Paeds · clinical-assessment-and-reasoning
Incidental findings and overdiagnosis in children
Also known as Paediatric overdiagnosis · Incidentaloma in children · Cascade testing paediatrics · Overtesting children · Low-value paediatric care · Choosing Wisely paediatrics
A fellowship approach to incidental findings and overdiagnosis in children: plain definitions, cascade mechanisms, age-aware examples from imaging, laboratories, monitors and labels, bedside re-anchor, act-observe-stop algorithms, communication of residual risk, and safe restraint without missing time-critical disease.
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Target exams
Red flags
- Unexpected result plus evolving physiology, caregiver concern or high pre-test threat
- Incidental label used to end search while must-not-miss scripts remain open
- Cascade delaying resuscitation, source control or senior review
- Age-wrong reference intervals or contaminated samples treated as disease
- Continuous-monitor alarms driving treatment without bedside reassessment
- Discharge after a cascade with no residual-risk statement or follow-up owner
- Family anxiety escalating without clear explanation of what is and is not being chased
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Board mappings
- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 12: Communication with patients, families, and health professionals
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Clinical Applications
- Medical Sciences
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- 2. Professional skills and knowledge: Communication
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- Health promotion and illness prevention
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
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- General Pediatrics Content Outline — Domain 24: Patient Safety, Quality Improvement, and Research Methods
- General Pediatrics Content Outline — Universal Task 2: Epidemiology and Risk Assessment
- General Pediatrics Content Outline — Universal Task 3: Diagnosis
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- General Pediatrics EPA 8: Executing Clinical Handovers Within or Across Settings
- Patient Care 3: Organize and Prioritize Patient Care
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Medical Expert
- Pediatrics: Foundations EPA #1 — Recognizing deteriorating and/or critically ill patients and initiating stabilization and management
- Pediatrics: Foundations EPA #8 — Communicating assessment findings and management plans to patients and/or families
- Pediatrics: Foundations EPA #10 — Transferring clinical information between health care providers during handover
You ordered a test for one problem. The report answers a different question. A well-looking child now has an “abnormal” flag, a tiny lesion on imaging, or a monitor alarm. Families look at you. The trap is to treat the flag as if it were the patient. The skill is to decide, out loud, what this finding means for this child tonight. [1] [5]
Overview & Definition
Picture a school-age child who had a CT after trauma. The scan answers the trauma question. It also mentions a small renal cyst or a lung nodule the family never knew about. That unexpected result is an incidental finding — something unrelated to the question that prompted the test. [19] [5]
Overdiagnosis is different. It is the detection of a true abnormality that would not have caused symptoms or harm in that child’s lifetime, yet still triggers a disease label, further tests or treatment. Brodersen’s definitional work separates this from ordinary false positives and from underdiagnosis. [2] [1]
Newman-Toker’s unified model helps keep three errors distinct. Underdiagnosis misses disease that is present. Misdiagnosis applies the wrong label. Overdiagnosis applies a disease label to a condition that would not have mattered. You can harm a child with any of the three. [3]
Overtesting is ordering tests that were unlikely to help. Overtreatment is treating disease that did not need treatment, or treating with excess intensity. Cascades link them: one low-value test can manufacture a label that forces more care. [4] [6] [28]
