What not to do – paediatrics
But Doctors bury their mistakes
28 July 2014
Dr Lee Hudson, consultant general paediatrician, discusses what has fallen out of favour in paediatric primary care
Do not use a bag collection route to obtain a urine specimen when investigating
UTI in an infant.
These increase the risk of contamination and evidence shows that bags may
sterilise truly infected urine samples.1 Clean-catch specimens are recommended in the community.
A diagnosis of a UTI should not be made following a positive dipstick test for
leucocyte esterase alone.
Leucocytes are frequently found in urine when a child has infection elsewhere.
The finding of nitrites (with or without leucocyte esterase) on an appropriately
collected, fresh specimen in children is suggestive of a UTI. Care must be taken in
reaching a diagnosis, especially in infants, as false diagnosis leads to
inappropriate antibiotics which may partially mask another focus, such as
meningitis. Ideally, UTIs should be diagnosed by confirmed microbiological
evidence, particularly in children under three, to guide treatment and any further
investigations (for unusual organisms). Following clinically successful treatment
of a UTI in a child – defined as adherence to treatment and resolution of
symptoms – a repeat specimen is not indicated.2
Do not use antipyretic agents with the sole aim of reducing body temperature in
children with fever.
Despite widespread use, there is surprisingly little evidence for the efficacy of
antipyretics in the treatment of fever in children. Giving medications to children
can be challenging and potentially more distressing than the fever itself,
especially when oral intake is reduced. Most parents and health professionals feel
comforted by the child’s improved appearance and function when fevers subside,
yet this will frequently occur without administration of antipyretics. Reassurance
and assessment for red flags (such as rashes or irritability, especially in young
infants and unvaccinated children), with appropriate safety netting, should be the
Avoid combining antipyretics simultaneously in children with fever.
If medications are to be given, there is insufficient evidence suggesting that
simultaneous ibuprofen and paracetamol is better than individual therapy, in
particular in improving discomfort.4
There is no evidence that antipyretics prevent febrile seizures.
Although many parents may find the use of antipyretics reassuring, a number of
studies have failed to demonstrate a role for them in the prevention of febrile
convulsions for either primary or recurrent seizures.5
Do not perform tepid sponging to reduce fever.
Care must be taken with physical methods to reduce fever. Tepid sponging should
not be performed as it tends to reduce peripheral temperature, leads to a rise in
core temperature and increases discomfort.3 Over-exposure by under-dressing
children can lead to similar problems. The best advice is to not under-dress or
over-wrap children with fevers.
Do not automatically empirically treat a UTI with trimethoprim.
The most common pathogenic organism in UTI in children is Escherichia coli.
Increasing levels of resistance of E.coli to trimethoprim across the UK6 means
that GPs should seek local microbiological guidance for empirical therapy. A
single, simple UTI is relatively common in childhood, and prophylactic antibiotics
are not indicated as risk of recurrence is low and treatment contributes to
bacterial resistance.2 Children who have recurrent UTIs (more than three simple
UTIs) should be considered for prophylaxis, and generally referred to a
paediatrician for consideration of imaging.2
Local or systemic decongestants and antihistamines should not be prescribed or
advised for otitis media with effusion.
A Cochrane review showed these medications caused significant side-effects and
do not alter disease outcome.7 Where families have used over-the-counter
remedies by the time of consultation, the advice should be to stop them unless
there is significant benefit.
Antibiotics should not be routinely prescribed for otitis media with effusion.
Another Cochrane review showed that long-term courses were needed to see
benefits from antibiotics, which were offset by side-effects and potential
Tricyclic medication (such as imipramine) should not be used as a first-line
treatment for bed-wetting.
Side-effects, although rare, can be significant (mostly relating to the
cardiovascular system) and a physician with expertise in enuresis should
supervise their use. Initial management should begin with advice on toileting and
fluid intake.9 Second-line treatment depends on whether a family and child’s
goals are short-term (drug therapy) or longer-term (where alarms will be more
effective). Goals frequently correspond with a child’s age and the impact of bed
wetting on function (such as sleepovers). Strategies using the interruption of
urinary stream, or encouraging infrequent passing of urine during the day to
increase bladder capacity, should not be recommended as the value is unproven
compared with the treatments mentioned above.9
Dr Lee Hudson is a consultant general paediatrician at Great Ormond Street
Etoubleau C, Reveret M, Brouet D et al.
UTI in children. London: NICE; 2007
Feverish illness in children. London: NICE; 2013
Wong T, Stang AS, Ganshorn H et al.
Combined and alternating paracetamol and ibuprofen therapy for febrile children. Cochrane Database Syst Rev, 2013; CD009572
Strengell T, Uhari M, Tarkka R et al.
Antipyretic agents for preventing recurrences of febrile seizures: randomized controlled trial. Arch Paediatr Adolesc Med 2009;163:799.
Chakupurakal R, Ahmed M, Sobithadevi DN et al.
Urinary tract pathogens and resistance pattern. J Clin Pathol 2010;63:652-4
Griffin G, Flynn CA.
Antihistamines and/or decongestants for otitis media with effusion (OME) in children. Cochrane Database Syst Rev, 2011; 7:CD003423
Van Zon A, van der Heijden GJ, van Dongen TM et al.
Antibiotics for otitis media with effusion in children. Cochrane Database Syst Rev, 2012; 9:CD009163
Nocturnal enuresis – the management of bed wetting in children. London: NICE; 2010
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