American Academy of Pediatrics Releases New List of Medical Procedures Doctors and Patients Should Think Twice About

As part of the Choosing Wisely campaign, the AAP focuses on endocrine-related tests for short height and early puberty. Tests are not always necessary for otherwise healthy children.

Elk Grove Village, IL—Five tests commonly ordered for signs of early puberty, short height and other endocrine-related concerns in children and teens may not always be needed, especially if a child is otherwise healthy, according to the American Academy of Pediatrics.

As part of the ongoing Choosing Wisely campaign, the AAP released a new list of tests and procedures that should prompt careful discussion between parents and physicians. The list, compiled by the AAP Section on Endocrinology, includes several tests commonly ordered when a parent is concerned a child is too short, entering puberty too early, overweight, or has an enlarged thyroid.

The list is available at http://www.choosingwisely.org/societies/american-academy-of-pediatrics-section-on-endocrinology/.

Many times, these children are healthy, and additional testing would expose them to unnecessary risks for few benefits, said Paul Kaplowitz, MD, PhD, FAAP, past chairperson of the AAP Section on Endocrinology.

"As a pediatric endocrinologist, I've counseled many parents who are worried about their children's growth," Dr. Kaplowitz said. "There is a wide range of what is 'normal' for child growth and development. If a child is otherwise healthy and is following their own curve, what the parents often need is reassurance that their child is fine, and not a lot of testing."

The new Choosing Wisely list supports evidence-based strategies to choose tests when appropriate and to avoid them when they are unlikely to benefit the child, or possibly cause harm. The "Five Things Physicians and Patients Should Question" list of tests to question includes:

1. Hormone tests for children with pubic hair and/or body odor but no other signs of puberty. The AAP advises against these tests when development of pubic or axillary hair and/or underarm odor aren't accompanied by other physical signs of sexual maturation such as breast development in girls, or rapid growth.
2. Screening tests to detect chronic disease or endocrine disorders in healthy children growing at or above the 3rd percentile with a normal growth rate. Even in children below the 3rd percentile for height with a normal history and physical exam, these tests only reveal new, underlying conditions about 1 percent of the time. In patients with significantly short stature or who are well below their genetic potential based on the height of their parents, the AAP advises tiered or sequential screening.
3. Routine vitamin D screening in otherwise healthy children, including those who are overweight or obese. Vitamin D deficiency screening is only advised for patients with disorders linked with low bone mass, such as rickets, or a history of repeated, low-trauma bone fractures. Vitamin D supplements are a cost-effective option for children with insufficient dietary intake or for obese children, who often have low vitamin D levels.
4. Thyroid function and/or insulin levels tests in children with obesity. Testing thyroid function in obese children should be considered only if the growth rate is below what it should be, or if there are other signs of a thyroid problem. Measuring insulin levels in obese children does not affect how doctors treat them.
5. Routine thyroid ultrasounds in children who have simple goiters or autoimmune thyroiditis. The AAP advises limiting this test to children who have significantly enlarged thyroid glands, swelling on just one side of the neck, or nodules that can be felt through the skin during a physical exam. Overuse of ultrasonography can cause needless anxiety for patients and parents, waste families' time and health care dollars.

"This new Choosing Wisely list will enhance discussions physicians and families have about issues in growth and development that often come up, and help craft the best treatment plans," Dr. Kaplowitz said.

Choosing Wisely is an initiative of the ABIM Foundation and partner organizations throughout the field of medicine. This is AAP's third Choosing Wisely list, developed after months of careful consideration and review and using the most current evidence about management and treatment options. The full list gives more detail as to the reasons for taking a closer look at each test or treatment, and cites evidence related to each recommendation.

To date, 125 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the conversations about appropriate care. With the release of these new lists, the campaign will have covered more than 510 recommendations for tests and procedures overused and inappropriate, and that physicians and patients should discuss. The campaign also continues to reach millions of consumers nationwide through consumer and advocacy partners led by Consumer Reports—the world's largest independent product-testing organization—which has worked with the ABIM Foundation to distribute patient-friendly resources for consumers and physicians to engage in these important conversations.

To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit www.ChoosingWisely.org.

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The American Academy of Pediatrics is an organization of 66,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults.