Choosing Wisely: When to Question Tests, Procedures or Treatment for Pediatric Surgery

The American Academy of Pediatrics (AAP), as part of the national Choosing Wisely® campaign, has developed a new list of medical tests, treatments and procedures that may be over-utilized and not necessary in many cases -- this time focusing on pediatric surgery.

The National Choosing Wisely Program, an evidence-based resource, provides five situations in which physicians and patients should pause and discuss whether the routine medical tests, treatments and procedures are necessary. There are better options, for instance, than routinely relying on whole-body computed tomographic scans (CT scans) for pediatric patients with traumatic injuries.

“The CT scan is a common and helpful tool in diagnosing injuries, but it comes with other risks that should be taken into consideration,” said Alan Ladd, MD, FAAP, who, along with David H. Rothstein, MD MS FAAP, spearheaded the selection process for Choosing Wisely’s list on pediatric surgery. “Parents should be encouraged to ask questions about any tests, medications or procedures so they can understand the benefits and risks.”

In some cases, parents request care that is not supported by the evidence. For instance, a parent of a toddler with an umbilical hernia may assume that surgery is necessary sooner rather than later. Yet the evidence shows that waiting until the child is 4-5 years old is the right thing to do for most children.

The AAP Section on Surgery’s Subcommittee on Education and Delivery of Surgical Care selected the top five topics for Choosing Wisely based on a review of the literature and expert opinion, which was subsequently reviewed by dozens of other specialists from other areas of pediatric medicine.

The five procedures are:

• Avoid the routine use of whole-body computed tomography (CT) scanning in pediatric trauma patients.
• Avoid using CT scans as the first method of evaluating suspected appendicitis; ultrasound should be the preferred initial test performed.
• Avoid performing anti-reflux operations during gastrostomy insertion in most children who are otherwise growing and thriving with gastric feedings.
• Avoid referring most children with umbilical hernias to a pediatric surgeon until around age 4-5 years.
• Reduce post-operative use of opioids by administering acetaminophen and/or non-steroidal anti-inflammatory medications.

The Choosing Wisely list for pediatric surgery can be found here: http://www.choosingwisely.org/societies/american-academy-of-pediatrics-section-on-surgery/

Choosing Wisely® is an initiative of the ABIM Foundation, which seeks to promote conversations between clinicians and patients in choosing care that is supported by evidence; does not duplicate other tests or procedures already received; is free from harm; and truly necessary. At least 80 medical specialty societies have published more than 500 recommendations of overused tests and treatments as a result of the initiative, launched in 2012.

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The American Academy of Pediatrics is an organization of 67,000 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.