CHOOSING WISELY
Strategic Advisory Group
Corinne Wyder
Chair
Primary care pediatrician Burgdorf, Swiss delegate European Academy of Paediatrics
ABOUT
CHOOSING WISELY
The Choosing Wisely Strategic Adivsory Group is an initiative ignited by the broader campaign led by the ABIM Foundation. The overarching aim is been to ignite conversations between clinicians and patients regarding the necessity of tests, treatments, and procedures. Originating in 2012 with nine national specialty societies representing 375,000 clinicians, the campaign initially presented 45 examples of commonly utilized tests or treatments lacking strong supporting evidence. Over the years, this initiative has evolved, with more than 80 specialty societies contributing additional examples until 2023. Societies, like EAP, have been encouraged to publish individual lists.
ABOUT US
the CW SAG of EAP was established in 2018 and is consisting of active 32 members from 19 European countries.
In 2024, a key achievement was the release of the Top 10 Choosing Wisely Recommendations for Physicians and Parents, designed to promote smarter medicine and informed decision-making.
Need the CW Resources in a different Language?
The Choosing Wisely EAP Strategic Advisory Group is very happy to share the below documents, brochures and information from “Paediatrics Switzerland & Smarter Medicine (Choosing Wisely)”.
EAP Statement on
Choosing Wisely
List of Recommendations in Paediatrics
GASTROENTEROLOGY
- Don’t routinely use acid blockers or motility agents for the treatment of gastroesophageal reflux in infants. — CW Canada (Canada)
- Do not routinely order abdominal X-rays for the diagnosis of non-specific abdominal pain in children. — RACP Paediatrics & Child Health Division (Australia)
- Polyethylene Glycol should be used in preference to Lactulose in the treatment of chronic constipation in children. — RCPCH (UK)
- Do not use serologic test for the diagnosis of celiac disease in children, until the gluten has been introduced in the diet. — Spanish Association of Pediatrics (Spain)
INFECTIOLOGY
- Don’t routinely do a throat swab when children present with a sore throat if they have a cough, rhinitis, or hoarseness as they almost certainly have viral pharyngitis. — CW Canada (Canada)
- Don’t do throat swabs in children below 3 years of age. — (Israel)
- Cough and cold medicines should not be prescribed, recommended or used for respiratory illnesses in young children. — AAP (USA)
- Antibiotics should not be used for viral respiratory illnesses (sinusitis, pharyngitis, bronchitis and bronchiolitis). — AAP (USA)
- Don’t administer antibiotics in children with acute pharyngitis unless microbiologic confirmation of streptococcal infection has been carried out. — Italian Society for Preventive and Social Pediatrics (Italy)
- Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteriuria. — AAP (USA)
- Avoid ordering follow-up urine cultures after treatment for an uncomplicated urinary tract infection (UTI) in patients that show evidence of clinical resolution of infection. — American Academy of Pediatrics – Section on Nephrology and the American Society of Pediatric Nephrology (USA)
- Don’t perform voiding cystourethrogram (VCUG) routinely in first febrile urinary tract infection (UTI) in children aged 2 -24 months. — American Academy of Family Physicians (USA)
- Do not diagnose Urinary Tract Infection based on urine cultures alone. — Federazione Italiana medici pediatri (Italy)
- Do not routinely use Antibiotics in newborns >36-48 hours when bacterial infection is unlikely. — Noewegian paediatric society (Norway)
- 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. — RACP Paediatrics & Child Health Division (Australia)
- Do not use salmeterol in children with acute asthma. — Società Italiana per le Malattie Respiratorie Infantili (SIMRI) (Italy)
- Don’t prescribe Chest Radiography to confirm diagnosis and to follow up in a not complicated pneumonia in children. — Associazione Culturale Pediatri (ACP) (Italy)
- Don’t treat otitis media (middle ear infection) with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option. — The Royal Australian College of General Practitioners (Australia)
- Avoid routine antibiotic treatment for acute ear infection in children over 1 year of age. — Norwegian Society of paediatrics (Norway)
- When possible, do not give immediate antibiotic therapy in acute otitis media. — Israel
- Do not routinely use Systemic steroids in airway infections (except moderate/severe pseudocroup) — Norwegian Society of paediatrics (Norway)
- Do not treat a fever systemically unless there are symptoms of discomfort. If you decide to treat it, use an appropriate dose avoiding combined/alternate use of paracetamol and ibuprofen. — Federazione Italiana medici pediatri (Italy)
- Do not use corticosteroids for fever management — Federazione Italiana medici pediatri (Italy)
- Do not to delay the empirical antibiotic therapy at the suspicion of invasive meningococcal disease by the fact of obtaining crops (blood and/or cerebrospinal fluid). — Spanish Association of Pediatrics (Spain)
- Do not give antibiotics routinely to children with gastroenteritis — Spanish Association of Pediatrics (Spain)
- Do not routinely use antibiotics in acute gastroenteritis. — Israel
- Don’t prescribe blood exams in children with acute pharyngitis. — Italian Society for Preventive and Social Pediatrics (SIPPS) (Italy)
- If throat culture is performed, susceptibility tests on isolates should not be executed in children with acute pharyngitis. — Italian Society for Preventive and Social Pediatrics (SIPPS) (Italy)
- Don’t shorten antibiotic course in children with acute pharyngitis and microbiologic confirmation of streptococcal infection. — Italian Society for Preventive and Social Pediatrics (SIPPS) (Italy)
- Avoid taking urine samples from children > 2 months with symptoms and signs of respiratory infection, unless the child is septic, predisposed to urinary tract infection or has specific urinary tract symptoms. — Norwegian Society of paediatrics (Norway)
- Don’t administer steroids to children with acute pharyngitis. — Italian Society for Preventive and Social Pediatrics (SIPPS) (Italy)
TRAUMA/EMERGENCY
- Don’t routinely obtain CT scanning of children with mild head injuries.
