Saturday, June 18, 2011

Munchausen's by Doctor: A Previously Unrecognized Entity

One of the most important jobs of a pediatrician is to imbue parents with self-confidence. Instead, we often confuse them, scare them and fill them with self-doubt. This can have a long-term detrimental effect on the parent-child relationship. Parents whose child experienced an illness early in life can fall prey to the Vulnerable Child Syndrome, where they perceive that their now healthy child is still somehow medically fragile and prone to illness. This not only can result in unnecessary medical interventions; it can lead to behavioral and developmental problems in the child.

Why do doctors create the belief that children are ill when they are not? For starters, with the exception of checkups, every encounter a child has with his physician results in a diagnosis. This is obligatory, as physician visits are compensated by insurance companies based on diagnostic codes that are catalogued in a constantly updated publication known as the International Classification of Disease Manual or ICDM. There is no code for "healthy child" or "normal", though there is code V65.5: "Person with feared complaint in whom no diagnosis was made" or "worried well". But physicians who use this code run the risk of not getting paid for the visit. Insurance companies view such encounters as superfluous. No, it's safer, from a financial standpoint, to report that the child was sick.

So most children are assigned an ersatz diagnosis to justify a medical visit. From the doctor's perspective, the diagnosis is tentative and plays more of a bookkeeping function than a medical one. There is danger in this. Diagnostic labels tend to stick. What was a provisional diagnosis, long discarded by the treating physician, becomes a permanent part of the medical record. And the diagnosis remains cemented in the parent's mind. That perfect little baby is no longer perfect. He has "Reflux". He is sick. He is vulnerable.

The tendency to diagnose illness in healthy children is also driven by the failure of many pediatricians to recognize the wide range of normal when it comes to children's behavior, development, growth, and pattern of expulsion of bodily contents from various orifices. Differences in doctors' confidence in their clinical skills, variations in comfort in dealing with uncertainty, and unique personality traits of the physician all lead to wide discrepancies in how symptoms are interpreted. I have met many a neurotic pediatrician who instinctively sees a tempest when a lonely cloud drifts across a blue sky. These doctors tend to have practices full of high strung parents.

In some instances doctors jump at the chance of making an "interesting diagnosis" to relieve the drudgery of seeing an endless parade of runny noses. In the television coverage of a recent devastating earthquake, I was surprised to learn that in order to keep search and rescue dogs from becoming discouraged, human volunteers hide in the rubble from time to time so that they can be "found". This is essential to keep the dogs keen and it has a salubrious effect on their psychological well-being. I believe doctors have the same need. If a "good find" is not available, a doctor will sometimes just make one up.

I once attended a drug company sponsored lecture featuring a distinguished visiting allergist at a restaurant with gaudy Victorian d├ęcor. Having arrived early, I was invited to dine with the scheduled speaker and a local family practitioner who had also come early for the talk. The family doctor, a kindly gentleman whose long face was exaggerated by his bald pate, started describing a very interesting case he had seen some weeks earlier.

A middle aged man presented to his office with a hacking cough. Further discussion brought to light that the patient owned a parrot. The family doctor paused for effect, smiled, leaned forward as if revealing a secret and said, "The gentleman had Psittacosis".

Psittacosis, also known as "parrot fever", is an infection caused by the bacteria Chlamydiophila Psittacci, which can be inhaled from bird droppings. The diagnosis is suspected based on history and physical and is confirmed by one of several blood tests.

"How interesting", said the allergist. "How did you make the diagnosis?"

The smile vanished from the family doctor's face. He straightened his spine and said, "Sir, he had a parrot!"

The gentleman may have had Psittacosis, but the family doctor fell a little short of proving the diagnosis. And he was offended by the allergist's query which in effect questioned the validity of his diagnosis. The family doctor was proud of having made the diagnosis of psittacosis. To suggest that the diagnosis was wrong was like finding a live person in the rubble of an earthquake, only to be told he is a stooge.

What I am suggesting is that doctors get an emotional high from doctoring. Medical students experience this when they successfully insert their first I.V. Residents are overjoyed when they succeed in performing a spinal tap on an infant on their first try. And many doctors in practice like to boast that they have a high proportion of ill children on their patient panel.

There is nothing wrong in deriving pleasure from helping your fellow man, after all it is a common motivator for pursuing a career in medicine. But we must be sure that the procedure we are doing is in the interest of the patient rather than for our own mental well-being. Along these lines, I believe there is a previously unrecognized phenomenon that I have dubbed "Munchausen's syndrome by doctor".

Munchausen's syndrome, named after Baron Karl Friedrich von Munchausen, an eighteenth century German nobleman with a penchant for telling fantastic tales of his implausible feats and unbelievable exploits, is a condition in which an individual fabricates symptoms in order to receive medical care. It must be distinguished from malingering, which is the feigning of illness in order to gain a surreptitious objective (such as skipping work or defrauding an insurance company) in that the entire goal is to be a patient and assume the role of the infirm. It is also distinct from conversion disorder, an involuntary condition with psychological underpinnings in which an individual perceives symptoms consistent with a morbid condition even when the condition is not present.
Munchausen syndrome by proxy is a form of child abuse in which an adult (usually a parent) fabricates symptoms or induces illness in a child so as to get attention and fulfill a pathologic psychological need. Some parent groups argue that there is no such thing as Munchausen's by proxy, that it is a diagnosis invented by a callous medical establishment that is unsympathetic to the plight of parents whose children have true medical needs. Yet there is ample documentation, including the use of covert video surveillance in the hospital setting, that shows parents suffocating, poisoning and producing fractures in their own children.

