The Peds NP: Pearls of Pediatric Evidence-Based Practice

Plant-based Milks (S8 Ep. 57)

Got milk? The answer is complicated.  While plant-based beverages are accused of posing as animal by-product imposters, the FDA claims that consumers know the difference.  But most parents don't recognize that plant-based milks lack the same micro and macronutrient profile as cow's milk or soy milk.  This leaves pediatric providers with the very important job of assessing nutrition and guiding parents on what beverages their infants and toddlers should be drinking.  

Respiratory Virus Testing (S8 Ep. 56)

Just because you can, doesn't mean you should.  In the depths of respiratory virus season, providers often order unnecessary tests that won't alter the course of treatment for the child presenting with upper respiratory symptoms.  This episode covers 5 common pathogens, the indications to test a child presenting with symptoms, and how to talk to families requesting tests.  

References:

Centers for Disease Control and Prevention (2022). Influenza antiviral medications: Summary for clinicians. Retrieved from https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm#Table1

Frost, H. M., & Hersh, A. L. (2022). Rethinking Our Approach to Management of Acute Otitis Media. JAMA pediatrics, 176(5), 439–440. https://doi.org/10.1001/jamapediatrics.2021.6575

Giovanni Piedimonte, Miriam K. Perez; Respiratory Syncytial Virus Infection and Bronchiolitis. Pediatr Rev December 2014; 35 (12): 519–530. https://doi.org/10.1542/pir.35-12-519

Liu, J. W., Lin, S. H., Wang, L. C., Chiu, H. Y., & Lee, J. A. (2021). Comparison of Antiviral Agents for Seasonal Influenza Outcomes in Healthy Adults and Children: A Systematic Review and Network Meta-analysis. JAMA network open, 4(8), e2119151. https://doi.org/10.1001/jamanetworkopen.2021.19151

Parikh R, Mathai A, Parikh S, Chandra Sekhar G, Thomas R. Understanding and using sensitivity, specificity and predictive values. Indian J Ophthalmol. 2008 Jan-Feb;56(1):45-50. doi: 10.4103/0301-4738.37595. PMID: 18158403; PMCID: PMC2636062.

Spencer D. Johnson, Jennifer S. Harthan, Tammy Than, Mary K. Migneco, Ellen Shorter, Meredith M. Whiteside, Christina E. Morettin, Christian K. Olson, Crystal A. Rosemann, Mathew S. Margolis, Leonard W. Haertter, Julia B. Huecker, Bojana Rodic-Polic, Richard S. Buller, Gregory A. Storch, Mae O. Gordon, Andrew T. E. Hartwick; Predictive Accuracy and Densitometric Analysis of Point-of-Care Immunoassay for Adenoviral Conjunctivitis. Trans. Vis. Sci. Tech. 2021;10(9):30. doi: https://doi.org/10.1167/tvst.10.9.30.

Stanford T. Shulman, Alan L. Bisno, Herbert W. Clegg, Michael A. Gerber, Edward L. Kaplan, Grace Lee, Judith M. Martin, Chris Van Beneden, Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 55, Issue 10, 15 November 2012, Pages e86–e102, https://doi.org/10.1093/cid/cis629

Stanford Medicine. (2022). Common cold in children. Retrieved from https://www.stanfordchildrens.org/en/topic/default?id=upper-respiratory-infection-uri-or-common-cold-90-P02966

Walsh, P. S., Schnadower, D., Zhang, Y., Ramgopal, S., Shah, S. S., & Wilson, P. M. (2022). Association of Early Oseltamivir With Improved Outcomes in Hospitalized Children With Influenza, 2007-2020. JAMA pediatrics, 176(11), e223261. https://doi.org/10.1001/jamapediatrics.2022.3261

World Health Organization. (2019). WHO launches new global influenza strategy. https://www.who.int/news-room/detail/11-03-2019-who-launches-new-global-influenza-strategy

AOM Microbiology Update (S8 Ep. 55)

Not all bacterial infections need an antibiotic.  It may sound hard to believe, but if we all followed the AAP guidelines on the management of otitis media in children and actually used a watch-and-wait approach in appropriate patients, upwards of 75% of the antibiotics prescribed for otitis media could be avoided.  Why? Because the microbiology of AOM has changed, but our prescribing practices haven't.  This episode is a great guideline refresher and microbiology update while learning how to talk parents into partnership on watchful waiting.   

