Doctors agree: Sometimes it's best to do less.

By David L. Hill, M.D.
July 27, 2015
Girl sick in bed
Credit: Stephanie Rausser

I became a pediatrician so that I could help make sick kids well. After 15 years in practice, however, I've learned that in many cases, the less I do the better off children are. That's not to say that we doctors don't make a difference; it's just that helping kids requires less intervention than you'd think. Even for a problem as straightforward as an ear infection, the fix (antibiotics) is often more likely to do harm than to help.

To make things easier for doctors like me, the American Academy of Pediatrics (AAP) and the ABIM Foundation, which is the charitable arm of the American Board of Internal Medicine, have created a list of procedures and tests that are commonly used and may not need to be. The goal is to get doctors and patients alike to discuss how necessary they are before agreeing to them as a matter of routine. The groups picked ten items, some of which are common enough that your child has probably already encountered at least one. Here are the six I feel should always be questioned, plus one I'd love to add.

1. Cough-and-cold medicines for kids younger than 4

Your toddler is up all night coughing, it sounds horrible, and you wish you could give him something to help him sleep. I've been there and, as it turns out, there is something you can give: honey, which coats the throat, easing some of the discomfort that causes coughing. A study from Penn State Hershey College of Medicine showed that for children over 1 year of age, honey works better than dextromethorphan, the most commonly used cough medicine. Since honey can cause potentially lethal botulism in infants, children under age 1 should instead get corn syrup (either light or dark is fine).

Dextromethorphan can also be dangerous for young kids. In fact, in 2008 the FDA did "strongly recommend" against OTC cough products for children under age 2, and manufacturers took them off the shelves. Since then, drugmakers have labeled these medicines (usually called cough suppressants) for use only in kids ages 4 and above. Still, 40 percent of parents admit to trying it for younger children, found a survey from C. S. Mott Children's Hospital, in Ann Arbor, Michigan.

Codeine, a narcotic used in the past to treat cough in children, has never been proven to work for kids, and it's even more dangerous than dextromethorphan. For this reason, since 1997 the AAP has discouraged doctors from prescribing it. Some coughs warrant medical attention, of course. If your child is wheezing, short of breath, or complaining of chest pain, get him help immediately. A viral cough can last three weeks; if your child is coughing longer than that, it's also time to get a doctor's advice.

2. Antibiotics for upper-respiratory infections

Your child has a fever of 102°F, green snot, a deep cough, and a red throat -- in other words, a rotten cold. You may know that antibiotics don't do anything for viral illnesses except potentially cause side effects. And yet doctors estimate that American kids receive around 10 million unnecessary prescriptions a year. How can you prevent your child from taking a drug she doesn't need?

It helps to know what symptoms are normal for a cold virus. Expect a fever for the first few days, often above 102°F. For a fever over 104°F, call a doctor. I get concerned about fevers that last longer than three days or that occur after the first few days of illness. Any fever in an infant younger than 3 months deserves immediate attention.

About 10 percent of colds do lead to treatable bacterial infections. Giving antibiotics right away does nothing to prevent them, but some symptoms can help you spot the infection and make your child a bit more comfortable. Yellow or green discharge is pretty much part of every cold, but a runny nose that lasts longer than ten to 14 days or a cough that lasts longer than three weeks may suggest a bacterial sinus infection, so call your child's doctor. Also call if your child complains of ear pain or if you notice green or yellow discharge from her eyes.

Kids sick in bed
Credit: Stephanie Rausser

3. Medication for garden-variety infant reflux

Gastroesophageal reflux (GER) is nearly universal among infants, especially in the first six months of life. Gastroesophageal reflux disease (GERD) is much less common; it's among the most overdiagnosed and overtreated conditions in pediatrics.

Normal babies spit up all the time. (I think my dry-cleaner threw a party every time we had a new baby.) Most of these babies are "happy spitters," not nearly as bothered by their reflux as their parents are. Babies with GERD, on the other hand, have signs of more serious illness: failing to gain weight, crying with every feed, arching their back, wheezing, coughing, or gagging.

