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PEDIATRICS Vol. 109 No. 3 March 2002, pp. 522-523

EXPERIENCE AND REASON

Two Wrongs Don’t Make a Right: Harm Aggravated by Inaccurate Information on the Internet


   ABSTRACT
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There has been much concern expressed in the literature about the use of medical information on the Internet by patients and families. Although much work has been done to quantify the misinformation available on the Internet, there have not been reports of actual harm to children resulting from this misinformation. We present the case of a 1-year-old boy whose clinical course of diarrhea was complicated not only by inaccurate advice given by the emergency room physician, but also by the same advice received from the Internet.

Key Words: Internet • child • case report • medical errors • harm

Abbreviations: ER, emergency room


   INTRODUCTION
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 INTRODUCTION
CASE REPORT
 DISCUSSION
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The Internet is creating new opportunities for people to access information and to communicate with one another. Little is known, however, about the influence that information found on the Internet can have on the way people make decisions related to their health and its impact on health-related outcomes.

In this article, we describe a case in which health care information obtained by parents from the Internet was associated with an adverse outcome in a pediatric patient presenting with diarrhea. To our knowledge, this is the first reported case of harm in children associated with the use of information found on the Internet.


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C.M., a previously well 1-year-old boy, had an illness that began with nausea and vomiting, followed by diarrhea. He was initially seen in the emergency room (ER) of a local hospital where a preliminary diagnosis of otitis media was made. He was prescribed antibiotics and sent home. His diarrhea continued for 2 more days, and he was brought back to the ER where he was diagnosed with gastroenteritis and dehydration. Antibiotics were discontinued. Specific advice was given by the ER staff to stop foods and use soft drinks or fruit juice for rehydration. Following this, the parents used their home computer to access health care information from the Internet about the management of diarrhea in children. They found a Web site with information from a purported tertiary care pediatric medical center based in the United States, and felt reassured when they found that the advice they found on this site regarding rehydration and management of diarrhea was congruent with the advice they had received at the ER.

The advice on the Internet site specified: "Give clear fluids every 2 to 3 hours. These may include Pedialyte (Abbott Laboratories, Abbott Park, IL), flat cola, ginger ale, tea with sugar, Kool Aid (Kraft Foods, East Hanover, NJ), or Jello (Kraft Foods, East Hanover, NJ)"; "Stop all regular foods and fluids"; "For children drinking regular milk, give no milk or milk products for 1 week"; Call your doctor if "your child does not urinate for over 12 hours."

Over the following week, C.M. experienced persistence of his diarrhea and became increasingly weak. He was eventually taken to his family physician who referred him to the tertiary care Pediatric Gastroenterology service at McMaster University Medical Center, where he was admitted. At that time C.M. was noted as being pale, irritable, and appearing wasted. Serum electrolytes, including sodium, were normal. C.M.’s parents were distraught and adamant that they had carefully followed the instructions from both the ER staff and the Internet site. The parents were confused, as they could not understand why their child had not improved with the treatment that had been provided, as they had followed the recommendations carefully.

In the hospital, C.M. was started on Pedialyte and reintroduced to solids. Over the 2 days C.M. was as inpatient, his clinical condition improved. He was sent home with instructions to continue with appropriate fluid and food intake.

When asked about the Internet site that they used, C.M.’s parents were able to provide a printed copy of the information they found. On additional review, it became obvious that they had not misinterpreted the information on the site, which did not conform to standards of care outlined in any available clinical practice guideline.

C.M.’s parents were both disappointed and frustrated that they were not provided with adequate information and advice. When asked their opinion about reporting C.M.’s case in a peer-reviewed journal, they were supportive, seeing it as an opportunity to prevent similar events from happening to other families.


   DISCUSSION
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This is perhaps the first reported case in which use of information found on the Internet has been associated with physical harm to a pediatric patient. It remains to be determined why there is no more reported evidence on this important issue. It might be attributable to lack of incentives for busy clinicians to explore and report cases in which information on the Internet can be associated with health outcomes in any direction. It might also be attributable to publication bias. Even less likely is the fact that it might be attributable to a lack of harm associated with inappropriate use of health information available on the Internet.

