American Academy of Pediatrics

Ten Things Physicians and Patients Should Question

Released February 21, 2013 (1-5) and March 17, 2014 (6-10); #1, 3, 9 updated July 13, 2016; #1, 2, 4, 5 and 10 updated June 12, 2018; Last reviewed 2022

  1. 1

    Antibiotics should not be used for viral respiratory illnesses (sinusitis, pharyngitis, bronchitis and bronchiolitis).

    Antibiotics should not be used for upper respiratory illnesses characterized by congestion, cough, or pharyngeal pain unless criteria for bacterial sinusitis or Group A streptococcal pharyngitis are met. The vast majority of these infections are caused by viruses.


    Respiratory infections account for the majority of antibiotic prescriptions for children, and it is estimated that 50% of antibiotic prescriptions for respiratory infections in children are unnecessary. Antibiotic use for viral respiratory illnesses not only leads to higher healthcare costs and more adverse events, but also can lead to antibiotic resistance.

  2. 2

    Cough and cold medicines should not be prescribed, recommended or used for respiratory illnesses in young children.

    Research has shown these products offer little benefit to young children and can have potentially serious side effects. Many cough and cold products for children have more than one ingredient, increasing the chance of accidental overdose if combined with another product.

  3. 3

    Computed tomography (CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.

    Minor head injuries occur commonly in children and adolescents. Approximately 50% of children who visit hospital emergency departments with a head injury are given a CT scan, many of which may be unnecessary. Unnecessary exposure to x-rays poses considerable danger to children including increasing the lifetime risk of cancer because a child’s brain tissue is more sensitive to ionizing radiation. Unnecessary CT scans impose undue costs to the health care system. Clinical observation prior to CT decision-making for children with minor head injuries is an effective approach.

  4. 4

    Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.

    Imaging, including head CT, brain MRI, and skull films are associated with some risk and do not help with diagnosis or treatment of simple febrile seizures. MRI is associated with risks from required sedation and high cost. Head CTs can slightly increase the long-term risk for cancer.

  5. 5

    Computed tomography (CT) scans are not always necessary in the routine evaluation of abdominal pain.

    CT imaging in the emergency department evaluation of children with abdominal pain is frequent and can be inconsistently used, including overused. While radiation is necessary to perform a CT scan, there is both misunderstanding and often concern about the radiation necessary and the debate over the potential long-term development of cancer from this radiation. There also is the potential for an unnecessary amount of radiation from inappropriately performed CT examinations, as there are unique approaches and considerations with CT examinations in children that allow for lower radiation doses. CT can be very valuable in the setting of pediatric abdominal pain, but only when it is the correct test to do at the time (as opposed to waiting, or using another test that does not depend on ionizing radiation especially ultrasound), and performed in the right way (child-sized CT techniques).

  6. 6

    Don’t prescribe high-dose dexamthasone (0.5 mg/kg per day) for the prevention or treatment of bronchopulmonary dysplasia in pre-term infants.

    High-dose dexamethasone (0.5 mg/kg day) does not appear to confer additional therapeutic benefit over lower doses and is not recommended. High doses also have been associated with numerous short- and long-term adverse outcomes, including neurodevelopmental impairment.

  7. 7

    Don’t perform screening panels for food allergies without previous consideration of medical history.

    Ordering screening panels (IgE tests) that test for a variety of food allergens without previous consideration of the medical history is not recommended. Sensitization (a positive test) without clinical allergy is common. For example, about 8% of the population tests positive to peanuts but only approximately 1% are truly allergic and exhibit symptoms upon ingestion. When symptoms suggest a food allergy, tests should be selected based upon a careful medical history.

  8. 8

    Avoid using acid blockers and motility agents such as metoclopramide (generic) for physiologic gastroesophageal reflux (GER) that is effortless, painless, and not affecting growth.  Do not use medication in the so-called “happy-spitter.”

    There is scant evidence that gastroesophageal reflux (GER) is a causative agent in many conditions though reflux may be a common association. There is accumulating evidence that acid-blocking and motility agents such as metoclopramide (generic) are not effective in physiologic GER. Long-term sequelae of infant GER is rare, and there is little evidence that acid blockade reduces these sequelae. The routine performance of upper gastrointestinal (GI) tract radiographic imaging to diagnose GER or gastroesophageal disease (GERD) is not justified. Parents should be counseled that GER is normal in infants and not associated with anything but stained clothes. GER that is associated with poor growth or significant respiratory symptoms should be further evaluated.

  9. 9

    Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteriuria.

    There is no evidence that surveillance urine cultures or treatment of asymptomatic bacteriuria is beneficial. Surveillance cultures are costly and produce both false positive and false negative results. Treatment of asymptomatic bacteriuria is harmful and increases exposure to antibiotics, which is a risk factor for subsequent infections with a resistant organism. This also results in the overall use of antibiotics in the community and may lead to unnecessary imaging.

  10. 10

    Infant home apnea monitors should not be routinely used to prevent sudden death syndrome (SIDS).

    There is no evidence that the use of infant home apnea monitors decreases the incidence of SIDS and should not be used routinely for this purpose; however, they might be of value for selected infants at risk for apnea or cardiovascular events after discharge.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Academy of Pediatrics is an organization of 62,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults.

