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At the heart of general practice since 1960

What not to do - paediatrics

Dr Lee Hudson, consultant general paediatrician, discusses what has fallen out of favour in paediatric primary care

Investigation

Do not use a bag collection route to obtain a urine specimen when investigating UTI in an infant.

These increase the risk of contamination and evidence shows that bags may sterilise truly infected urine samples.1 Clean-catch specimens are recommended in the community.

A diagnosis of a UTI should not be made following a positive dipstick test for leucocyte esterase alone.2

Leucocytes are frequently found in urine when a child has infection elsewhere. The finding of nitrites (with or without leucocyte esterase) on an appropriately collected, fresh specimen in children is suggestive of a UTI. Care must be taken in reaching a diagnosis, especially in infants, as false diagnosis leads to inappropriate antibiotics which may partially mask another focus, such as meningitis. Ideally, UTIs should be diagnosed by confirmed microbiological evidence, particularly in children under three, to guide treatment and any further investigations (for unusual organisms).  Following clinically successful treatment of a UTI in a child – defined as adherence to treatment and resolution of symptoms – a repeat specimen is not indicated.2

Treatment

Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever.3

Despite widespread use, there is surprisingly little evidence for the efficacy of antipyretics in the treatment of fever in children. Giving medications to children can be challenging and potentially more distressing than the fever itself, especially when oral intake is reduced. Most parents and health professionals feel comforted by the child’s improved appearance and function when fevers subside, yet this will frequently occur without administration of antipyretics. Reassurance and assessment for red flags (such as rashes or irritability, especially in young infants and unvaccinated children), with appropriate safety netting, should be the first-line approach.

Avoid combining antipyretics simultaneously in children with fever.

If medications are to be given, there is insufficient evidence suggesting that simultaneous ibuprofen and paracetamol is better than individual therapy, in particular in improving discomfort.4

There is no evidence that antipyretics prevent febrile seizures.

Although many parents may find the use of antipyretics reassuring, a number of studies have failed to demonstrate a role for them in the prevention of febrile convulsions for either primary or recurrent seizures.5

Do not perform tepid sponging to reduce fever.

Care must be taken with physical methods to reduce fever. Tepid sponging should not be performed as it tends to reduce peripheral temperature, leads to a rise in core temperature and increases discomfort.3 Over-exposure by under-dressing children can lead to similar problems. The best advice is to not under-dress or over-wrap children with fevers.

Do not automatically empirically treat a UTI with trimethoprim.

The most common pathogenic organism in UTI in children is Escherichia coli. Increasing levels of resistance of E.coli to trimethoprim across the UK6 means that GPs should seek local microbiological guidance for empirical therapy. A single, simple UTI is relatively common in childhood, and prophylactic antibiotics are not indicated as risk of recurrence is low and treatment contributes to bacterial resistance.2 Children who have recurrent UTIs (more than three simple UTIs) should be considered for prophylaxis, and generally referred to a paediatrician for consideration of imaging.2

Local or systemic decongestants and antihistamines should not be prescribed or advised for otitis media with effusion.

A Cochrane review showed these medications caused significant side-effects and do not alter disease outcome.7 Where families have used over-the-counter remedies by the time of consultation, the advice should be to stop them unless there is significant benefit.

Antibiotics should not be routinely prescribed for otitis media with effusion.

Another Cochrane review showed that long-term courses were needed to see benefits from antibiotics, which were offset by side-effects and potential antibiotic resistance.8

Tricyclic medication (such as imipramine) should not be used as a first-line treatment for bed-wetting.

Side-effects, although rare, can be significant (mostly relating to the cardiovascular system) and a physician with expertise in enuresis should supervise their use. Initial management should begin with advice on toileting and fluid intake.9 Second-line treatment depends on whether a family and child’s goals are short-term (drug therapy) or longer-term (where alarms will be more effective). Goals frequently correspond with a child’s age and the impact of bed wetting on function (such as sleepovers). Strategies using the interruption of urinary stream, or encouraging infrequent passing of urine during the day to increase bladder capacity, should not be recommended as the value is unproven compared with the treatments mentioned above.9

Dr Lee Hudson is a consultant general paediatrician at Great Ormond Street Hospital

