Alternative Medicine and the Vulnerable Child…..
A concept that has been well-recognized in pediatric medicine, at least since it was first described in 1964, is that of vulnerable child syndrome (VCS). In the past, I have mistakenly refered to this entity as “sick child syndrome” but that is problematic in that it implies that it only occurs in the aftermath of illness. As I will explain in detail, there is much more to the development of VCS and it is the concern of VCS in children without true medical problems that led me to the connection with alternative medicine. I’ll explain, but first a primer on VCS.
VCS is a potential consequence of extreme parental anxiety in response to the perception of vulnerability in their child. This perception leads to abnormal parental behaviors, such as overprotection and excessive focus on future health complaints from that child. Ultimately, these behaviors can result in the child suffering severe separation anxiety, behavior problems, difficulty in school, and abnormal fixation on their own health. It is also very common for families with VCS to overuse medical services, sometimes seeking medical attention in emergency departments or physician’s offices several times each month, and there have even been links to physically abusive relationships between children and their families.
The parental anxiety at the heart of VCS tends to be initiated by the diagnosis of significant illness in a particular child, or by a high-risk pregnancy/delivery during which the life of the child or mother was at risk. But, and this is important, it can occur even when the illness in question is not serious, or when there isn’t any illness in the first place. It is, after all, the perception of vulnerability that is at the heart of VCS. This unfounded anxiety can even stem from something as seemingly innocuous as a false positive newborn screen result that is quickly determined to be spurious. Naturally, as with most disorders of a psychological nature, factors that can potentiate the untoward effects of VCS can include environmental and family stress, poor social support and low socioeconomic status.
I often discuss the role of pediatric medical professionals in the development of VCS with colleagues but I am frequently disappointed with these interactions and left feeling as if it is an issue that doesn’t receive the respect that it deserves. I think that for many providers, the fear of missing a potentially serious medical condition, even a very unlikely one, outweighs the risk of longterm psychological complications that can sometimes occur when we dust off the old diagnostic shotgun or go on investigatory expeditions with low pre-test probability of success.
There is also, I think, a general acceptance of performing tests to “rule-out” problems rather than to “rule-in” problems that are felt to be likely based on history and examination. This is common amongst medical practitioners as well as lay persons. Recently a friend asked me what harm lay in obtaining medical tests that may not actually be necessary but might serve as a means of comforting a family, or a physician, that is worried about a particular disease process. The answer, of course, is that our tests often are imperfect and have a large subjective component to their interpretation which leads to a large number of false positive determinations. These false positives lead to more intervention, much of which has inherent risk associated with it, and they can lead to VCS in some instances. There are other reasons to avoid unnecessary testing but to me this is the most important.
A common example of this occurs when the prototypical febrile 15-month old with symptoms consistent with a viral lung infection is brought into the emergency department or primary care doctor’s office during the Winter months. The evidence is clear that these kids, with rare exception, do not have bacterial pneumonia and do not benefit from the routine ordering of chest films or complete blood counts but they are very frequently obtained anyway in order to rule out something which would require antibiotic therapy. These xrays and labs are often equivocal or consistent with a viral lower respiratory process, but studies in these situations tend to serve as a Rorschach inkblot test with the interpreter seeing in them whatever he had already decided was causing the symptoms. In these cases, it is a bacterial process and the IV antibiotics are soon running.
It is a very difficult task for a hospitalist to explain why an intervention that was just begun is being discontinued, especially one which makes such intuitive sense to a family. The physician ordering the antibiotics typically does not explain the ambiguities of such a diagnosis. They do not typically explain the extremely low incidence of bacterial pneumonia in such situations, or even discuss the difference between viral and bacterial pneumonia. They tend to walk in and confidently diagnose a bacterial pneumonia, and the use of antibiotics for pneumonia is seemingly hardwired in the psyche of the general public. So when I stop the ceftriaxone, and begin talking about viruses and the reassuring chest xray obtained the night before, I sometimes meet up with parental anxiety and resistance to supportive, non-pharmaceutical interventions. On many occassions, I’ve seen these families during future admissions where a history of bacterial pneumonia is given. Sadly, I also have experienced on many occassions the subsequent concerning changes in how these children are cared for, such as the concern for another episode of bacterial pneumonia leading to seeking emergency care in the middle of the night for what is clearly another viral infection that could have been treated at home, or could have been easily handled by their primary care physician the following morning.
