Overdiagnosis: How Our Compulsion for Diagnosis May Be Harming Children (Pediatrics. 2014 Oct 6)

Pediatrics. 2014 Oct 6.
.
Coon ER, Quinonez RA, Moyer VA, Schroeder AR.

Overdiagnosis occurs when a true abnormality is discovered, but detection of that abnormality does not benefit the patient. It should be distinguished from misdiagnosis, in which the diagnosis is inaccurate, and it is not synonymous with overtreatment or overuse, in which excess medication or procedures are provided to patients for both correct and incorrect diagnoses.
Overdiagnosis for adult conditions has gained a great deal of recognition over the last few years, led by realizations that certain screening initiatives, such as those for breast and prostate cancer, may be harming the very people they were designed to protect. In the fall of 2014, the second international Preventing Overdiagnosis Conference will be held, and the British Medical Journal will produce an overdiagnosis-themed journal issue.
However, overdiagnosis in children has been less well described. This special article seeks to raise awareness of the possibility of overdiagnosis in pediatrics, suggesting that overdiagnosis may affect commonly diagnosed conditions such as attention-deficit/hyperactivity disorder, bacteremia, food allergy, hyperbilirubinemia, obstructive sleep apnea, and urinary tract infection.
Through these and other examples, we discuss why overdiagnosis occurs and how it may be harming children. Additionally, we consider research and education strategies, with the goal to better elucidate pediatric overdiagnosis and mitigate its influence.

http://pediatrics.aappublications.org/content/early/2014/09/30/peds.2014-1778.long

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TABLE 1 Examples of Possible Overdiagnosis in Pediatrics

Diagnosis - Evidence of Overdiagnosis

ADHD
The youngest children for a given grade level are significantly more likely than their older classmates to receive a diagnosis of ADHD. Although this phenomenon has been labeled overdiagnosis, one could argue that misdiagnosis is more appropriate (ie, immaturity is misdiagnosed as ADHD).

Aspiration
The natural course of aspiration detected by swallow study in anatomically and neurologically normal infants is complete resolution. It is unknown whether making this diagnosis benefits infants. The largest assessment of outcomes for neurologically impaired infants found that fundoplication did not reduce their risk of hospitalization for respiratory illness.

Bacteremia
A trial of children age 3–36 mo presenting to an emergency department with fever .39°C treated 19 children with bacteremia with placebo (no antibiotic). Eighteen children had spontaneous resolution of bacteremia at 48 h. None developed serious morbidity (meningitis, pneumonia, bone or joint infection, cellulitis).

Cholelithiasis
50% of children diagnosed with cholelithiasis in 1 study were completely asymptomatic at diagnosis, of whom 95% were free of complications on long-term follow-up.

Food allergy
Children can have positive immunoglobulin E test results indicating sensitization but not necessarily suffer from a clinical allergy.87 For example, 17% of people are sensitized to a major food allergen, but only 2.5% have a clinical food allergy.

Gastroesophageal reflux
Reflux is common in the first 6 mo of age and nearly completely resolves by 12 mo of age, independent of any medical interventions.89,90 A randomized trial found no benefit to treatment of symptoms attributed to gastroesophageal reflux disease in infants but did find that medication increased the risk of lower respiratory tract infections. Yet gastroesophageal reflux disease diagnoses and treatments with medication for infants are common and increasing.

Hyperbilirubinemia
There was no change in mortality due to kernicterus between 1979 and 2006,14 despite increased vigilance for hyperbilirubinemia, including bilirubin testing and phototherapy.

Hypercholesterolemia
The 2011 National Heart, Lung, and Blood Institute guidelines recommend universal screening for children age 9–11 and potentially qualify 200 000 children for treatment, with unclear evidence for long-term harms and benefits of diagnosis and treatment.

Hypoxemia in bronchiolitis
Hospital admissions for children with bronchiolitis have significantly increased since 1980, a period coinciding with increased use of pulse oximetry, yet mortality from bronchiolitis during the same time period has been unchanged. Oxygen saturation changes as small as 2% significantly increase a physician’s decision for admission, and the diagnosis of hypoxemia by continuous pulse oximetry prolongs hospitalization, but there is no evidence that supplemental oxygen for transient desaturations benefits children.

Medium-chain acyl-coenzyme
A dehydrogenase deficiency A portion of newborns identified by newborn screening may never experience symptoms of their enzymatic defect. Studies have
identified affected but completely asymptomatic older siblings of screening-identified newborns,11 and some mutations identified by newborn screening have acylcarnitine profiles that normalize over time. Neuroblastoma A portion of neuroblastoma diagnoses will regress without treatment. Screening children for neuroblastoma identifies more lower-stage cancers but does not reduce end-stage neuroblastoma or mortality.

OSA, obstructive sleep apnea
In 1 trial, almost half of children with OSA randomized to watchful waiting had complete normalization of their polysomnographic findings 7 mo after enrollment. The same trial failed to show a benefit for the primary outcome (attention and executive function) after surgical intervention for OSA. Tonsillectomy rates nearly doubled between 1996 and 2006,107 a proportion of which probably are attributable to the surgical indication of OSA, which increased from 12% of patients in 1970 to 77% in 2005.