References

  1. Etoubleau C, Reveret M, Brouet D et al. Moving from bag to catheter for urine collection in non-toilet-trained children suspected of having urinary tract infection: a paired comparison of urine cultures. J Paediatr 2009;154:803-6
  2. NICE. CG54: UTI in children. London: NICE; 2007
  3. NICE. CG160: Feverish illness in children. London: NICE; 2013
  4. Wong T, Stang AS, Ganshorn H et al. Combined and alternating paracetamol and ibuprofen therapy for febrile children. Cochrane Database Syst Rev, 2013; CD009572
  5. Strengell T, Uhari M, Tarkka R et al. Antipyretic agents for preventing recurrences of febrile seizures: randomized controlled trial. Arch Paediatr Adolesc Med 2009;163:799.
  6. Chakupurakal R, Ahmed M, Sobithadevi DN et al. Urinary tract pathogens and resistance pattern. J Clin Pathol 2010;63:652-4
  7. Griffin G, Flynn CA. Antihistamines and/or decongestants for otitis media with effusion (OME) in children. Cochrane Database Syst Rev, 2011; 7:CD003423
  8. Van Zon A, van der Heijden GJ, van Dongen TM et al. Antibiotics for otitis media with effusion in children. Cochrane Database Syst Rev, 2012; 9:CD009163
  9. NICE. CG111: Nocturnal enuresis – the management of bed wetting in children. London: NICE; 2010

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Readers' comments (13)

  • Are you serious??!! this is your invaluable advice to GPs at the frontline of medicine seeing 50-60 patients a day, every day, mostly feverish children especially in winter months? A child has a fever- don't recommend paracetamol, and definitely don't recommend paracetamol and ibuprofen if the temperature has not settled with one agent? Do not give simple advice such as tepid sponging or reducing dressing for high fevered child not responding to other measures? Do not give antibiotics for a UTI (despite child being symptomatic, leukocyte positive and no overt signs of meningitis) or purulent ear discharge? Well GOSH I would love to be in your confidently benign position, and would also love for you to be in my lowly but anecdotally rigorous daily trial. Large scale randomised double controlled trials are all very useful, and I am sure Cochrane's Database has helped advance the practice of modern medicine manifold since its inception, but if the best it can come up with is advice to non medical parents who have a clearly unwell children is to just let it pass with no intervention, then I for one would like someone else to pay my medical indemnity fees!! Or do we now refer all up for a paeds review if symptoms not settling in the 2 days it takes for parents to re-present to the practice when nothing has changed (who would otherwise just go to A+E as they have lost all confidence in their evidence based BUT do nothing GP).

    My patients are a name, not a NICE or Cochrane database number, thank you very much!! And I think I will stick to dealing with them on a case by case basis.

    Disillusioned GP Partner (1.5yrs)

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  • Entirely agree with the above comment. Perfectly highlights the difference between academia only orientated medicine and real life practice. The LAT and GMC would be inundated with complaints of lazy GPs doing nothing collecting their supposed fat pay checks.

    Furthermore, most children seen acutely at children's unit invariably are commenced on antibiotics even if a suspected viral source "just in case".

    As a "trial" - could a GP practice local to GOSH invite the author to do a children's only surgery at their practice in deep mid-winter? - I would be very interested to read a follow up piece from the author reflecting on this experience.

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  • all seems perfectly reasonable and evidence based to me. If you keep up to date with NICE guidelines, this should be nothing new to GPs.

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  • I can't help feeling this paediatrician should spend some time in primary care and on general paeds wards.

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  • I completely agree with all the points above except the use of antipyretics in children with fever.
    By now, most of us GPs should actually not be advising on tepid sponging or treating UTI just on leucocytes on dipstick.
    Evidence also supports the point on use of antipyretics in children but practically this is almost not possible.
    Just last week I saw a 4 year old child with fever and coryza. Her mother was freaking out because of the fever and the child seemed sleepy. I knew this child had nothing else wrong with her and advised to use antipyretics. I reviewed the next day and this child was back to her normal self. If I sent that mother away without antipyretics and just 'reassured' her, she would pitched up in A and E over night and maybe given antibiotics 'just in case'.

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  • Fully agree with points raised from both sides and
    think this Academic should work few days in general practice ,

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  • Perfectly sensible advice. Happy that I'm already doing this already. Can't really understand the vitriol and ranting.

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  • no comment

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  • I quite agree with the rest except for anipyretics.

    Not sure if the recommending doctor is a parent but if you have a child with high fever, you know how difficult it becomes to continue to care for her. Simple tasks such as drinking, sleeping or not crying becomes difficult.

    Unless there are evidence using antipyretics causes harm (which is not mentioned in the article), I see no reason to advice against this. It's like saying using a car reduces exercise and only helps the convenience - well there's a news for you, modern society requires convenience to function unless you want to go back to middle age living.

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  • Lack of evidence is not the same as lack of effect. How many of us have watched our kids get a bit better after Calpol or Junifen when they have a fever. They also FEEL better- ask them.

    I shamelessly use antibiotics for AOM and would, were I in practice still, continue to do so.

    This is therapeutic nihilism, and just the current "fashion" as the title rather suggests.

    Some might say that this is close to a sort of "Medically sanctioned low-grade child abuse"- Discuss.

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