So what is the connection between alternative medicine and VCS? It is actually pretty obvious and I’m feeling rather sheepish about not having thought of this before. The science-based practice of pediatric medicine and the confusing jumble of unproven modalities lumped under the term alternative medicine differs in many ways. One of the most prominent is the plain fact that when a child is brought to a practitioner of (insert random alt med entity), or that child’s parents visit the website of a proponent of such an entity, they are rarely if ever told that nothing is wrong. There is always something that can be fixed, often with multiple visits or supplements which just so happen to be sold right there in the office or by the author of the website. Chiropractors tend to find subluxations. Practitioners of traditional Chinese medicine discover stagnant chi. Naturopaths uncover ill effects of a toxic world. Numerous quacks order blood tests designed to confirm their suspicions of harmful heavy metal levels. Countless websites tout hypothyroidism and adrenal fatigue as near ubiquitous etiologies for any symptom you can dream up. Or maybe it is all because of abnormal body acidity. Or yeast. Or liver flukes. All of these have been proposed as the cause for almost all illness.
In contrast, as a pediatric hospitalist, someone who by definition only takes care of children sick enough to be admitted to a hospital, I still spend a large percentage of my day reassuring parents and patients that things are going to be okay, that their child’s condition is self-limited and that they will return to full health. On many occasions I prescribe no treatment at all, and participate in what has been called “masterly inactivity”, the calculated observation of a child in order to avoid unnecessary testing or pharmaceutical intervention. In the day to day workings of a primary care doctor, the overwhelming majority of visits are for well children check-ups or self-limited complaints with most receiving only advice and reassurance. We are able to this because most of us strive to base management decisions on the best evidence available, as free as is humanly possible from biased interpretations and certainly free from the impact of an irrational devotion to any unscientific and unproven belief systems. There are exceptions of course, but these are not common.
I am forced to recognize that despite my best efforts to reassure some families, there will be times when a pathologic anxiety will develop. To give just one example, it seems painfully obvious that if the family of a healthy child brings their child to a chiropractor, and were told that one or more subluxations exist which need immediate treatment, and longterm maintenance treatment to prevent their recurrence, that the risk of VCS would be very real. Just google the terms “SIDS” and “subluxation”, and you will find chiropractic websites and articles discussing that connection. Now imagine the fear that some families must go through believing that their child is at risk of dying in their sleep if they don’t see a chiropractor, as is recommended by many of them, in the newborn period. This is just one of innumerable examples of alt med practitioners sowing the seeds of fear and anxiety by validating fictional problems. There are worse, much worse.
What really got me thinking about VCS in this context was the recent publication of an article on the ethics of complementary and alternative medicine in Pediatrics in Review. Peds in Review is the journal of the American Academy of Pediatrics (AAP) and is geared towards continuing education for pediatricians. It contains review articles, quizzes, and cases designed for maximized learning, and is heavily used by pediatric residents. I’ve been reading it monthly since 2003 and have noticed the steady creep of alternative medicine nonsense into its pages, usually with review articles of the use of alt med for specific medical diagnoses. These articles tend to be poorly written and seem to rely on misinformed or biased sources such as the National Center for Complementary and Alternative Medicine (NCCAM), a propaganda machine for alt med that has also wasted over a billion taxpayer dollars on studying alternative practices with zero plausibility and heaps of prior negative studies. Much of their budget goes towards supporting biased unscientific alt med education in medical schools, hence my use of the word propaganda.
Although this particular article was perhaps a little better than many treatments of alternative medicine by the AAP, it still left a lot to be desired. My next post will focus on the errors in the article. At no point in the discussion did the risk of VCS come up. I believe that although there are greater potential risks of exposing children to these unproven modalities, the development of VCS should certainly be included. I would not be surprised at all if VCS is a much more common outcome than those other more serious bad outcomes like stroke from manipulation of the neck or toxicity from unregulated herbal supplements.