References:

American Academy of Pediatrics. (2019). Chapter quality network improving antibiotic prescribing for children: Change package. Retrieved from https://downloads.aap.org/DOCCSA/CQN%20ABX%20Change%20Package%20Final%20October%202019.pdf

Frost, H. M., & Hersh, A. L. (2022). Rethinking Our Approach to Management of Acute Otitis Media. JAMA pediatrics, 176(5), 439–440. https://doi.org/10.1001/jamapediatrics.2021.6575

Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., Joffe, M. D., Miller, D. T., Rosenfeld, R. M., Sevilla, X. D., Schwartz, R. H., Thomas, P. A., & Tunkel, D. E. (2013). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964–e999. https://doi.org/10.1542/peds.2012-3488

Sanchez, G.V., Fleming-Dutra, K.E., Roberts, R.M., & Hicks, L.A. (2016). Core elements of outpatient antibiotic stewardship. MMRW Recomm Rep., 65(6), p. 1-12. doi: 10.15585/mmrw.rr.6506a1

Smolinski, N. E., Antonelli, P. J., & Winterstein, A. G. (2022). Watchful Waiting for Acute Otitis Media. Pediatrics, 150(1), e2021055613. https://doi.org/10.1542/peds.2021-055613

Sun, D., McCarthy, T. J., & Liberman, D. B. (2017). Cost-Effectiveness of Watchful Waiting in Acute Otitis Media. Pediatrics, 139(4), e20163086. https://doi.org/10.1542/peds.2016-3086

Venekamp, R. P., Sanders, S. L., Glasziou, P. P., Del Mar, C. B., & Rovers, M. M. (2015). Antibiotics for acute otitis media in children. The Cochrane database of systematic reviews, 2015(6), CD000219. https://doi.org/10.1002/14651858.CD000219.pub4

Stop prescribing Benadryl™ (S8 Ep. 54)

If you've been looking for a New Year's Resolution to make a real difference in your practice, stop prescribing diphenhydramine.  Despite being a common over-the-counter medication, its potent anticholinergic side effects and sedation make it a poor choice for children.  Review the common misuses for the drug and practical, evidence-based alternatives to help get diphenhydramine out of your prescribing practice in 2023.  

References:

Bachur RG, Monuteaux MC, Neuman MI. A comparison of acute treatment regimens for migraine in the emergency department. Pediatrics 2015;135:232-238.

Brady, K.B. (2020). 'Benadryl challenge": What pediatricians need to know. AAP News. Retrieved from https://publications.aap.org/aapnews/news/6210/Benadryl-Challenge-What-pediatricians-need-to-know

Chehab, H., Fischer, P. R., & Christenson, J. C. (2021). Preparing Children for International Travel. Pediatrics in Review, 42(4), 189–202. https://doi.org/10.1542/pir.2018-0353

Ghossein N, Kang M, Lakhkar AD. Anticholinergic Medications. [Updated 2022 May 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555893/

Green, J.L., Wang, G.S., Reynolds, K.M., Banner, W., Bond, G.R., Kauffman, R.E., Palmer, R.B., Paul, I.M., Dart, R.C. (2017). Safety profile of cough and cold medication use in pediatrics. Pediatrics, 139(6), e20163070. doi: 10.1542/peds.2016-3070

Guthrie, C.C., & Nathani, Y. (2019). Acute treatment of pediatric migraine. Pediatric Emergency Medicine Reports. Relias Media. Retrieved https://www.reliasmedia.com/articles/144150-acute-treatment-of-pediatric-migraine

Palmer, R. B., Reynolds, K. M., Banner, W., Bond, G. R., Kauffman, R. E., Paul, I. M., Green, J. L., & Dart, R. C. (2020). Adverse events associated with diphenhydramine in children, 2008-2015. Clinical toxicology (Philadelphia, Pa.), 58(2), 99–106. https://doi.org/10.1080/15563650.2019.1609683

