The American Society of Hematology (ASH) and the American Society of Pediatric Hematology/Oncology (ASPHO) recently collaborated to create a pediatric-focused list for the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine Foundation.1 In partnership with leading national medical societies, Choosing Wisely aims to promote dialogue between clinicians and patients to help prevent unnecessary medical procedures.2

Using an evidence-based approach, the ASH-ASPHO Task Force agreed on 5 hematologic tests and treatments that providers and patients should question due to a lack of supporting evidence and associated risk and cost with unlikely benefit.1 The resulting ASH-ASPHO Choosing Wisely recommendations are summarized below:

Recommendation 1: Avoid routine preoperative hemostatic testing such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) in otherwise healthy children with no personal or family history of bleeding.


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As untargeted screening does not effectively detect the risk of perioperative bleeding, providers should conduct a thorough patient history to identify signs and/or symptoms of abnormal bleeding. Delaying surgical procedures due to abnormal hemostatic testing may ”cause harm by inducing stress and anxiety in patients and families and lead to inefficiencies in use of resources,” as in cases of same-day cancellations of scheduled procedures, according to the paper.1

“This recommendation is the one closest to my heart,” said lead author Sarah H. O’Brien, MD, pediatric hematologist, researcher, and associate professor of pediatrics at the Nationwide Children’s Hospital and the Ohio State University Wexner Medical Center in Columbus, OH. “In practice, I’ve seen patients scheduled for tonsillectomy and it’s canceled at the last minute because someone sees a lab value that makes them uncomfortable—I’ve even had patients already sedated and in the OR when the surgery was canceled.”

Recommendation 2: Avoid platelet transfusion in asymptomatic children aged 1 year or older with hypoproliferative thrombocytopenia and a platelet count >10 × 103/μL unless an invasive procedure is planned or the patient develops signs and/or symptoms for bleeding.

In such cases, attainment of platelet thresholds above 10 × 103/μL are not associated with a reduction in bleeding risk, and patients may experience serious adverse effects after multiple platelet transfusions. In addition, platelets “are an expensive, resource-intensive, biologic product, and the stewardship of this life-supporting, limited blood supply is critical to patient safety,” the authors wrote.This recommendation aligns with those of several other medical organizations calling for the prudent use of platelet transfusions.1

Recommendation 3: Avoid inherited thrombophilia (IT) testing in children with catheter-related thrombosis and no positive family history of thrombosis.

While venous catheters represent the most common risk factor for provoked pediatric thrombosis, a 2016 meta-analysis of 1279 children with central venous catheters (CVCs) found a low prevalence of thrombophilia and a weak association with CVC-associated venous thromboembolism (VTE).3

IT testing is also costly, potentially harmful in cases of misinterpretation, and results do not inform the “initial anticoagulation management of children with their first episode of provoked VTE from any acquired cause, as suggested in the ASH 2018 guidelines for pediatric VTE,” the researchers stated in the report.1,4

Recommendation 4. Avoid transfusion of packed red blood cells (pRBCs) in asymptomatic children with iron deficiency anemia (IDA) in the absence of evidence for active bleeding or hemodynamic instability.

Administration of pRBCs does not ensure resolution of IDA and exposes patients to risks such as transfusion reactions and blood-borne infections. For patients with severe IDA, effective treatment consists of oral or intravenous iron supplementation to replenish iron stores while addressing the underlying etiology of IDA.1

“In hematology, we have more experience with iron now and can use it to prevent the need for blood transfusions in most of our patients,” Dr O’Brien said. “How pediatricians can help with that is when they see a patient in the office with severe IDA, rather than send them to the ER, they can call hematology and we can help triage over the phone where the patient should be—maybe the patient can be seen in clinic the next day.”

Recommendation 5. Avoid routine administration of granulocyte colony-stimulating factor (G-CSF) for prophylaxis of children with asymptomatic autoimmune neutropenia (AIN) and no history of recurrent or severe bacterial or fungal infections.

A large cohort study showed no association between the presence or absence of antineutrophil antibodies and the risk of infection in children with AIN, and G-CSF administration in children with AIN showed no clear benefit in reducing infection rates in 2 recent studies.5,6

Furthermore, the authors explained that the “unnecessary routine use of G-CSF could lead to intolerable adverse effects, such as bone pain from excess neutrophil pool expansion in the marrow, injection site pain or infection, and avoidable health care costs.”1

Regarding next steps in this area, Dr O‘Brien noted that “many of the items on the Choosing Wisely list fall under the purview of hematologists, but we need to get the word out to surgeons as well.” In the future, it would be “great to take a look at our pediatric oncology practices and find opportunities for reducing harm and costs and unnecessary testing.”

References

  1. O’Brien SH, Badawy SM, Rotz SJ, et al. The ASH-ASPHO Choosing Wisely Campaign: 5 hematologic tests and treatments to question. Blood Adv. 2022;6(2):679-685. doi:10.1182/bloodadvances.2020003635
  2. Choosing Wisely. Our mission.  Accessed February 18, 2022.
  3. Neshat-Vahid S, Pierce R, Hersey D, Raffini LJ, Faustino EV. Association of thrombophilia and catheter-associated thrombosis in children: a systematic review and meta-analysisJ Thromb Haemost. 2016;14(9):1749-1758. doi:10.1111/jth.13388
  4. Monagle P, Cuello CA, Augustine C, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism. Blood Adv. 2018;2(22):3292-3316. doi:10.1182/bloodadvances.2018024786
  5. Farruggia P, Fioredda F, Puccio G, et al. Idiopathic neutropenia of infancy: data from the Italian Neutropenia Registry. Am J Hematol. 2019;94(2):216-222. doi:10.1002/ajh.25353
  6. Kirk SE, Grimes AB, Shelke S, Despotovic JM, Powers JM. The cost of a “benign” condition: healthcare utilization and infectious outcomes in young children with primary autoimmune neutropenia. Pediatr Blood Cancer. 2020;67(4):e28146. doi:10.1002/pbc.28146