Coon and colleagues framed the paediatric problem clearly: our compulsion for diagnosis can harm children through labels, procedures and anxiety even when natural history is mild. Ward Platt’s commentary places the same tension inside child health more broadly. [1] [26]
References28ShowHide
- [1]Coon ER Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics, 2014.PMID 25287462
- [2]Brodersen J Overdiagnosis: what it is and what it isn't. BMJ evidence-based medicine, 2018.PMID 29367314
- [3]Newman-Toker DE A unified conceptual model for diagnostic errors: underdiagnosis, overdiagnosis, and misdiagnosis. Diagnosis (Berlin, Germany), 2014.PMID 28367397
- [4]Deyo RA Cascade effects of medical technology. Annual review of public health, 2002.PMID 11910053
- [5]Ganguli I Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA network open, 2019.PMID 31617925
- [6]Størdal K Overtesting and overtreatment-statement from the European Academy of Paediatrics (EAP). European journal of pediatrics, 2019.PMID 31506723
- [7]Money NM 2021 Update on Pediatric Overuse. Pediatrics, 2022.PMID 35059726
- [8]Money NM 2019 Update on Pediatric Medical Overuse: A Systematic Review. JAMA pediatrics, 2020.PMID 32011675
- [9]Coon ER 2018 Update on Pediatric Medical Overuse: A Review. JAMA pediatrics, 2019.PMID 30776069
- [10]Jankauskaite L Overuse of medical care in paediatrics: A survey from five countries in the European Academy of Pediatrics. Frontiers in pediatrics, 2022.PMID 36177454
- [11]Jankauskaite L Over-investigation and overtreatment in pediatrics: a survey from the European Academy of Paediatrics and Japan Pediatric Society. Frontiers in pediatrics, 2024.PMID 38455393
- [12]Schuh S Evaluation of the utility of radiography in acute bronchiolitis. The Journal of pediatrics, 2007.PMID 17382126
- [13]Quinonez RA When technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis. BMJ (Clinical research ed.), 2017.PMID 28814557
- [14]Coon ER Continuous Physiologic Monitoring: False Alarms and Overdiagnosis. Journal of hospital medicine, 2018.PMID 29694451
- [15]Chi KW Parental Perspectives on Continuous Pulse Oximetry Use in Bronchiolitis Hospitalizations. Pediatrics, 2020.PMID 32675334
- [16]Looijmans-van den Akker I Overdiagnosis of asthma in children in primary care: a retrospective analysis. The British journal of general practice : the journal of the Royal College of General Practitioners, 2016.PMID 26917656
- [17]Kazda L Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review. JAMA network open, 2021.PMID 33843998
- [18]Coon ER Paediatric overdiagnosis modelled by coronary abnormality trends in Kawasaki disease. Archives of disease in childhood, 2018.PMID 29472194
- [19]Ugalde IT Incidental Findings on Computed Tomography in Children With Blunt Abdominal Trauma. Annals of emergency medicine, 2025.PMID 39846906
- [20]Sullivan G Brain 3T magnetic resonance imaging in neonates: features and incidental findings from a research cohort enriched for preterm birth. Archives of disease in childhood. Fetal and neonatal edition, 2024.PMID 38960453
- [21]Louie JP When less is more: Overdiagnosis and overtesting in pediatric febrile seizures in the adult emergency department. The American journal of emergency medicine, 2025.PMID 40532406
- [22]Størdal K Reducing the use of proton pump inhibitors in infants with reflux symptoms. BMJ (Clinical research ed.), 2024.PMID 38816024
- [23]Brändle G An Opinion on Medical Overuse in the Context of the European Academy of Paediatrics Choosing Wisely Initiative. Acta paediatrica (Oslo, Norway : 1992), 2026.PMID 41992654
- [24]Ray S Risk of over-diagnosis of hypotension in children: a comparative analysis of over 50,000 blood pressure measurements. Intensive care medicine, 2017.PMID 28526952
- [25]Merten EC Overdiagnosis of mental disorders in children and adolescents (in developed countries). Child and adolescent psychiatry and mental health, 2017.PMID 28105068
- [26]Ward Platt M Overdiagnosis and child health. Archives of disease in childhood, 2018.PMID 29643100
- [27]Clinker CE Preoperative Echocardiography in Pectus Excavatum: High Rate of Incidental Findings, Low but Clinically Important Yield of Significant Anomalies. Journal of pediatric surgery, 2025.PMID 40930387
- [28]Gram EG Less is more for patients, practitioners, public and planet: a taxonomy for the harms of too much medicine. BMJ evidence-based medicine, 2025.PMID 41047163