— American Association of Neurological Surgeons and Congress of Neurological Surgeons (USA) - Don’t routinely repeat labs hemoglobin and hematocrit in the hemodynamically normal pediatric patients with isolated blunt solid organ injury.
— American Academy of Nursing (USA) - Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children.
— American College of Emergency Physicians (USA)
NEPHROLOGY
- Do not initiate an outpatient hypertension (HTN) work-up in asymptomatic pediatric patients prior to repeating the blood pressure measurement.
— American Academy of Pediatrics – Section on Nephrology and the American Society of Pediatric Nephrology (USA) - Do not place central lines or peripherally inserted central lines (PICC) in pediatric patients with advanced (Stage 3-5) chronic kidney disease (CKD)/end-stage renal disease (ESRD) without consultation with pediatric nephrology.
— American Academy of Pediatrics – Section on Nephrology and the American Society of Pediatric Nephrology (USA) - Do not initiate a work up for hematuria or proteinuria before repeating an abnormal urine dipstick analysis (UA).
— American Academy of Pediatrics – Section on Nephrology and the American Society of Pediatric Nephrology (USA) - Don’t order routine screening urine analyses (UA) in healthy, asymptomatic pediatric patients as part of routine well child care.
— American Academy of Pediatrics – Section on Nephrology and the American Society of Pediatric Nephrology (USA)
ORTHOPEDICS
- Do not order a screening hip ultrasound to rule out developmental hip dysplasia or developmental hip dislocation if the baby has no risk factors and has a clinically stable hip examination.
— American Academy of Pediatrics – Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (USA) - Do not order radiographs or advise bracing or surgery for a child less than 8 years of age with simple in-toeing gait.
— American Academy of Pediatrics – Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (USA) - Do not order custom orthotics or shoe inserts for a child with minimally symptomatic or asymptomatic flat feet.
— American Academy of Pediatrics – Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (USA) - Do not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory and plain radiographic examinations have been completed.
— American Academy of Pediatrics – Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (USA) - Do not order follow-up X-rays for buckle (or torus) fractures if they are no longer tender or painful.
— American Academy of Pediatrics – Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (USA) - Helmet therapy is not effective in the treatment of positional plagiocephaly in children, other treatment options should be considered and discussed with your patient.
— RCPCH (UK)
ENDOCRINOLOGY
- Avoid ordering LH and FSH and either estradiol or testosterone for children with pubic hair and/or body odor but no other signs of puberty. — American Academy of Pediatrics – Section on Endocrinology (USA)
- Avoid routinely measuring thyroid function and/or insulin levels in children with obesity. — American Academy of Pediatrics – Section on Endocrinology (USA)
- Avoid routinely ordering thyroid ultrasounds in children who have simple goiters or autoimmune thyroiditis. — American Academy of Pediatrics – Section on Endocrinology (USA)
- Avoid ordering Vitamin D concentrations routinely in otherwise healthy children, including children who are overweight or obese. — American Academy of Pediatrics – Section on Endocrinology (USA)
- Avoid ordering screening tests looking for chronic illness or an endocrine cause, including CBC, CMP, IGF-1, thyroid tests, and celiac antibodies, in healthy children who are growing at or above the 3rd percentile for height with a normal growth rate. — American Academy of Pediatrics – Section on Endocrinology (USA)
NEONATOLOGY
- Avoid routine screening term-equivalent or discharge brain MRIs in preterm infants.
— American Academy of Pediatrics – Section on Perinatal Pediatrics (USA) - Avoid routine daily chest radiographs without an indication for intubated infants.
— American Academy of Pediatrics – Section on Perinatal Pediatrics (USA) - Avoid routine use of pneumograms for pre-discharge assessment of ongoing and/or prolonged apnea of prematurity.
