dehydration, feeding difficulties, young age (<12 weeks), and hypoxia. One hundred forty-five (79.6%) and 71 (39.0%) patients were administered antibiotic and antiviral therapy, respectively. Twenty-three patients (13.7%) were given HFOT, and 179 (99.4%) were given bronchodilators. None of the complaints, physical signs, or laboratory parameters had statistically significant associations with radiologic findings (P > 0.05). History of wheezing and presence of rales and dehydration in physical examination were associated with antibiotic use (P < 0.001).

CONCLUSIONS

The decision of hospitalization was generally appropriate. However, laboratory and radiologic tests and treatments including HFOT, bronchodilator, antibiotic, and antiviral therapies were used excessively and inefficiently. Physicians' decisions were not based on evidence or on the clinical findings of the patient. The results of this study should prompt investigations into the reasons underlying these clinical decisions and development of practice models that can provide solutions specifically targeting the decision-making processes of physicians caring for young children with LRI at the emergency department.

Overuse of medical care in paediatrics: A survey from five countries in the European Academy of Pediatrics

Studies and initiatives such as the "Choosing wisely" (CW) campaign emphasise evidence-based investigations and treatment to avoid overdiagnosis and overtreatment. The perception of the extent of medical overactivity among professionals and drivers behind are not well studied in the paediatric field.

AIM

We aimed to investigate the physicians' opinion and clarify the main drivers regarding medical overactivity in member countries of the European Academy of Paediatrics (EAP).

METHODS

In this study, paediatricians, paediatric residents, primary care paediatricians, and family doctors treating children were surveyed in Norway, Lithuania, Ukraine, Italy, and Switzerland. Over-investigation was defined as "diagnostic work-up or referral that is unlikely to provide information which is relevant for a patient" and overtreatment was defined as "treatment that does not benefit or can harm more than benefit the patient." The original questionnaire was developed in 2018 by a working group from the Norwegian Paediatric Association.

RESULTS

Overall, 1,416 medical doctors participated in the survey, ranging from 144 in Lithuania to 337 in Switzerland. 83% stated that they experienced over-investigation/overtreatment, and 81% perceived this as a problem. The majority (83%) perceived expectations from family and patients as the most important driver for overtreatment in their country. Other drivers for overuse were use of national guidelines/recommendations, worry for reactions, and reduction of uncertainty.

CONCLUSION

This is the first study investigating knowledge and attitude toward medical overactivity in European countries. Despite different cultural and economic environments, the patterns and drivers of increased investigations and medicalisation are similar.

Antibiotic prescribing for children with upper respiratory tract infection: a Finnish nationwide 7-year observational study

Upper respiratory tract infection (URTI) is a self-limiting viral infection and should not be treated with antibiotics. The aim was to evaluate antibiotic prescriptions for children with uncomplicated URTI in a large nationwide private clinic network between 2014 and 2020. Special focus was given to macrolide prescriptions and costs. The data were obtained from the electronic health records (EHR) of the largest private healthcare company in Finland (with about 250,000 paediatric visits annually across the country). The collected variables included diagnoses, age, visit year, speciality of the doctor, and prescribed antibiotics. The number of uncomplicated URTIs in < 18-year-old children was 156,187 (53.0% in boys). The prescription rate of antibiotics decreased from 18.0% in 2014 to 8.8% in 2020, and that of macrolides from 6.1 to 1.7%. The costs decreased accordingly. Paediatricians prescribed antibiotics less often than general practitioners or ear, nose, and throat specialists.

CONCLUSION

Antibiotic prescriptions for uncomplicated URTIs, especially macrolides, decreased substantially during the 7-year surveillance period; however, 8.8% of children still received unnecessary antibiotics. To further reduce unwarranted antibiotic prescriptions, active interventions are needed that can be performed by applying the available EHR system.

WHAT IS KNOWN

• Upper respiratory tract infection (URTI) is the most common infection in children. Uncomplicated URTI is a self-limiting viral infection, and antibiotic treatment is not warranted.

WHAT IS NEW

• Almost 9% of children with uncomplicated URTIs still received unnecessary antibiotics. Paediatricians prescribed antibiotics less often than general practitioners or ear, nose, and throat specialists. To further reduce unwarranted antibiotic prescriptions, active interventions are needed that can be performed by applying the available EHR system.