Paul, I.M., Yoder, K.E., Crowell, K.R., Shaffer, M.L., McMillan, H.S., Carlson, L.C., Dilworth, D.A., Berlin, C.M. (2004). Effect of dextromethorphan, diphenhydramine, and placebo on nocturnal cough and sleep quality for coughing children and their parents. Pediatrics, 114(1), e85-e90. doi: 10.1542/peds.114.1.e85

Shaker, M. S., Wallace, D. V., Golden, D. B. K., Oppenheimer, J., Bernstein, J. A., Campbell, R. L., Dinakar, C., Ellis, A., Greenhawt, M., Khan, D. A., Lang, D. M., Lang, E. S., Lieberman, J. A., Portnoy, J., Rank, M. A., Stukus, D. R., Wang, J., Collaborators, Riblet, N., Bobrownicki, A. M. P., … Wang, J. (2020). Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. The Journal of allergy and clinical immunology, 145(4), 1082–1123. https://doi.org/10.1016/j.jaci.2020.01.017

Stern J, Pozun A. Pediatric Procedural Sedation. [Updated 2022 Sep 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572100/

Trottier ED, Bailey B, Lucas N, Lortie A. Prochlorperazine in children with migraine: A look at its effectiveness and rate of akathisia. Am J Emerg Med 2012;30:456-463

Case study: Adolescent female with foot burning (S7 Ep. 53)

In the last case study in our series on Cognitive Bias in Healthcare, attribution error (among others) of an adolescent female with foot burning reveals how two more best practices for avoiding cognitive bias can help providers think metacognitively.  Review all 8 best practices and start to implement them to reduce diagnostic error.

References:

Marshall, T.L., Rinke, M.L., Olson, A.P.J., Brady, P.W. (2022). Diagnostic error in pediatrics: A narrative review. Pediatrics, 149 (Supplement 3): e2020045948D. 10.1542/peds.2020-045948D

The Canadian Medical Protection Authority. Common cognitive biases: Influences on decision making. Good Practices Guide. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/human_factors/Cognitive_biases/common_cognitive_biases-e.html

Yale, S. C., Cohen, S. S., Kliegman, R. M., & Bordini, B. J. (2022). A pause in pediatrics: implementation of a pediatric diagnostic time-out. Diagnosis (Berlin, Germany), 9(3), 348–351. https://doi.org/10.1515/dx-2022-0010

Case study: Adolescent female with arm pain (S7 Ep. 52)

The next case study in our series on cognitive bias in healthcare follows an obese adolescent female with arm and neck pain who felt unheard during the 4 prior emergency room visits that week.  Listen as the differential diagnosis takes on a completely different angle and the pressure of making the diagnosis goes sky high!  We will unpack additional forms of cognitive bias and 2 more best practices for avoiding diagnostic error in the clinical setting.  

References:

Hulens, M., Rasschaert, R., Vansant, G., Stalmans, I., Bruyninckx, F., & Dankaerts, W. (2018). The link between idiopathic intracranial hypertension, fibromyalgia, and chronic fatigue syndrome: exploration of a shared pathophysiology. Journal of pain research, 11, 3129–3140. https://doi.org/10.2147/JPR.S186878

Mondragon J, Klovenski V. Pseudotumor Cerebri. [Updated 2022 Sep 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536924/

Norris, D., Clark, M. S., & Shipley, S. (2016). The Mental Status Examination. American family physician, 94(8), 635–641.

Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity reviews : an official journal of the International Association for the Study of Obesity, 16(4), 319–326. https://doi.org/10.1111/obr.12266

The Canadian Medical Protection Authority. Common cognitive biases: Influences on decision making. Good Practices Guide. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/human_factors/Cognitive_biases/common_cognitive_biases-e.html

Villines, Z. (2021). What to know about obesity discrimination in health care. Medical News Today. https://www.medicalnewstoday.com/articles/obesity-discrimination-in-healthcare

Case study: 4 month old with constipation (S7 Ep. 51)

In the first case study of our mini-series on Cognitive Bias in Health Care, we meet a 4 month old female referred to the emergency department for constipation.  Spoiler alert: We know it's not constipation... so we explore how her presentation and physical exam clash with the initial medical decision making.  Try to spot the cognitive bias and test yourself on building a differential diagnosis.  Lastly, we explore 4 best practice techniques to help you avoid bias in the first place.  