— American Academy of Pediatrics – Section on Perinatal Pediatrics (USA) - Don’t prescribe high-dose dexamthasone (0.5 mg/kg per day) for the prevention or treatment of bronchopulmonary dysplasia in pre-term infants.
— AAP (USA) - Avoid formula supplement in the first days of life for healthy, full term, breast-fed newborns without proved medical contraindications.
— Associazione Culturale Pediatri (ACP) (Italy)
RHEUMATOLOGY
- Don’t repeat a confirmed positive ANA in patients with established JIA or systemic lupus erythematosus (SLE).
— American College of Rheumatology – Pediatric Rheumatology (USA) - Don’t perform methotrexate toxicity labs more often than every 12 weeks on stable doses.
— American College of Rheumatology – Pediatric Rheumatology (USA) - Don’t routinely perform surveillance joint radiographs to monitor juvenile idiopathic arthritis (JIA) disease activity.
— American College of Rheumatology – Pediatric Rheumatology (USA) - Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.
— American College of Rheumatology – Pediatric Rheumatology (USA) - Don’t order autoantibody panels unless positive antinuclear antibodies (ANA) and evidence of rheumatic disease.
— American College of Rheumatology – Pediatric Rheumatology (USA)
OPHTHALMOLOGY
- Don’t order retinal imaging tests for children without symptoms or signs of eye disease.
— American Association for Pediatric Ophthalmology and Strabismus (USA) - Don’t routinely order imaging for all patients with double vision.
— American Association for Pediatric Ophthalmology and Strabismus (USA) - Don’t recommend vision therapy for patients with dyslexia.
— American Association for Pediatric Ophthalmology and Strabismus (USA) - Annual comprehensive eye exams are unnecessary for children who pass routine vision screening assessments.
— American Association for Pediatric Ophthalmology and Strabismus (USA) - Don’t put asymptomatic children in weak reading glasses.
— American Association for Pediatric Ophthalmology and Strabismus (USA)
ALLERGOLOGY
- Don’t perform screening panels (IgE tests) for food allergies without previous consideration of the pertinent medical history.
— CW Canada (Canada) - Don’t perform screening panels for food allergies without previous consideration of medical history.
— AAP (USA) - Do not routinely use test with IgE panels for food allergy.
— Noewegian paediatric society (Norway)
PULMOLOGY
- Do not routinely order chest X-rays for the diagnosis of asthma in children.
— RACP Paediatrics & Child Health Division (Australia) - Do not perform an x ray as a routine in a child that presents in the ER with an acute asthmatic attack.
— Unknown (Israel) - Do not perform chest X-ray in a child with suspected non-severe community-acquired pneumonia or with uncomplicated acute asthma.
— Società Italiana per le Malattie Respiratorie Infantili (SIMRI) (Italy) - Do not order chest radiographs in children with asthma or bronchiolitis.
— Society of Hospital Medicine (USA) - Do not prescribe antihistamines for preventing asthma in children.
— Italian Society for Pediatric Respiratory Diseases (SIMRI) (Italy) - Asthma should not be diagnosed without performing spirometry.
— Italian Society for Pediatric Respiratory Diseases (SIMRI) (Italy)
INVESTIGATIONS
- Do not do a Chest X ray without a clear clinical suspicion.
— Società Italiana per le Malattie Respiratorie Infantili (SIMRI) (Italy) - Infant home apnea monitors should not be routinely used to prevent sudden death syndrome (SIDS).
— AAP (USA) - Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.
— AAP (USA) - It is not recommended to perform imaging studies in a simple febrile convulsions.
— Unknown (Israel) - Do not perform, routinely, electroencephalogram or studies of neuroimaging (CT, MRI), in children with simple febrile convulsion.
— Spanish Association of Pediatrics (Spain) - Don’t routinely order an EEG on neurologically healthy children who have a simple febrile seizure.
— American Academy of Nursing (USA) - Don’t apply continuous cardiac-respiratory or pulse oximetry monitoring to children and adolescents admitted to the hospital unless condition warrants continuous monitoring based on objectively scored cardiovascular, respiratory, and behavior parameters.
— American Academy of Nursing (USA) - Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.
— Society of Hospital Medicine (USA) - It is not recommended to check vitamin D levels in healthy children.
— Unknown (Israel) - Do not repeat hemoglobin electrophoresis (or equivalent) in patients who have a prior result and who do not require therapeutic intervention or monitoring of hemoglobin variant levels.
— American Society for Clinical Pathology (USA)
NEUROLOGY
- Buccal midazolam or lorazepam should be in the treatment of prolonged seizures in young people and children, as these are the most effective treatments, in preference to rectal and intravenous diazepam.