Antibiotic therapy in children with community-acquired pneumonia

PubMed was reviewed on antibiotic treatment of community-acquired pneumonia (CAP) in children for the years 2011-2020, and three clinical trials in high-income and eight in low-income countries were found. Prospective studies combining laboratory and clinical findings for steering of antibiotic treatment found that five-day courses were equally effective as longer courses. No new antibiotics were launched for children's CAP during the last 10 years. Five-day courses are equally effective as 7- to 10-day courses for CAP in children. Stewardship of antibiotics needs lessening of exposure to antibiotics by better targeting their use and by shortening the lengths of antibiotic courses.

Medications Reconciled at Discharge Versus Admission Among Inpatients at a Children's Hospital

BACKGROUND AND OBJECTIVES

Discharge prescription practices may contribute to medication overuse and polypharmacy. We aimed to estimate changes in the number and types of medications reported at inpatient discharge (versus admission) at a tertiary care pediatric hospital.

METHODS

Electronic medication reconciliation data were extracted for inpatient admissions at The Hospital for Sick Children from January 1, 2016, to December 31, 2017 (n = 22 058). Relative changes in the number of medications and relative risks (RRs) of specific types and subclasses of medications at discharge (versus admission) were estimated overall and stratified by the following: sex, age group, diagnosis of a complex chronic condition, surgery, or ICU (PICU) admission. Micronutrient supplements, nonopioid analgesics, cathartics, laxatives, and antibiotics were excluded in primary analyses.

RESULTS

Medication counts at discharge were 1.27-fold (95% confidence interval [CI]: 1.25-1.29) greater than admission. The change in medications at discharge (versus admission) was increased by younger age, absence of a complex chronic condition, surgery, PICU admission, and discharge from a surgical service. The most common drug subclasses at discharge were opioids (22% of discharges), proton pump inhibitors (18%), bronchodilators (10%), antiemetics (9%), and corticosteroids (9%). Postsurgical patients had higher RRs of opioid prescriptions at discharge (versus admission; RR: 13.3 [95% CI: 11.5-15.3]) compared with nonsurgical patients (RR: 2.38 [95% CI: 2.22-2.56]).

CONCLUSIONS

Pediatric inpatients were discharged from the hospital with more medications than admission, frequently with drugs that may be discretionary rather than essential. The high frequency of opioid prescriptions in postsurgical patients is a priority target for educational and clinical decision support interventions.

Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value

OBJECTIVES

The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children.

METHODS

A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations.

RESULTS

Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis.

CONCLUSIONS

We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.

Patterns of medication errors involving pediatric population reported to the French Medication Error Guichet

Background

Medication error is a global threat to patient safety, particularly in pediatrics. Yet, this issue remains understudied in this population, in both hospital and community settings.

Objectives

To characterize medication errors involving pediatrics reported to the French Medication Error Guichet, and compare them with medication errors in adults, in each of the hospital and community settings.

Methods

This was a retrospective secondary data analysis of medication errors reported throughout 2013-2017. Descriptive and multivariate analyses were performed to compare actual and potential medication error reports between pediatrics (aged <18 years) and adults (aged >18 and <60 years). Two subanalyses of actual medication errors with adverse drug reaction (ADR), and serious ADR were conducted.

Results

We analyzed 4,718 medication error reports. In pediatrics, both in hospital (n=791) and community (n=1,541) settings, antibacterials for systemic use (n=121, 15.7%; n=157, 10.4%, respectively) and wrong dose error type (n=391, 49.6%; n=549, 35.7%, respectively) were frequently reported in medication errors. These characteristics were also significantly more likely to be associated with reported errors in pediatrics compared with adults. In the hospital setting, analgesics (adjusted odds ratio (aOR)=1.59; 95% confidence interval (CI) 1.03:2.45), and blood substitutes and perfusion solutions (aOR=3.74; 95%CI 2.24:6.25) were more likely to be associated with reported medication errors in pediatrics; the latter drug class (aOR=3.02; 95%CI 1.59:5.72) along with wrong technique (aOR=2.28; 95%CI 1.01:5.19) and wrong route (aOR=2.74; 95%CI 1.22:6.15) error types related more to reported medication errors with serious ADR in pediatrics. In the community setting, the most frequently reported pediatric medication errors involved vaccines (n=389, 25.7%). Psycholeptics (aOR=2.42; 95%CI 1.36:4.31) were more likely to be associated with reported medication errors with serious ADR in pediatrics. Wrong technique error type (aOR=2.71; 95%CI 1.47:5.00) related more to reported medication errors with ADR in pediatrics.