References

Abimanyi-Ochom, J., Bohingamu Mudiyanselage, S., Catchpool, M., Firipis, M., Wanni Arachchige Dona, S., & Watts, J. J. (2019). Strategies to reduce diagnostic errors: a systematic review. BMC medical informatics and decision making, 19(1), 174. https://doi.org/10.1186/s12911-019-0901-1

Benninga, M. A., Faure, C., Hyman, P. E., St James Roberts, I., Schechter, N. L., & Nurko, S. (2016). Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology, S0016-5085(16)00182-7. https://doi.org/10.1053/j.gastro.2016.02.016

Bolick, B.N., Reuter-Rice, K., Madden, M.A., & Severin, P.A. (2021). Pediatric Acute Care: A Guide for Interprofessional Practice (2nd ed). Elsevier.

Centers for Disease Control and Prevention. (2021). Botulism: Diagnosis and treatment. https://www.cdc.gov/botulism/testing-treatment.html

Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine; Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. Washington (DC): National Academies Press (US); 2015 Dec 29. 3, Overview of Diagnostic Error in Health Care. Available from: https://www.ncbi.nlm.nih.gov/books/NBK338594/

Ely, J. W., & Graber, M. A. (2015). Checklists to prevent diagnostic errors: a pilot randomized controlled trial. Diagnosis (Berlin, Germany), 2(3), 163–169. https://doi.org/10.1515/dx-2015-0008

Graber, M. L., Sorensen, A. V., Biswas, J., Modi, V., Wackett, A., Johnson, S., Lenfestey, N., Meyer, A. N., & Singh, H. (2014). Developing checklists to prevent diagnostic error in Emergency Room settings. Diagnosis (Berlin, Germany), 1(3), 223–231. https://doi.org/10.1515/dx-2014-0019

Marshall, T.L., Rinke, M.L., Olson, A.P.J., Brady, P.W. (2022). Diagnostic error in pediatrics: A narrative review. Pediatrics, 149 (Supplement 3): e2020045948D. 10.1542/peds.2020-045948D

O’Hagan, T., Fennell, J., Tan, K., Ding, D., & Thomas-Jones, I. (2019). Cognitive bias in the clinical decision making of doctors. Future Healthcare Journal, 6(1), s113.

Tabbers, M. M., DiLorenzo, C., Berger, M. Y., Faure, C., Langendam, M. W., Nurko, S., Staiano, A., Vandenplas, Y., Benninga, M. A., European Society for Pediatric Gastroenterology, Hepatology, and Nutrition, & North American Society for Pediatric Gastroenterology. (2014). Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of Pediatric Gastroenterology and Nutrition, 58(2), 258–274. https://doi.org/10.1097/MPG.0000000000000266

The Canadian Medical Protection Authority. Common cognitive biases: Influences on decision making. Good Practices Guide. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/human_factors/Cognitive_biases/common_cognitive_biases-e.html

Zabidi-Hussin Z. A. (2016). Practical way of creating differential diagnoses through an expanded VITAMINSABCDEK mnemonic. Advances in medical education and practice, 7, 247–248. https://doi.org/10.2147/AMEP.S106507

The context of bias (S7 Ep. 50)

There are many factors that contribute to the way we perceive and interpret information... and lots of ways that our brains skew our perspectives that can lead to cognitive bias.  The second episode in our Cognitive Bias in Healthcare mini-series discusses the features of information delivery that impact our decision-making and how our brains distort them to cause diagnostic error.  