I believe that there is a Munchausen Syndrome by doctor, where a perfectly healthy child is diagnosed with, and treated as having a disease for the pure psychological need of the treating physician. The parent becomes an unwitting accomplice, becoming thoroughly convinced that their child is terribly ill, always on the brink of a medical catastrophe, requiring multiple daily medications to allay a crisis. These children tend to be labeled with several diagnoses from a limited pool, most frequently asthma, gastro-esophageal reflux, gluten insensitivity, recurrent infections (bronchitis, sinusitis and ear infections), and allergies to multiple foods and medications. The child frequently presents to the Emergency Room with a shopping bag full of medications, often including Metoclopramide, Lansoprazole, Fluticasone, Montelukast, Levalbuterol, Tacrolimus, antihistamines and the ubiquitous antibiotic. And the child looks completely well despite the parents' and referring doctor's anxiety. And stopping the pharmaceuticals results in no ill effect.

I believe that Munchausen's syndrome by doctor is far more common than Munchausen by proxy, which has been estimated to affect 2 out of 100,000 children. As in Munchausen by proxy, there are, in my opinion, certain personality traits that are more common in those doctors that perpetrate Munchausen syndrome by doctor. These individuals are basically insecure, and try to compensate by interpreting every symptom in its most malicious form, falling victim to a neurotic paranoia which can be kept at bay only through the incessant ordering of laboratory studies and the prescription of treatment upon treatment. The offices of these doctors are almost always full, seeing as each patient requires frequent visits. And they attract ever more individuals who, in their state of anxiety, are oddly reassured by being told that their child is ill; but at least they are in the hands of a doctor that will see them over and over, and who will provide the most aggressive treatments (whereas the other doctor just kept telling them there was nothing wrong with their child).

Convincing a parent that her child is ill is a treacherous threshold to cross. The perception that one's child is ill always alters the way the parent views and treats her child. It can undermine the confidence and sabotage the effectiveness of a parent. Again, one of the most important jobs a pediatrician has is to reassure parents so they can be more effective and self-confident, yet we frequently do the opposite, either as a result of our own insecurity, out of sheer ignorance and, on occasion, because of a pathologic impulse to feel needed, appreciated and valuable.

Dr. Palmieri is a board-certified pediatrician and the author of "Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care".

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Friday, June 10, 2011

7 Medications Pediatricians Should Never Prescribe...But Still Do

Almost every visit to the pediatrician results in the prescription of one or more medications. As a parent, you'd like to trust that the medications your doctor prescribes for your child are selected based on careful reflection, and are not only effective, but safe. Unfortunately that's not always the case. As a board-certified pediatrician of sixteen years I regret to confess that many of the treatments we provide are ineffective, while others can cause grave harm. Too often, we doctors stray from accepted standards of care as a matter of expediency, the result of habit, or to satisfy perceived parental expectations. Nowhere is this so apparent as when a pediatrician prescribes a medication that experts agree should never be used by primary care doctors.

A medication that is shunned by pediatricians typically possesses one or more of the following features: it is not safe; it is not effective; its use has been supplanted by newer, better choices; pediatricians do not have the expertise required to prescribe the drug. Using these criteria, let us examine 7 medications that your pediatrician should never prescribe under any circumstance.


Pediatricians commonly use this medication for the treatment of nausea and vomiting that often accompany viral intestinal infections. Unfortunately, it doesn't work very well and it frequently produces drowsiness, dizziness and confusion: symptoms we'd like to avoid in a child whose mental status must be monitored as an indicator of dehydration. The intra-venous use of this medication has resulted in tragic events requiring the amputation of limbs due to the caustic nature of the drug, and is now prohibited in many hospitals. Fortunately, we have a much more effective medication at our disposal with a far better safety profile; which makes one wonder why some doctors still cling to Promethazine.

Cough suppressants:

The common cold is the most common ailment in childhood. It is natural to want to provide some relief to a child whose cough is keeping her from sleeping. Unfortunately, the cough medications we have at our disposal have not been shown to be effective in children and may cause unacceptable side-effects. Over the counter cough medicines almost universally include the active ingredient, Dextromethorphan (DM), whereas prescription versions may employ Codeine. Both these drugs are derivatives of opiates. Respiratory depression and behavioral problems have been observed in children taking these products, and in infants, overdoses have resulted in deaths.

In October 2007, the American Academy of Pediatrics proposed to the Food and Drug Administration that the following warning be included on the labeling of cough medications:
"This product has been shown to be ineffective in the treatment of cough and cold in children under six years of age. Serious adverse reactions, including but not limited to death have been reported with the use, misuse and abuse of this product." Inexplicably, many pediatricians continue to routinely prescribe these medications even to infants.

