I really want you to trust your child’s doctor. I really want them to trust you, too. Partnership is key to any relationship. Recently an article was published in the Archives of Internal Medicine entitled The “Top 5″ Lists in Primary Care. It sounded more like a blog post than an article. In media summaries, reporters wrote about less being more. Not surprisingly, it was right up my alley. Like I’ve said many times before, in medicine, less is often more. Partnering with your child’s doctor is essential in assuring that when nothing needs to happen, nothing does.
This list is a reminder for us all.
The group authoring the article is part of the “The Good Stewardship Working Group” and represents 22,000 physicians for the National Physicians Alliance. Their intentions: to find 5 things “not-to-do” in primary care. For pediatrics, the committee used evidence (Cochrane reviews, AAP/AAFP Guidelines, The FDA, NAEPP), experience in the office, and field testers (pediatricians) to generate a list of what to avoid/what not to do, to avoid harm. The goal is to improve health, reduce burdens both financially and physically, and ultimately to empower patients, parents, and pediatricians to avoid unnecessary testing and intervention. I’m sharing them here because good care is partnered care. Being a strong, informed parent is likely the best asset your child will ever have in a health system. Parents need to know this list. If I could tattoo it on your arm, I would. You’re the strongest and most motivated person to advocate for your child. You’re also the most likely to help avoid unnecessary and dangerous intervention alongside the doctor or nurse caring for your child. The “don’t” list according to this group:
- No Antibiotics For Sore Throat Unless Child Tests Positive For Strep: Seems like a no-brainer, but it’s not. The committee asserts that most pharyngitis (throat infections) are caused by viruses, so antibiotics do no good. A “rapid strep test” is usually done in under 15 minutes in the office (the throat swab) and is over 95% correct. When it’s negative, there is no need for antibiotics. Yet research has found that patients are given antibiotics more than 1/2 the time! Without any fever, without enlarged lymph nodes, without gooey tonsils, and when a cough is present, it’s far more likely that a virus is causing the sore throat. In that case, antibiotics only cause harm like setting children up for antibiotic resistance, diarrhea, stomach upset, increased medical visits, and ultimately increased cost to all of us. Less is more. Make sure your child has the dreaded throat swab before giving them antibiotics.
- No Head CT Or Diagnostic Images For Minor Head Injuries Without Loss Of Consciousness Or Other Risk Factors: Head CT after a child falls on their head is often not needed. Getting x-rays and CT scans of the head poses a risk for children, including an increased risk of cancer (the article cites as high as 1 case in every 1400 infants exposed to cranial[head] CT). Remember this blog post on the 5 things you can do to reduce radiation exposure for your child? If you child isn’t dizzy, doesn’t have external signs of injury (a huge goose egg), no changes in their nerves or neurologic function, and didn’t have a huge fall (fall from 3 ft or more, more than 5 stairs, or a bicycle-related injury, etc), or is under 2 years of age, it’s unlikely that a CT scan of their head is necessary. Getting CT scans and x-rays in low risk patients (those without above symptoms) rarely detects abnormalities that need surgery. Ensure your child needs an x-ray or CT after a fall by talking with the doctor about risks. Refer to Image Gently for more information and ways to communicate with the doctor.
- Don’t Refer Patients To Specialists Early in the Course of the Problem With Ear Infections: Most cases of ear infections resolve on their own in a matter or weeks to months without any significant consequences. Early referral to a surgeon for ear tubes is likely not in your child’s best interest unless they have underlying craniofacial abnormalities, neurologic problems, significant language delay, learning problems, or structural abnormalities of the ear/ear drum. Most pediatricians I know won’t refer a healthy child with ear infections to a specialist unless they have had 6 ear infections in one season or they are unable to clear an ear infection after a number of months. Wait, watch, and support. If your worry continues, talk with the pediatrician.
- Don’t Use Cough and Cold Medicines: There is little science that over-the-counter (OTC) cough and cold medication reduce cough, runny nose, or ever shorten the duration of the cold. Repeatedly research finds that the medications cause more harm than good, including consequences as terrible as death. Since OTC cough and cold medications were pulled off the market in 2007, rates of ER visits are down. This article reports that despite warnings and withdrawal from the market, over 10% of children use a cough and cold medicine every single week! Don’t do it. Less is more.
- Don’t Forget To Use Inhaled Corticosteroids To Control Asthma Appropriately: This is one on the list that encourages an act of intervention to prevent long-standing complications. Research supports the use of daily inhalers with corticosteroids to help control persistent asthma symptoms in children with chronic wheezing. If your child has wheezed more than 4 times in the last 6 months or has needed oral medications (corticosteroids) for wheezing twice in a 6 month time period, your child should be on a daily inhaler to prevent asthma symptoms. Getting at-risk children on these medications will reduce ER visits, hospital admissions, and suffering. Inhaled corticosteroids are well tolerated, easy to use, low risk, and can reduce medical visits and complications. Ask your pediatrician about daily prevention if you believe your child is a persistent wheezer. We use these medications from infancy all the way through adulthood to avoid asthma attacks.
How do those sound? You headed to the tattoo parlor? Are these sensible to you? Is it hard to talk about this with your child’s doctor or nurse? Have you advocated for non-intervention before?