There are ample data in adult medicine than up to a third of the treatments and interventions we do in adults are useless at best, maybe harmful. Nobody knows if a similar percentage applies to children, but it is certainly true we do too many tests on kids in the hospital. I have to say that intensivists like me are frequent offenders with all the “routine” blood tests and chest x-rays we do. It is true intensive care requires more intensive testing, but every time I order a test these days I’m much more aware of these questions when I do so than I was in the past: Do I really need it? What will I do differently depending upon the test result? Now a new initiative from the professional organization of pediatric hospital doctors addresses this problem directly. It’s called Choosing Wisely. It’s patterned after a similar program by pediatric radiologists aimed at reducing radiation exposure, the Image Gently program.
The program recommendations starts small with 5 simple, concrete guidelines. All of these have been or are common practices of dubious or no benefit.
- Do not order chest x-rays on children with straightforward asthma or bronchiolitis.
- Do not use steroids in children less than 2 years of age with pneumonia
- Do not use bronchodilators (like albuterol) in children with bronchiolitis
- Do not routinely treat gastro-esophageal reflux in infants with acid suppression therapy (like Zantac or Prilosec)
- Do not use a pulse oximeter machine on children who are not receiving oxygen therapy. (This is a device that goes on a finger or a toe and measures oxygen in the blood continuously.)
These are all very sensible guidelines, but they’re only a beginning. The idea is not to forbid doctors from doing these things, but rather to make us think twice about ordering them to make sure they make sense for a particular patient. We don’t want to add cost, and certainly not risk, without adding any benefit.
I’ve been doing this blog for three years, and by far the post that has provoked the most interest is this one, about the safety of x-rays. The comments, now at 102, keep steadily coming. Google tells me that the most common search string that brings folks here is some variant of the question: “how safe are x-rays?” Recent studies, such as this one, have highlighted the issue of CT scans.
The important thing to understand is that nobody wants to stop doing x-rays and CT scans. The latter in particular represent a quantum leap in our diagnostic ability, and appropriate x-ray studies improve and even save children’s lives. What we want is to strike a balance between doing too few and too many. The question always to consider is this: what is the risk of doing the x-ray or CT (still very, very tiny) versus the risk of not doing the study, of not getting the information the study provides. If the study is needed to rule out the possibility of a serious condition, then the risk/benefit calculation virtually always favors doing the test.
There is another consideration, one highlighted recently by the Alliance for Radiation Safety in Pediatric Imaging, an initiative led by pediatric radiologists — the Image Gently initiative. The concept is simple: use only as much radiation as you need to get a good picture. In the past, CT scanners in particular often used radiation doses more appropriate for adults than children. Using that dose causes risk without adding benefit.
If my child needed a CT scan, I would ask the doctor to lay out the risk/benefit ratio — the risk of doing versus not doing the scan. If the scan is needed, I’d then ask if the radiologist will use the minimum dose required to get a good picture.
This site, from the International Atomic Energy Agency, has lots of useful information about protecting patients from unnecessary radiation.
Here’s a useful short post by a pediatric radiologist about all this.