Guidelines to help avoid unnecessary and potentially harmful tests and treatments
Advances in technology have spurred better outcomes for infants treated in neonatal intensive care units, but parents and physicians need to work together to avoid unnecessary and potentially harmful tests and treatments, according to new Choosing Wisely® recommendations developed by neonatologists at Beth Israel Deaconess Medical Center (BIDMC) and published online in Pediatrics, the scientific journal of the American Academy of Pediatrics (AAP).
"Infant mortality has dropped dramatically over the past 50 years, with almost all of the impact resulting from care to the mother prior to a high-risk birth or to intensive care provided to the baby afterward," said DeWayne Pursley, MD, MPH, FAAP, Chair of the Department of Neonatology and Pediatrician-in-Chief at BIDMC and senior author of the recommendations published in the August issue of Pediatrics. "Advanced tests and treatments have been important factors in that drop, but we need to use them more wisely."
Pursley said the recommendations are based on the premise there are a number of low-value tests and treatments used in newborn care around the country: "Eliminating routine use of these tests and treatments and focusing only on cases where they are justified could both increase care quality and reduce unnecessary costs."
To that end, Pursley and his colleagues set out to identify opportunities to improve care of newborns through AAP's newest list of recommendations in the Choosing Wisely® campaign, an initiative of the ABIM Foundation. The Top 5 recommendations focus on the routine use of antibiotics and anti-reflux medications as well as unnecessary x-rays, MRIs and overnight lung activity monitoring.
"There is insufficient evidence that these tests and treatments lead to healthier babies," said Pursley, adding that overuse of certain medications and treatments could, in fact, be harmful to infants.
The AAP Section on Perinatal Pediatrics conducted a national survey of pediatricians, neonatologists and pediatric medical and surgical specialists who were asked to consider a range of tests and treatments conducted on high- and low-risk newborns. Respondents provided examples that, in their opinion, lacked evidence of effectiveness, were associated with evidence of ineffectiveness, or unnecessarily used staff or material resources. More than 1,000 respondents offered 2,870 suggestions. An expert panel led by Pursley reviewed and analyzed the responses to identify the Top 5:
- Avoid routine use of anti-reflux medications for treatment of symptomatic gastroesophageal reflux disease (GERD) or for treatment of apnea and desaturation in preterm infants.
Gastroesophageal reflux is normal in infants, but there is minimal evidence that reflux causes interruptions in breathing (apnea) and low blood oxygen concentration (desaturation). In fact, several studies show that the use of some anti-reflux medications may have adverse physiologic effects, including bowel tissue death, infection, hemorrhage or patient death.
- Avoid use of antibiotics for longer than 48 hours in absence of bacterial infection.
There is not enough evidence to support antibiotic treatment for more than 48 hours to rule out bacterial infection in preterm infants who do not show symptoms. Prolonged antibiotic use may be associated with bowel tissue death and patient death in extremely low-birth weight infants.
- Avoid routine use of pneumograms for pre-discharge assessment of ongoing and/or prolonged apnea of prematurity.
Cardio-respiratory events are common in both term and pre-term infants. Pneumograms - recordings of breathing effort, heart rate, oxygen level and air flow from the lungs during sleep - are often prescribed as part of pre-discharge assessments of ongoing or prolonged sleep apnea of premature babies. Although there may be a role for pneumograms in cases in which the cause of such events is in doubt, the authors note that their routine use to monitor respiratory function have not been shown to reduce acute, life-threatening events or mortality.
- Avoid routine daily chest radiographs without an indication for intubated infants.
The authors note that intermittent chest x-rays may identify unexpected findings, but "there is no evidence documenting the effectiveness of daily chest x-rays in reducing adverse outcomes for intubated infants. Further, this practice is associated with increased radiation exposure."
- Avoid routine screening term-equivalent or discharge brain MRIs in pre-term infants.
The authors advise against the routine use of brain magnetic resonance imaging (MRI) in pre-term infants to identify signs of potential long-term neurodevelopmental issues. Pursley notes that normal MRI brain scans of high-risk babies suggest a low-risk of neurodevelopmental problems. However, an abnormal scan only suggests a risk of problems in 50 percent of high-risk babies.
Significantly, the recommendations for the continued testing of these infants rarely change as a result of the study, and some parents simply choose not to have their babies tested when the results may not offer a definitive prognosis.
"There is a fair amount of variation in neonatal clinical practice around the country," Pursley said. "This Top 5 list focuses on five specific opportunities to provide better, higher-value neonatal care, but other low-value tests and treatments are used routinely. We hope that hospitals and newborn care providers will use this list as a starting point in efforts to improve care quality and avoid unnecessary tests and treatments."
"In general, newborn care providers do a good job communicating with families about the care of their babies, but there is always room to do better," added first author Timmy Ho, MD, FAAP, a neonatologist at BIDMC. Our hope is that caregivers and families will use this list as a starting point in discussions about tests and treatments and whether or not they add value to a baby's care."