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CLINICAL REVIEW: Rita Sharma mother's view BMJ 2003; 327: 916-a [Full text]

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Clinical Diagnoses in Pediatrics

Kieran J. Phelan   (18 October 2003)

Clinical Diagnoses in Pediatrics 18 October 2003
Kieran J. Phelan, Asst. Prof. Pediatrics Cincinnati Children's Hospital Medical Center Send response to journal: Re: Clinical Diagnoses in Pediatrics	Dr. Sharma, I enjoyed your insights as a physician and parent. I have had similar guilt-ridden experiences as a parent and pediatrician myself. A comment I usually wait to make to parents in my clinic (physicians or otherwise)until the child is closer to 12 months is that there are often two seemingly universal aspects to parenting (and pediatrics) that advisors frequently neglect to mention: chronic intermittent feelings of guilt and fear. No matter how hard we try (as physicians and parents) there will always be the question: did we do it right and have we done enough? Clinical diagnoses in pediatrics, such as Kawasaki Disease and Attention Deficit Hyperactivity Disorder to name but two, are frought with a great degree of worry and stress on the part of parents and clinicians. The problem is that even though we have some seemingly beneficial therapies (IVIG and aspirin in the former and stimulants in the latter), the degree of objective certainty with which to make the diagnoses is unavailable (no blood, genetic, or other objective 'gold standard' test). Therefore, we are left with making these diagnoses on more clinical or subjective/experiential grounds. Kawasaki disease is particularly frustrating in that many of the usual viral illnesses contracted by children attending daycare or preschool can 'fit' the waste basket syndrome of 'atypical Kawasaki Disease'. I agree with the approach taken by your physician(s) in your daughter's case and it would do alot of parents and children a service, in my opinion, if less cases of 'atypical Kawasaki Disease' or 'atypical ADHD' were made in the clinical setting. In truely ambiguous cases one might look to individual patient trials or 'N of 1' trials in helping assure the diagnosis. Children in such trials are randomized to periods of placebo or medication in an effort to objectively assess reponse. In those who respond (eg a reduction in symptoms, sedimentation rate or C-reactive protein) to the active treatment, the diagnosis becomes more certain. Chronic, non-fatal diseases with rapid onset and offset of medication effect are the ideal ones (eg stimulants for ADHD) for such methods but with a little forethought and preparation, one can imagine such an approach for over-used diagnoses such as Kawasaki Disease. Competing interests: None declared