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A paediatric axiom

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    How is a general practitioner (or a paediatrician, for that matter) to know that a child has a relatively rare disease such as cancer? The answer, perhaps, lies in a paediatric commonplace, an axiom of paediatric practice: listen carefully to the parents—they know their own child and are probably right. (Don't all medical students have that branded on their brain stems on their first day in paediatrics?) Axioms, of course, don't have to be proved; they are agreed starting points from which everything else follows. Paediatrics has but one axiom of axioms: the best interests of the child come before everything else. That's the ace of trumps in the axiom pack. As a subsidiary axiom though, this one (the one about parents) doesn't seem a bad card to hold in your hand. It's an axiom to remember. (We'll forget child abuse for now; that's covered in the panaxiom.) Perhaps a Radio 2-type jingle would help to preserve and spread the meme:  Now you shouldn't be able to stop singing that to yourself for the rest of the day.  In Leicester (Mary Dixon-Woods and colleagues.Lancet2001;357:670–4) semistructured interviews were conducted with parents of 20 children, some one to 36 months after the diagnosis of cancer (leukaemia (9), brain tumour (2), other solid tumour (9)) in their child. Disputes with doctors had occurred in 10 cases, almost invariably because of delays in diagnosis when the parents “knew there was something wrong”. Three of these 10 children had acute lymphoblastic leukaemia and the diagnosis was made on a blood test after a 3 or 4 week period of “wait and see”. (Many parents accepted that such delay was reasonable when the symptoms were non-specific.) Seven of the 10 had solid tumours diagnosed between 2.5 and 8 months after the onset of symptoms. What upset parents was failure to investigate persisting symptoms, failure to investigate alarming symptoms such as fits, incoordination, sudden onset paralytic squint, or haematuria, and failure to give enough credence to their feeling that something about their child was “not right”. Diagnostic delays occurred both in general practice and in secondary paediatrics. Sometimes the wait to be seen in a paediatric clinic seemed unduly long. Some older children hid their symptoms or resisted being taken to a doctor.  This type of research, being purely qualitative, tells us nothing about the positive predictive value of “not-right-ness”. But parents arespecialists on the subject of their own child and, although their recollections could have been influenced by various factors such as fear, anger, self blame, or the human need to say “I told you so”, the facts as related by these parents were usually confirmed by the medical records. Parents aren't always right, of course, and reassurance (though not empty, ill considered reassurance) is important but, at the very least, believing in the axiom makesus nicer people.  In primary or secondary practice the probability of a child having cancer is usually low, but parental concern is a factor which must weigh heavily in any child care equation. Humility and an ear to listen with; how often has any one of us been short of either or both? Remember, da da-da da da-da-de da. Go on, sing along with Archie.

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