The case also illustrates how inaccurate information on the Internet can contribute to the consequences of following advice received through face-to-face encounters with health care professionals when such information departs from evidence-based clinical practice guidelines.1 This is particularly relevant for highly prevalent conditions such as diarrhea in children. A recent study, for instance, has shown that there are hundreds of sites on the Internet that contain information about the management of diarrhea in children.2 Although some of these sites, including those maintained and supported by the Canadian Paediatric Society, the World Health Organization and the American Academy of Pediatrics, offer evidence-based recommendations that have been peer-reviewed,3–6 the majority provide information that is inaccurate.2

This seems to be the case for other common conditions such as fever and cough in children.7,8 In this particular case, it is possible that the advice received in the ER increased the likelihood of C.M.’s parents being more receptive to a site that contained inaccurate information. As access to the Internet increases, cases of harm associated with it are likely to become more frequent. Harm could happen even before patients interact with health professionals, as information found on the Internet, whether inaccurate or accurate but misinterpreted, may lead to delays in seeking attention. Less likely, but still possible, could be that cases of harm occur when patients choose to follow information found on the Internet that contradicts advice given by health professionals.

There is no justification for the dearth of evidence on the way in which the use of the Internet can influence health-related decisions and outcomes. More than ever, we need formal studies on the use of the Internet by different groups of decision-makers, on the relationship between information found on the Internet and in other sources, and on factors and strategies that minimize the risk of harm associated with the use of this powerful medium and communication tool. Until all this happens and we gain more knowledge about how to harness the power of the Internet, the best protection for the public will continue to be a good dose of common sense and courage to challenge any advice they receive, regardless of the source, when following such advice does not produce the anticipated results.


   AN ECONOMIST LOOKS AT PREMATURITY
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"Broad economic aggregates, such as lifetime costs attributable to the specific sequelae of preterm and low birth weight, can provide a basis for assessing competing strategies for research and prevention."

Petrou S, Sach T, Davidson L. The long-term costs of preterm birth and low birth weight. Child Care Health Dev. 2001;27:97–115

Submitted by Student

Anthony George Crocco, MD

Postgraduate Medical Education
McGill University
Montreal, Quebec, Canada H3G 1Y6

Miguel Villasis-Keever, MD, MSc

Health Information Research Unit (HIRU), Faculty of Health Sciences
McMaster University
Hamilton, Ontario, Canada L8N 3Z5
Clinical Epidemiology Unit at Pediatric Hospital
Instituto Mexicano del Seguro Social (IMSS)
Mexico City, Mexico CP 6698

Alejandro R. Jadad, MD, DPhil, FRCPC

Centre for Global eHealth Innovation
Rose Family Chair in Supportive Care
Departments of Anesthesiology and Health Policy, Management, and Evaluation
University Health Network and University of Toronto
Toronto, Ontario, Canada M5G 2C4

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   FOOTNOTES
 
Received for publication May 23, 2001; Accepted Sep 10, 2001.

Address correspondence to Alejandro R. Jadad, MD, DPhil, FRCPC, Centre for Global eHealth Innovation, Toronto General Hospital, Eaton Wing EN 6-238, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4. E-mail: ajadad{at}uhnres.utoronto.ca


   REFERENCES
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 INTRODUCTION
 CASE REPORT
 DISCUSSION
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 REFERENCES
 

  1. Reis EC, Goepp JG, Katz S, Santosham M. Barriers to use of oral rehydration therapy. Pediatrics.1994; 93 :708 –711[Abstract]
  2. McClung HJ, Murray RD, Heitlinger LA. The Internet as a source for current patient information. Pediatrics.1998; 101(6) . Available at: http://www.pediatrics.org/cgi/content/full/101/6/e2
  3. Canadian Paediatric Society. Dehydration and diarrhea. Available at: http://www.cps.ca/english/carekids/babies/Dehydration.htm. Accessed February 21, 2001
  4. World Health Organization. The treatment of diarrhoea. Available at: http://www.who.int/chd/publications/cdd/textrev4.htm. Accessed February 21, 2001
  5. World Health Organization. Advising mothers on management of diarrhoea in the home. Available at: http://www.who.int/chd/publications/cdd/advising/adv mom.htm. Accessed February 21,2001
  6. American Academy of Pediatrics. The management of acute gastroenteritis in young children. Available at: http://www.aap.org/policy/gastro.htm. Accessed February 21,2001
  7. Impicciatore P, Pandolfini C, Casella N, Bonati M. Reliability of health information for the public on the World Wide Web: systematic survey of advice on managing fever in children at home. BMJ.1997; 314 :1875 –1879[Abstract/Full Text]
  8. Pandolfini C, Impicciatore P, Bonati M. Parents on the Web: risks for quality management of cough in children. Pediatrics.2000; 105(1) . Available at: http://www.pediatrics.org/cgi/content/full/105/1/e1
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics



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