Skull fracture
Children with isolated skull fractures have excellent outcomes without neurosurgical intervention, yet they are subjected to repeat CT scanning and often hospitalized.

UTI , urinary tract infection
According to a Pediatric Research in Office Settings study of young, febrile infants, of 807 febrile infants never tested or treated for UTI, 61 were predicted to have a UTI based on the application of predictors of UTI in infants who did undergo urine testing. Only 2 of the 807 infants not initially tested or treated were later diagnosed with a UTI, and none suffered immediate morbidity or mortality.

VUR , vesicoureteral reflux
Most VUR, including high-grade VUR, resolves over time, and few if any interventions for VUR decrease rates of renal scarring or insufficiency.

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Жозефа Врачи Сообщений: 2072 Рейтинг: 125 Регистрация: 17.05.2012	#2 1 21.10.14 14:12 TABLE 1 Examples of Possible Overdiagnosis in Pediatrics Diagnosis - Evidence of Overdiagnosis ADHD The youngest children for a given grade level are significantly more likely than their older classmates to receive a diagnosis of ADHD. Although this phenomenon has been labeled overdiagnosis, one could argue that misdiagnosis is more appropriate (ie, immaturity is misdiagnosed as ADHD). Aspiration The natural course of aspiration detected by swallow study in anatomically and neurologically normal infants is complete resolution. It is unknown whether making this diagnosis benefits infants. The largest assessment of outcomes for neurologically impaired infants found that fundoplication did not reduce their risk of hospitalization for respiratory illness. Bacteremia A trial of children age 3–36 mo presenting to an emergency department with fever .39°C treated 19 children with bacteremia with placebo (no antibiotic). Eighteen children had spontaneous resolution of bacteremia at 48 h. None developed serious morbidity (meningitis, pneumonia, bone or joint infection, cellulitis). Cholelithiasis 50% of children diagnosed with cholelithiasis in 1 study were completely asymptomatic at diagnosis, of whom 95% were free of complications on long-term follow-up. Food allergy Children can have positive immunoglobulin E test results indicating sensitization but not necessarily suffer from a clinical allergy.87 For example, 17% of people are sensitized to a major food allergen, but only 2.5% have a clinical food allergy. Gastroesophageal reflux Reflux is common in the first 6 mo of age and nearly completely resolves by 12 mo of age, independent of any medical interventions.89,90 A randomized trial found no benefit to treatment of symptoms attributed to gastroesophageal reflux disease in infants but did find that medication increased the risk of lower respiratory tract infections. Yet gastroesophageal reflux disease diagnoses and treatments with medication for infants are common and increasing. Hyperbilirubinemia There was no change in mortality due to kernicterus between 1979 and 2006,14 despite increased vigilance for hyperbilirubinemia, including bilirubin testing and phototherapy. Hypercholesterolemia The 2011 National Heart, Lung, and Blood Institute guidelines recommend universal screening for children age 9–11 and potentially qualify 200 000 children for treatment, with unclear evidence for long-term harms and benefits of diagnosis and treatment. Hypoxemia in bronchiolitis Hospital admissions for children with bronchiolitis have significantly increased since 1980, a period coinciding with increased use of pulse oximetry, yet mortality from bronchiolitis during the same time period has been unchanged. Oxygen saturation changes as small as 2% significantly increase a physician’s decision for admission, and the diagnosis of hypoxemia by continuous pulse oximetry prolongs hospitalization, but there is no evidence that supplemental oxygen for transient desaturations benefits children. Medium-chain acyl-coenzyme A dehydrogenase deficiency A portion of newborns identified by newborn screening may never experience symptoms of their enzymatic defect. Studies have identified affected but completely asymptomatic older siblings of screening-identified newborns,11 and some mutations identified by newborn screening have acylcarnitine profiles that normalize over time. Neuroblastoma A portion of neuroblastoma diagnoses will regress without treatment. Screening children for neuroblastoma identifies more lower-stage cancers but does not reduce end-stage neuroblastoma or mortality. OSA, obstructive sleep apnea In 1 trial, almost half of children with OSA randomized to watchful waiting had complete normalization of their polysomnographic findings 7 mo after enrollment. The same trial failed to show a benefit for the primary outcome (attention and executive function) after surgical intervention for OSA. Tonsillectomy rates nearly doubled between 1996 and 2006,107 a proportion of which probably are attributable to the surgical indication of OSA, which increased from 12% of patients in 1970 to 77% in 2005. Skull fracture Children with isolated skull fractures have excellent outcomes without neurosurgical intervention, yet they are subjected to repeat CT scanning and often hospitalized. UTI , urinary tract infection According to a Pediatric Research in Office Settings study of young, febrile infants, of 807 febrile infants never tested or treated for UTI, 61 were predicted to have a UTI based on the application of predictors of UTI in infants who did undergo urine testing. Only 2 of the 807 infants not initially tested or treated were later diagnosed with a UTI, and none suffered immediate morbidity or mortality. VUR , vesicoureteral reflux Most VUR, including high-grade VUR, resolves over time, and few if any interventions for VUR decrease rates of renal scarring or insufficiency.