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Paediatrics – Only Negative Medical Ways ?

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

 

Investigation

 

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.

2

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

 

Treatment

 

Do not use antipyretic agents with the sole aim of reducing body temperature in

 

children with fever.

3

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

 

first-line approach.

 

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

 

antibiotic resistance.8

 

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

 

Hospital

 

References

Etoubleau C, Reveret M, Brouet D et al.

Moving from bag to catheter for urine collection in non-toilet-trained children suspected of having urinary tract infection: a paired comparison of urine cultures. J Paediatr 2009;154:803-6

NICE. CG54:

UTI in children. London: NICE; 2007

NICE. CG160:

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

NICE. CG111:

Nocturnal enuresis – the management of bed wetting in children. London: NICE; 2010

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