If you think your child has GERD, definitely talk to the doctor, who will discuss options that include medication as well as lifestyle changes. If she's spitting up like Old Faithful but still smiling and growing, talk to your dry-cleaner -- maybe you can get a volume discount.

4. Random testing for food allergies

We've all heard how dangerous food allergies can be. So you may wonder whether you should get your children tested before they ever taste their first peanut-butter sandwich. If it were that easy, that's what we'd do, but allergy tests are notorious for what we call "false positives," results that suggest an allergy when there's actually none.

With peanut allergies, around 8 percent of all kids will have a positive result, but only 1 percent actually have a real allergy, found AAP research. If after eating a particular food your child gets hives or mouth swelling, or wheezes, or feels light-headed, then he should be tested. The most common allergies involve nuts, milk, wheat, eggs, soy, and fish. If he has a sibling with peanut allergies but no reactions himself, there's no reason to test him.

Eczema, a dry-skin condition that causes itching, redness, bumps, and scaly patches, can worsen with some foods. But unless you've already noticed a strong relationship with a given food, the process of allergy testing is likely to be more confusing than helpful. As a rule, testing is only useful when there's a strong family or personal history to back it up.

5. Urine cultures

True or False: A child should never have bacteria in her urine.

False! Kids' urine often has bacteria that don't cause problems (a condition that's known as asymptomatic bacteruria) and will go away on their own. Even a child who's had past urinary-tract infections (UTIs) does not need a urinalysis (UA) or a culture simply to check whether she has one now, unless she's having pain while peeing, unexpected accidents, fever, tummy or back pain, or increasingly frequent urination. These tests are costly and can give both false-positive and false-negative results.

If the UA suggests an infection, a child should get both antibiotics and a urine culture. The culture allows us to confirm that there really are bacteria and determine which antibiotics will work to fight them.

6. Brain scans for simple febrile seizures

There are few experiences more frightening than watching your child have a seizure. Yet 2 to 5 percent of children between the ages of 6 months and 5 years have seizures with a fever, and it's not a sign of a larger problem. These episodes, called febrile seizures, often run in families; 25 to 40 percent of children with febrile seizures have a close family member who's also had them.

We call a febrile seizure "simple" when the child is in the appropriate age range, has never seized without also having had a fever, shakes all over (rather than on just one side), seizes for less than 15 minutes, and doesn't have another seizure within 24 hours. As scary as they look, simple febrile seizures are harmless.

Having a CT scan of the head to look for an underlying problem, on the other hand, exposes children to radiation, potentially increasing their risk of cancer. Head MRIs in young children usually require general sedation, which carries risks as well. You should still seek care if you think your child has had a febrile seizure. Your doctor can determine whether the episode was truly a simple febrile seizure and look for any signs of meningitis, during an evaluation that sometimes includes a spinal tap. But if everything checks out, the only things a brain scan will add are expense and risk.

One more practice to rethink: alternating fever medicines

This wasn't mentioned by the ABIM Foundation and the AAP, but if they ever ask me what else belongs on the list it will be my first choice. In my opinion the risks of overdose outweigh any benefit of a slightly lower temperature.

Many doctors still instruct parents to alternate between acetaminophen (Tylenol) and ibuprofen (Advil), often every 4 hours. Studies have shown that this approach may lead to slightly better fever reduction than using one drug alone.

The problem is that both of these medications can be dangerous when overdosed, and roughly half of parents give too-high doses, found a study in Pediatric Emergency Care. These meds are also often in combination cough-and-cold formulas, which increases the risk of double-dosing. The only reason to try to bring down fever is to make your child more comfortable, not to reach a "normal" temperature. To be truly dangerous, a temp must rise above 107°F. (Fever is never normal in an infant under 1 month of age and can be alarming in a baby younger than 90 days, so in those cases call the doctor right away.)

I advise parents to stick to one medicine, knowing that if their child is shivering with fever they can always try the other the next time a dose is needed. (Using one as a backup for discomfort is different from trying to follow a schedule for several cycles.) As a doctor and as a parent, I like anything that makes my life simpler, and I'll bet you do too!

Originally published in the September 2015 issue of Parents magazine.

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