The Evidence Mismatch in Pediatric Surgical Practice

Purpose: Outpatient pediatric surgical practice often involves conditions of limited morbidity but significant parental concern. We explore existing evidence-based management recommendations and the mismatch with practice patterns for four common outpatient pediatric surgical conditions. Methods: Using the Cochrane Rapid Review Group recommendations and librarian oversight, we conducted a rapid review of 4 outpatient surgical conditions: dermoid cysts, epigastric hernias, hydroceles, and umbilical hernias. We extracted patient demographics, intervention details, outcome measures and evaluated justifications presented for chosen management options. A metric of evidence volume (patient/publication ratio) was generated and compared between diagnoses. Results: Out of 831 articles published since 1990, we identified 49 cohort studies (10-dermoid cyst, 6-epigastric hernia, 25-hydrocele, and 8- umbilical hernia). The 49 publications included 34,172 patients treated across 18 countries. The evidence volume for each out-patient condition demonstrates <1 cohort/condition/year. The evidence mismatch rate varied between 33-75%; many existing recommendations are not evidence-based, sometimes conflicting and frequently misrepresentative of clinical practice. Conclusions: Published literature concerning common outpatient pediatric surgical conditions is sparse and demonstrates wide variations in practice. All individual practice choices were justified using either risk of complications or patient preference. Most early intervention practices were based on weak or outdated studies and “common wisdom” rather than genuine evidence. Level of evidence: III