When Paediatrics Gets It Wrong

Abstract

The former US president Barack Obama was once asked about his favourite book. He referred to a book about Abraham Lincoln and his practice of surrounding himself with cabinet members who disagreed with him and challenged him [1]. Unfortunately, some modern and historical episodes have not considered all the possible angles, and this has influenced medicine, including paediatrics, in a negative way. There have also been issues with dogmatic guidelines that have presented views strongly or positively, as if they were evidence based. Then there is the influence of groupthink, which is a psychological phenomenon that occurs when a group feel that they are special selected as if they were members of a noble English club [2]. They often find themselves on the moral correct side and have an inclination to become immune to critical thinking from the outside [2]. Preventing groupthink and dogmatism requires open, rational and critical discussions also about controversial issues, such as sudden infant death syndrome (SIDS). One book that got me thinking recently was by a new title by Dr. Marty Makary entitled Blind Spots: when Medicine Gets it Wrong, and What It Means for Our Health [1]. It echoed many of my own thoughts on key issues, including different guidelines within paediatrics.

The prominent American paediatrician Dr. Benjamin Spock (1903–1998) recommended that infants should not sleep on their backs, because of the risk of vomiting. Drawing on how adults were treated when they were in a coma, he recommended that infants should sleep in the prone position. However, this approach was associated with an actual increase in the rate of SIDS [3]. The guidelines were eventually changed at the start of the 1990s and Nordic paediatricians were among those who played an important role in changing Dr. Spock's recommendation. This case illustrate how eminence based knowledge had impact on paediatricians—even worldwide.

Paediatrics sometimes gets it really wrong, when preventive guidelines are based on consensus statements and groupthink rather than evidence-based medicine. One example is the claims, mainly in the USA, that peanuts caused allergies and severe asthma [1]. Guidelines issued by the American Academy of Paediatrics recommended that pregnant women and lactating mothers, as well as newborn infants should not be exposed to peanuts. These guidelines on total abstinence were supposed to prevent children from severe allergies and asthma [1].

When the AAP guidelines were published in Paediatrics in 2000, many American paediatricians advised mothers to abandon peanuts, to protect their children from future allergies and asthma. But the outcome was an unexpected increase in mild allergies and a huge increase in life-threatening asthma. However, American paediatricians maintained that if all parents complied with the AAP guidelines it would be possible to finally reduce peanut allergies [1]. However, it became clear that some parents did not follow the guidelines and their children developed allergies. It is possible that they then hesitated to contact healthcare professionals if their child exhibited allergic symptoms [1]. Interestingly, avoiding peanuts to protect children from allergic reactions even became the correct answer on US medical school tests and board exams [1].

One American paediatrician who did his residency at Duke Medical Center, did not follow the guidelines. Dr. Rebecca Buckley at the Duke Medical Center, recognised that the AAP guidelines violated a basic principle of immunology, namely tolerance, which is the body's natural way of accepting foreign molecules presented early on. It is like the dirt theory, whereby newborn infants exposed to dirt, dander and germs may run a lower risk of developing allergies. Dr. Buckley taught students and residents that abstaining from peanuts did not prevent peanut allergies, it caused them. Accordingly, she recommended that physicians did not follow the AAP guidelines [1].

These theoretical considerations were later supported by an empirical study by Lack et al., published in 2008, which compared children in Israel with Jewish children in UK [4]. But the results were apparently not sufficient to ‘uproot the groupthink among American paediatricians’ [1]. Wennergren commented on that paper in an editorial in Acta Paediatrica and concluded that the early introduction of peanuts and fish seemed to be better than avoidance [5]. But Lack et al.'s results were generally dismissed, at least in the US [1]. He and his group eventually initiated a randomised controlled trial (RCT) that showed that early exposure to peanuts prevented peanut allergies [6]. The results were published in 2015, 15 years after the AAP guidelines. However, the AAP guidelines were not revised for another 2 years, meaning that ‘an entire generation—millions of children—had been harmed by groupthink, and many are still feeling the effect’ [1].

The debate around peanuts and allergies illustrates that when paediatrics gets it wrong there are bad consequences for patients, medical education and residents. It shows how difficult it is to disagree with, or criticise, mainstream consensus and established guidelines. This issue also illustrates that academic education does not make prominent scientists immune against groupthink [2].

Another example of when paediatrics gets it wrong is that some clinicians have claimed that there are no downside to antibiotics. This claim has also been made in the US, where half of the prescriptions of antibiotics have been considered as unnecessary [1]. Sometimes the healthy balance of microorganisms in the gut is bombarded by antibiotics [1]. The subsequent effects are, at least hypothetically, that symptoms similar to issues like irritable bowel syndrome and inflammatory bowel diseases, might be caused. Moreover, the consequences of early treatments with antibiotics are suggested to be associated with a higher risks of conditions such as obesity, diabetes, asthma and celiac disease [1].

Over prescribing to very young infants might also have serious future consequences in childhood and adulthood. These consequences have not been sufficiently studied and represent blind spots within paediatrics but also within medicine in general. It is, however, particularly important within paediatrics because such gastrointestinal symptoms might be possible differential diagnoses in cases where a parent otherwise might be suspected for having induced or fabricated such symptoms (in cases of suspected factitious disorder imposed on another).

It is interesting to note that it was a randomised trial that resulted in the reversal of the peanut dogma and the AAP guidelines. This is a hopeful sign that even eminence-based guidelines that become dogmatic can eventually be changed. A well-conducted RCT poses the least risk of bias and accordingly represents the strongest evidence-based medicine. However, it is not always possible to conduct RCTs in all medical scenarios, such as diagnostic accuracy studies, for example, shaken baby syndrome. It would be difficult to question and critical discuss, for example, the AAP guidelines from the 2009 which amalgamated the diagnosis of shaken baby syndrome into the broader diagnosis of abusive head trauma [7]. But it is essential that clinicians and scientists who are prepared to disagree with controversial guidelines, are able to do so without risking their own career.

It sounds like a too optimistic attitude. But if we try and succeed, we might be able to resolve some scientific controversies within paediatrics.

Niels Lynøe: conceptualization, writing – original draft, writing – review and editing, formal analysis.

Was in 2014–2016 member of the SBU expert panel who conducted the SBU report about the diagnostic accuracy of isolated triad findings supposed to predict shaking.