References:

Arokszallasi, T., Balogh, E., Csiba, L., Fekete, I., Fekete, K., & Olah, L.. (2019). Acute alcohol intoxication may cause delay in stroke treatment – case reports. BMC Neurology, 19, 14. https://doi.org/10.1186/s12883-019-1241-6

Berkwitt, A., & Grossman, M. (2014). Cognitive bias in inpatient pediatrics. Hospital pediatrics, 4(3), 190–193. https://doi.org/10.1542/hpeds.2014-0002

Clark, B. W., Derakhshan, A., & Desai, S. V. (2018). Diagnostic Errors and the Bedside Clinical Examination. The Medical clinics of North America, 102(3), 453–464. https://doi.org/10.1016/j.mcna.2017.12.007

Croskerry, P., Singhal, G., & Mamede, S. (2013). Cognitive debiasing 2: impediments to and strategies for change. BMJ quality & safety, 22 Suppl 2(Suppl 2), ii65–ii72. https://doi.org/10.1136/bmjqs-2012-001713

Galvani, A. P., Parpia, A. S., Foster, E. M., Singer, B. H., & Fitzpatrick, M. C. (2020). Improving the prognosis of health care in the USA. Lancet (London, England), 395(10223), 524–533. https://doi.org/10.1016/S0140-6736(19)33019-3

Mamede, S., Splinter, T.A.W., Gog, T., Rikers, R., & Schmidt, H.G. (2012). Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. BMJ Quality & Safety, 21, p. 295-300. doi:10.1136/bmjqs-2011-000518

Marshall, T.L., Rinke, M.L., Olson, A.P.J., Brady, P.W. (2022). Diagnostic error in pediatrics: A narrative review. Pediatrics, 149 (Supplement 3): e2020045948D. 10.1542/peds.2020-045948D

Cognitive Bias in Healthcare (S7 Ep. 49)

This episode is the first installment on a new mini series on cognitive bias in pediatric healthcare.  We begin by discussing what cognitive bias is, how it becomes diagnostic error, and the impact on healthcare in America.  Begin to think about how you think and explore the interesting ways our brains use mental shortcuts to arrive at an answer.

References:

Balogh, E. P., Miller, B. T., Ball, J. R., Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, & The National Academies of Sciences, Engineering, and Medicine (Eds.). (2015). Improving Diagnosis in Health Care. National Academies Press (US).

Berkwitt, A., & Grossman, M. (2014). Cognitive bias in inpatient pediatrics. Hospital pediatrics, 4(3), 190–193. https://doi.org/10.1542/hpeds.2014-0002

Bordini, B. J., Stephany, A., & Kliegman, R. (2017). Overcoming Diagnostic Errors in Medical Practice. The Journal of pediatrics, 185, 19–25.e1. https://doi.org/10.1016/j.jpeds.2017.02.065

Carberry, A. R., Hanson, K., Flannery, A., Fischer, M., Gehlbach, J., Diamond, C., & Wald, E. R. (2018). Diagnostic Error in Pediatric Cancer. Clinical pediatrics, 57(1), 11–18. https://doi.org/10.1177/0009922816687325

CRICO. (2014). Malpractice risks in the diagnostic process. Retrieved from

https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-the-Diagnostic-Process

Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US).

Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err is Human: Building a Safer Health System. National Academies Press (US).

National Geographic Kids. (No date). 10 facts about great white sharks! Retrieved from https://www.natgeokids.com/uk/discover/animals/sea-life/great-white-sharks/

Royce, C.S., Hayes, M.M., & Schwartzstein, R.M. (2019). Teaching critical thinking: A case for instruction in cogntitive biases to reduce diagnostic errors and improve patient safety.

Review of the CDC’s Developmental Surveillance Checklist (S6 Ep. 48)

Developmental surveillance and screening work best to identify delays when used together.  The AAP and CDC teamed up to create a standardized developmental milestone checklist in order to improve the longitudinal monitoring of pediatric milestones at home by caregivers.  This episode reviews their publication and discusses what went into the checklist, its strengths, and areas for further research.   View the CDC's website for the full checklist and read the article here.

References:

CDC. (2022). Developmental surveillance resources for healthcare providers. Retrieved from https://www.cdc.gov/ncbddd/actearly/hcp/index.html.

Zubler JM, Wiggins LD, Macias MM, et al. Evidence-InformedMilestones for Developmental Surveillance Tools. Pediatrics. 2022;149(3):e2021052138