Evolving Paediatric Practice

Part of an international movement, Evolve is the RACP’s initiative to reduce clinical practices that are sometimes overused and not supported by current evidence. By identifying and decreasing low-value practices and interventions, Evolve aims to drive high-value, evidence-based, and safe care to improve patient health outcomes.
 
There are currently two paediatric Evolve lists available – Paediatrics & Child Health Division (PCHD) General Paediatrics and the Australasian Paediatric Endocrine Group. A number of other paediatric specialties are also developing lists.
 
The General Paediatrics Evolve List recommendations are: 

• Do not routinely prescribe oral antibiotics to children with fever without an identified bacterial infection.
• Do not routinely undertake chest X-rays for the diagnosis of bronchiolitis in children or routinely prescribe salbutamol or systemic corticosteroids to treat bronchiolitis in children.
• Do not routinely order chest X-rays for the diagnosis of asthma in children. 
• Do not routinely treat gastroesophageal reflux disease (GORD) in infants with acid suppression therapy.
• Do not routinely order abdominal X-rays for the diagnosis of non-specific abdominal pain in children. 

"All of us find we are using some of these practices at some point, or see them happening where we work. The main message of EVOLVE is to start noticing when this happens, and stop to think about why that might be and what you can do to improve things,” said PCHD President Dr Sarah Dalton.

“Do we order extra investigations or treatment out of habit, or because we want to do whatever we can to try and help? If we stopped for a moment to consider, we might realise that the intervention may not help at all. In fact, it can potentially be associated with harm for our patients or take up resources that would be better used elsewhere.

“Once you notice overuse and have ideas about how to reduce this, share your ideas with the team. Ask others what would help them. Consider if there are systems or processes that are inadvertently supporting these low-value practices such as checklists or electronic ordering systems, and if so see if they can be changed,” she said.
 
Dr Dalton also urged clinicians to talk with children and their families.

“Patients and carers need to be involved in decisions that affect them.  Encourage them to ask questions about the care that is right for them,” she said.

Paediatricians can play an important role in reducing low-value care, and Dr Dalton encourages everyone to consider: 

• Are these top five Evolve practices ones that I see happening? 
• How often are they things that I do? 
• What could I do to reduce this practice?
• How could I implement changes in my daily work? 
• How could I share ideas with my colleagues? 

Recommendations raised by the Australasian Paediatric Endocrine Group are: 

• Do not rely on random measures of circadian hormones for diagnostic purposes.
• Do not rely solely on bone age measurement for assessing growth in young children with short stature under two years of age.
• Do not routinely measure insulin-like growth factor binding protein 3 (IGFBP-3) for workup and diagnosis of childhood short stature.
• Do not initiate gonadotropin-releasing hormone (GnRH) analogue treatment in children outside of central precocious puberty, for the target outcome of delaying puberty and improving final adult height.
• Do not routinely prescribe aromatase inhibitors  to promote growth in children with short stature.

Other highly relevant Evolve items for paediatrics include: 

• Do not delay the introduction of solid/complementary foods to infants – Australasian Society of Clinical Immunology and Allergy (ASCIA) Infant Feeding Advice recommends early introduction of solid foods to infants, from four to six months old.
• Do not perform imaging of the brain to investigate for non-acute primary headache disorders – Australian and New Zealand Association of Neurologists.
• Do not use oral antibiotics for the treatment of atopic dermatitis unless there is clinical evidence of infection – New Zealand Dermatological Society.

If you are considering how you could implement the initiative in your practice and would like to share ideas and seek advice from your colleagues, please contact evolve@racp.edu.au