BMJ  2004;328 (3 January), doi:10.1136/bmj.328.7430.0-g

Editor's choice

A tough time for paediatricians

Paediatrics is a highly attractive specialty but also, as this issue shows, a tough one. Disease in the young is protean. Evidence is often lacking. The wrong intervention may lead to a lifetime of damage. And the sociology is complex: everybody is supposed to love children, but they are regularly abused. The British, for example, object vociferously to European attempts to stop them beating their children. "It never did me any harm," is the cry from people whose looks and behaviour belie their conviction.

One of Britain's most eminent paediatricians, Sir Roy Meadow, has been reported to the General Medical Council, the body that regulates British doctors, for his role as a prosecution witness in three trials where mothers were wrongly convicted of killing their babies (p 9). These convictions have all been overturned in the past year, and there may be a review of all cases in which Meadow gave evidence.

Meadow was one of the first to argue that some seeming cot deaths were the result of mothers deliberately harming their babies. There is no doubt that this happens, and little is more uncomfortable than the thought of a mother killing her child. But are such cases best dealt with by the courts? Giving evidence in such inevitably cloudy cases must be hard, particularly when the courts demand a binary outcome of guilty or not guilty. The process must be excruciating for the accused, their families, and those who must assemble and give evidence. The uncertainty that is normal in medicine clashes with the need of the courts for a certain answer.

The clash is further illustrated by a judge suggesting that photographs taken by colposcopy should not be used for second opinions in cases of possible child sex abuse (see bmj.com news extra). Doctors who examined a young girl judged that her hymen had been torn, and two experts who examined photographs agreed. Authorities have advised using photographs in order to avoid the trauma of further examinations, but when in the course of an appeal the two experts eventually examined the girl they decided her hymen was not torn.

Paediatric evidence of a different sort has come into question with the Committee on the Safety of Medicines advising against the use of most selective serotonin reuptake inhibitors (SSRIs) in people aged under 18 who are depressed (p 3). The fear is that the drugs may increase suicidal thoughts. The real problem is that there is hardly any research with these drugs in young people. The 40 000 or so children and adolescents in Britain taking antidepressants are doing so on the basis of evidence from a few hundred people.

If all this wasn't enough for paediatricians to worry about, in Britain they have also had to cope with the consequences of a television drama that seemed to strongly support the arguments that the measles, mumps, rubella (MMR) vaccine causes autism (p 50). Exactly what those consequences will be we must wait and see.

rsmith{at}bmj.com

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