PEM Rules: Less is More!

Each month Yaron Ivan, MD shares some of the rules from his popular podcast about Pediatric Emergency Medicine, PEM Rules.  To learn more about all of the rules, visit pemrules.com or on your favorite podcast platform.

Rule No 4: Less is more

This is probably one of the more important rules I practice each and every shift. This rule just might embody the core difference between adult and Pediatric Emergency Medicine.

The majority of children that present to the Emergency Department are generally healthy and well. They usually have no or very few comorbidities and are not on any chronic medications. Pediatric patients often present with mild conditions – or even with normal behavior – that are misinterpreted by the parents as abnormal, serious or dangerous.

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Example A– Fever and the Viral Illness

One of the most common presentations to the Pediatric ER is fever.  As physicians, we know that fever is part of the innate immune response, is normal, “natural”, beneficial, and does not lead to brain damage or febrile seizures.  In addition, fever in the pediatric patient is almost always secondary to a viral illness.  Parents, on the other hand, worry that a fever is dangerous, or indicative of a serious infection.

Yet if the child’s assessment indicates that the fever is not secondary to a serious / bacterial illness, then it is not likely harmful and possibly even beneficial.  Therefore, the less we do, the better off the patient will be as the body’s natural immune response kicks and does its work.

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The American Academy of Pediatrics (AAP) discourages the use of antipyretics for the purpose of keeping child normothermic.  In the ER, I discourage the parents from waking up the child for antipyretics administration and from alternating Acetaminophen and Ibuprofen (a practice that can easily lead to overtreating).

Here are some common facts about fever that I often share with parents:

• Young infants and children (unlike adults) often become highly febrile from benign, common viral illnesses.
• The most common cause of high fever in healthy vaccinated children is URI / viral illness for which there is no effective treatment.
• AAP discourages the use of cough and cold medications in children.
• The most common bacterial illness in young infants (even the ones who present with URI symptoms and bronchiolitis) is UTI.

This is why I often remind the residents that when a child presents with signs and symptoms of viral illness, it’s best to apply Rule number 4.   The less we do for treating the child, the better off the child will be.  This obviously does not include educating the parents, which is a key part of the ER visit for such a case.

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Administering OTC medications for fever is not evidence-based, is not recommend by the AAP and does not alter the course of illness.

A child with a URI will likely recover on his or her own.  Alternating Tylenol and Motrin to keep the child normothermic can lead to dosing errors and potentially prolong the illness, since fever suppresses viral replication and has other beneficial properties.

In addition, recommending something like cough and cold medications creates some expectations that after a dose or two the cough will improve. When that does not happen, the parents worry more or even return to the ER since “the medication is not working.”.  So Rule number 4 can go a long way towards managing unnecessary return visits.  It does not apply to educating and reassuring the parents.

The AAP supports this “less is more” approach as described in their guidelines.  Here are just a few examples to illustrate:

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–AAP does not support any treatment for bronchiolitis other than saline and suction (no bronchodilators, no steroids etc)

–AAP guidelines for Acute Otitis Media encourage watchful waiting for fully vaccinated children under many circumstances as  opposed to initiating antibiotic upon diagnosis

So, the next time you see a vaccinated, generally healthy child with high fever, remember that sometimes “less is more”.

Working Up the Patient

This rule also comes into play when working up pediatric patients. Given the statistics mentioned above, what is the utility of a CBC in a febrile child? CBC does not tell you where the infection is and certainly does not indicate whether it is bacterial or viral. That test in a febrile child will likely demonstrate leukocytosis, but what would you do with such result?

I often encourage the residents to obtain the test that will…

1. Give you an answer

AND

2. The answer changes the patient’s management or disposition

A good example of a worthwhile test is a urinalysis (UA). That test indicates UTI Vs no UTI which translates to antibiotics or no antibiotics. A complete blood count, however, does not indicate where the infection is nor whether it is viral or bacterial.  Another example of a test that is not helpful is a respiratory viral panel which tests the child for several benign common viruses for which there is no treatment whatsoever – so why bother?

So next time you see a vaccinated, generally healthy child, remember Rule number 4: Less Is More.

References:

• Lieberthal AS, Carroll AE, Chonmaitree T, et all. The Diagnosis and Management of Acute Otitis Media, Pediatrics 2013
• Rosenbloom et al. Do antipyretics prevent the recurrence of febrile seizures in children? A systematic review of randomized controlled trials and meta-analysis, Neurology, 2013
• Hudgings et al. Do Antipyretics Prolong Febrile Illness, J Fam Pract. 2004
• pemrules.com Episode 1.