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Experts Identify Top Five Unnecessary Tests, Treatments for Newborns

Surveyed physicians suggest 2,870 candidates

The use of unnecessary tests and treatments contributes to health care waste. The Choosing Wisely campaign –– launched by the ABIM Foundation in 2012 –– charges medical societies with identifying such items.

Timmy Ho, MD, and his colleagues at Beth Israel Deaconess Medical Center in Boston have identified five unnecessary tests and treatments in newborn medicine. An expert panel consisting of 51 individuals representing 28 perinatal care organizations helped narrow the list, which was based on results from a national survey. The recommendations were published online in Pediatrics.

A total of 1,047 survey respondents suggested 1,648 candidate tests and 1,222 treatments. Consensus was achieved on the top five items.

The expert panel concluded that clinicians should avoid:

1. Routine use of anti-reflux medications for the treatment of symptomatic gastroesophageal reflux disease (GERD) or for the treatment of apnea and desaturation in preterm infants

Gastroesophageal reflux is normal in infants. There is minimal evidence that reflux causes apnea and desaturation. Similarly, there is little scientific support for the use of H2 antagonists, proton-pump inhibitors, and motility agents for the treatment of symptomatic reflux. Importantly, several studies have shown that their use may have adverse physiologic effects as well as an association with necrotizing enterocolitis, infection and, possibly, intraventricular hemorrhage and mortality.

2. Routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection

There is insufficient evidence to support antibiotic treatment for more than 48 hours to rule out bacterial infection in asymptomatic term and preterm infants. Current blood-culturing systems identify most pathologic organisms prior to 48 hours. Prolonged antibiotic use may be associated with necrotizing enterocolitis and death in extremely low birth weight infants.

3. Routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity

Cardiorespiratory events are common in both term and preterm infants. Although there may be a role for pneumograms in selected cases where the etiology of the events is in doubt, they have not been shown to reduce acute life-threatening events or mortality from their routine use.

4. Routine daily chest radiographs without an indication for intubated infants

Although intermittent chest radiographs may identify unexpected findings, there is no evidence documenting the effectiveness of daily chest X-rays to reduce adverse outcomes. Further, this practice is associated with increased radiation exposure.

5. Routine screening term-equivalent or discharge brain MRIs in preterm infants

Findings on term-equivalent magnetic resonance imaging (MRI) correlate with neurodevelopmental outcomes at discharge and at 2 and 5 years of age. There is, however, insufficient evidence that the routine use of term-equivalent or discharge screening brain MRIs in preterm infants improves long-term outcomes.

“The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost,” the authors conclude. “This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.”

Sources: Choosing Wisely; July 20, 2015; and Pediatrics; July 20, 2015.

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