Sir:
In their timely and comprehensive review of the dangers of
overdiagnosing respiratory complaints in children, Weinberger et al(1),
kindly mentioned one of our two earlier publications on the subject of
diagnostic error in pediatric asthma(2),(3). At a time when symptom-based
diagnoses such as asthma, ADHD and depression are claimed to be
increasingly common amongst children, we believe the points the authors
raise about potential diagnostic error are well worth emphasising.
Although there are a number of ancillary tests available, asthma
remains a diagnosis based largely on self reported symptoms. Establishing
the significance of these reports can be difficult, even when given first
hand by an adult. Once a child's complaints of difficulty in breathing are
interpreted by a parent, the chance of diagnostic error increases.
National asthma studies based only on retrospective questionnaires about a
child's wheeze or cough during the past year, are also open to error.
Despite these problems, the asthma literature contains surprisingly little
research into diagnostic accuracy. At time of writing, a Medline search on
the terms asthma/children produced 31,213 results. A search on
asthma/children/diagnostic accuracy produced 19 (only 3 of which had any
relevance).
The steady secular trend of improved health over the last 100 years
has produced a generation of children, in developed countries, who are
healthier, larger and probably even smarter than at any time in history.
Claims of disease epidemics amongst this cohort (particularly those
lacking a dependable diagnostic test) should be treated with some caution.
If it doesn't seem likely that large numbers of healthy children require
regular treatment with inhalers then it seems sensible to question the
criteria upon which those treatments are based.
There is a truly urgent need for a more critical attitude towards
symptom based diagnoses throughout the broad field of pediatric medicine.
We hope that the work done in this area by Weinberger and our own group,
will stimulate much needed research into the reliability of pediatric
diagnoses based mainly on reported symptoms.
1. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing and
dyspnea are not asthma. Pediatrics 2007;120:855.
2. Seear M, Wensley D, West N. How accurate is the diagnosis of exercise
induced asthma among Vancouver schoolchildren? Arch Dis Child 2005;90:898.
3. Seear M, Wensley D. Chronic cough and wheeze in childen: do they all
have asthma? Eur Resp J 1997;10:342.
Conflict of Interest:
None declared
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