TABLE 1

Using PPI To Teach Value

SettingExamplePrepareProcessInitiate
OfficeParents of a thriving 4-mo-old infant ask if she needs medications for her “reflux.”Could acid suppressing medication help? Are there harms?Systematic review of articles on acid suppression harms and Choosing Wisely show no benefit and increased risk of infections.3,12Reassure family that spit-up is normal if growth is fine; come to shared decision not to use medication.
OfficeAn immunized 18-mo-old child has a normal neurologic exam and a viral exanthem after a simple febrile seizure.Does this child need more work-up for seizures? Is there potential harm from a CT scan?AAN/AAP guideline and Choosing Wisely: no EEG or head imaging needed. Consider potential harms of radiation, sedation, inadvertent findings.3,13Empathize with family on how frightening this was, but explain how it is also common and the absence of long-term effects. Counsel what to do if there is a recurrence.
OfficeA low-risk, 120-h-old, 41-wk gestation girl has a serum bilirubin of 20.1 mg/dL. Mother reports her milk is in, and baby has gained 20 g since the previous day. Should we initiate phototherapy? Are there side effects to phototherapy, such as impact on bonding?Measured level is below the AAP guideline phototherapy line; NNT in this category is >3000.14,15Discuss risks/harms of phototherapy and treatment alternatives, such as a repeat bilirubin level the next day and continued frequent breastfeeding in a comfortable home setting.
EDA 3-y-old girl presents with minor closed head injury after falling off a trampoline. She had no LOC and 2 episodes of emesis.What is this child’s risk of a TBI that needs neurosurgical intervention? What are the harms of a CT scan in terms of radiation, sedation, and costs?PECARN study risk calculation shows intermediate (0.8%) TBI risk.16Shared decision-making with family on options of observing for a few more hours in the ED for worsening symptoms versus risks of sedation and incidental findings on imaging.
InpatientA 6 y old initially admitted for peripheral IV antibiotics for acute hematogenous osteomyelitis is now afebrile, clinically improved, and has a significant decline in C-reactive protein.By what route should additional antibiotics be administered? What are the costs of PICC lines (including placement, risk of clots, infection, mechanical complications) versus oral antibiotics (including concerns about compliance).Large study showing equivalent cure rates for oral and IV antibiotics, but with higher risks for IV antibiotics administered at home via PICC after discharge.17Shared decision-making with family; they opt for discharge on an oral agent with weekly follow-up.
  • AAN, American Academy of Neurology; AAP, American Academy of Pediatrics; CT, computed tomography; ED, emergency department; IV, intravenous; PECARN, Pediatric Emergency Care Applied Research Network; PICC, peripherally inserted central catheter; TBI, traumatic brain injury.