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How do you decide which medical tests are necessary? 

Modern medicine offers many tools for diagnosing and treating children. But how do parents decide which ones are necessary?

This month, Dr. Lewis First, chief of pediatrics at Vermont Children's Hospital at Fletcher Allen Health Care, discusses the American Academy of Pediatrics' Choosing Wisely campaign, which aims to educate parents about the risks and benefits of common procedures and treatments so they can play a more active role in their kids' health care.

KIDS VT: Antibiotics are among the most overused treatments for children. Why?

DR. LEWIS FIRST: When a child has respiratory symptoms, or a fever, many parents who know that antibiotics kill germs think, "Why not give my child an antibiotic?" The problem is, most of the germs that make us sick are viruses, which don't respond to antibiotics. The more we use antibiotics, the more we put our kids at risk for other problems.

KVT: Such as?

LF: When bacteria are routinely exposed to antibiotics, they can change their structure to become resistant to that particular antibiotic, making them more difficult to treat later on. Many bacteria are now resistant to the common antibiotics we used to treat them as recently as 10 years ago. This requires us to use more expensive and complex antibiotics, which can have side effects such as allergic reactions and severe gastrointestinal distress.

KVT: When should parents feel comfortable using antibiotics?

LF: If your child tests positive for strep throat, or if a doctor says your child has a bacterial pneumonia, those are good reasons to use an antibiotic. But ear or sinus infections aren't always bacterial. In fact, most are caused by viruses. We'd rather observe the child, stay in touch with the family and then decide whether to prescribe an antibiotic based on your child's age, symptoms and medical history.

Also, when parents are given an antibiotic for their child, they should use the full course, even if the child gets better in two days. Don't save it for later. If we aren't good stewards of our antibiotics, we all pay the price.

KVT: Why do you advise against using cough and cold medicines for children under 4?

LF: Research shows, across the board, that they offer few benefits for kids. In small children, such medications can cause serious side effects, including dangerous heart rhythms, sedation, hyperactivity and breathing difficulties. Parents can get better results using a humidifier, good hydration and saline nose drops.

KVT: What about X-ray imaging when a child has a head injury?

LF: Just because a CT (computed tomography) scan is available, it shouldn't automatically be used. Nowadays, doctors have clear criteria for assessing a child's neurologic system after a mild traumatic brain injury. If the doctor is concerned, he or she will explain when a CT scan is needed. But if a child has an unremarkable physical exam, it's better to follow this child's recovery than expose him or her to unnecessary X-rays.

KVT: Why?

LF: One CT scan of the head exposes a child to 100-500 times more radiation than a chest X-ray. There's strong evidence that CT scans increase children's risk of brain tumors and leukemia; they also increase the cost of the entire health care system.

KVT: What if a child has a seizure?

LF: Doctors won't automatically order a CT scan or MRI (magnetic resonance imaging) if your child has had a convulsion with fever, also known as a febrile seizure. Again, we don't want to radiate a child for something that's fairly common. Fewer than 1 percent of kids will go on to have complications related to epilepsy, and in those rare cases, we typically see other signs that warrant the CT scan. Parents need to know that while they're scary to see and require medical attention, febrile convulsions are not dangerous.

KVT: MRIs don't use radiation, so what's the concern?

LF: Not only is an MRI expensive, but it often requires the child to be sedated and stay in the machine for a long time. If a child has a normal exam after coming through a febrile convulsion, it's better to keep the fever under control and figure out why he or she is sick. If the doctor or parent is worried, or if the seizures persist, then we'd want to get that image.

KVT: Are CT scans recommended for kids with abdominal pains?

LF: No. A child should not automatically get a CT scan just because the doctor doesn't know what is causing a belly pain. The risk and expense associated with this kind of imaging outweigh the potential benefits — unless we know exactly what we're looking for. We can do a lot more with a careful medical history, thorough physical examination and some laboratory tests.

KVT: How should parents question a physician if they think a test or procedure is unwarranted?

LF: Parents should be asking, "What is your medical decision based upon?" Nowadays our goal is to provide patient-focused, family-centered care. That means we'll have a conversation so we can work together to heal your child. We want to empower families to feel comfortable asking these questions so they can play a more active role in the health of their child.

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