— RCPCH (UK) - Don’t routinely order a head CT to assess for shunt failure in children with hydrocephalus.
— American Academy of Nursing (USA) - Do not use topic nasal therapy by micronized nasal douche using drugs not specifically authorized for this type of treatment.
— Federazione Italiana medici pediatri (Italy) - Avoid routine testing for antiepileptic drug (AED) levels in people with epilepsy.
— American Epileply Society (USA)
USEFUL RESOURCES
AND LINKS
National pediatric websites
Animations and videos
Suggested reading (22)
- Ahn HS, Welch HG. South Korea’s Thyroid-Cancer “Epidemic”–Turning the Tide. N Engl J Med. 2015;373:2389-90. https://doi.org/10.1056/nejmc1507622
- Born KB, Levinson W. Choosing Wisely campaigns globally: A shared approach to tackling the problem of overuse in healthcare. J Gen Fam Med. 2019;20:9-12. https://doi.org/10.1002/jgf2.225
- Bressan S, Romanato S, Mion T, Zanconato S, Da Dalt L. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19:801-7. https://doi.org/10.1111/j.1553-2712.2012.01384.x
- Brodersen J, Kramer BS, Macdonald H, Schwartz LM, Woloshin S. Focusing on overdiagnosis as a driver of too much medicine. BMJ. 2018;362:k3494. https://doi.org/10.1136/bmj.k3494
- Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307:1801-2. https://doi.org/10.1001/jama.2012.476
- Davies I, Burman-Roy S, Murphy MS, Guideline Development G. Gastro-oesophageal reflux disease in children: NICE guidance. BMJ. 2015;350:g7703. https://doi.org/10.1136/bmj.g7703
- Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2014:CD001266. https://doi.org/10.1002/14651858.cd001266.pub4
- Grossman Z, Hadjipanayis A, Stiris T, Del Torso S, Mercier JC, Valiulis A, Shamir R. Vitamin D in European children-statement from the European Academy of Paediatrics (EAP). Eur J Pediatr. 2017;176:829-31. https://doi.org/10.1007/s00431-017-2903-2
- Ho T, Dukhovny D, Zupancic JA, Goldmann DA, Horbar JD, Pursley DM. Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value. Pediatrics. 2015;136:e482-9. https://doi.org/10.1542/peds.2015-0737
- Jolley DL, Upham B, Fullerton L, Annett RD. Reduction in Head Computed Tomography Ordering in Pediatric Emergency Patients: Effect of National Publication and Local Availability of Urgent Neurology Appointments. Pediatr Emerg Care. 2019;35:199-203. https://doi.org/10.1097/pec.0000000000001757
- Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Jr., Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL, Pediatric Emergency Care Applied Research N. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-70. https://doi.org/10.1016/s0140-6736(09)61558-0
- Lightdale JR, Gremse DA, Section on Gastroenterology H, Nutrition. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 2013;131:e1684-95. https://doi.org/10.1542/peds.2013-0421
- Manrai AK, Patel CJ, Ioannidis JPA. In the Era of Precision Medicine and Big Data, Who Is Normal? JAMA. 2018;319:1981-2. https://doi.org/10.1001/jama.2018.2009
- Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ. 2002;324:886-91.
- Moynihan R, Smith R. Too much medicine? BMJ. 2002;324:859-60. https://doi.org/10.1136/bmj.324.7342.886
- Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018;66:516-54. https://doi.org/10.1097/mpg.0000000000001889
- Sattar N, Welsh P, Panarelli M, Forouhi NG. Increasing requests for vitamin D measurement: costly, confusing, and without credibility. Lancet. 2012;379:95-6. https://doi.org/10.1016/s0140-6736(11)61816-3
- Schilling FH, Spix C, Berthold F, Erttmann R, Fehse N, Hero B, Klein G, Sander J, Schwarz K, Treuner J, Zorn U, Michaelis J. Neuroblastoma screening at one year of age. N Engl J Med. 2002;346:1047-53. https://doi.org/10.1056/nejmoa012277
- Coon ER, Quinonez RA, Moyer VA, Schroeder AR. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics. 2014;134:1013-23. https://doi.org/10.1542/peds.2014-1778
- Coon ER, Young PC, Quinonez RA, Morgan DJ, Dhruva SS, Schroeder AR. Update on Pediatric Overuse. Pediatrics. 2017;139. https://doi.org/10.1542/peds.2016-2797
- Coon ER, Young PC, Quinonez RA, Morgan DJ, Dhruva SS, Schroeder AR. 2017 Update on Pediatric Medical Overuse: A Review. JAMA Pediatr. 2018;172:482-6. https://doi.org/10.1542/peds.2016-2797
- Quinonez RA, Coon ER, Schroeder AR, Moyer VA. When technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis. BMJ. 2017;358:j3850. https://doi.org/10.1136/bmj.j3850