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How This List Was Created

The American Academy of Pediatrics (AAP) employed a three-stage process to develop its list. Using the Academy’s varied online, print and social media communication vehicles, the first stage invited leadership of the Academy’s 88 national clinical and health policy-driven committees, councils and sections to submit potential topics via an online survey. The second stage involved expert review and evaluation of the management groups that oversee the functions of the committees, councils and sections. Based on a set of criteria (evidence to document unproven clinical benefit, potential to cause harm, over-prescribed and utilized, and within the purview of pediatrics) a list of more than 100 topics was narrowed down to five. Finally, the list was reviewed and approved by the Academy’s Board of Directors and Executive Committee.

AAP’s disclosure and conflict of interest policy can be found at


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    Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles III S, Hernandez-Cancio S.  Clinical practice guideline for the diagnosis, management, and prevention of bronchiolitis.  Pediatrics. Nov 2014;134(5):e1474-502.

    Fleming-Dutra KE, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA 2016; 1864-73.

    American Academy of Pediatrics. Antimicrobial resistance and antimicrobial stewardship: appropriate and judicious use of antimicrobial agents.  In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2018:906-913-880.

  2. Carr BC. Efficacy, abuse, and toxicity of over-the-counter cough and cold medications in the pediatric population. Currt Opin Pediatrics. 2006 Apr;18(2):184–88.

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    Kuppermann N, Holmes, JF, Dayan PS, Hoyle JD Jr, Atabaki SM, et al Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low-risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet. 2009 Oct;374(9696):1160–70.

    Nigrovic LE, Schunk JE, Foerster A, Cooper A, Miskin M, Atabaki SM, Hoyle J, Dayan PS, Holmes JF, Kuppermann N, Traumatic Brain Injury Group for the Pediatric Emergency Care Applied Research Network. The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Pediatrics [Internet]. 2011 Jun;127(6):1067–1073.

    Ryan ME, Palasis S, Saigal G, Singer AD, Karmazyn B, Dempsey ME, Dillman JR, Dory CE, Garber M, Hayes LL, Iyer RS, Mazzola CA, Raske ME, Rice HE, Rigsby CK, Sierzenski PR, Strouse PJ, Westra SJ, Wooten-Gorges SL, Coley BD. Appropriateness criteria head trauma—child. J Am Coll of Radiol. Oct 2014;11(10):939-47.

    Borland ML, Dalziel SR, Phillips N, Dalton S, et al on behalf of the Paediatric Research in Emergency Department International Collaborative Group. Vomiting with head trauma and risk of traumatic brain injury. Pediatrics. 2018 Apr; 141(4) e20173123.

  4. American Academy of Pediatrics. Subcommittee on Febrile Seizures. Febrile Seizures: Guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics [Internet]. 2011 Feb;127(2):389–394.

    Matthews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. Cancer risks in 680,000 people exposed to computed-tomography scans in childhood and adolescence: data linkage student of 11 million Australians. BMJ 2013 May 21;346:f2360.

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    Broder JS, Frush DP. Content and style of radiation risk communication for the pediatric patients. J Am Coll Radiol 11(3):238-42, 2014.

    Frush DP, Frush KS, Oldham KT. Imaging of acute appendicitis in children: EU versus U.S. … or US versus CT? A North American perspective. Pediatr Radiol. 39(5):500-5, 2009.

    Horner KB, Jones A, Wang L, Winger DG, Marin JR.Variation in advanced imaging for pediatric patients with abdominal pain discharged from the ED. Am J Emerg Med. 2016 Dec;34(12):2320-2325.

    Niles LM, Goyal MK, Badolato GM, Chamberlain JM, Cohen JS. US Emergency Department Trends in Imaging for Pediatric Nontraumatic Abdominal Pain. Pediatrics. 2017 Oct;140(4). pii: e20170615. doi: 10.1542/peds.2017-0615. Epub 2017 Sep 15.

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    Larson DB, Johnson LW, Schnell BM, et al. Rising use of CT in child visits to the emergency department in the United States, 1995-2008. Radiology. 2011 Jun;259(3):793-801.

    Niles LM, Goyal MK, Badolato GM, Chamberlain JM, Cohen JS. US emergency department trends in imaging for pediatric nontraumatic abdominal pain. Pediatrics. 2017; 140: Epub 2017 Sep 15.

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  6. Watterberg KL; American Academy of Pediatrics Committee on Fetus and Newborn. Postnatal corticosteroids to prevent or treat bronchopulmonary dysplasia. Pediatrics. 2010 Oct;126(4):800–8.

  7. Sicherer SH, Wood RA; American Academy of Pediatrics Section on Allergy and Immunology. Allergy testing in childhood: using allergen-specific IgE tests. Pediatrics. 2012 Jan;129(1):193–7.

  8. Lightdale JR, Gremse DA; American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 2013 May;131(5):e1684–95.

  9. Kemper KJ, Avner ED. The case against screening urinalysis for asymptomatic bacteriuria in children. Am J Dis Child. 1992 Mar;146(3):343–6.

    Nicolle LE. Asymptomatic bacteriuria: when to screen and when to treat. Infect Dis Clin North Am. 2003 Jun;17(2):367–94.

    Roberts KB, Downs SM, Finnell SM, Hellerstein S, Shortliffe LD, Wald ER, Zerin JM.  American Academy of Pediatrics Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics.  Sep 2011;128(3):595–610. (Reaffirmed: Pediatrics. Dec 2016;138(6):e20163026.)

  10. Moon RY; American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: updated 2016  recommendations for a safe infant sleeping environment. Pediatrics. 2016 Nov;138(5):e20162938.