Conclusions

We identified pediatric-specific medication error patterns in the hospital and community settings. Our findings inform focused error prevention measures, and pave the way for interventional research targeting the needs of this population.

Hypovitaminosis D in migrant children in Switzerland: a retrospective study

Cholecalciferol (vitamin D₃) is essentially known for its role in the phosphocalcic metabolism and its associated pathologies, such as rickets. In Switzerland, 35 to 50% of children are vitamin D deficient. Due to skin colour, poor nutrition, living conditions and cultural practices, migrant population is particularly at risk. Our aim is to attest the prevalence of hypovitaminosis D in children arriving in Switzerland. We retrospectively assessed 528 children's vitamin D status and parathyroid hormone, phosphate and calcium levels between 2015 and 2018 by electrochemiluminescence and spectrophotometry. Cholecalciferol was considered insufficient under 50 nmol/L and severely deficient below 25 nmol/L. Seventy-three percent of children showed hypovitaminosis D and 28% had a severe deficiency. Highest prevalence of deficiency was found in children from Eastern Mediterranean (80%) and African regions (75%). Severe deficiency was more prevalent in the South East Asian (39%) and Eastern Mediterranean regions (33%) and more frequent in females. Deficiency was more frequent and more severe in winter. Hypovitaminosis D increased with age. Two children presented with all three biological manifestations associated to severe hypovitaminosis D (hyperparathyroidism, hypocalcaemia and hypophosphatemia).Conclusion: A majority of migrant children presented with hypovitaminosis D. They should be supplemented to prevent complications. A strategy could be to supplement all children at arrival and during wintertime without regular vitamin D level checks. What is Known: Hypovitaminosis D is frequent in children and can lead to bone-related complications. Migrant children are particularly at risk of deficiency. What is New: Three-quarters of migrant children evaluated at our migrant clinic in Geneva's children hospital are deficient in vitamin D, one third severely. A strategy to correct the deficiency would be to supplement all migrant children at arrival and in winter.

Overmedicalization in Children with Medical Complexity

Children with medical complexity (CMC) are a unique pediatric patient population with increased exposure and interactions with the health care system and reliance on family caregivers. These attributes place CMC at high risk of overmedicalization (OM). This article reviews the risk factors for OM in CMC and presents an algorithm that primary providers can use to recognize and address this issue. Involvement of a broad multidisciplinary team, including child advocacy when needed, is recommended. The article also focuses on challenges and additional considerations that arise when medical child abuse as the cause of OM is suspected in this population. [Pediatr Ann. 2020;49(11):e478-e485.].

Influence of radiographic examination findings on recommendations made during routine clinical re-evaluation of dogs with uncomplicated tibial plateau leveling osteotomy

OBJECTIVE

To determine the influence of follow-up radiographic examination on recommendations made during routine clinical re-evaluation of dogs that had undergone uncomplicated tibial plateau leveling osteotomy (TPLO).

STUDY DESIGN

Retrospective multi-institutional case series.

ANIMALS

Client-owned dogs (N = 1010) that underwent uncomplicated TPLO.

METHODS

Records from 11 institutions were searched for dogs that had been treated with unilateral TPLO and had no history of postoperative complications before their routine follow-up examination. The frequency of change in further clinical recommendations resulting from client- or clinician-voiced concerns or radiographic abnormalities was investigated.

RESULTS

Follow-up evaluation was performed at a median of 6 (range, 4-15) weeks after TPLO. Radiographic examination findings contributed to a change in recommendations in 4.15% (38/915) of dogs presented without client concerns and without abnormalities at orthopedic examination. Abnormal radiographic findings alone influenced the management of 3.76% (38/1010) of dogs. An association was detected between clinical features and radiological findings leading to a change in recommendations (P < .0001). Administration of analgesia at the time of follow-up was associated with radiographic abnormalities (P = .017) and change in postoperative plans (P = .0007).

CONCLUSION

Radiographic examination findings at follow-up did not influence the management of most dogs with uncomplicated TPLO.

CLINICAL SIGNIFICANCE

Radiographic examination findings are unlikely to influence the treatment of dogs that seem to be recovering uneventfully from an uncomplicated TPLO without concerns from clients, analgesia, or abnormal findings on thorough orthopedic examination by a surgical specialist, at the time of the planned clinical re-evaluation.