Dexamethasone eye drops:

This is an example of a medication that can be extremely efficacious, but which pediatricians should not prescribe because they lack the requisite expertise to use it safely. Dexamethasone is a steroid that is utilized for its anti-inflammatory properties. These eye drops are a powerful tool for a variety of conditions but require a careful eye exam by an ophthalmologist prior to their use. If applied in the midst of some eye infections, Dexamethasone-containing drops can exacerbate the infection and lead to irreparable eye injury. This medication is best left to the eye specialists.

Nystatin with Triamcinolone Combination Cream:

Sometimes the sum of the parts is less than the individual parts. Nystatin is a useful topical antifungal, routinely used to treat diaper rashes that have an overgrowth of yeast. Triamcinolone is a potent steroid cream that is effective in treating a variety of inflammatory conditions of the skin, including eczema. The problem arises when these two medications are combined. Doctors, wanting to add some anti-inflammatory effect in the treatment of a yeast rash, or uncertain as to whether the rash is the result of a fungal infection or due to plain inflammation, mistakenly instruct parents to use this product in the diaper area. The potency of all steroid creams is multiplied when applied to skin that is occluded by dressings, plastic wraps, or diapers. When applied under cover of a diaper, Triamcinolone can lead to ulcerations of the skin, which often intensify as a well-meaning parent continues to apply ever more cream in a frantic but futile attempt to alleviate the worsening rash. Only thin applications of far weaker steroid creams might be applied to this extremely delicate area of the body, and only after the careful consideration of potential risks and benefits.


A few decades ago, Cefaclor was one of the only oral preparations of a family of antibiotics known as the Cephalosporins, which are commonly used to treat a variety of childhood infections. This particular medication, however, has a much higher rate of allergic reactions compared to other drugs in its class, including a particularly severe complication known as Serum Sickness-Like Reaction, in which children develop rash, fever, swollen, painful joints, and other troubling symptoms. Furthermore, many bacteria have become resistant to this drug. In a large study published in 2003, out of 19 antibiotics tested, Cefaclor was the least likely to kill the most common bacterium implicated in ear infections, sinus infections and pneumonia. Academic medical centers have stopped using this medication some 20 years ago, but some doctors in the community just can't break the habit.

Albuterol Oral Syrup:

Albuterol by inhalation, either in an aerosol or inhaler form, remains the most important rescue medicine for the treatment of asthma attacks. When the medication is inhaled, it travels directly to receptors located on the walls of the respiratory airways, signaling muscle fibers to relax, thereby reducing bronchial constriction and improving the flow of air in and out of the lungs. The inhaled route maximizes the amount of medication delivered to its intended target and mitigates common side-effects, such as jitteriness and an accelerated heart rate, that are produced when the drug enters the bloodstream. When the oral formulation is used, the medication must first be absorbed from the intestinal tract into the circulation, by which it then travels throughout the body, with just a fraction of the ingested dose eventually finding its way onto the receptors of the airways. This is a highly ineffective delivery system that magnifies the side-effects while minimizing effectiveness. Albuterol oral syrup is often used not for asthma, but as a type of ersatz cough medicine; a practice that is a relic of the past.

Anti-Diarrhea Compounds:

Diarrhea is a common occurrence in childhood, most often the result of a viral gastroenteritis; what is commonly referred to as the "stomach flu". At times, it can be the result of bacterial dysentery. The key to the treatment of this usually self-limited but bothersome condition is to provide hydration and nutrition. Guidelines from the American Academy of Pediatrics and the Center for Disease Control and Prevention discourage the use of anti-diarrhea compounds due to their lack of efficacy and the potential for serious side-effects, including severe cramping, and temporary paralysis of the gut, which can lead to a concentration of bacteria and their toxins in the setting of dysentery. Unfortunately, many pediatricians are either unaware of, or choose to ignore these recommendations.

At its best, the practice of pediatrics incorporates scientific evidence, critical thinking, best practices, and accepted standards of care, while embracing humility and a deep compassion; ever cognizant of each child's unique constitution and the cultural values of his family. Too often, we doctors fall far short of this objective, particularly when we are rushed, when we don't take the time to listen patiently or examine carefully, or when we fall into the ruts of habit, not questioning what we think we know.

Sir William Osler, a renowned 19th century physician who practiced at a time where many of the treatments were ineffective and fraught with hazards, wrote, "One of the first duties of the physician is to educate the masses not to take medicine": an admonition that retains a clear ring of truth even in the 21st century. All medications have potential side-effects and, particularly in children, a wise philosophy is to use the fewest medications with the most favorable safety profile for the least amount of time.

Many childhood illnesses are self-resolving conditions that doctors should manage by providing comfort to the child and by counseling parents, rather than blithely dispensing prescriptions designed to subdue symptoms without a conscientious attempt at identifying the true nature of the underlying condition. We doctors must do better. The best parents can do is to become informed consumers of health-care, and never hesitate to question their doctor.

Dr. Palmieri is a board certified pediatrician and the author of Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care. His interests include patient safety and how cognitive errors lead to errors in diagnosis and treatment.