Prior to utilizing medical therapies and practices to manage asthma and sleep disorders in children, pediatricians and families should consider the new guidance from Choosing Wisely, according to the American Academy of Pediatrics (AAP). The list, “Five Things Physicians and Patients Should Question,” was developed by members of the AAP Section on Pediatric Pulmonology and Sleep Medicine.

Choosing Wisely is an American Board of Internal Medicine (ABIM) Foundation initiative that creates recommendation lists aimed to enhance communication between clinicians and patients. Recommendations put forth promote choosing evidence-based care, improving the quality of care patients receive, and reducing medical waste. 

In the recently published guidance, 5 main evidence-based recommendations regarding therapies and practices used to treat asthma and sleep disorders in pediatric patients were highlighted. The first point discusses the importance of evaluating a patient’s current asthma therapy prior to stepping up treatment. It is suggested that providers review medication adherence and device technique with the patient’s family, as well as obtain a refill history from the patient’s pharmacy, before making treatment changes.

Additionally, the AAP recommends against the use of long-acting beta agonist (LABA)/steroid combination drugs as initial therapy for children with intermittent or mild persistent asthma; these should be reserved for those with moderate or severe persistent asthma. 

The third point on the Choosing Wisely list states that nebulized medications should not be administered by the “blow by” technique or by putting the mask or nebulizer tubing close to the patient’s nose and mouth, rather than securing it properly to the face. Instead, it is recommended that a t-piece with a mouthpiece or face mask be used.

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The fourth item on the list pertains to pediatric sleep studies. According to the guidance, these studies should be performed in sleep labs that have experience with children. Prior to making a referral, it is suggested that physicians inquire about the level of experience the sleep lab personnel have with pediatric patients. Moreover, results obtained from the sleep study should not be interpreted using adult standards, as there are differences in values for adults and children.

Lastly, the AAP recommends against the routine use of airway clearance therapy for patients with asthma, bronchiolitis, or pneumonia since there is limited evidence for it in the management of acute respiratory problems or for any chronic condition in the outpatient setting other than bronchiectasis.

Additional information, including the rationale behind this list, can be found on the Choosing Wisely website.


  1. Make wise choices in pediatric pulmonology, sleep medicine. AAP News. Accessed August 31, 2020.
  2. American Academy of Pediatrics. Five Things Physicians and Patients Should Question.