Q&A: Most overused procedures in pediatrics

Key takeaways:

• Researchers examined studies on pediatric medical overuse.
• Ear tube placement and tonsillectomy are among the most commonly overused interventions.

Pediatrics published a review of important areas of pediatric care that may be wasteful or harmful to children.

The authors examined 201 published articles pertaining to pediatric medical overuse.

Nathan M. Money, DO, an assistant professor of pediatrics in the division of inpatient medicine at the University of Utah School of Medicine, co-wrote the review. We spoke with Money about its major themes and some commonly overused procedures.

Healio: What prompted this review?

Money: Unnecessary health care comprises a substantial amount of waste in our country, even among providers who are caring for children. We perform these reviews every 2 years now, to highlight recently published literature that describes important areas of overuse. We do this so pediatric providers can be aware of these areas and also hopefully avoid unnecessary care that might be providing more harm than good to our patients.

Healio: What major themes did the review uncover?

Money: There were three major themes that we came up with from the 10 articles that we chose. The first one was articles that encouraged providers to question routine practices that may be habit driven rather than evidence based. For example, one article described routine temperature measurement at well-child visits, which is something that's nearly universally done at pediatric clinics but without evidence that really supports that there is benefit from this practice. This study highlighted the potential harm of routine temperature measurements in well-appearing children, including delayed vaccinations and excess antibiotic prescriptions.

Another theme involved the indications of common pediatric surgeries like ear tubes and gastrostomy tube placement, which hopefully should encourage providers to exercise prudence when considering referring a child for seemingly routine surgeries.

The last theme was raising awareness for adverse effects of commonly overused treatments like acid suppression in infants with reflux, or over-the-counter cough and cold medication use in children.

Healio: What are some commonly overused procedures, and what are the adverse effects from using them too much?

Money: The two that come to mind most readily are ear tube placement and tonsillectomy. These procedures are so commonly performed that even rare adverse events for these procedures become relevant because of the sheer volume of procedures that are performed each year. They certainly have indications for their use and benefit many children. However, there are data out there, particularly for tonsillectomy, that show that these procedures are overused.

Both of these procedures carry risk of complications, both during the surgery and also in the time following surgery. For example, the article we highlighted in our review describes rates of deaths among children that are undergoing tonsillectomy, which although is a small percentage, becomes significant when you consider how many children undergo tonsillectomies each year. Additionally, children who undergo tonsillectomy are occasionally hospitalized afterward for complications due to pain. Some of them have difficulty with drinking and need IV hydration, and others have life-threatening bleeds in the days following the surgery.

These potential adverse outcomes for very common surgeries should make those of us who are referring for these procedures think very closely about whether the procedure will definitively benefit the child.

Healio: What would you like providers and pediatricians to take away from this?

Money: The main message that we hope to convey to the readers is that no matter how benign certain medical interventions may seem, everything we do as providers has a potential for downstream consequences, and sometimes these consequences might outweigh the potential benefit that we were trying to provide to our patients.

As providers, it's our responsibility to be aware of the evidence-based indications for the treatments we provide. But to take it a step further, we should be well equipped to discuss the likelihood and magnitude of both the benefits and also the harms of the treatments that we are recommending to our patients.

References:

Money NM, et al. Pediatrics. 2023;doi: 10.1542/peds.2023-062650.