The 'maternal grimace' sign. A clue to the importance of the contextual diagnosis

Parents sometimes present illness in a child as an expression of their own distress, and patient-centered medicine attempts to address the underlying causes of problems by incorporating psychosocial factors in the diagnosis. However, in the real world of busy primary care, it is not always possible or appropriate to broaden every consultation, and the clinician may have to rely on certain clues that suggest the importance of exploring hidden reasons for consulting. Two cases are presented in which a mother's dramatic grimace during the gentle examination of a comfortable child alerted the clinician to parental anxiety disproportionate to the child's illness. Addressing parental anxiety proved fruitful. This "maternal grimace sign," pointing to the importance of the contextual diagnosis, underlines the usefulness of careful observation of all those involved in the consultation and may have implications for the way clinicians choose to position children and parents during physical examinations.