January 13, 2016

Closing the knowledge gap on prevention in pediatrics


Does routine screening for autism, high cholesterol, and other problems improve kids’ health? We need better research to find out, Dr. Grossman says.

by David C. Grossman, MD, MPH, Senior Investigator, Group Health Research Institute

When physicians nationwide recommend routine screening tests during well-child visits, most parents assume the tests have been scientifically proven to improve children’s health. That is, the kids tested will experience more benefit than harm. Many parents may believe, for example, that it’s always best to test children early for problems like autism, high blood pressure, high cholesterol, and so on. After all, it can’t hurt. Right?

But for some tests, experts don’t actually know if the pros outweigh the cons—especially for healthy kids who show no symptoms. Many screening tests reliably identify targeted conditions and can lead to successful treatments. (Depression screening is a good example.) But we need to learn more about what can go wrong. Examples of potential harm include overdiagnosing children, thereby subjecting them to unnecessary drugs and procedures; exposing kids to psychosocial stresses such as anxiety and labeling; and causing financial stress on families as parents miss work or struggle to pay for follow-up care. Without a better understanding of evidence regarding both harms and benefits, we don’t know if routinely testing children with no symptoms leads to better health outcomes overall.

Such evidence gaps are common in most areas of medicine—but even more so in pediatric preventive care. To make recommendations on preventive screening, pediatricians and family physicians have relied heavily on their own experience and guidelines based on expert opinion. Often, they have not had the scientific evidence needed to support their recommendations. With my colleague, Dr. Alex R. Kemper, deputy editor of Pediatrics and a professor of pediatrics at Duke University, I recently addressed this problem in a “Perspectives” commentary Confronting the Need for Evidence Regarding Prevention for the journal.

Dr. Kemper and I believe that it’s high time that pediatricians and others advocate for better funding and execution of research to achieve a higher-quality evidence base in pediatric primary care. Better evidence would protect children from harm while giving providers better guidance for prioritizing services when time with patients is limited.

As members of the U.S. Preventive Services Task Force (USPSTF), Dr. Kemper and I are working with others to systematically review pediatric preventive services and identify those that need more evidence in order to support a clear recommendation. The USPSTF has provided the U.S. Congress a report summarizing the gaps that must be closed to improve the evidence prevention for children.

As we wrote in Pediatrics, “We need no less information on the optimal way to screen for hypertension in children than we do for hypertension in adults. We need more high-quality studies about the outcomes of early-identified cases of autism, including understanding the effectiveness of competing interventions. We should have as many trials and meta-analyses in prevention as we do for specialty treatments like cancer. We should not be afraid to question our current recommendations; for example, will 31 well-child visits (as recommended by the American Academy of Pediatrics) over a childhood lead to improved health outcomes compared with a lower or higher number?”

To learn more about our efforts, please read our commentary Confronting the Need for Evidence Regarding Prevention. And please join us in advocating for higher-quality evidence to improve preventive services for children.